Lip Reconstruction Treatment & Management

Updated: Mar 14, 2016
  • Author: Michael R Shohet, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
  • Print
Treatment

Surgical Therapy

Because no surgical defect is the same, an individualized approach must be anticipated. General guidelines exist to help in the classification of defects according to depth and location. Such simplified categorization has its limitations but is quite instrumental in providing an organized approach to this highly variable problem.

In this section, superficial and full-thickness defects are discussed separately because the treatment options vary substantially.

Superficial defects of the upper lip

Most upper lip reconstructions involve the perioral skin rather than the vermilion or red lip because basal cell carcinoma is overwhelmingly the predominant pathology. Because of the lack of excess skin in the areas between the lip and nose, many reconstructions for this area use medial cheek advancement. Superficial defects of the lateral upper lip may be closed primarily in harmony with the relaxed skin tension lines. Defects closer to the nasolabial sulcus may be closed primarily within this fold. Small defects in those lateral subunits may also be amenable to an A-T closure using incisions at the vermilion border or medial cheek advancement. Larger superficial defects of the lateral upper lip may require excision of the entire subunit. In patients with adequate cheek laxity, an inferiorly based nasolabial flap may provide coverage of the entire lateral upper lip.

In the less-common circumstance of superficial defects of the red lip with remaining orbicularis, full-thickness grafting or healing by secondary intention is most appropriate because any advancement in this region usually results in untoward distortion of the upper lip projection. The donor site for red lip defects is the buccal surface of the red lip at a separate site. The donor site can be left to heal by secondary intention. Superficial defects within the philtral subunit may also be allowed to close by secondary intention or by full-thickness skin grafting typically from the periauricular region.

Superficial defects of the lower lip

A variety of techniques are important in the management of lower lip defects. Very common problems encountered in the lower lip are leukoplakia and actinic cheilitis. These conditions are often observed in association with squamous cell carcinomas. For this reason, lip shave or superficial excision, including vermilionectomy, of such damaged mucosa is commonly employed. Buccal mucosa can be undermined sharply and bluntly to allow advancement to the previous red-white junction. Occasionally, such defects are too large to allow undermining alone, and a pedicled flap must be used. The ventral surface of the anterior tongue is a dependable location. Flap division requires a separate procedure and can be performed 2 weeks after the initial procedure. Smaller partial-thickness defects can often be allowed to heal secondarily, or buccal surface grafts can be harvested from a separate site and used for a full-thickness graft.

Similar to the upper lip, common adjuncts include A-T flaps with relaxing incisions either at the vermilion border or at the labiomental crease.

Full-thickness defects

Deeper facial defects often require a wide variety of flap techniques to optimize closure. A brief discussion of the more widely used tissue transfer techniques precedes discussion of the approach and philosophy to closure based on location.

In 1898, Abbe first described the lip switch flap (Abbe flap), which was originally designated as a complete philtral reconstruction for the relief of the bilateral cleft lip deformity. The use of this flap has been liberalized, and today it is quite useful and a versatile means of both lower and upper lip reconstructions. The flap can be taken from either lip, and its shape and size are dependent on the defect. Typically, a flap half the size of the defect is adequate because the change of length of both lips is symmetric. The flap is incised full thickness with care at the vermilion border of one side to leave it pedicled on a small amount of mucosa and the labial artery. A meticulous 3-layer closure at both the donor and recipient sites is standard. Two stages are required because the pedicle must be ligated and inset at approximately 3 weeks after the principle procedure.

The Abbe lip switch flap. Typically, the flap is h The Abbe lip switch flap. Typically, the flap is half the width of the defect to allow for symmetric shortening of the upper and lower lip. A second stage is necessary to ligate the pedicle and finalize flap inset.

For those defects that extend laterally to include the oral commissure, the Estlander flap (lateral lip switch flap) is a useful procedure. This is a lip switch technique similar to the Abbe flap and typically uses a medially based full-thickness upper lip. Oral continence results are excellent, although a second stage often is necessary to correct the typical rounding at the new commissure. This second-stage commissuroplasty is typically performed 12 weeks after the initial procedure and includes a triangular incision laterally at the modiolus. The red lip extending to the lower lip is elevated superficially and used to repair the upper lip laterally. Buccal mucosa is elevated inferiorly and advanced externally to close the remaining lower lip defect at the oral commissure.

The Estlander lateral lip switch flap. Note that a The Estlander lateral lip switch flap. Note that although complete inset is accomplished at the initial stage, a second stage is often warranted to allow for better definition of the oral commissure. As described by Converse, the modiolus is expanded followed by mucosal advancement flaps.

In a 1974 report, Karapandzic describes the standard procedure that functionally reconstructs large defects of both the upper and lower lips. [1] This method is based on the principle that the best form of reconstruction comes from tissue that most closely resembles the tissue being replaced—in this case, the lip and cheek. Musculocutaneous flaps with a width equal to the height of the defect are formed on both sides of the defect. The neurovascular supply to the orbicularis oris musculature, namely the facial artery and facial nerve branches, are dissected out and spared. A gradual cutting of the peripheral muscle fibers and concentric undermining allows advancement without the need to extend within the mucosa. Because only the peripheral rim of orbicularis oris muscle is incised, and the buccinator muscle is preserved, complete and immediate function is restored.

The Karapandzic flap is a suitable option for larg The Karapandzic flap is a suitable option for large lower lip defects. The neurovascular pedicles are preserved allowing for adequate sensation and motor function. Since no additional tissue is advanced, a limitation is microstomia.

The nasolabial fold provides color- and texture-matched tissue to the upper and lower lips. An excellent blood supply based on the facial arteries and a natural-appearing scar at the donor site reinforces this flap as a useful adjunct in lip reconstruction. Most flaps for this purpose are based inferiorly and may include myocutaneous or cutaneous donor layers. The Gate flap is essentially a larger, innervated, inferiorly based, myocutaneous nasolabial flap that can be used for unilateral or bilateral closure of defects of the entire lower lip if needed. Motor function is not quite as automatic as in the Karapandzic flap, but donor tissue is more abundant. Therefore, this flap is a useful option in cases that are limited by significant microstomia and by limited oral access when a Karapandzic flap is used.

Perialar crescentic cheek excision is a useful technique for defects of the upper lip that require musculocutaneous advancement from adjacent cheek tissue. Simple advancement would cause bunching at the perialar folds. This excision is essentially an elliptical excision with the upper part shifted laterally to avoid the nostril. The perialar skin may be preserved as a caudally based flap to reconstruct columellar or nostril floor defects.

Large defect of the lateral upper lip side unit is Large defect of the lateral upper lip side unit is addressed with a perialar crescentic cheek advancement flap. The muscular continuity is preserved, allowing for complete functional restoration.

A variety of donor sites have been described for use in lip reconstruction. These sites are based on the size and nature of the lip defect and associated surrounding facial structures. Consider microvascular free tissue transfer techniques in situations in which the protocols outlined below are not adequate.

Full-thickness defects of the upper lip

Defects of up to one third of the upper lip, not including the majority of the philtral subunit, may be closed primarily without risk of significant tightening. Often this closure also requires a perialar excision and advancement. Meticulous realignment of the vermilion border is paramount.

Full-thickness defects that involve a majority of the philtral subunit are treated very effectively with replacement of the entire philtral subunit. An Abbe flap from the lower lip can adequately reconstruct the central subunit, and depending on the size of the residual lateral subunit defects, these defects can often be closed with careful approximation to the Abbe flap. Precisely scratching or tattooing the red-white border prior to excision can facilitate alignment of the vermilion border.

For full-thickness defects that include greater than one half of the upper lip, an inclusion of more than 1 subunit is necessary. Using the above-mentioned techniques in combination, nearly all but the largest defects are amenable to closure. For example, a defect including the central subunit and most of a lateral or both lateral subunits can be reconstructed employing advancement flaps for the lateral subunits and a central Abbe flap for philtral reconstruction.

With care to align the flaps in a position approximating the philtrum, natural appearing contours are possible. Excision of excess perialar skin in a crescentic fashion is necessary to avoid blunting in this area. Initial alignment of the philtral reconstruction as a means of orientation ensures that the philtrum is centrally located in relation to the nasal columella. The initial alignment also ensures that adequate advancement of the lateral subunits can be performed without risk of excess tension on this central reconstruction, with resultant lateral deviation and an awkward appearing upper lip.

Although rare, full-thickness defects of the entire upper lip can be a serious challenge. Bilateral nasolabial flaps may be used for the lateral subunits, and an Abbe flap may be used for the central subunit in patients with adequate cheek laxity. Advancement of labial mucosa onto the skin flaps recreates a red lip subunit. Another option in patients with less skin laxity is the Karapandzic flap using a reverse elevation. While effective in closing such challenging defects, microstomia can be problematic.

Full-thickness defects of the lower lip

V-excision with primary closure is considered adequate in most full-thickness defects encompassing up to one third of the lower lip. The vermilion border must be realigned meticulously to avoid malalignment. A 3-layer closure, including the oral mucosa, the orbicularis oris muscle, and the overlying skin in individual layers, generally is necessary for full-thickness reconstruction. A W-shaped excision may be used to avoid crossing the mentolabial crease and to allow for even larger defects to be closed primarily.

For larger centrally located defects in which closure certainly affects the mentolabial crease, bilateral advancement flap (double-barrel) closures allow adequate undermining in cases of defects up to three fourths of the lower lip. Another option for larger defects laterally located, but not including the oral commissure, is the Abbe flap. As previously discussed, the upper lip donor site should be approximately one half of the size of the defect. For defects that include the oral commissure, the Estlander flap often is an excellent option. Because this flap generally causes rounding of the oral commissure, a secondary commissuroplasty procedure is usually necessary at a separate time.

A fan flap, first described by Gillies and popularized by Millard, is another option. [3] This flap has a superiorly based pedicle that provides additional tissue to the lip so that microstomia is avoided. Because of the reorientation of the orbicularis oris muscle, a lack of motor function and minimal return of sensation results in this portion of the flap. Buccal advancement is often necessary to recreate the border between the vermilion and the red and white portions of the lip.

The Karapandzic flap is an excellent 1-stage option for innervated and well-vascularized closure of defects of one half of the upper lip or larger. However, the significant limitation of this flap is microstomia. For patients in whom oral access is not sufficient to use this type of reconstruction, other options are available. Bilateral Gillies fan flaps result in adequate coverage for defects of varying thickness, even for full defects. Because of the reorientation of the muscle and orientation of tissue transfer, motor function and sensitivity of the flap are limited. Advancement of buccal mucosa to the advanced skin is often necessary to recreate a red-white border.

Bernard Von Burow popularized the bilateral cheek advancement flap, which is another option for total lip defects. Webster later modified this technique. In this reconstruction, large cheek advancement flaps are designed, with excess advanced skin oriented within the nasolabial folds superiorly and in the crease between the mentum and the cheek inferiorly. Advancement of buccal mucosa is necessary for creation of a new vermilion. Because denervation is necessary to advance the cheek musculature, a lack of motor function and sensitivity results, which limits this type of tissue transfer.

A prospective study by Denadai et al indicated that a modified Bernard-Webster flap can effectively repair full-thickness lower lip defects produced by squamous cell carcinoma excisions and covering more than one third of the lower lip’s length. Ten of the study’s 12 patients had no complications, with the other two experiencing wound dehiscence. Although transient and permanent functional abnormalities were encountered in recent and late postoperative assessments of 10 patients, 10 patients reported their late functional results to be satisfactory. [4]

Okochi et al described the use of a modified Bernard technique called the hemi-Bernard method, for unilateral, full-thickness lower lip reconstruction following malignant tumor resection. The technique, performed on three patients in the study, allowed retention of orbicularis oris muscle movement and extension of lower lip length. [5]

A study by Ayhan et al indicated that sensory recovery can be expected in noninnervated flaps used in total lower lip reconstruction and that this recovery is influenced by factors such as patient age and the type of flap used. In the study, sensory recovery was found to be more likely with the use of fasciocutaneous free flaps than with musculocutaneous flaps. The investigators also found that the flap’s ability to regain the sense of touch (including two-point discrimination) and temperature perception were related to the age of the patient, whether he or she smoked, and whether the patient had undergone radiation treatment. Ayhan and colleagues concluded that noninnervated flaps should attain “reasonable” sensory recovery if the patient is relatively young, if the recipient bed has enough surface contact area and is free of marked scarring, and if the major sensory nerve in that area has been retained. [6]

Next:

Preoperative Details

Discussion of risks and alternatives is a fundamental part of informed consent prior to any surgical procedure; lip reconstruction is no exception. Because the exact reconstructive option is not often known at the onset of the procedure, the above guidelines allow an organized discussion of the possibilities.

Previous
Next:

Intraoperative Details

These details have been highlighted in the discussion of each reconstructive option (see Surgical therapy). In the cases of multilayered closure, general guidelines for the choice of suture material are worthy of mention. Mucosa is typically closed with a faster self-absorbing suture such as chromic suture. Muscle layers are better approximated with a longer lasting nonreactive material. Polydioxanone (PDS) fulfills these criteria. The skin is optimally addressed with a nonresorbable nonreactive monofilament, such as nylon or Prolene.

Previous
Next:

Postoperative Details

Routine surgical wound care includes regular cleaning of suture lines to minimize crust formation. Hydrogen peroxide solution is helpful for atraumatic removal. Antibiotic ointment is generally used in all nonmucosal sites for the first 48 hours, after which benefits of the antibiotic are not clear.

Optimal wound closure excludes tension at the suture lines. For this reason, sutures can be removed from 4-7 days postoperatively. Adjunctive means of minimizing tension at the suture sites include Steri-strips and layered closure.

Previous
Next:

Follow-up

Secondary procedures are generally timed on an individual basis. In general, pedicle insets in the case of lip switch techniques can be performed at approximately 3 weeks following the initial operation.

Revision and secondary commissuroplasty procedures are best performed when most of the healing and postoperative edema is completed, usually after a minimum of 3 months.

Previous
Next:

Complications

Given the relatively generous vascular supply of most head and neck structures, including the perioral region, postoperative infectious complications involving the lips and oral commissure are uncommon. Flap necrosis may sometimes follow inadvertent kinking or ligation of the labial artery during lip switch procedures; therefore, meticulous handling of the tissues is warranted. Often the hypoesthesia of the donor and recipient sites warrants frequent reminding; therefore, instruct the patient to avoid aggressive opening of the mouth and to take care while eating in order to minimize pedicle trauma in the postoperative period.

Recurrent disease is another unfortunate complication of any oncologic procedure. Use frozen section pathology or Mohs techniques judiciously in order to minimize the incidence of recurrence.

Previous