Lip Reconstruction Procedures Treatment & Management Page 1 of 9

Lip Reconstruction Procedures Treatment

& Management

Author: Ali Sajjadian, MD, FACS; Chief Editor: Deepak Narayan, MD, FRCS more...

Updated: May 11, 2010

Medical Therapy
No medical therapy exists for lip loss. Dental prosthetics are ineffective for lip restoration. However, they do have
substantial value in replacing loss of maxillary or mandibular bony support for the lips in certain circumstances when
these underlying structures are missing.

Preoperative Details
Preoperative considerations include determination of whether the conditions are appropriate for reconstruction, flap
design along with appropriate markings, oral hygiene, preparation of surgical area, and communication of possible
outcomes with the patient.

Oncologic resection is a major cause of lip defects. Hence, prior to reconstruction, pathology results on complete
resection of tumor and clear surgical margins must be confirmed. When trauma is the etiology or accompanies the
defect, it is imperative to allow recovery while keeping in mind the possibility of distortion of local anatomy and
vascular supply.

Flap design includes assessing the size and shape of the defect and the availability of replacement tissue.[13] As
such, the location of the donor sight may vary (from local to distant flaps) based on defect size and whether the
surrounding anatomy is preserved, since trauma is often extensive and may not be localized. Prior to administration
of anesthetics, mark the cutaneous-vermilion border to aid in realignment and note relevant cosmetic landmarks such
as folds, shadows, and tension lines. This is imperative, as injection of local anesthetics distorts the normal anatomy.
Oral hygiene should be optimized and hairs trimmed to decrease the chance of infection.

Since the obstacles of reconstruction may not be apparent prior to surgery, communicate to the patient or family the
variability in functional and aesthetics outcomes. Doing so instills reasonable expectations that may make the
postoperative period less difficult for the patient or the family.

Defect repair
Different defects require different repair techniques. Alternatively, different techniques may be appropriate for a
particular defect. Tables 2 and 3 outline defect types, sizes, and locations and the appropriate techniques that may
be used in repairing those defects. Details concerning specific techniques are discussed in the next section.

Table 2. Partial-Thickness Defect Repair (Open Table in a new window)

Defect Type Lower Lip Defects Upper Lip Defects

1-2 cm >2 cm
Mucosal -Primary closure -Primary closure Inferiorly based
nasolabial flap

-Secondary intention -Secondary closure

-Vermilionectomy/laser ablation -Vermilionectomy/laser ablation

Midline -Bilateral advancement flap Philtrum only:

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-Adjacent labiomental crease A-to- -Secondary intention

T flap

-Full-thickness skin graft

Adjacent to philtrum:

-Perialar crescentic advancement

flap

Lateral -Advancement flap In order of increasing laterality of

defect:

-Rotation flap
-Inferiorly based nasolabial flap

-Transposition flap
-Laterally based rotation flap

-Primary closure

Adjacent A-to-T flap A-to-T flap

vermilion

Table 3. Full-Thickness Defect Repair (Open Table in a new window)

Defect Type Lower Lip Defects Upper Lip Defects

Defect Size Defect Size
< 30% 30-60% >60% < 30% 30-60% >60%
Midline Primary -Bilateral -Karapandzic Primary -Perialar crescentic -Nasolabial flap
closure advancement flap closure advancement flap and and Abbe flap
flap Abbe flap

-Bernard- -Karapandzic flap

-Karapandzic Burow flap -Karapandzic flap and and Abbe flap
flap Abbe flap

-Gillies fan -Regional flap

flap

-Free flap
-Regional flap

-Free flap

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Near oral Primary -Abbe flap ... Primary -Unilateral perialar ...
commissure closure closure crescentic
advancement flap

-Depressor
anguli oris flap
-Abbe flap

Involving oral Primary Estlander flap ... Primary Estlander flap ...
commissure closure closure
Philtrum only ... ... ... -Primary ... ...
closure

-Abbe
flap

Intraoperative Details
A number of repair techniques are described below.

Primary closure
Primary repair involves reapproximation of defect edges and is generally reserved for smaller defects and involves
consideration of several factors (see images below). Closure should occur along relaxed skin tension lines or, when
possible, along folds (eg, nasolabial). Typically, tissue is at a premium in defect reconstruction; however, if
necessary, excessive tissue must be excised and the vermilion border must be realigned exactly to ensure
appropriate aesthetic outcome. This is most often performed using a Burow wedge or V excision based on the
vermilion with a 30-degree apex (or an A-to-T flap). This is also where preoperative markings greatly aid in repair.
Repair options may include M-plasty or Z-plasty to release tension that would distort the shape of the mouth or the
vermilion border.

Wedge excision and primary closure.

Left: A patient with midline and left lateral lesions each occupying less than one third of the lower lip. Right: Wedge excision of the
lesions.

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Left: Small lower left lip lesion. Center: Excision and primary closure. Right: Postoperative results.

Left: Near midline small upper lip defect. Right: Burow wedge excision with primary closure (A-to-T flap).

Left: Right upper lip defect (~1/3). Right: Primary closure of defect.

Closure is generally done in 3 or 4 layers, making sure the knots are buried or embedded to prevent surface
irregularities, vermilion border and muscle approximation are precise, and wound edges are everted to prevent
noticeable scar formation.

Cross-lip flap
Cross-lip flap reconstruction allows for repair of fairly large defects with tissue that is similar to the excised tissue. It
allows for distribution of upper and lower lip discrepancy that would occur with primary closure. The technique allows
for minimal disruption of muscle orientation in both donor and recipient sites. Though denervation of the orbicularis
oris may occur, the orbicularis muscle reinnervates with adequate functioning with one-year postoperative
electromyography. The disadvantage of this technique is that it reduces the oral circumference; microstomia
becomes an important issue with increasingly large defects.

Abbe flap
Used for repair of defects near the oral commissure, the flap is planned about one-half the size of defect (see image
below). One aspect of the flap is incised full-thickness, while the inferiormost aspect of the flap is only excised three-
fourths full-thickness to create a pedicle that preserves the vascular supply (labial artery). Three-layer closure is
performed, with emphasis on accurate alignment of the vermilion border. At 3 weeks, the pedicle is separated and
the mucosa is repaired or allowed to heal as necessary.

Abbe flap technique.

Estlander flap
As the first step in commissure reconstruction, the Estlander flap allows for repair of defects at the oral commissures.
With a base larger than that of the Abbe flap, the full-thickness incision is placed along the nasolabial fold (see image
below). Upon realignment of the vermilion border, the mucosa may need to be advanced to match the thickness of
the recipient site. A commissureplasty is then performed at 3 months to restore the normal appearance of the angle
of the mouth. A modification to the Estlander flap is the reverse Abbe flap, which avoids revision commissureplasty
by transposing instead of rotating the flap.

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Estlander flap technique.

Gillies fan flap

An extension of the Estlander flap, the Gillies flap allows for subtotal or total lip reconstruction. This is accomplished
through bilaterally expanding the tissue used to include areas lateral to the commissures. The flap is rotated to create
new commissures while advanced medially to fill the defect (see image below). Though this method leads to
denervation, it does preserve partial continuity of the musculature, which was shown by Gillies to regain eventual
partial function through neurotization.[14] However, sensory loss and vermilion deficiency continue to be
disadvantages to this technique. Later, the Karapandzic flap improved on this technique by maintaining the
neurovascular structures.

Gillies fan flap technique.

Karapandzic flap
Used primarily for midline medium-sized defects, the Karapandzic flap has also been used in total lower lip defects
(see images below). Since this is an innervated flap with neurovascular structures intact, this method of repair allows
for immediate muscle use as compared to cross-lip flap and fan flap techniques. The method involves the use of
tissue surrounding the defect. Three-quarter–thickness incisions are made, and, with separation of muscle fibers
allowing for advancement of the flap, the tissue around the defect is reapproximated. Perioral incisions extending
along the nasolabial fold ease the advancement of the flap medially. Though a very useful technique, the drawback
of this method is the considerable microstomia that may result.

Karapandzic flap technique.

Left: A patient with a midline upper lip lesion. Right: Reconstruction of medium to large upper lip defect with a modified unilateral
Karapandzic flap. The nasal defect was closed with an internal mucosal advancement flap, a cartilage graft from concha of the
ear, and a paramedian forehead flap for external reconstruction.

Bernard-Burow flap

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The Bernard-Burow flap allows reconstruction of larger lower lip defects using advancement of adjacent cheek tissue
(see image below). The method involves transposition of triangular flaps with bases at the level of the commissures
and flipping over of superior triangular flaps to reconstruct the vermilion using buccal mucosa. These earlier methods
transected perioral musculature, which resulted in complete loss of muscle function.

Bernard-Burow flap technique.

The Webster modification of the Bernard-Burow flaps involves locating the triangular flaps along the nasolabial fold
with excision only through skin and subcutaneous tissue to preserve the neuromuscular structures. The modification
also calls for paramental Burow triangles that facilitate the advancement of cheek tissue. Williams introduced a
combination Bernard-Burow and cross-lip flap that addresses the lip tissue discrepancy and allows for replacement
of the philtral subunit in subtotal or total lip reconstruction. Though these methods allow for repair of large centrally
located defects, the disadvantages include loss of motor and sensory function; however, typically, the tightness of the
reconstruction may provide sufficient oral continence.

Perialar crescentic advancement flap

Essentially a modification of the Bernard-Burow flap, the perialar crescentic advancement flap alters the location of
the scar so that it lies within the perialar and nasolabial folds, allowing for less distortion due to tension (see image
below). The technique, used primarily for upper lip repair, involves a curvilinear incision that naturally follows the
nasolabial fold and is generally 3 times larger than the diameter of the defect. It allows for musculocutaneous
advancement of adjacent cheek tissue and may be combined with an Abbe flap to reconstruct central defects, as
well.

A and B. Central upper lip defect reconstruction with the perialar skin crescent method that retains motor and sensory innervation
to the advanced upper lip lateral elements and uses an Abbe flap for philtral reconstruction. Used with permission of WB
Saunders Company.

Depressor anguli oris flap

First described by Tobin, this composite flap consists of muscle, skin, and buccal mucosa and maintains its motor
and sensory innervation in the repair of lateral lower lip defects.[15] Based superiorly, the flap contains the marginal
mandibular branch of the facial nerve (motor) and the mental branch of the trigeminal nerve (sensory). Bilateral flaps
allow for repair of larger subtotal lower lip defects (see image below).

Bilateral depressor anguli oris total lower lip reconstruction. A. Flap design shows the relationships of the incision, muscle, motor
nerve (VII), and sensory nerve (V). B. Flap transposition reorients the depressor anguli oris to restore the lower lip oral sphincter.
Vermilion is created by mucosal advancement. C. Flap insert and direct donor defect closure complete the reconstruction.

Nasolabial flap

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These flaps, originally inferiorly based and rotated around the commissures as described by von Bruns, allow for total
lower lip reconstruction (see image below). The technique uses bilateral nasolabial tissues and rotates them inferiorly
and medially to re-form a complete lower lip. As with other procedures, the buccal mucosa is later used to form the
vermilion. Fujimori and Meyer later describe modifications to this technique that allow for full-thickness island flap
transfer via the angular vessels.[16, 17] Nevertheless, the methods result in denervation with less than satisfactory oral
sphincter function.

von Bruns nasolabial flap technique.

Regional and free flaps

When significant trauma or very large oncologic resections make the use of local tissues impossible, regional or
distant flaps are necessary for lower face and lip reconstruction (see image below). Regional flaps include
submandibular, anterior cervical, forehead, deltopectoral, and sternocleidomastoid musculocutaneous flaps. More
recently, radial forearm free flaps employing microvascular techniques for extensive lower lip defects have been
described.[18] Though insensate and lacking motor functionality, various steps have been described to improve oral
competence. For example, the tendon of the palmaris longus may be attached to the modiolus, thereby acting as a
scaffold for the newly constructed lip.

Left: Excision of large lesion occupying greater than 85% of the upper lip. Center: Selection of regional temporal interpolated flap
based on the temporal artery. In this case, significant involvement of the cheek as well as compromised vasculature secondary to
Mohs surgery did not allow for an advancement flap such as the Karapandzic flap. Right: Postoperative follow-up showing good
aesthetic reconstruction of the ala of the nose, upper and lateral lip, and cheek.

Other options described in the literature include use of the gracilis and anterolateral thigh free flaps for large defects.
Though this discussion is beyond the scope of this article, osteocutaneous radial forearm, fibula, and subscapular
flaps can be used to provide a rigid reconstruction when defects involve bony structures.

Other microvascular developments include replantation of traumatic amputation of the upper or lip. This method also
results in a denervated flap (though neurotization has been shown) and, when selected for appropriate cases, has
been shown to have excellent cosmetic results.

Vermilionectomy and laser ablation

Actinic cheilitis and squamous cell carcinoma in situ (most commonly of the lower lip; see image below) are the
primary indications for vermilionectomy or laser ablation. Two or three passes using a carbon dioxide laser allows for
cosmetically superior removal of confirmed lesions. When indicated, a vermilionectomy is performed using a fusiform
excision in a submucosal plane.

Left: Superficial lower lip cancer. Center: Resection of cancer with margins including the entire segment of the dry and major
segment of the wet portion of the lower lip. Right: Vermilion advancement flap after dissection intraorally to the gingivobuccal
sulcus.

When more fullness is desired, a posterior musculomucosal flap is advanced, and the vermilion border is
reapproximated, making sure no tension exists on the incision line. If incisions must cross the vermilion border, they
should do so at 90 degrees to allow for exact realignment, since even a 1-mm discrepancy along the border is
noticeable at 3 feet (typical conversation distance). Again, proper marking of the vermilion-cutaneous border is
critical. Possible disadvantages to the lip shave technique include loss of lip pout and inward drawing of hair, which
may lead to constant irritation of mucosa.

Secondary intention

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Secondary intention involves the union of 2 granulating surfaces accompanied by suppuration and delayed closure.
With the lips, the risk of scar formation with wound contraction is increased; as such, lesions allowed to heal by
secondary intention must be appropriately selected. Granulation can be allowed after some Mohs surgeries,
superficial defects of the vermilion (eg, after carbon dioxide treatment for actinic cheilitis), and superficial defects of
the cutaneous portion of the lip (especially the lateral upper cutaneous lip adjacent to the alar-cheek junction).
However, the risk of distortion through wound contraction, which increases with the increasing depth or width of the
wound, must be considered.

Full-thickness skin grafts

Skin grafts are not commonly used in lip repair, as the risk of graft failure is higher because of the inability to
immobilize the lips. Furthermore, matching the color and texture of the skin at donor and recipient sites is difficult. In
men, lack of hair on the upper lip may be quite obvious. Inability to find a good match results in an unnatural and
patchy appearance. Philtral defects may even be expanded to include the entire philtrum so that a full-thickness skin
graft may be used in reconstruction with good cosmetic outcomes. Donor locations can be preauricular,
postauricular, supraclavicular, forehead, upper eyelid, and cervical. Less ideal donor sites include hairless groin skin,
dorsum of the foot, wrist flexion crease, and elbow crease.

Postoperative Details
Postoperative care of patients who have undergone lip reconstruction involves appropriate wound care. Oral hygiene
should be maintained with antiseptic mouthwash, a diluted hydrogen peroxide rinse, or both. Cutaneous suture lines
should be cared for in the typical postoperative fashion by routinely cleansing with soap, hydrogen peroxide, or both,
followed by the application of antibiotic ointment.

Excess tension on the repair should be avoided. This includes minimizing talking, minimizing facial expressions, and
consuming only small bites of food. Initially, a liquid or soft food diet may be necessary, while those with extensive
reconstructions may require placement of feeding tubes.

Sutures may be removed as early as 1 week postoperatively. Cross-lip pedicles may be separated at 3 weeks. The
timing of revision or staged (eg, commissureplasty) surgeries varies based on the complexity of the reconstruction.

Follow-up
Perform periodic follow-up care at appropriate intervals to observe the natural return of function and to ensure that
scar contracture does not distort the result. If either complication is noted, appropriate physical therapy and scar
contraction treatment measures may be instituted. If the reconstruction was performed for oncologic purposes, the
follow-up schedule should be tailored to detect potential recurrence.

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's
patient education article Cancer of the Mouth and Throat.

Complications
Early complications
Given the rich vascular supply of the lips, meticulous intraoperative hemostasis is imperative to reduce the risk of
postoperative hematoma formation and hemorrhaging. Conversely, the extensive vascular supply makes flap loss or
necrosis less likely. However, pedicles must be handled with care, as kinking or damage to the vascular supply could
increase the risk of flap loss. This is especially critical when the vascular supply has been compromised by extensive
trauma.

Infection, suture abscess, sialocele, and fistula formation can be minimized with appropriate care of suture lines,
appropriate preoperative oral hygiene, perioperative prophylactic antibiotics, and careful surgical technique.

Late complications
Aesthetic and functional loss can arise from scar formation and wound contracture, which can be prevented with
eversion of the wound edges with subcutaneous sutures and epidermal vertical mattress sutures. They can also be
treated with release and Z-plasty. Another potential complication is hypertrophic scar formation and pincushioning.
This may be treated with intralesional corticosteroid injections but may require revision surgery.

With reconstructions due to oncologic resections, tumor recurrence is a dreaded complication. Hence, negative
margins on pathology must be confirmed prior to reconstruction.

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Many flap techniques lead to insensate lips. This may lead to inadvertent repeated trauma to the flap and stress on
the pedicle by the patient. As such, part of the preoperative and postoperative instructions to the patient should be a
reminder about this possible complication or expected adverse effect.

Outcome and Prognosis

Careful selection of techniques appropriate to the defect, in addition to observing principles of preserving and
restoring motor and sensory function, has substantially improved the results of contemporary reconstructions
compared to those obtained historically. The development and recognition of the innervated composite flaps also has
substantially enhanced outcome as compared with historic procedures, which often cut across valuable
neuromuscular structures and impaired the quality of outcome.

Future and Controversies

Substantial opportunity exists for future contributions to the field, particularly in the case of massive lip loss in which
no perioral tissues are available for reconstruction. The techniques for achieving best functional outcome when
distant tissues must be imported by pedicle or microsurgical technique are incompletely defined at present. Currently,
no generally available method achieves a high-quality aesthetic and functional result in total loss of both upper and
lower lips.

Partial face transplantation (including the lips) is an option that may be considered as an experimental approach to
solving the problem of massive lip loss. Despite the publicity surrounding the few reported cases, numerous practical
problems remain to be solved, including donor shortage and the risks of immunosuppression.

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