Pedicle Flaps in Reconstruction

of the Lip
Shan X. Baker, M . D . , F.A.C.S." and Charles J . Krause, M . D . , F.A.C.S.?

Because of the key role played by the lips in made not to extend the incision beyond the
deglutition, in formation of speech, and in fa- mental crease, since to do so creates an un-

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cial expressions, their reconstruction offers
unique challenges to the surgeon. Few other
sites require attention to such precise details
of form and function.
Surgical procedures to reconstitute the lip,
whether the defect was caused by the excision
or the traumatic loss of tissue, may be classi-
fied as follows:' (1)those that use remaining
lip tissue, (2) those that borrow tissue from
the opposite lip, (3) those that use adjacent
tissue, and (4) those that use distant flaps.
The algorithms displayed in Tables 1 and 2
may be helpful in the cognitive process of
managing the problem of lip reconstruction.
This method categorizes the size of lip defects
into those of less than one-half the width of
the lip, those between one-half and two-thirds
of the lip, and defects that are greater than
two-thirds of the entire lip width.
DEFECTS LESS THAN ONE-HALF OF THE LIP
Defects of less than one-half of the lip width
can usually be managed by primary closure.
The V-shaped excision in its simplest form is
usually adequate for primary closure, though
modifications to include a W-plasty or lateral
advancement flaps may be required when the
defect base is broad. Every attempt should be
sightly pointed chin. Primary closure should
be in three layers-mucosa, muscle, and
skin-taking care to perform a precise ap-
proximation of the "white line" at the vermi-
lion border on either side of the defect.
Primary closure of defects in the midline of
the upper lip can be facilitated by excising a
crescent of cheek skin in the perialar region
(Fig. I)." This method is similar to that de-
scribed by Dieffenbach and Webster.' Peri-
alar skin excision allows advancement of the
remaining lip segments medially and lessens
the wound tension after primary closure.
Vermilion mucosal defects may be recon-
structed with simple mucosal advancement
flaps from inside the mouth. When vermilion
substance has been lost in addition to mu-
cosa, a flap of muscle and mucosa from the
anterior tongue may be used. A mucosal flap
from the ventral surface of anterior tongue is
initially attached to the skin at the vermilion-
cutaneous border. Ten to twenty days later,
the pedicle is transected at the tongue tip, re-
taining muscle for bulk and mucosa for ver-
milion reconstruction. Though this technique
does not result in discernable limitation of
tongue mobility, the newly created vermilion
mucosa retains a somewhat pebbled surface,
reminiscent of the tongue surface.

"Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of

Michigan, Ann Arbor, Michigan
:Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, University
of Michigan, Ann Arbor, Michigan
Thieme-Stratton Inc., Facial Plastic Surgery 111,1983
FACIAL PLASTIC SURGERY V o l u m e 1, N u m b e r 1, 1983

Table 1.

Lower l i defect
~

Defect
I
<l/~ of lip to
I
Z/jot lip

Close primarily Full thickness Adequate adjacent lnadequate adjacent

oedicled flao from cheek tissue cheek tissue
upper lip or
karapandzic flap

Does defect involve Midline defect Regional flap

I
oral commissure distant flap
revascularized flap

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Estlander flap Abb6 flap Close with Full thickness
advancement f l a ~ svia nasolabial
method of ~ u r i o w , transpositional
Bernard, or Webster flap

Table 2.

Upper lip defect

I
Defect <l/2 of lio l/2 to 2/3 of lip >~/3 df lip

Midline

1
Perialar cheek
excisions and
primary closure
by advancement
Latr I
Primary
closure
Full thickness pedicled
flapKarapandzic
from lower flap
lip or

Does defect involve

yes/I commissu~o
Adequate adjacent
e

Midline defect
kt i s s u e

Lateral defect
Inadequate adjacent
cheekiissue

Temporal forehead flap

regional flap
revascularized flap

Estlander flap Abbe flap close with Full thickness

advancement flaps nasolabial
via method of transpositional
Dieffenbach and flap
Webster
 PEDICLE FLAPS IN RECONSTRUCTION OF THE LIP-Baker,
Figure 1. Primary closure
of defects in the midline of the
upper lip can be facilitated by
excising a crescent of cheek
skin in the perialar region. If
wound closure is under ex-
cessive tension, an Abbk flap
may be added in the midline.
(Cancer of the Head and
Neck, Suen JY, Myers EN,
1981.)
DEFECTS ONE-HALF TO TWO-THIRDS OF
THE LIP
Reconstruction of defects consisting of from
one-half to two-thirds of the lip width usually
requires lip augmentation procedures. Clo-
sure can be most readily achieved by a full
thickness pedicle flap from the opposite lip
(lip-switch flaps) or from the adjacent cheek.
The Karapandzic flap5may also be effective in
closing medium-sized defects of the lip, and
in some instances may provide better func-
tional results than other static flaps. This
technique consists of circumoral incisions
through skin and subcutaneous tissue, en-
compassing the remaining portions of upper
and lower lips. The orbicularis oris is mobi-
lized and remains pedicled bilaterally on the
superior and inferior labial arteries. Ade-
quate mobilization enables primary closure of
the defect by rotating portions of the unoper-
ated lip into the defect.
AbbC-Estlander Flaps
Local flaps are preferable to regional flaps
for closing defects of less than two-thirds of
the lip width because of their close skin color
and texture match, and the availability of mu-
cous membrane. Defects located medially are
best closed using an Abbe flap consisting of a
full thickness flap from the opposite lip pedi-
Krause
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cled on the vermilion border and containing
the labial artery (Fig. 2).6Estlander's original
operation was devised for closure of lower lip
defects near the commissure of the mouth.7
Since the original description of the Abbe and
Estlander flaps, the operations have been
modified in many ways to accommodate
surgical defects anywhere in the lower or
upper lip.
The Abbe and Estlander flaps should be
constructed so that the height of the flap
equals the height of the defect. The width of
the flap should be approximately one-half that
of the defect to be reconstructed, so that the
two lips are reduced in width proportion-
ately. The pedicle should be made narrow to
facilitate rotation, but care must be taken not
to injure the labial artery (see Fig. 2). The sec-
ondary defect should be closed in three lay-
ers. Accurate approximation of the vermilion
border of the flap with that of the defect pre-
vents a notched appearance.
The superiorly based Estlander flap may be
modified from its original description by de-
signing the flap so that it lies within the na-
solabial fold (Fig. 3). This provides better scar
camouflage of the donor site and at the same
time allows easy rotation of the flap into the
lower lip defect. Oral commissure distortion
is caused by the Estlander flap. This distor-
tion, or microstomia, may be corrected with a
secondary commissuroplasty when desired.
The pedicle of the Abbe flap crosses the oral 63
 FACIAL PLASTIC SURGERY Volume 1, Number 1, 1983
a -..
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stoma and may be severed in two to three
weeks. During this time, the patient is main-
tained on a liquid or soft diet that does not
require excessive chewing. It is essential that
precise approximation of the vermilion bor-
der be assured at the time of pedicle sever-
ance.
DEFECTS GREATER THAN TWO-THIRDS OF
THE LIP
Defects greater than two-thirds of the entire
lip, and some smaller lateral defects, are best
reconstructed using adjacent cheek flaps in the
form of advancement or transposition flaps.
Massive or total lip defects are best recon-
structed using regional or distant flaps or re-
vascularized flaps.
Figure 3. The superiorly based Estlander flap may be modified from its original description by designing the flap
64 so that it lies within the nasolabial fold. (Cancer of the Head and Neck, Suen JY, Myers EN, 1981.)
Figure 2. A, Defect of up-
j-3 per Ilp.
B, Defect reconstructed with
Abbe flap from lower lip. It is
essential that precise approxi-
'. mation of the vermilion bor-
der be assured at the time of
pedicle severance.
>--
4
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Adjacent Cheek Flaps
Large defects of the upper lip may be recon-
structed by excising crescent-shaped perialer
cheek tissue and advancing flaps medially. If
the wound closure is too tight, an Abbe flap
may be added in the midline (see Fig. 1).
Similarly, midline lower lip defects may be
closed by full thickness advancement flaps as
described by Burrow, Bernard, May, and
W e b ~ t e r . ~These
" techniques require exci-
sions of additional triangles in the nasolabial
region to allow advancement of the cheek flaps
(Fig. 4). The triangular excision should follow
the lines of the nasolabial fold and should in-
clude only skin and subcutaneous tissues. The
underlying muscle is mobilized to form a new
commissure. The mucous membrane is sepa-
rated from the muscle and advanced outward
 PEDICLE FLAPS IN RECONSTRUCTION OF THE LIP-Baker, Krause

Figure 4. Technique for

closure of midline lower lip
defects with advancement
flaps from the adjacent cheek.
Additional triangles in the na-
solabial region are excised to
enable advancement. (Cancer
of the Head and Neck, Suen
JY, Myers EN, 1981).

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Figure 5. Nasolabial trans-
position flap used to recon-
struct upper lip defect. A, De-
fect of upper lip. B, Flap
designed.

Figure 5, Continued. C,
F l a ~trans~osed.D. Six months
postoperative.
 FACIAL PLASTIC SURGERY Volume 1, Number 1, 1983
to provide a vermilion border. Incisions are
made in the gingival buccal sulcus, as far back
as the last molar tooth if necessary, to allow
proper approximation of the remaining seg-
ments without tension.
Nasolabial transposition flaps based inferi-
orly on the facial artery are useful in recon-
structing lip defects as large as three-fourths
of the width of the lip (Fig. 5). Matched full
thickness flaps can be created in the area of
the nasolabial folds, with a Z-plasty at their
base to increase the amount of advancement.
The flaps are advanced into the lip defect and
sutured in three layers. Mucosa from the flaps
can be advanced to create a new vermilion, or
a tongue flap may be required.
Distant Flaps
Adjacent cheek tissue may not be applica-
ble or sufficient for reconstruction of very large
or total defects of the lip. In such cases, re-
gional flaps may be used for reconstruction.
Excisions of the lower lip, chin, and anterior
section of the mandible for carcinoma often
require such flaps for reconstruction.
The temporal forehead flap may be used for
upper lip reconstruction, but the unsightly
secondary deformity precludes its common
use. The temporal forehead flap may be lined
with a split thickness skin or mucosa graft. In
males, hair-bearing scalp may be incorpo-
rated to provide hair growth for scar camou-
flage.
In the past, the medially based deltopec-
toral or Bakamjian flap12 has been the most
commonly used regional flap for reconstruc-
tion of the lower lip (Fig. 6). The deltopectoral
flap may be lined with a skin or mucosal graft.
The flap may also be turned on itself to supply
the inner lining of the reconstructed lip.
More recently, the pectoralis major myocu-
taneous flap has been used for lip reconstruc-
tion following extensive ablative surgery for
malignancy of the anterior floor of the mouth
involving large portions of the lip or skin of
the chin (Fig. 7). Ariyan was the first to de-
scribe the pectoralis myocutaneous flap and
reported its use in the reconstruction of large
facial defects.13Since the introduction of this
flap, it has gained wide popularity among
head and neck reconstructive surgeons. The
pectoralis major myocutaneous flap has the
advantage of being an axial myocutaneous flap
that may be elevated as a strip of muscle and
66 an attached segment of overlying skin for a
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Figure 6. Medially-based deltopectoral flaps may be
used to reconstruct large defects of the upper or lower
lip. The flap was lined with a split thickness skin graft to
provide an inner lining of the reconstructed lip. A, Re-
current carcinoma of the upper lip.
one-stage reconstruction of the lip. A portion
of the flap may be turned on itself to provide
tissue for the inner aspect of the lips andlor
the anterior floor of the mouth. The flap has
sufficient bulk to provide structural support
when a mandibulectomy is necessary for tu-
mor exenteration.
When large segments of the lower lip have
been resected, oral competence requires ade-
quate support for the reconstructed lip.
Whenever possible, orbicularis oris muscle
flaps should be advanced, with or without
overlying skin and mucosa, into the recon-
structed lip segment. If this is not possible, it
may be necessary to sling the lower lip with a
fascia lata graft from upper lip muscle on
either side.
When the anterior mandibular arch has
been resected or destroyed, oral competence
requires support of the lower lip. This is best
accomplished by reconstructing the mandi-
bular arch, though sometimes soft tissue mass
alone (as with a pectoralis major myocuta-
neous flap) will provide sufficient rigidity to
allow oral competence. The authors prefer to
use an iliac crest bone graft to restore the
mandibular arch, in a separate stage after
achieving soft tissue healing of the oral cav-
ity. Stabilization of the mandibular segments
 PEDICLE FLAPS IN RECONSTRUCTION OF THE LIP-Baker, Krause

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1
Figure 6, Continued. B, Defect following surgical resection. C, Medially based deltopectoral flap.

is provided by an acrylic biphase appliance

and the graft itself using figure-of-8 wires.
More recently, composite osteomyocutaneous
flaps have been developed to provide vascu-
larized bone grafts for mandibular recon-
struction. Various methods of design and use
of such flaps have been suggested, with the
most effective techniques yet to emerge.
Because of their important function as the
threshold to the oral cavity and the focus of
facial expression, the lips play a crucial role in
life. Reconstruction of these structures, there-
fore, requires skill and attention to precise
detail, as the reconstructive surgeon restores
form and function. Some of the important
principles necessary to correct such defects
successfully have been discussed here.
Figure 6, Contin1ued. D, Nine months postoperative.

Figure 7. A, Extensive carcinoma of the anterior floor of the mouth with involvement of the skin of the lower lip
and chin.
B, Area of skin resected in addition to the entire anterior mandibular arch.
 FACIAL PLASTIC SURGERY Volume 1, Number 1, 1983
C .I.
Figure 7, Continued. C, Surgical defect with preser-
vation of the vermilion.
REFERENCES
Kazanjian VH, Converse JM: The Surgical Treatment of Fa-
cial Injuries, 2nd ed. Baltimore: Williams & Wilkins, 1959
Baker SR: Lip reconstruction. In Holt GR, Gates GA, Mat-
tox DE, Eds: Decision Making in Otolaryngology. Burling-
ton, Ontario: BC Decker, Inc, 1983
Baker SR, Krause CJ: Cancer of the lip. In Sven JY, Myers
EN, Eds: Cancer of the Head and Neck. New York: Chur-
chill Livingstone, 1981
Webster JP: Crescentric peri-alar cheek excision for upper
lip flap advancement with a short history of upper lip re-
pair. Plast Reconstr Surg 16:434,1955
Karapandzic M: Reconstruction of lip defects by local ar-
terial flaps. Br J Plast Surg 27:93, 1974
Abbe R: A new plastic operation for the relief of deform-
ity due to double hairlip. Med Rec 53:477,1898
Estlander JA: Eine Methode aus der einen Lippe Sub-
stanzverluste der anderen zu Erstegen. Arch Klin Chir
14:622, 1872
Burrow CA: Betschreibung einer neuer Transplantations-
Methode (Methode der Seitlichen Dreiecke) zum Wied-
erersatz verlorengegangener theile des geischts. Berlin:
Nauck, 1855
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Bernard C: Cancer de la levre inferieure opere par un
procede nouveau. Bull Soc Chir 3:357,1853
May H: Reconstructive and Reparative Surgery, 2nd ed.
Philadelphia: FA Davis, 1960
Webster RC, Coffey RJ, Kelleher RE: Total and partial re-
construction of the lower lip with inverted muscle bearing
flaps. Plast Reconstr Surg 25:360, 1960
Bakamjian W: A two-stage method for pharyngoesopha-
geal reconstruction with a primary pectoral skin flap. Plast
Reconstr Surg 36:173, 1965
Ariyan S, Krizek TJ: Reconstruction after resection of head
I and neck cancer. Cine Clinics, Clinical Congress of the
American College of Surgeons, Dallas, Texas, October 1977
Figure 7, Continued. D and
E, Reconstructed lip by a pec-
toralis major myocutaneous
flap. The mandibular arch was
reconstructed with a bone
graft from the iliac crest.