Reconstruction NORMAN M. ROWE BARRY ZIDE ‘This chapter reviews the tenets of reconstruction of the lips and provides a classification system that can assist in rendering appropriate care. ‘The recon- structive choices represent those that are reliable and are most likely to fulfill the reconstructive and aesthetic goals specific to each defect. Etiopathogenesis Most malignant neoplasms of the upper lip are basal coll carcinomas, whereas malignancies of the lower ip tend to be squamous cell carcinomas due to ‘chronic exposure to the sun. The nature of the tumor plays a role in overall therapy. Basal cell carcinomas of the upper lip, unless very large, do not metasta- size and thus may not require as large an excisional margin (minimum of 5 mm of normal tissue) as do lower lip tumors, which may metastasize, especially when the commissure is involved. ‘Reconstruction of the lips and commissure is also indicated after thermal and electrieal burns. Pathologic Anatomy Knowledge of the topographic landmarks (Fig. 1) and the underlying muscles, vessels, and nerves of the lips and checks is essential when planning any reconstructive procedure. ‘The lips are approximated through the action of the orbicularis oris muscles. The deep elements of the orbicularis constrict the lips to the level of the alveolar arch, whereas more superficial elements Gncorporating decussating fibers of the buccinator muscle) purse and protrude the lips. ‘The primary ‘upper lip elevator is the levator labii superioris Lip and Oral Commissure Figure 1 * Surcical toporraphic landmarks of tho lips pital columns, 2, pital dimple, 3, Canis bow: 4, white 5, tubercle; 6, commissure; 7, varniion. (From McCarthy AIG fed, Plastic Surgery, vel 3. Phiadoiphia, WE Saunders, 1990, p 2008) muscle, The lateral aspect of the lip is elevated by the zygomaticus major and the levator angularis oris muscles, whereas the risorius and buceinator are accessory muscles. The primary lip depressor is tho deproseor labii inferioris with a socondary effect by the platysma and a somewhat lateval effect pro- vided by the depressor angularis oris, The elevators of the lower lip, as well as the muscle that maintains central lower lip position, are the paired mentalis muscles, which ingert into and give bulk to the central chin pad. It should be noted that the sphine- teric function of the orbicularis oris muscle is inde- pendent of the other accessory muscles of facial expression, ‘The primary motor nerves of the lips are the buceal and marginal mandibular branches of the facial nerve, and sensory innervation is provided primarily by the infraorbital nerve and the mental rami of the trigeminal nerve. The arterial supply is via the superior and infe- rior labial arteries off the external maxillary (facial) 129130 —— Up end Oral Commissure Reconstuetion ‘Mucosa! advancement Vermilion flap Facial artery ‘museulamucosal fap Tongue tap Macical tattoo Vermin thao “Tongue flap Orbiculers oris muscle flag Vermilion defects Commissure defects artery, which is derived from the external carotid artery, Venous drainage is provided by the anterior facial _vein with lymphatic drainage via the sub- mandibular and submental basins. Goals of Reconstruction ‘The aims of lip reconstruction are to achieve + Skin coverage + Oral lining + Vermilion + An adequate stomsl diameter + Sensation + A competent oral sphincter Choices for lip reconstruction, in descending order of preference, are the remaining lip, the opposite lip, the adjacent check, and distant tissue. ‘Vormilion defects can be treated with a variety of techniques (Table 1). Small, isolated vermilion defects are best treated with mucosal advancement (ip shave), which can often be accomplished simply with a V-Y advancement. Disadvantages include Joss of lip pout and a resulting inward pull at tho mucosal-squamous junction. Alternatively, the ‘mucosa can be advanced as a bipedicled flap and the donor site allowed to heal secondarily, a technique that may pull in the lip but usually to a lesser degree, The entire vermilion can also be elevated as 2 unipedicled flap based on the labial artery and used to close isolated vermilion defects. Bilateral laps can be used to close central defects. Pedicled vermilion flaps ean also be used as a staged procedure to repair defects of the opposite lip. If adequate vermilion is not available, a mucosal flap is used, but the color mateh of the mucosa for ‘the neovermilion is less than optimal. A facial artery musculomucosal flap (FAMM) based on the facial artery can also he used and can include mucosa, sub- mucosa, and the buccinator muscle, as well as the facial artery and sts venous plexus, Tt has superior color match with minimal donor site morbidity, but the mucosa tends to be too smooth in texture. Tf labial or buccal mucosa from either lip is not available, a pedicled tongue flap is the next source of donor tissue, although its use results in color and texture mismatch. The flap may be based posteriorly or, less commonly, anteriorly, The fap is usually divided after 2 weeks, Other options include full- thickness grafts of palatal mucosa. These grafts are for minor contour and size defects and must be placed well posterior to the wet-dry line hecause of color mismatch. For total lip defects, including vermilion defects, medical tattooing of a’ microvascular free flap is & technique of last resort. Lower Lip Reconstruction The lower lip has a less obvious central structure than the philtral columns of the upper lip (although itis usually concave below the vermilion), and there- foro it may sustain greater loss without the distor- tion seen in the upper lip. This anatomic finding permits harvesting of larger amounts of tissue for ‘upper lip reconstruction. Lip dofects must be quantified and systematically approached. Lower lip defects are usually divided into thirds, with total lip reconstruction being separate subeategory (Table 2). Defects Less than a Third of the Lower Lip "These defects are usually amenable to primary closure. It is important, to realign the essential lip elemenis to reestablish balance and funetion. When involved, the muscle should be reapproximated Surgical excision should follow a straight wedge, an ‘Meplasty base, or a wedge that extends along the labiomental fold laterally. Wedge excision that includes the muscle is sometimes not necessary if some muscle can be salvaged. Defects between a Third and Two Thirds of the Lower Lip Larger defects can often be treated with a cross lip flap. As much as 2 em of the lateral portion of the upper lip may he harvested with little donor ite morbidity. With this technique, the philtral columns shift slightly to the donor area, The flap is tradi- tionally designed half as wide as the defect and is based on the labial artery. If the artery is damaged, the flap can be transferred on a im mucosalFaBLe 2 Treatment oft Lip and Ora Commissure Reconstruction LESS THAN BETWEEN ONE THIRD (ONE THIRD __AND TWO THIRD’ Tower lip Primary closure Primary closure fects Abbe’s fap Estlander flap Stop reconstruction Upper fip Primary closure. Abbé’ flap defects. Reverse Estlendot flap Cheek advancament, ‘transposition on composite Worsuyangis) flap pedicle. Cross lip flaps ean be safely divided at 9 to 12 days. Defocts of the commissure (see Table 1) or lateral part of the lower lip are well suited for reconstruc. Ran with an Estlander flap. The lateral portion of the upper lip is rotated around the commissure to repair defects ofthe lower lip (Fig. 2). The technique wens be used in conjunction with a lower lip medial Figuro 2.» The Eender fap s based on he ut yprer tp eens around the conmissu to aa deo of he | Ber brsiared ote bb uted in adion to 2 wet Kp medias vancemeant 19 case larger detest, (rom | MeCorhy JG fe Pte Sua, vol 3 Pradepio, WE | Ssuncers, 1880, p 2022) GREATER THAN RECONSTRUCTION Nasolabial and mucosal flaos Cervicofacial flap Microvascular free flap + Keranandzic's fe ‘Webster's Bernaré-Burow “ uojonnsusaay ‘H0N pus PECL Microvascular free feo, advancement for a defect measuring the lower lip. However, the tion can be used for ‘Each horizontal step measures half ‘at at least two to three steps are dofect (Fig. 3). When combined ised for total lip reeon- lower lip defects. the defect so th: required to close the with other methods, it can be ws struction, but the incisions are inevitably fects Greater than Two Thirds of the Lower Lip ‘The Karapandzic flap is 1ip and lateral aspect of the cheel/i rotation flap of the upper ip that maintains Figure 3 + Tho stop method of reconstruction: each Nove ait the. defect, at lags two £9 thro Slope ore required to close the defect. (From Me Pisstic Sugary, vl Fontal step measures 1 3. Phladoipnia, WB Saunders, 1482 —— Up endl Oral Commissure Reconstruction Figure 4 = The Kerapandtle flap maintains a noucovescular pede t Faure rte bos math conta defects involving legs then tho total lower lip (80%) ani not involving te commissure Mctarhy 26 led) Plastic Surgery, vol 8. Phladelia, WE Sounders, 1980, p 2023.) ‘ovo rotation flaps 1 a neurovascular pedicle to preserve sphincter func- tion (Fig, 4). This technique is best used for central defects involving less than the total lower lip (80%) ‘and sparing the commissure, ‘The main disadvan- tage of this technique is the potential for micro- stomia, which requires correction by either = teoth-bone appliance or a commissuroplasty. "The Bernard-Burow cheiloplasty involves full- thicknoss excision of four triangles, two from the check at the level ofthe alar rim and two at the level of tho oral commissure (Fig. 5). The two cheek flaps ‘are advanced and joined at the midline, The mucosa in the labiobuccal suleus is advanced for recon- struction of the vermilion. Important modifications of the flap include (1) excision of only skin and sub- cutaneous tissue lo maintain innervated flaps, (2) positioning of the superior triangular excisions Taterally in the nasolabial fold instead of next to the commissures, and (3) positioning of the inferior tri- ‘angular incision more medially near the menton. ‘The technique has been further modified by placing the triangular areas of excision at the upper lip vermilion. Total Lower Lip Reconstruction ‘Total lower lip defects have historically been managed with local and regional flaps, with mixed resulis. Microsurgical tissue transfer bas, however, ‘emerged as the preferred technique. The most. com- monly used flap is the radial forearm free flap, a thin pliable flap that can be folded on itself to provide both lip lining and cover. It can be trans- ferred with the palmaris longus tendon, which when suspended to the maxilla or, more commonly, the zygoma, can act asa sling to provide oral com- petence, Microvascular anastomoses are typically performed to the facial, lingual, or transverse cervi- tal artery, along with the facial or external jugular vein. Secondary refinements include tattooing of the yermilion and hair transplantation to recreate a beard.Mobster mosticaton ofthe Sereard-Burow chelopasiyinvalves fullthickness excision of Jes, tv from the cheek at tho level ofthe aar rim and two a tn fovl of the oval cornmissre “Tho two chesk Hlps are edvancad and joined atthe mine. The mucasa is mobilzed to form a vermilon From MeCarty JG led: Paste Surgery, vol 3 Priadeptis, WE Sauncers, 1980, 9 2020) Lip and Orel Commissure Reconstruction —~ 183 The Upper Lip ‘The concept of the aesthetic subunit principle ean be applied to lip reconstruction by subdividing the upper lip into aesthetic units. The lateral subunits are composed of the philiral column, nostril sill, alar base, and the nasolabial crease, whereas ‘each medial subunit consists of half of the philtrum. The most aesthetically pleasing donor tissue for upper lip reconstruction is the lower lip, that is, a cross lip flap, which can often spontaneously reinnervate. Philtral Defects. Philtral defects aro bost divided into defects greater than or less than 50%, Defects less than 50% can generally be closed primarily to provide a narrow, albeit satisfactory, philtram. If the defect is only cutaneous, a full-thickness skin graft can give excel- lent results, Philtral defects greater than 50%, especially if the vermilion is involved, are well suited to an Abbé flap reconstruction. Care should be taken ta harvest the Abbé flap from the center of the lower lip because it results in a more favorable scar. This lower lip sear often benefits from a small Z-plasty. Defects Less than a Third of the Upper Lip Direct primary closure with meticulous attention to anatomic alignment is the procedure of choice (Fig. 6). Care should be taken because the vermilion tapers laterally. Small vermilionplasties may be necessary {0 equalize the height of the vermilion on each side. Defects between a Third and Two Thirds of the Upper Lip For defects involving @ third of the upper lip and central in location, an Abbé or cross lip flap remains the best option. A similarly sizod defect more Iater- ally situated ean be treated with perialar erescentic excisions and cheek advancement (Webster's tech- nique), A larger, superiorly based nasolabial flap can also be used; however, thoso flaps require secondary debolking. Defects closer to two thirds of the upper lip and central in location can be treated with an Abbé flap in addition to bilateral cheek advancement. The Abbé flap should be placed centrally to mimic the philtrum, As an alternative, bilateral Yotsuyanagi flaps (1998) based on the angular arteries can recon- struct two-third defects of the upper lip. This flap184 — Lip and Ora! Commissure Reconstuction fi, Correct a Figure 6 + The white rol should bo incisad at 99 degrees te provont postoperative notching, (rem MeCarhy J led: Plastic Sugery, vol 3. Phiadelpia, WB Saunders, 1980, 6 2014) can be used to replace the entire lateral subunit of the upper lip. For more lateral defects of the upper lip located near the commissure, reverse Estlander flaps also provide excellent results, Reconstruction of Hair-Bearing Tissue In male patients, the results of lip reconstruction can be disappointing because of either absence of hair or, as in the case of cross lip flaps, hair growth in the opposite direction. For patients with absent, hair growth, hair transplantation can be a satisfac- tory option. Even if the hair is shaved, the stubble hides sears and adds natural texture to the skin. The entire upper lip can be resurfaced with a hair-bearing microvascular free flap that can be based on the superficial temporal vessels. Tt pro- vides beard and bulk to the upper lip, albeit exces- sive in volume. Pearls and Pitfalls + Lower lip support is essential to prevent drool ing. A static or dynamic sling may be created to accomplish this task. * The upper lip hangs like a window shade and is less important for oral hygiene. * Vermilion reconstruction must result in a sat- istactory color and texture match, ‘SUGGESTED READINGS Burgot GC, Moniek FJ: Aesthetic restoration of one-half the upper lip. Plast Reconstr Surg 7&58S, 1056, Converse Jil (ed): Kazantian and Converses Surgical treatment ‘of Facial Injries, vol 2, Sed ed. Baltimore, Williams de Wilkins, 1974, pp 949-996 Karapandtic M: Reconstruction of lip defects by local arterial ‘aps. Br J Plast Surg 27:93, 1974 Yotsuyanagi T, Yokori K, Urushidate 8, Sawada ¥: Functional and ‘esthetic reconstruction using a nasolabisl orbicularis oris ‘myecutaneous flap for large defects of the upper lip. Reconstr Surg 101-1624-1629, 1998, {ide BW: Deformitios ef the lips and checks. In McCarthy JG (ed ‘Plastic Surgery, vol 3. Philadelphia, Saunders, 1990, pp 2008- 2068,