Practical Plastic Surgery

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Figure 33.11. Full-thickness excisions of the lower lip. Defects up to one-third of the lower lip can be excised and closed primarily. Lateral defects or larger central defects may require partial-thickness wedge excisions from the labiomental fold (A-D).

If the commissure is involved, both the Karapandzic and Estlander flaps may be used; however, the Karapandzic is probably the better choice because it is better at maintaining oral competence. If the commissure is not involved, the Karapandzic or the Abbe flaps may be used. The Abbe flap is insensate; however it does provide a better cosmetic result.

In the case of larger lower lip defects (more than two-thirds of the lip), if there is

33sufficient adjacent cheek tissue, the surgeon may employ the Karapandzic (Fig. 33.13) or the Bernard-Burow’s (Fig. 33.16) techniques. The Karapandzic flap may be used for defects up to three-fourths of the lower lip width whereas, the Bernard-Burow’s can be used to reconstruct the entire lower lip. If enough cheek tissue is not available, distant or free flaps may be used for reconstruction.

Abbe Flap

Application: Upper and lower lip reconstruction Defect size: One-third to two-thirds of the lip width Donor site: Opposite lip

Blood supply: Medial or lateral labial artery

Comments: Ideal for reconstruction of the philtrum; often used with other methods for reconstruction of large defects; insensate.

This flap is often the first option in reconstruction of medium-sized upper and lower lip defects that do not involve the commissures. A full-thickness mucomusculocutaneous flap based on the medial or lateral labial artery is transposed from the opposite lip into the defect (Fig. 33.12). It may be used alone or in conjunction with other reconstructive measures such as perialar crescentic excisions. Typically done in two stages, the Abbe flap is set in place in the first stage and divided 14-21 days later in a second-stage procedure. One-fourth to one-third of the lower lip can be taken without significant loss of function. Studies have demonstrated evidence of muscle function in the transferred flap at its recipient site. Although this technique can be utilized for either lip, it is best for upper lip reconstruction because the lower lip has greater laxity and can contribute more tissue without disturbing a major central structure. Furthermore, the Abbe flap can be used to replace the entire philtral subunit.

The Abbe flap does not recruit new lip tissue; it simply transplants tissue from the lower (or upper) lip to its counterpart. Thus, the size of the oral aperture remains the same as if the lip defect is closed primarily. The goal is to recruit enough unaffected lip tissue to balance the discrepancy in lip lengths after a medium-sized excision.

A wedge-shaped pedicle flap is harvested from the opposite lip. At minimum the width of the flap should be one-half the size of the defect. The height of the flap should match the height of the defect, and the flap should be designed with sufficient tissue to permit a 180˚ arc of rotation into the defect. Because contralateral labial arteries form robust anastomotic connections in the midline, the flap can be based medially or laterally. Starting at the apex, an incision is made through skin, muscle and mucosa and is extended toward the vermilion border. As the vermilion border is approached, careful scissor dissection will avoid injury to the labial artery which can be found between the deep layers of orbicularis oris muscle and the mucosa approximately at the level of the vermilion border. Initial division of the nonpedicle side of the flap can locate the position of the labial artery and aid in its identification on the pedicle side. The pedicle should be at least 1 cm in width in order to maintain adequate venous drainage. The flap is rotated upon its pedicle, and a stay suture is placed after exact approximation of the vermilion border. The flap is secured with a three-layer closure approximating mucosa, muscle and skin, and the donor site is closed primarily or with the aid of crescentic excisions (labiomental or perialar depending on the donor site). The pedicle is usually divided 14-21 days later.

The most common complication is flap loss due to inadequate blood supply. Careful dissecting technique, an adequate soft tissue envelope around the artery,

and ample flap width minimize flap ischemia. Careful attention should be paid to 33 the accurate approximation of the vermilion border of both donor and recipient

sites before and after pedicle division. Since the lower lip vermilion can be significantly thicker than that of the upper lip, resection of the vermilion can be undertaken in a secondary procedure for improved aesthetic result. Excessive pulling while

C D

E

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Figure 33.12. The Abbe flap. A lower lip lesion is excised and reconstructed with an Abbe flap from the upper lip. Perialar crescentic excision helps to close the donor defect. See text for full details.

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D

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Figure 33.13. Lower lip reconstruction with the Karapandzic flap. A central lower lip defect is reconstructed using bilateral Karpandzic flaps. Avoiding deep dissection laterally helps to properly identify and avoid injury to the neuromotor and blood supply (C). See text for details.

raising the flap may result in the removal of excessive muscle from the donor lip leaving a notched defect on the closure.

Karapandzic Flap

Application: Upper and lower lip reconstruction Defect size: One-third to two-thirds of lip width Donor site: Cheek and lip advancement

Blood supply: Preserved labial arteries

Comments: A sensate and functional flap with poor aesthetic results; oral competence preserved at the expense of microstomia; ideal for reconstruction of large defects in the midline.

This is a sensate axial musculomucocutaneous flap based upon the superior and inferior labial arteries (Figs. 33.13, 33.14). It provides good oral competence and is useful for closing one-half to two-third defects of the upper lip and defects up to three-quarters of the lower lip. It is ideal in situations where no new lip tissue is required in central defects or lateral defects that involve the commissure. The blood supply is more robust than the Abbe flap, but the aesthetic outcome is inferior. Because new lip tissue is not recruited, microstomia may result after closure of larger defects.

A semicircular incision of adequate length to close the defect is extended from the defect toward the commissures. The skin incisions are made with a scalpel, and careful mobilization of subcutaneous tissues is achieved using electrocautery. By spreading the orbicularis oris muscle longitudinally along the line of the incision, or on a plane parallel to the fibers, separation from the adjacent musculature is attained while maintaining the nerves and vessels intact. Laterally, at the level of the commissures, the skin is incised only down to subcutaneous tissue. Careful dissection is needed to identify and preserve the labial arteries and buccal nerve branches. The flaps are rotated medially to close the defect, and a stay suture is placed after meticulous reapproximation of the vermilion border. The defect is closed in three-layers approximating mucosa, muscle and skin. Complications of this technique include microstomia and visible scarring. Secondary revision of the commissure is often indicated to prevent oral crippling in feeding, hygiene maintenance and denture placement. The circumoral scarring after this procedure is more noticeable because the scars do not lie in natural skin creases.

Figure 33.14. Upper lip reconstruction with the Karapandzic flap. Similar to the lower lip, the neuromotor and blood supply should be identified and preserved.

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The Estlander Flap

Application: Upper and lower lip reconstruction Defect size: One-third to two-thirds of lip width Donor site: Opposite lip

Blood supply: Medial labial artery

Comments: Insensate but oral competence is preserved; one-step procedure that results in a rounded neo-commissure; frequently requires revision.

The Estlander flap is similar to the Abbe lip switch flap, but it is modified for use around the corner of the mouth (Fig. 33.15). It is a one-step procedure but sometimes requires future revision to improve the commissure. Continuity of the orbicularis oris ensures adequate oral competence; however, the modiolus functional region is distorted leading to altered oral animation. This alteration is compounded by a rounded neo-commissure which lacks definition. The flap is designed to be about half the width of the defect to cover. It is based on the opposite lateral lip. The vascular pedicle is within the pivoting point, supplied by the contralateral labial artery. It is rotated into the defect, and the donor site is closed primarily.

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Figure 33.15. The Estlander flap. Similar to the Abbe flap, this flap is better suited for defects close to or involving the commissure.

Figure 33.16. Bernard- A Burow’s technique for reconstruction of large lower lip defects. Partial-thick- ness Burow’s excisions laterally in the cheek and labiomental fold help to close the defect (A). The neo-vermilion is constructed using buccal mu-

cosa (B).

B

Bernard-Burow’s Technique

Application: Lower lip (mainly) and upper lip reconstruction Defect size: Two-thirds to full lip width

Donor site: Cheek

Blood supply: Labial and facial artery branches

Comments: Insensate but oral competence is preserved; one-step procedure that results in a rounded neo-commissure; frequently needs revision.

Although most commonly used in lower lip reconstruction, this technique can be useful in large defects of the upper lip as well. This is an advancement flap utilizing the remaining lip tissue and the cheeks for closure of the defect. For closure of very large defects this technique can be combined with an Abbe flap (from the opposite lip).

Closure technique is different for upper lip and lower lip defects (Fig. 33.17). For the upper lip, a perialar excision of skin and subcutaneous tissue is performed in the shape of a triangle (or crescent). Burow’s triangles are also excised lateral to the lower

33lip. Adequate mobilization of the flaps is achieved by making bilateral incisions in the gingivobuccal sulci being careful to leave sufficient gingival mucosa for subsequent closure of the mucosal layer. The tissue is advanced medially to close the defect and is sutured in three layers. The skin and subcutaneous tissue perialar incisions are closed in a single layer. Perialar crescentic excisions are more aesthetically pleasing but may not provide enough mobility. The vermilion is reconstructed using cheek

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Figure 33.17. Bernard-Burow’s technique for reconstruction of large upper lip defects. Partial-thickness triangular Burow’s excisions in the perialar and commissure area help to advance the cheek tissue medially (A). The vermilion is reconstructed using buccal mucosa (C). Additional lip tissue can be recruited from a lower lip Abbe flap (B) if needed.

buccal mucosa. The resulting insensate, nonfunctional upper lip does not usually lead to oral incompetence. This is because gravity charges the lower lip with the responsibility of oral competence. The most common complication of this procedure is microstomia, which can sometimes be improved by combining this technique with an Abbe flap. This technique can also cause some excessive tension on the upper lip and cheek resulting in distortion of the nasolabial fold.

In the Bernard-Burow’s technique for the lower lip, four Burow’s triangles are excised lateral to the nasolabial folds and in the labiomental groove to allow relief space for advancement of bilateral lower cheek flaps medially to fill the defect. Exci-

sion of these triangles avoids a typical tight lower lip and excess upper lip, and can 33 vary in size as long as closure is achieved without tension. A minor modification in

the originally proposed procedure preserves innervation and function by avoiding deep dissection through perioral muscles. Although a bulkier upper lip and poor anterior projection at the vermilion is common, this procedure remains a suitable option for reconstructing very large defects.

Free Flaps

The emergence of microvascular free tissue transfers in the mid-1980s has considerably influenced methods used to repair massive facial defects involving the lips. Free flaps are often used in conjunction with an advancement flap from the remaining lip or adjacent cheek in order to meet the ideal reconstructive goals. Several methods of reconstruction using a wide variety of potential donor sites in the head and neck have been described. The radial forearm-palmaris longus tendon free flap has proven to be one of the preferred techniques for repairing substantial lip defects. A sensory component can be added by incorporating the lateral antebrachial cutaneous nerve. Recently, Lengele described a prefabricated gracilis muscle free flap for the lower lip that simultaneously reconstructs the labial muscular sling with mucosa, tendinous suspension and a skin cover. As with other reconstructive options, the selected method of free tissue transfer must address the soft tissue needs of each specific defect and the expressed goals of the individual patient.

Pearls and Pitfalls

Every lip reconstruction must be evaluated on a case by case basis. The lips of older patients tend to be more conducive to primary closure due to greater laxity. Reconstruction of facial defects in male patients may require the use of hair-bearing tissue. For women, when reconstructing the vermilion it is preferable to use tissue that will accept lipstick adequately, since application of lipstick can be helpful in camouflaging vermilion scars. Having considered the unique needs of each patient, the surgeon’s options can be divided into three main categories: those that employ remaining lip tissue including primary closure; methods using local flaps (such as from the cheek); and others techniques involving distant flaps.

When performing lip reconstruction, the surgeon should adhere to a few key principles. Place incisions in relaxed skin tension lines whenever possible. In cases involving the vermilion border, mark the transition point before application of local anesthesia. Always align the markings of the white roll as the first step in closure. Finally, use deep absorbable sutures to oppose orbicularis oris fibers so that the closure scar does not widen or indent.

Suggested Reading

1.Behmand RA, Rees RS. Reconstructive lip surgery. In: Achauer BM, Eriksson E, Guyuron B, Coleman IIIrd JJ, Russell RC, Vander Kolk C, eds. Plastic Surgery: Indications, Operations, and Outcomes. St. Louis: CV Mosby, 2000:1193-1209.

2.Kroll SS. Repair of lip defects with the Abbe and Estlander flaps. In: Evans GRD, ed. Operative Plastic Surgery. New York: McGraw-Hill, 2000:289-297.

3.Kroll SS. Repair of lip defects with the Karapandzic flap. In: Evans GRD, ed. Operative Plastic Surgery. New York: McGraw-Hill, 2000:298-307.

4.Kroll SS. Staged sequential flap reconstruction for large lower lip defects. Plast Reconstr Surg 1991; 88(4):620-625.

5.Pribaz J, Stephens W, Crespo L et al. A new introral flap: Facial artery musculomucosal (FAMM) flap. Plast Reconstr Surg 1992; 90(3):421-425.

6.Spira M, Hardy SB. Vermilionectomy: review of cases with variations in technique.

33Plast Reconstr Surg 1964; 33:39-46.

7.Wechselberger G, Gurunluoglu, Bauer T et al. Functional lower lip reconstruction with bilateral cheek advancement flaps: Revisitation of Webster method with a minor modification in the technique. Aesthetic Plast Surg 2002; 26(6):423-428.

8.Zide BM. Deformities of the lips and cheeks. In: McCarthy JG, ed. Plastic Surgery. New York: WB Saunders Co., 1990.