Mucosal Advancement Flaps

The most favored method of restoration of the vermilion is anterior advancement of the mucosa that lines the inner surface of the lip (Fig. 19-4). A mucosal flap is created by undermining beneath the labial mucosa in a plane that is deep to the minor salivary glands and superficial to the posterior surface of the orbicularis oris. If necessary, dissection may extend the entire vertical height of the lip to the apex of the gingivolabial sulcus. The flap is advanced forward over the free margin of the lip to the desired point, which is usually the anterior vermilion line. Because the vermilion is actually a modified mucosal surface, reconstruction with labial mucosa offers a close substitute. In most cases, a slight prominence of the soft tissue at the mucocutaneous junction is considered to be a favorable feature of lip contour. However, it is difficult to restore this fullness in areas reconstructed by mucosal advancement flaps. This may be related to contraction of the mucosal flap as the wound heals. There is less flap retraction when dissection of the flap requires limited undermining of the mucosa of the lip.

Reconstruction of the vermilion with a mucosal advancement flap may produce a pleasing aesthetic restoration of either lip. However, several difficulties may be encountered with this technique. An early difficulty is restoration of accurate positioning of the anterior vermilion line when there is an adjacent skin defect at the lip margin. In such instances, wound contraction inherent to wound maturation may influence the position of the vermilion line. If distortion or displacement of the anterior vermilion line occurs, repositioning of the reconstructed line may be possible with revision surgery. Another difficulty encountered with mucosal advancement flaps is that the flaps tend to display a slightly deeper red color than that of the natural vermilion, especially in those with more “weathered” lips. In some cases, the darker red color can impart a slightly feminine appearance to the reconstructed vermilion, particularly when the flap covers a large surface area (Fig. 19-5).

Because greater scar contraction occurs when mucosal advancement flaps cover a large surface area, eventual wound contraction may cause the body of the lip to assume a more rounded appearance. As the vermilion line is pulled posteriorly by wound contraction, adjacent whisker hairs may begin to turn up slightly and become a source of irritation to the opposing lip when the mouth is closed. This may require repositioning of the anterior vermilion line of the reconstructed lip.

Whereas a majority of patients regain some degree of touch, pain, and temperature sensation to the reconstructed vermilion within a matter of several months after the employment of mucosal advancement flaps, there are individuals in whom sensory return is inadequate. Influenced by Karapandzic’s concept of lip flap design, this author performs dissections with a selective spreading technique in an attempt to preserve the small neural and vascular structures that are encountered as the mucosal advancement flap is dissected (see Fig. 19-4B).^1,5,6 These neurovascular structures are then gently stretched forward with advancement of the mucosal flap.

Mucosal V-Y Island Advancement Flaps

In some cases, small volume deficiencies of the vermilion may be restored with V-Y advancement flaps of labial or buccal mucosa (Fig. 19-6). The advancement flap is created by a V-shaped incision with the apex of the incision positioned toward the gingivolabial sulcus. Mucosal V-Y advancement flaps may also be created as island flaps to repair small adjacent vermilion defects. Incisions are made to the level of the orbicularis oris, creating an island flap that is pedicled on the underlying deep tissue. The triangle-shaped island is advanced into the adjacent recipient site, maintaining sufficient deep tissue attachments to ensure its viability. The donor site is closed primarily by direct approximation of the adjacent wound margins, resulting in a Y configuration to the wound closure. Closure of the donor site assists with securing the position of the advancement flap. Most V-Y island advancement flaps of the lip are designed to advance in a vertical or near-vertical orientation. There are some cases in which horizontal tissue movement is employed, with use of either a single island flap or bilateral opposing island flaps. Mucosal V-Y island advancement flaps are best suited for repair of small defects of the vermilion.

Mucosal Cross-Lip Flaps

A vermilion defect may in some cases be restored with an interpolated cross-lip transfer of labial mucosa or vermilion along with some underlying soft tissue (Fig. 19-7). Cross-lip transfer may be accomplished with a single-pedicle flap for small defects or a bipedicle flap (“bucket handle”) for wider defects that extend horizontally across the lip (Fig. 19-8). A cross-lip mucosal flap is typically designed as a linear band of mucosa, harvested from the region immediately posterior to the posterior vermilion line of the donor lip. The width of the band is determined by the width of the vermilion defect and by what will allow donor site wound closure. The mucosal flap is most often elevated in the plane immediately superficial to the orbicularis muscle, although some muscle may be included in the flap when it is necessary to fill a soft tissue defect of the recipient lip. The labial artery may be incorporated into larger flaps, providing an axial circulation and ensuring a greater likelihood of flap viability. Once it is dissected, the flap is transferred across the oral aperture to the vermilion defect and sutured in place (Fig. 19-9). The donor site is closed primarily. Division of the pedicle and flap inset are performed 3 weeks later as a second-stage procedure.

An alternative design of a cross-lip mucosal flap that does not require an axial pattern vascular supply is a broad flap pedicled on the free margin of the donor lip that can be separated after 16 days.⁷ Use of this flap causes greater restriction of mouth opening while the pedicle is in place.

Tongue Flaps

Portions of the mucosal surface of the anterior tongue may be transferred to the lip to repair a vermilion defect. A mucosal flap in the form of an interpolated tongue flap is constructed for this purpose (Fig. 19-10).^8,9 Mucosa transferred to the lip from the dorsal surface of the tongue will maintain the many fine filiform papillae that are characteristic of the glossal surface. Use of a tongue flap to restore the vermilion will likely create a red vermilion that can be surprisingly satisfactory. A glossal flap is usually harvested from the ventral surface of the tongue for lower lip repair and from the dorsal surface of the tongue for repair of the upper lip. It is also possible to design a flap from the lateral margin of the tongue. In nearly all cases, the pedicle is created at or near the free margin of the tongue. The leading edge of the flap is sutured to the anterior border of the vermilion defect in the best possible manner, anticipating that there will be considerable pulling with tongue movements. Attachment of the flap to the posterior border of the defect is accomplished at a second stage after division of the pedicle and flap inset. The second stage is usually performed 3 weeks after initial flap transfer. The tongue donor site wound may be closed partially or allowed to granulate while the pedicle of the flap remains attached to the recipient lip. Tongue flaps are awkward and difficult for the patient. For this reason, tongue flaps are not considered a first choice for vermilion reconstruction.

Vermilion Advancement Flaps

A full-thickness loss of vermilion and immediate underlying muscle may be a difficult defect to reconstruct. If the defect involves less than one-third of the width of the lip vermilion, it is possible to repair the defect by creating an advancement flap of the remaining vermilion (Fig. 19-11).^2,10 A full-thickness incision is made along the anterior vermilion line inferior to the labial artery. The flap includes the vermilion portion of the orbicularis muscle. Flap dissection may require a lengthy incision to allow adequate stretch. A meticulous wound closure is necessary to minimize visible scars in this aesthetically sensitive region.

Fusiform Repair

The preferred method for dealing with most cutaneous tumors of the lip remains fusiform excision and primary wound repair. When possible, the fusiform excision is oriented with its long axis parallel to relaxed skin tension lines of that region of the lip. From an aesthetic viewpoint, it is preferable that fusiform excisions be confined within the boundaries of the lip, avoiding extension beyond the melolabial or mental crease lines. An M-plasty at the end of the excision line may be useful in avoiding the need to extend an incision beyond the aesthetic borders of the lips or into the vermilion (Fig. 19-12). This will require closure of two small and slightly diverging incision lines near the involved end. M-plasty may also reduce tissue redundancies, particularly near the free margin of the lip.

Intralabial and Perilabial Flaps

Labial Rotation and Advancement Flaps

Labial cutaneous rotation and advancement flaps are used to repair skin defects of either lip. Flaps are designed to move skin medially from the area immediately lateral to the defect. Transfer of such flaps often involves moving skin around the oral commissure in a manner that employs variable degrees of rotation and advancement. The nature of the tissue movement is dependent on the exact location, size, and shape of the defect. Defects located laterally require flaps that are transferred to the recipient site with greater pivotal movement (Fig. 19-14). Defects located medially require flaps that are transferred primarily by advancement. For laterally located upper lip skin defects, rotation flaps are designed so that the lateral border of the flap is in or parallel to the melolabial crease. Flaps may extend inferiorly below the level of the oral commissure on the involved side (Fig. 19-15). Because the distance between the melolabial crease and vermilion diminishes near the oral commissure, the peripheral border of the flap is extended lateral to the crease into the cheek as necessary to achieve adequate flap width. Careful flap design is required to ensure that the width of the flap provides adequate vertical height to the reconstructed lip.

Dissection of labial rotation and advancement flaps is in the subcutaneous tissue plane superficial to the level of the orbicularis and facial muscles. For rotation flaps, a longer wound border is expected in the cheek lateral to the flap. This disparity in wound length can usually be accommodated by equally dividing the skin redundancy during wound closure. If necessary, a small equalizing Burow triangle of skin is excised from the cheek opposite the most inferior portion of the flap or in the alar-facial sulcus.¹¹

Cutaneous lip rotation flaps are most frequently employed to repair defects involving the more lateral portion of lip skin (see Fig. 19-14). In contrast, advancement flaps are most commonly used to repair centrally located cutaneous defects. As the flap is advanced medially, its base often overlaps the oral commissure. This redundancy of skin at the commissure may require excision. In more extreme cases, the oral commissure may be pulled superiorly or inferiorly with medial advancement of the flap. This may be self-correcting as the natural pulling of the lip musculature causes a corrective adjustment over time (see Figs. 19-14 and 19-15).

For unilateral cutaneous lip defects, the surface area requirements of a laterally based labial rotation or advancement flap designed for repair of the defect may be reduced by use of a concurrent opposing medially based flap constructed of skin from the opposite side of the defect. For upper lip defects, the opposing flap is designed with incisions extending from the defect beneath the base of the nose and along the anterior vermilion line to a desired point. For lower lip defects, incisions for the medial opposing flap are usually placed along the anterior vermilion line and in the mental crease. Movement of the opposing medially based flap is considerably less than that of the laterally based flap as there is less skin redundancy of the central lip. For upper lip defects, it is easy to distort the philtrum and nasal base when bilateral flaps are used. Extending the incision across the superior margin of the philtrum causes it to widen somewhat, whereas use of a shorter incision tends to cause the philtrum to be displaced laterally.

Melolabial Flaps

Transposition of skin from the medial cheek or melolabial fold may be used to restore a cutaneous defect of either lip. The typical melolabial flap has a linear and triangular design with an outline that tapers to a distal point. The medial border of the flap is designed in the melolabial crease. The lateral border is marked so that the flap is sufficiently wide to meet the requirements of the lip defect. The flap is designed slightly wider than the height of the lip defect in anticipation of wound contraction. This is particularly important when reconstruction involves a large defect or the defect encroaches on the free margin of the lip. Wound contraction may result in a deficient height of the reconstructed lip. For this reason, flaps used to repair defects near the lip margin must be of sufficient width to prevent the need for stretching of the flap in the vertical plane.

Melolabial cutaneous transposition flaps may be designed with a pedicle that is either superiorly or inferiorly based. A flap with a superiorly based pedicle is commonly used to reconstruct defects of the central upper lip. A flap with an inferiorly based pedicle is often used to reconstruct defects involving more lateral portions of the upper or lower lip. Use of melolabial flaps to repair the lips incurs some degree of flattening of the melolabial folds. Flaps with a superiorly based pedicle produce the greatest degree of distortion of the melolabial fold as they extend across the most defined and visible portion of the fold. A second surgical stage involving revision of the pedicle to align scars parallel to the melolabial crease is frequently indicated in cases in which a melolabial transposition flap is used to reconstruct the upper lip.

There is considerable tendency for linear transposition flaps to become slightly raised, causing a trap-door deformity as scar tissue matures beneath the flap and along its margins. Trap-door deformities may be minimized by wide undermining around the margins of the wound and by approximation of deep tissue layers, creating eversion of all skin edges. In some cases, it may be helpful to place one or more “tacking” sutures on the ventral surface of the flap before approximation of wound edges. This reduces the space available for collection of blood between the flap and recipient site. A collection of blood beneath a flap is a common cause of trap-door deformity.

Distortion of the melolabial fold and crease, alteration in the orientation of facial hair growth pattern, and tendency toward development of trap-door deformity are reasons that melolabial cutaneous transposition flaps are not frequently used to repair skin defects of the lips. Cutaneous defects in the central portion of the lip are often best reconstructed with bilateral advancement flaps. Larger (≥2 cm) central defects usually are converted to full-thickness defects and closed primarily (Fig. 19-16). Similar to centrally located defects, small laterally located cutaneous defects of the lip can be closed with bilateral advancement flaps, often in the form of an A-T plasty (Fig. 19-17). Larger (≥2 cm) laterally located cutaneous defects of the upper lip are effectively reconstructed with V-Y subcutaneous tissue pedicled melolabial advancement island flaps (see Chapter 12) (Fig. 19-18). The flap is freed from its orbicularis muscle attachments near the commissure and is based solely on the abundant subcutaneous fat located just lateral to the commissure. This is only when the flap is sufficiently large to necessitate the incorporation of skin of the melolabial fold into the flap.

For sizable (2-3 cm) lip skin defects adjacent to the inferior border of the ala, it may be beneficial to excise the small peninsula of skin between the ala and melolabial fold in the process of enlarging the defect so that the defect extends to an aesthetic boundary.⁸ The peninsula is then reconstructed by appropriately designing the island flap so that the superior portion of the flap replaces the peninsula (Figs. 19-18 and 19-19). This technique provides the best camouflage because the superior border of the flap is positioned within the aesthetic boundaries of the alar-facial sulcus and melolabial crease. When this peninsula is not replaced, the flap must cross the base of the peninsula and may mar an otherwise excellent result.

The major advantage of subcutaneous tissue pedicled melolabial advancement flaps used to repair sizable cutaneous defects of the upper lip is that there is no need to resect standing cutaneous deformities because these do not develop with this flap. For this reason, they are particularly advantageous compared with transposition and cutaneous pedicled advancement flaps, which often have sizable deformities that must be resected and discarded. There is no wasted skin with the island flap. Another important advantage of the island flap is that there is considerably less dead space beneath the flap as well as beneath skin surrounding the donor defect compared with use of cutaneous pedicled flaps. Less dead space means less space available for collection of blood and serum. Therefore, there is less risk for development of a hematoma compared with use of other types of flaps.

Primary Repair

Primary repair of either lip provides satisfactory results for full-thickness defects of as much as one-third the width of the lip. Wedge or V-shaped full-thickness lip excision and primary wound closure have long been the most common method of treatment of most malignant neoplasms of the lip (see Fig. 19-20). Closure of the V-shaped defect is oriented parallel to relaxed skin tension lines of the lip. In the central portion of the lip, the V-shaped excision is oriented vertically, with equal length given to the two borders of the V (Fig. 19-20). In more lateral regions of the lip, the V is skewed to produce a more angulated wound closure line matching the natural relaxed skin tension lines of the lateral lip (Fig. 19-21).

Optimal primary repair of full-thickness lip defects requires approximation of at least four tissue layers: mucosa, muscle, subcutaneous tissue including deep dermis, and epithelium of the skin. The tendency toward development of a retracted and depressed lip scar is appreciably reduced when the wound is repaired with accurate approximation of the lip muscle. Precise approximation of the subcutaneous tissue layer is accomplished with sutures that are adjacent to or include the deep portion of the reticular dermis. The epithelium of the skin is closed in a manner that ensures a slight eversion of the skin edges. Attention to detail throughout wound closure will achieve an optimal scar that is narrow and flush with adjacent lip tissue.

The anterior vermilion line is the principal landmark of the lip. To ensure symmetry, its precise location on opposing edges of the wound should be identified early in the course of lip repair. Once it is identified, the line is marked in some way as a reference to help guide the rest of the lip repair. To serve this purpose, a 6-0 silk suture may be inserted at the anterior vermilion line and initially left untied. Of equal aesthetic importance is satisfactory approximation of the posterior vermilion line, which for the purpose of repair is the visible posterior limit of the vermilion.

It is important to minimize irregularity or disparity in vertical height and contour of the vermilion between the two margins of a lip defect. The vermilion of the lateral portion of the lip is normally narrower than the central portion. As the two borders of the lip defect are approximated, accommodation for the disparity of the width of the vermilion is accomplished by forward advancement of vermilion of the lateral lip segment and simultaneous slight posterior advancement of vermilion of the medial border of the wound.

The portion of the orbicularis muscle that lies immediately beneath the vermilion and superior to the horizontal plane of the anterior vermilion line is known as the vermilion muscle and is the principal tissue that produces the fullness and rounded appearance of the free margin of the lip. Failure to achieve accurate muscle approximation of this region will significantly increase the likelihood of development of a notched or retracted vermilion with wound maturation. This portion of the orbicularis muscle is approximated with two or three sutures placed immediately beneath the vermilion, between the anterior and posterior vermilion lines.

During excision of a lip neoplasm and primary wound closure, the V-shaped excision is designed in such a way that it extends the complete height of the lip from the vermilion to the mental crease in the case of the lower lip and to the base of the nose or melolabial crease in the case of the upper lip. This is usually necessary to create an acute angle for ease of wound closure. In some cases, maintaining the V-shaped design within these borders can compromise the adequacy of resection margins, thereby necessitating modification of the design. A slightly greater amount of tissue can be resected around a lip tumor by modifying the shape of the excision so that it has the configuration of a shield or is U-shaped. In more lateral portions of the lip, a shape that is more skewed, like that of a “hound’s tooth,” will allow the final scar to parallel the more angulated relaxed skin tension lines natural to this region. Wound closure is performed in a manner similar to that of the V-shaped excision, except that it must accommodate the disparity of lengths between the two wound margins.

A W-shaped excision is another way of achieving greater resection of lip tissue without extending the apex of the excision beyond the mental or melolabial crease (Fig. 19-22). The apexes of the three points of the W usually remain within the confines of the lip aesthetic region. When the points must extend beyond the aesthetic region of the lip, consideration is given to placing the apex of the central point of the W at the mental or melolabial crease, depending on the location of the excision. This design provides a natural break between the single vertical scar line of the lip and the diverging distal scar lines required for closure of the more peripheral wound (see Fig. 19-22). In some situations, designing the two angles of the W with dissimilar sizes can achieve a more natural appearing scar, particularly for excision of tumors of the lateral lip. W-shaped excisions of lateral portions of the lip are best accomplished by designing a smaller angle of the W medially and a larger angle laterally (Fig. 19-23).

Bilateral Lip Advancement Flaps

Reconstruction of rectangular full-thickness defects of either lip may be achieved with bilateral advancements of the remaining lip segments (Figs. 19-24 and 19-25). Bilateral advancement flaps of the lower lip are created with release of the remaining lip segments by incisions along the mental crease. Incisions are curved gently downward at each end of the crease to follow the superior margin of the aesthetic border of the chin. Incisions may be full thickness or partial thickness as required by the situation. Although it is not necessary, dissection through the subcutaneous tissue and muscle layer of the flaps may be performed in the fashion described by Karapandzic, which attempts to preserve neural and vascular structures to offer optimal preservation of sensory function and tissue vascularity (see later section on Karapandzic flaps).1,5,6 Because of the elasticity of mucosa, the mucosal portion of full-thickness incisions is not carried as far laterally as that of the skin and muscle. Approximation of the two flaps is accomplished in a fashion similar to that described for full-thickness primary lip repair. For full-thickness defects of the lower lip repaired with bilateral advancement flaps, accommodation is made for tissue redundancy along the superior margin of the chin as the lip flaps are advanced. This is accomplished by performing bilateral excisions of equalizing Burow triangles of skin from the chin side of the incision.^1,11,12

A variation for designing bilateral advancement flaps to repair full-thickness defects of the lower lip advocated by Isaksson and Johanson uses a stair-step design (Fig. 19-26).^13,14 The lip tumor is removed by a rectangular excision. To create the advancement flaps, a series of bilateral square or rectangular incisions are made that connect in a downward diagonal fashion following the aesthetic border of the chin. At the termination of the incisions, bilateral small triangles of skin are excised. As the lip segments are advanced for wound closure, the series of rectangles and terminal triangles are closed, creating a stair-step wound closure line that is intended to minimize the effects of scar contracture. Although this is a functional and novel method of repair, it creates a scar that is not as natural to the lower face as one placed directly in the mental crease.

Bilateral advancement flaps may also be used for reconstruction of full-thickness defects of the upper lip. To facilitate medial advancement of lip tissue, excision of crescent-shaped segments of skin from the cheek in the region immediately lateral to the nasal alae is usually required (Figs. 19-27 and 19-28). The perialar crescent excisions are of skin only, with care taken to minimize disruption of sensory nerve fibers to the upper lip. For centrally located upper lip defects, advancement flaps do not provide restoration of the philtrum. A vague semblance of the philtrum is provided by the central vertically oriented scar. Lack of an actual philtrum tends to be less obvious in older patients.

Bilateral advancement flaps are best suited for restoration of full-thickness defects of the central region of the upper or lower lip because of the equal pull on the tissues of the lateral lip. Bilateral advancement flaps are less ideal for repair of defects of lateral portions of the lips. For the upper central lip, it is best to minimize lateral tissue movement because it often causes distortion of the philtrum. Reconstruction of full-thickness defects of the lip will cause them to be tighter and less compliant than the opposite, unviolated lip. This tends to be more obvious when the lips are closed. Tightness of the reconstructed lip tends to lessen over time because of gradual accommodative tissue stretching.

Circumoral Full-Thickness Rotation Advancement Flaps

Full-thickness composite lip flaps can be transferred around the oral commissure as either single or bilateral opposing flaps. This method of reconstruction, first described in 1857 by von Bruns, is intended to restore a complete and functional muscle sphincter (Fig. 19-29).^1,15 Flap movement employs both rotation and advancement as the flap is transferred around the oral commissure to close the defect. This method of reconstruction is more commonly employed for reconstruction of full-thickness defects of the lower lip but may be reversed for upper lip repair as well. Flaps are designed to optimize preservation and function of the remaining orbicularis muscle.

Karapandzic Flaps

A significant modification of the full-thickness circumoral composite rotation advancement lip flap was described by Karapandzic in 1974. This modification preserves most of the neural and vascular structures entering the flap (Fig. 19-30).^1,5,6 The technique typically involves the creation of bilateral opposing flaps that may be of different lengths, depending on the circumstances. Unique to the Karapandzic technique is making incisions for the flaps that are not full thickness. Incisions are made through the skin of the flaps and separate incisions through the mucosa on the deep surface of the flaps. Dissection of the flaps is performed with an attempt to identify and to preserve as many neural and vascular structures as possible. Separation of the subcutaneous tissue and muscle of the flaps from the adjacent facial tissues is performed bluntly with scissors to gently spread the tissue apart to avoid cutting through any neural or vascular structures unless necessary (see Fig. 19-30B). Neural and vascular structures are dissected sufficiently to allow them to be stretched and carried along with the transfer of the flaps without the need to cut the structures. This approach maximizes vascular supply and preserves optimal motor and sensory function to the reconstructed lip, minimizing the need for reinnervation.

An incision to create a Karapandzic flap is made parallel to the free margin of the lips, creating a flap with a uniform width throughout. To optimize aesthetic results in reconstruction of the lower lip, an incision is made along the course of the mental crease as far as possible and then carried around the oral commissure and into the melolabial crease (Fig. 19-31). Flap design is modified but is similar for reconstruction of upper lip defects (Fig. 19-32). Bilateral flaps are designed so that their width remains nearly uniform, with a tolerance for variation that is only gradual when attempts are made to accommodate the natural facial features at the periphery of the flaps.

Full-thickness circumoral flaps in the form of Karapandzic flaps are most ideal for reconstruction of large centrally located full-thickness defects of the lower lip and, to a lesser degree, the upper lip. Flaps may be adapted to repair full-thickness defects of more lateral regions of the lower lip, but there is greater limitation to their use for reconstruction of defects of the lateral upper lip. Whereas full-thickness lip flaps can readily be advanced past the midline of the lower lip, this maneuver is not generally favored in the upper lip, where it will cause distortion of the philtrum.

A helpful feature in restoration of central full-thickness defects of either lip is to design bilateral flaps of similar size (mirror image), which ensures symmetry. In reconstruction of the lateral portion of the lower lip, bilateral flaps are commonly designed of different lengths, with a preference to create longer flaps from the contralateral lower lip (Fig. 19-33). This approach may avoid distortion of the central region of the upper lip.

For repair of centrally located lower lip defects, bilateral flaps are created by making incisions from the defect that extend laterally and superiorly around the oral commissure into the melolabial creases. The incisions typically end at the level of the nasal alae. This provides composite flaps that offer symmetry with respect to the nasal base and the reconstructed oral stoma. Once the flaps have been dissected, it is best to first secure together the two opposing borders and then to adjust the remaining wound closure to the surrounding facial tissues (see Fig. 19-33E). Care is taken to reattach the various muscles of facial expression to the orbicularis muscle in anatomically appropriate orientation and location, although to a large extent this occurs naturally as the wound margins heal. Failure to perform a meticulous layered wound closure can result in a scar that has a “clown-like” appearance as it encircles the lips. Some degree of distortion of the oral commissure is inevitable, causing the commissures to be more rounded. In the majority of cases, the position of the commissure is unchanged but the shape is blunted and pulled slightly in the direction of flap transfer. Bilateral commissure distortion tends to be less apparent than unilateral distortion.

In some patients, the Karapandzic technique may be used to repair a defect as large as two-thirds of the width of either lip (Fig. 19-34). However, there is variability among patients as to how well lip tissue will stretch without excessive distortion of the commissures or creation of limiting microstomia. Lip tissue of older patients is more redundant and tolerant to stretching. A smaller mouth opening may not be acceptable for patients who wear dentures and must be able to pass dentures in and out of the mouth with relative ease. However, the oral aperture can be made larger over time with persistent stretching of the lips by either repeated manual manipulation or insertion of an adjustable lip-stretching mouth appliance.

Transoral Cross-Lip Flaps

Commissureplasty

A problem inherent to all cross-lip flaps with a pedicle that becomes the oral commissure is blunting and distortion of the involved commissure. A later-stage commissureplasty is often necessary. The simplest method of commissureplasty involves making a horizontal full-thickness incision at the level of the blunted commissure that extends laterally to a point corresponding in position to that of the contralateral normal commissure (Fig. 19-52).³³ Labial mucosa is then advanced forward on each side of the incision to restore a vermilion surface. In some cases, it may be helpful to remove a small triangle of skin and subcutaneous tissue from the area of the commissureplasty for a more natural result. This is performed cautiously to avoid oral incontinence.

An alternative method of commissureplasty makes use of small flaps of vermilion and orbicularis muscle (Fig. 19-53). A triangle of skin and subcutaneous tissue is excised immediately lateral to the blunted commissure. The apex of the triangle extends to the point of the new commissure. A small vermilion flap is created from one lip and left pedicled on the opposite lip. A horizontal incision is made through the muscle tissue to the point of the new commissure. The vermilion flap is advanced to this point. A small flap is created from the mucosa of the lip serving as the donor for the vermilion flap. The mucosal flap is advanced over the free border to restore the vermilion of the donor lip.

Bilateral Cheek Advancement Flaps

Full-thickness lip defects of up to half of the width of either lip can usually be restored satisfactorily with bilateral lip advancement flaps. For larger defects, it is usually best to consider some other method of lip repair that will add more tissue to the reconstructed lip. The elasticity of lip tissue will vary among patients, as does tolerance for microstomia. In some situations, repeated manual stretching or use of a prosthetic lip-stretching appliance may help reduce problems with microstomia. In other cases, it will be necessary to recruit tissue from the adjacent cheek during reconstruction to prevent microstomia. Bernard in 1852 and von Burow in 1853 and 1855 advanced the concept of using tissue from the cheeks to restore major defects or complete loss of the upper or lower lips.1,11,34 Tissue is advanced horizontally from the medial aspect of one or, more commonly, both cheeks in the form of bilateral opposing cheek advancement flaps. This method of lip repair has been referred to as a Bernard cheiloplasty. Standing cutaneous deformities form on either side of the base of each advancement flap and are referred to as Burow triangles.^11,34 A major feature of Bernard cheiloplasty is the resection of Burow triangles of skin resulting from the advancement of the cheek flaps. Excision of the triangles facilitates tissue advancement. Reconstruction of the upper lip with bilateral opposing cheek advancement flaps requires excision of four triangles of cheek skin (Fig. 19-54). Bilateral triangles of skin and subcutaneous tissue are removed from the vicinity of the alar-facial sulci superior to the flaps. Additional triangles of skin are removed from the cheek inferior to the flaps and lateral to the oral commissures. When the Bernard cheiloplasty is used to reconstruct full-thickness defects of the lower lip, reconstruction requires excision of three triangles of skin (Fig. 19-55). Triangles are removed bilaterally superior to the oral commissures. A larger triangle of skin is excised in the midline extending inferiorly from the lip defect into the chin as necessary.

Modifications of the Bernard–von Burow flaps have subsequently been described by several authors.35–37 In 1960, Webster proposed a modified design for lower lip reconstruction that employs a more linear horizontal advancement of cheek tissue compared with the Bernard–von Burow techniques. This modification positions scars in natural facial skin creases and avoids violation of the aesthetic region of the chin (Fig. 19-56).^1,35 The Webster design also minimizes the tendency for vertical deficiency in the midline of the reconstructed lower lip (Fig. 19-57).

These techniques were originally described with use of full-thickness cheek incisions and do not restore the orbicularis muscle sphincter. It is of greater benefit to the patient if flaps can be transferred with minimal violation of the facial musculature by limiting the extent of full-thickness incisions. There is also benefit to the patient if flaps are dissected with minimal violation of the sensory innervation of the flap tissue. Limiting the extent of incisions to create flaps helps preserve sensory innervation to the region. Therefore, a preferred approach for performing the Bernard and Webster cheiloplasties is to make incisions only through the skin and subcutaneous tissue layer. Labial and buccal mucosa incisions are made separate from skin incisions. The mucosal incisions do not usually require extension as far laterally as the skin incisions. Mucosal incisions are typically made at the same level as the skin incisions but may be offset at a slightly superior or inferior level, depending on which lip is reconstructed. The offset provides more mucosa that can be advanced with the flap. This additional mucosa is used to create mucosal flaps that are draped across the free margins of the flaps to restore the vermilion of the lateral portions of the reconstructed lip. What remains of orbicularis muscle is freed up sufficiently to allow flap advancement. Violation of the facial mimetic musculature is minimized by blunt spreading of tissue to enable adequate stretching without separation of the muscle attachments of the cheek flaps. Freeman³⁷ has described a dissection along the orbicularis muscle of the opposite lip in an attempt to advance more of this muscle along with the cheek advancement flaps with the intent of improving lip function. However, this is technically difficult to accomplish.

Reconstruction of full-thickness defects of the lip with opposing cheek advancement flaps is technically difficult and oral functioning is fair at best (see Fig. 19-57). The lack of a functional muscle sphincter is offset in part by the tightness that is inherent to the reconstructed lip by this surgical approach. Whereas basic mouth opening and closing may be acceptable, more specialized lip functions, such as whistling and kissing, tend to be significantly impaired (see Fig. 19-57G, H).

Melolabial Transposition Flaps

Similar to cutaneous melolabial transposition flaps used to reconstruct cutaneous defects of the lip (see section on melolabial flaps for cutaneous repair), a thicker composite melolabial transposition flap consisting of skin and subcutaneous tissue may be used to repair full-thickness lip defects. In such instances, it is necessary to line the deep surface of the flap. This is most commonly achieved with a skin graft (Fig. 19-58). A split-thickness skin graft can be used for this purpose with perhaps an improved survival of the graft compared with use of a full-thickness skin graft. However, full-thickness skin grafts cause less wound contraction. There is considerable tendency for contraction of the melolabial flap and the lining skin graft. For this reason, both graft and flap are designed wider than the vertical height of the lip defect. The skin graft is draped over the free margin of the flap for restoration of the vermilion. A mucosal free graft may subsequently be used to replace the skin graft of the reconstructed vermilion. This is performed as a secondary procedure once the skin graft has completely healed.

Melolabial flaps have a random vascular supply. Thus, they are at greater risk of necrosis when they are long relative to flap width. A greater risk of necrosis is also observed in patients who use tobacco products or have been irradiated. When there is concern for the viability of a melolabial transposition flap, employment of an initial delay may be appropriate, especially if the flap is lengthy (see Fig. 19-58). Whenever flap delay is used, consideration is given to placement of a lining skin graft on the deep surface of the flap at the time of delay. The flap is then transferred to the lip as a composite flap. This approach avoids the difficulty of securing a skin graft to the deep surface of the flap after it has been positioned in the lip recipient site. Less inflammation occurs if the grafted skin is made to extend to at least one of the skin margins along the border of the delayed flap. This provides a portal for drainage of fluid collecting beneath the flap. This maneuver also serves to begin the process of vermilion restoration necessary for the free margin of the reconstructed lip.

The use of skin-lined melolabial transposition flaps to reconstruct full-thickness lip defects will result in a thin adynamic lip segment. Designing the flap with a greater width than the vertical height of the lip defect is advisable so that the reconstructed lip will maintain adequate vertical height after wound contraction and scar maturation (Fig. 19-59). Although the flap should not be subjected to excessive wound closure tension, some tightness of the reconstructed lip can help offset the problems associated with an adynamic lip segment. Bilateral melolabial transposition flaps may be used to reconstruct large full-thickness lip defects or complete absence of the lip; one flap is used for the external lip surface, and the other is turned inward to provide lining for the reconstructed lip. However, this technique requires flaps with extended lengths, and it is technically difficult to inset the flaps while working around the pedicle of the lining flap.

Island Flaps

Several island flaps have been described for use in reconstruction of full-thickness lip defects. McHugh³⁸ has described a horizontally oriented island flap consisting of tissue from the cheek that is transferred to the lower lip by a V-Y advancement. Fugimori³⁹ and Stranc and Robertson⁴⁰ have described a design for an island flap that employs the transfer of vertically oriented tissue to the lip from the melolabial region. The flap is pedicled on a subcutaneous tissue pedicle and is pivoted 90° and set horizontally into the lower lip. Bilateral island flaps may be used to repair larger lip defects. The island flap is created by making an incision completely around the designed flap. The flap remains pedicled on the subcutaneous tissue immediately beneath the flap. A mucosal advancement flap is draped over the free margin of the newly reconstructed lip to provide a vermilion replacement.

Horizontally oriented V-Y island advancement flaps championed by McHugh require incisions through skin and subcutaneous tissue externally and mucosa internally while maintaining the facial muscle attachments to the flap.³⁸ The flap described by Fugimori³⁹ and Stranc and Robertson⁴⁰ is also based on the facial musculature and requires a 90° pivot, so a greater dissection within the muscle layer is required to enable flap transfer compared with the McHugh flap. Island flaps have less of a problem with bulkiness of the pedicle than flaps with a cutaneous pedicle do. The pedicle of island flaps must have an adequate random vascular supply or be designed with an axial vascular system based on branches of the facial artery. Concerns with use of island flaps for major lip reconstruction include difficulty with flap mobilization, impairment of facial nerve function, difficulty with orientation of the flap, appearance of scar lines, and viability of the flap. At present, island flaps are not considered a first choice for full-thickness lip reconstruction.

Temporoparietal Scalp Flaps

Interpolated temporoparietal scalp flaps used for lip reconstruction are technically regional flaps. In some situations, the temporoparietal flap may prove to be useful for reconstruction of large full-thickness defects of the upper or lower lip. Description of the flap is included in this chapter because it can offer a reasonably simple functional flap for restoration of a variety of large lip defects without disruption of the opposing lip and adjacent perioral structures. The temporoparietal scalp flap is based on the posterior branch of the superficial temporal artery that travels from the preauricular region superiorly beneath the skin in the plane of the temporoparietal fascia to the midline of the scalp. In many patients, the course of the artery can be detected with gentle palpation and can be mapped out very well with use of a Doppler device. The flap is created by making vertical incisions angled posteriorly on both sides parallel to the course of the posterior branch of the superficial temporal artery (Fig. 19-60). The flap is pedicled on tissue in the immediate preauricular region at the level of the zygoma. Care is taken to avoid injury to the temporal artery and accompanying venous drainage, particularly in the region of the pedicle.

In anticipation of wound contraction, it is best to design the flap with a width that exceeds the vertical height of the recipient lip defect. The distal end of the flap is tapered near the center of the scalp. The flap is designed with sufficient length to reach the recipient site without excessive wound closure tension. The long flap is possible because it is designed as an axial flap based on the temporal artery. It is better to construct a flap with extra length than to risk injury to the pedicle by extending the inferior dissection below the level of the zygoma. The scalp donor site is closed primarily in some cases but not in all. Closure depends on the width of the flap and the laxity of adjacent scalp. Closure of the donor site with excessive tension may result in loss of hair in the region. If scalp wound closure tension is excessive, a portion of the wound may be left open to heal by secondary intention or repaired with a skin graft. The resulting scar or skin graft can subsequently be excised and the wound closed by scalp advancement. The proximal portion of the flap not used to reconstruct the lip may be returned to the scalp when the flap is inset.

When full-thickness lip defects are reconstructed with an interpolated temporoparietal scalp flap, the deep surface of the flap is usually covered with either a full-thickness or split-thickness skin graft to provide an intraoral surface lining. Whereas a split-thickness skin graft is relatively easy to harvest and can have a long length to cover a sizable portion of the flap’s undersurface, a full-thickness skin graft offers a more durable tissue surface and is relatively less prone to contraction. It can be challenging to securely attach a skin graft to the deep surface of the temporoparietal scalp flap as the flap is being transferred to the mouth because a bolster dressing to secure the skin graft is awkward and may risk impairment of vascularity to the flap. When possible, it may be preferable to stage the procedure by delaying the flap and placing a skin graft on the ventral surface of the flap (Fig. 19-61). Use of a delayed stage can help “train” the flap tissue to adapt to an alteration in its vascular supply while simultaneously allowing a skin graft to heal to the deep surface of the flap. The second stage is then performed, transferring the composite flap to the recipient lip site. During the delay stage, the distal end of the flap may remain attached to the scalp in the form of a bipedicle flap until the time of actual flap transfer.

When a temporoparietal flap is used in a staged procedure, the edges of the skin graft are sutured to both borders of the flap. The graft should be sufficiently large to eliminate the need to stretch the skin graft as it is sutured in place. Approximating the edges of the skin graft to one or both borders of the flap minimizes accumulation of serum and other debris beneath the flap during healing. Suturing of the graft to the posterior flap border provides the restoration of a vermilion. The skin graft is designed longer than necessary to offer greater flexibility when the flap is transferred to the mouth. In addition, a long skin graft lining the temporoparietal scalp flap will serve to lessen contracture of the flap width during the phase that it remains pedicled. The skin graft also lessens the tendency for maceration of the cheek skin due to contact between the cheek and the undersurface of the flap pedicle. The skin graft is removed from the portion of the pedicle returned to the scalp when the flap is inset.

The temporoparietal scalp flap can be designed for reconstruction of an entire upper or lower lip. It can be designed as a bipedicle flap that is connected across the top of the scalp and transferred to the lip as an interpolated flap in a bucket-handle fashion. Such a flap design is more safely accomplished by use of a delayed stage as circulation across the top of the scalp is random. It is possible to reconstruct an entire lip with use of a single-pedicled temporoparietal flap (Fig. 19-62). In such cases, use of a delayed stage is preferred to ensure the vascularity of the distal end of the flap. Insetting of a single-pedicle flap is much easier than that of a bipedicle flap. A single-pedicle flap also causes less distortion of the scalp. It is also appreciably easier for the patient to deal with a flap pedicled on only one side of the face. The amount of surface contact between the flap and the lip recipient site influences how long the flap remains pedicled to the scalp. In most cases, a period of at least 3 weeks is used between the initial transfer of the flap to the mouth and flap inset, but this interval can be varied. On occasion, division of the pedicle may be performed in stages to reduce the risk of flap necrosis.

Scalp skin has a different character than lip skin (Fig. 19-63). Because the temporoparietal scalp flap is hair bearing, it is more suited to reconstruction of the lip in men. Hair growth on the flap can simulate a moustache or beard and aid in camouflage of the reconstruction (Fig. 19-64). It is important to appreciate that reconstruction with a temporoparietal scalp flap does not restore motor function to the lip but will serve as a static mouth cover. Adynamic reconstruction is better suited to restoration of the upper lip than of the lower lip.

Other Flap Reconstructions

A number of additional flaps from regional or distant sites may be used to reconstruct full-thickness defects of the lip. These flaps are beyond the purpose of this chapter and are mentioned only briefly for completeness.41–44 Regional and distant flaps are usually selected for lip reconstruction when there is need for total restoration of either lip. Historically, the most common regional flap used for this purpose consisted of transposition of forehead skin pedicled laterally on the anterior branch of the superficial temporal artery. This flap remains an option for reconstruction of the entire lip; however, it is currently less favored as it requires multiple stages and tends to cause a “skull-like” appearance of the donor forehead, which is covered with a split-thickness skin graft.41,43 The deltopectoral chest flap offers a large quantity of tissue that can be used for reconstruction of major defects of one or both lips.^42,43 Whereas the pedicle is based on multiple intercostal perforating arteries from the anterior chest wall, the useable distal portion of the flap has a random circulatory supply, and thus the flap requires delay to ensure its viability. Redundant pedicle tissue of the flap may be folded and used for lip lining. This approach provides improved results compared with use of a skin graft to line the flap.

In addition to the deltopectoral chest flap, other flaps constructed from the platysma and sternocleidomastoid muscles have been used to reconstruct large full-thickness lip defects. These muscle flaps are difficult to dissect and are uncertain in their result. The current trend for total lip reconstruction is immediate single-stage reconstruction with a microsurgical flap. The radial forearm flap is the preferred flap because it offers a relatively thin and pliable skin flap and limited donor site morbidity in most patients.⁴⁴ Although regional, distant, and microsurgical flaps can transfer large surface areas of skin and soft tissue to the region of the lip, such flaps provide limited or no dynamic motion of the reconstructed lip and show considerable tendency to sag, particularly when they are used to reconstruct the lower lip.

1. Mazzola, RF, Lupo, G. Evolving concepts in lip reconstruction. Clin Plast Surg. 1984; 11:583.

2. Zide, BM, Deformities of the lips and cheeks. Plastic surgery. McCarthy, JG, eds. Plastic surgery; vol. 3. WB Saunders, Philadelphia, 1990.

3. Park, C, Lineaweaver, WC, Buncke, HJ. New perioral arterial flaps: anatomic study and clinical application. Plast Reconstr Surg. 1994; 94:268.

4. Kriet, JD, Cupp, CL, Sherris, DA, Murakami, CS. The extended Abbe flap. Laryngoscope. 1995; 105:988.

5. Karapandzic, M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg. 1974; 27:93.

6. Jabaley, ME, Clement, RL, Orcutt, TW. Myocutaneous flaps in lip reconstruction: application of the Karapandzic principle. Plast Reconstr Surg. 1977; 59:680.

7. Reid, DA. A mucosal cross-lip flap. Br J Plast Surg. 1956; 9:106.

8. McGregor, IA. The tongue flap in lip surgery. Br J Plast Surg. 1966; 19:253.

9. Bakamjian, V. Use of tongue flaps in lower lip reconstruction. Br J Plast Surg. 1964; 17:76.

10. Goldstein, MH. A tissue-expanding vermilion myocutaneous flap for lip repair. Plast Reconstr Surg. 1984; 73:768.

11. von Burow, CA. Beschreibung einer neuen Transplantations-methode (Method der seitlichen Dreiecke) zum Wiederersatz verlorengegangener Teile des Gesichts. Berlin: Nauck; 1855.

12. Szlazak, J. The application of a Burow triangular flap in reconstruction of the lower lip. Br J Plast Surg. 1958–1959; 11:128.

13. Isaksson, I, Johanson, B. Partial reconstruction of the lower lip. Panminerva Med. 1967; 9:420.

14. Johanson, B, Aspelund, E, Breine, U, Holmstrom, H. Surgical treatment of non-traumatic lower lip lesions with special reference to the step technique. Scand J Plast Reconstr Surg. 1974; 8:232.

15. von Bruns, V. Chirurgischer Atlas: Bildliche Darstellung der chirurgischen Krankheiten und der zu ihrer Heilung erforderlichen Instrumente, Bandagen und Operationen, II Abt, Kau- und Geschmaks-Organ. Tubingen: Luupp; 1857.

16. Sabattini, P. Cenno storico dell’origine e progressi della rinoplastica e cheiloplastica. Bologna: Belle Arti; 1838.

17. Stein, SAW. Laebedannelse udført paa en ny methode. Hospitals-Meddelelser. 1848; 1:212.

18. Buck, G. Contributions to reparative surgery: showing its application to the treatment of deformities, produced by destructive disease or injury; congenital defects from arrest or excess of development; and cicatricial contractions from burns. New York: D Appleton; 1876.

19. Abbe, RA. A new plastic operation for the relief of deformity due to double hairlip. Med Rec. 1898; 53:477.

20. Franchebois, P. Improved surgical treatment of cancer of the lower lip. Int Surg. 1975; 60:204.

21. Templer, J, Renner, G, Davis, WE, Thomas, JR. A modification of the Abbe-Estlander flap for defects of the lower lip. Laryngoscope. 1981; 91:153.

22. McCarn, KE, Park, SS. Lip reconstruction. Facial Plast Surg Clin North Am. 2005; 13:301.

23. Smith, JW. The anatomical and physiologic acclimatization of tissue transplanted by the lip switch technique. Plast Reconstr Surg. 1960; 26:40.

24. Thompson, N, Pollard, AC. Motor function in Abbe flaps: a histochemical study of motor reinnervation in transplanted muscle tissue of the lips in man. Br J Plast Surg. 1961; 14:66.

25. Estlander, JA. Eine Methode aus der einen Lippe Substanzverluste der anderen zu ersetzen [reprinted in English translation in Plast Reconstr Surg 42:361, 1968]. Arch Klin Chir. 1872; 14:622.

26. Baker, SR, Swanson, NA. Local flaps in facial reconstruction. St. Louis: Mosby; 1995.

27. Baker, SR, Krause, CJ. Cancer of the lip. In: Suen JY, Myers EN, eds. Cancer of the head and neck. New York: Churchill Livingstone, 1981.

28. Kazanjian, VH, Roopenian, A. The treatment of lip deformities resulting from electric burns. Am J Surg. 1954; 88:884.

29. Martin, HE. Cheiloplasty for advanced carcinoma of the lip. Surg Gynecol Obstet. 1932; 54:914.

30. Murray, JF. Total reconstruction of a lower lip with bilateral Estlander flaps: case report. Plast Reconstr Surg. 1972; 49:658.

31. Gilles, H, Millard, R. The principles and art of plastic surgery. London: Butterworth; 1957.

32. McGregor, IA. Reconstruction of the lower lip. Br J Plast Surg. 1983; 36:40.

33. Anderson, R, Kurtay, M. Reconstruction of the corner of the mouth. Plast Reconstr Surg. 1971; 47:463.

34. Bernard, C. Cancer de la lèvre inférieure: restauration á l’aide de deux lambeaux latéraux quadrilatères: guérison. Bull Mem Soc Chir Paris. 1853; 3:357.

35. Webster, RC, Coffey, RJ, Kelleher, RE. Total and partial reconstruction of the lower lip with innervated muscle-bearing flaps. Plast Reconstr Surg. 1960; 25:360.

36. Webster, JP. Crescentic peri-alar cheek excision for upper lip flap advancement with a short history of upper lip repair. Plast Reconstr Surg. 1955; 16:434.

37. Freeman, BS. Myoplastic modification of the Bernard cheiloplasty. Plast Reconstr Surg. 1958; 21:453.

38. McHugh, M. Reconstruction of the lower lip using a neurovascular island flap. Br J Plast Surg. 1977; 30:316.

39. Fujimori, R. “Gate flap” for the total reconstruction of the lower lip. Br J Plast Surg. 1980; 33:340.

40. Stranc, MF, Robertson, GA. Steeple flap reconstruction of the lower lip. Ann Plast Surg. 1983; 10:4.

41. McGregor, IA, Reconstruction following excision of intraoral and mandibular tumors. Reconstructive plastic surgery. Converse, JM, eds. Reconstructive plastic surgery; vol. 5. WB Saunders, Philadelphia, 1977.

42. Bakamjian, V, Culf, NK, Bales, HW. Versatility of the deltopectoral flap in reconstructions following head and neck cancer surgery. In: Sanvenero-Rosselli G, Boggio-Robutti G, eds. Transaction of the 4th International Congress of Plastic Surgery, Rome. Amsterdam: Excerpta Medica, 1969.

43. Renner, G. Lip reconstruction. In: Day TA, Girod DA, eds. Oral cavity reconstruction. New York: Taylor & Francis, 2006.

44. Sadove, RC, Luce, EA, McGrath, PC. Reconstruction of the lower lip and chin with the composite radial forearm–palmaris longus free flap. Plast Reconstr Surg. 1991; 88:209.