Lip reconstruction is guided by defect location, size and depth. This article details the local flap, free flap and primary closure options for lip reconstruction.
Summary Card
Anatomy
The lip is composed of skin, muscle and mucosa. Its blood supply is the labial arteries.
Principles
Restore the layers of the lip. Key landmarks to preserve include the philtrum, modiolus, cupid's bow and vermillion.
Reconstruction Options
The lip can be reconstructed by primary closure, local flap or free flap. This depends on the patient and lip defect (size and location).
Primary Closure
Defects <1/3 of the lip and appropriate soft tissue laxity.
Abbe Lip Switch Flap
Defects <1/3 of the lip and an intact commissure
Abbe-Estlander Flap
Defects <1/3 of the lip and an involved commissure
Karapandzic Flap
Central defects <2/3 of the upper and lower lip.
Bernard-Burow Cheiloplasty
Central defect >2/3 of lower lip, causes incompetence & microstomia
Free Flap
Radial forearm flap to reconstruct the entire lip. There is no motor innervation, and cosmesis can be poor.
Flashcards
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Anatomy of Lip Reconstruction
Key Point
The lip is composed of skin, muscle and mucosa. It is supplied by the labial arteries. Key landmarks include modiolus, cupid's bow, vermillion, and philtrum.
Lip reconstruction recreates the skin, muscle, and mucosa elements of the lip to maintain oral competence, speech and cosmesis.
The neurovascular anatomy of the lip is detailed below
- Motor: buccal and mandibular branches of the facial nerve
- Sensory: infraorbital (upper), mental (lower) branches of trigeminal nerve.
- Blood supply: superior and inferior labial branches of the facial artery
The landmarks of the lip are illustrated below.
Principles of Lip Reconstruction
Key Point
Lip reconstruction should restore the layers of the lip. There are key anatomical landmarks that should also be preserved.
"Restoration is designed from within.... the mucosal lining should be considered first, then the supporting structures, and then finally the skin covering". This was outlined in Sir Harold Gilles's seminal publication, illustrated below.
Lip Reconstruction Options
Key Point
Lip reconstruction is guided by the location, size and depth of the defect. Reconstructive options include primary closure, local flap or free flap. Landmarks, competence and function should be preserved when possible.
Lip reconstruction should aim to restore "like with like". The reconstruction is dependent on the following factors:
- Location: upper lip vs lower lip, central vs lateral vs commissural
- Size and depth: <1/3 vs <2/3, skin vs mucosal vs muscle, vermillion
- Goals: function vs cosmesis vs maintaining oral aperture (important for dentures)
The lip reconstructive options are illustrated in the table below.
Primary Lip Closure
Key Point
This is indicated in patients with defects <1/3 of the lip and appropriate soft tissue laxity. It is commonly used after wedge excision of lip lesions, such as squamous cell carcinoma.
- Indications: defect <1/3 of the lip and appropriate soft tissue laxity
- Benefit: single stage, innervated, muscle continuity
- Limitations: small defects, can remove cupid's bow/philtrum.
- Design: Realign all layers of the lip (skin, muscle and mucosa).
Abbe Lip Switch Flap
Key Point
This is indicated in compliant patients with defects <1/3 of the lip and an intact commissure. The second-stage release should be performed in 2-3 weeks.
- Indications: defect <1/3 of the lip + intact commissure + compliant patient
- Benefit: muscle continuity, preserves landmarks (cupid's bow, philtrum, modiolus)
- Limitations: two-stage, insensate
- Design: full thickness, half the defect width, based on ipsilateral labial artery
- Tip: protect the labial artery with a cuff of muscle and ensure adequate mouth opening during the 2-week period between the first and second stages.
Abbe-Estlander Flap
Key Point
This is indicated in compliant patients with defects <1/3 of the lip and an involved commissure. The second-stage release should be performed in 2-3 weeks.
- Indications: defect <2/3 of upper and lower lip + commissure affected
- Benefit: single-stage is possible
- Limitations: insensate, can distort oral animation as modiolus altered.
- Design: full thickness, third-half defect width, contralateral labial artery
- Tip: protect the labial artery with a cuff of muscle; it may require secondary commissuroplasty.
Karapandzic Flap
Key Point
This is indicated in central defects <2/3 of the upper and lower lip. This single-stage procedure is based on the bilateral labial arteries. It can lead to microstomia
The karapandzic flap is an orbicularis oris myocutaneous flap with an axial blood supply.
- Indications: central defect <2/3 of upper and lower lip
- Benefit: single-stage, sensate, preserves oral competence and landmarks (philtrum and modioulus)
- Limitations: can lead to microstomia
- Design: rotational, circumoral flaps based on the bilateral labial arteries
- Tip: preserve the vascular pedicles and buccal branches by performed intramuscular dissection
Bernard-Burow Cheiloplasty
Key Point
This is indicated in central defects >2/3 of the lower lip. This single-stage procedure is based on the subdermal plexus and can result in oral incompetence and microstomia
- Indications: central defect >2/3 of the lower lip
- Benefit: single-stage
- Limitations: insensate, can lead to oral incompetence and microstomia
- Design: medial advancement of the cheek with Burow's triangles.
- Tip: based on facial subunits and the dermal plexus
Free Flap Reconstruction
Key Point
The radial forearm flap can be considered for reconstructing the entire lip in patients with irradiated tissue (post-tumour resection). There is no motor innervation, and cosmesis can be poor.
- Indications: total or near total loss of the lip
- Benefit: good soft tissue coverage with potential for sensation with lateral antebrachial cutaneous nerve
- Limitations: no motor innervation, poor cosmesis (colour and lip landmarks)
- Design: radial forearm and palmaris longus
- Tip: consider in patients after tumour resection and radiotherapy to local tissues.
There are currently published case reports on the role of an innervated gracilis muscle in providing a functional lower lip.
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