Lip Cancer and Reconstruction

Naren N Venkatesan MD

Faculty Advisor Raghu Athre MD

University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

December 2011

Overview

bull Anatomy

bull Function

bull Lip Cancer

ndash Brief Facts

ndash PathologyStaging

ndash Treatment

bull Key Flaps for Reconstruction

Anatomy

Melolabial crease

Labiomandibular crease

Red Lip

White Lip Vermillion Border

Mental Crease

Anatomy

Philtral Ridge

Anatomy

Anatomy

Arterial Details

bull Course of Facial Artery

ndash Branches off External Carotid Artery

ndash Courses across the mandible to the oral commissure

ndash Deep to Risorius and Superficial to Buccinator

ndash Can be found approximately 1 ndash 2 cm from oral commissure2

Further Arterial Details

bull Superior Labial Artery ndash Deep to Zygomaticus Major ndash Gives of Angular artery then

enters orbicularis oris ndash Runs along upper lip and

anastamoses with opposite side

bull Inferior Labial Artery ndash Branches from Facial Artery

near the commissure ndash Deep to Depressor Angularis

Oris ndash Enters Orbicularis Oris and runs

along lower lip to anastamose with opposite side

Anatomy

bull Subunits

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Overview

bull Anatomy

bull Function

bull Lip Cancer

ndash Brief Facts

ndash PathologyStaging

ndash Treatment

bull Key Flaps for Reconstruction

Anatomy

Melolabial crease

Labiomandibular crease

Red Lip

White Lip Vermillion Border

Mental Crease

Anatomy

Philtral Ridge

Anatomy

Anatomy

Arterial Details

bull Course of Facial Artery

ndash Branches off External Carotid Artery

ndash Courses across the mandible to the oral commissure

ndash Deep to Risorius and Superficial to Buccinator

ndash Can be found approximately 1 ndash 2 cm from oral commissure2

Further Arterial Details

bull Superior Labial Artery ndash Deep to Zygomaticus Major ndash Gives of Angular artery then

enters orbicularis oris ndash Runs along upper lip and

anastamoses with opposite side

bull Inferior Labial Artery ndash Branches from Facial Artery

near the commissure ndash Deep to Depressor Angularis

Oris ndash Enters Orbicularis Oris and runs

along lower lip to anastamose with opposite side

Anatomy

bull Subunits

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Anatomy

Melolabial crease

Labiomandibular crease

Red Lip

White Lip Vermillion Border

Mental Crease

Anatomy

Philtral Ridge

Anatomy

Anatomy

Arterial Details

bull Course of Facial Artery

ndash Branches off External Carotid Artery

ndash Courses across the mandible to the oral commissure

ndash Deep to Risorius and Superficial to Buccinator

ndash Can be found approximately 1 ndash 2 cm from oral commissure2

Further Arterial Details

bull Superior Labial Artery ndash Deep to Zygomaticus Major ndash Gives of Angular artery then

enters orbicularis oris ndash Runs along upper lip and

anastamoses with opposite side

bull Inferior Labial Artery ndash Branches from Facial Artery

near the commissure ndash Deep to Depressor Angularis

Oris ndash Enters Orbicularis Oris and runs

along lower lip to anastamose with opposite side

Anatomy

bull Subunits

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Melolabial crease

Labiomandibular crease

Red Lip

White Lip Vermillion Border

Mental Crease

Anatomy

Philtral Ridge

Anatomy

Anatomy

Arterial Details

bull Course of Facial Artery

ndash Branches off External Carotid Artery

ndash Courses across the mandible to the oral commissure

ndash Deep to Risorius and Superficial to Buccinator

ndash Can be found approximately 1 ndash 2 cm from oral commissure2

Further Arterial Details

bull Superior Labial Artery ndash Deep to Zygomaticus Major ndash Gives of Angular artery then

enters orbicularis oris ndash Runs along upper lip and

anastamoses with opposite side

bull Inferior Labial Artery ndash Branches from Facial Artery

near the commissure ndash Deep to Depressor Angularis

Oris ndash Enters Orbicularis Oris and runs

along lower lip to anastamose with opposite side

Anatomy

bull Subunits

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Anatomy

Anatomy

Arterial Details

bull Course of Facial Artery

ndash Branches off External Carotid Artery

ndash Courses across the mandible to the oral commissure

ndash Deep to Risorius and Superficial to Buccinator

ndash Can be found approximately 1 ndash 2 cm from oral commissure2

Further Arterial Details

bull Superior Labial Artery ndash Deep to Zygomaticus Major ndash Gives of Angular artery then

enters orbicularis oris ndash Runs along upper lip and

anastamoses with opposite side

bull Inferior Labial Artery ndash Branches from Facial Artery

near the commissure ndash Deep to Depressor Angularis

Oris ndash Enters Orbicularis Oris and runs

along lower lip to anastamose with opposite side

Anatomy

bull Subunits

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Anatomy

Arterial Details

bull Course of Facial Artery

ndash Branches off External Carotid Artery

ndash Courses across the mandible to the oral commissure

ndash Deep to Risorius and Superficial to Buccinator

ndash Can be found approximately 1 ndash 2 cm from oral commissure2

Further Arterial Details

bull Superior Labial Artery ndash Deep to Zygomaticus Major ndash Gives of Angular artery then

enters orbicularis oris ndash Runs along upper lip and

anastamoses with opposite side

bull Inferior Labial Artery ndash Branches from Facial Artery

near the commissure ndash Deep to Depressor Angularis

Oris ndash Enters Orbicularis Oris and runs

along lower lip to anastamose with opposite side

Anatomy

bull Subunits

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Arterial Details

bull Course of Facial Artery

ndash Branches off External Carotid Artery

ndash Courses across the mandible to the oral commissure

ndash Deep to Risorius and Superficial to Buccinator

ndash Can be found approximately 1 ndash 2 cm from oral commissure2

Further Arterial Details

bull Superior Labial Artery ndash Deep to Zygomaticus Major ndash Gives of Angular artery then

enters orbicularis oris ndash Runs along upper lip and

anastamoses with opposite side

bull Inferior Labial Artery ndash Branches from Facial Artery

near the commissure ndash Deep to Depressor Angularis

Oris ndash Enters Orbicularis Oris and runs

along lower lip to anastamose with opposite side

Anatomy

bull Subunits

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Further Arterial Details

bull Superior Labial Artery ndash Deep to Zygomaticus Major ndash Gives of Angular artery then

enters orbicularis oris ndash Runs along upper lip and

anastamoses with opposite side

bull Inferior Labial Artery ndash Branches from Facial Artery

near the commissure ndash Deep to Depressor Angularis

Oris ndash Enters Orbicularis Oris and runs

along lower lip to anastamose with opposite side

Anatomy

bull Subunits

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Anatomy

bull Subunits

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Functional Importance

bull Roles

ndash Oral Competence

ndash Deglutition

ndash Expression of Emotions

ndash Speech ndash required for 6 consonants

bull Purely Labial ndash ldquobrdquo ldquomrdquo ldquowrdquo ldquoprdquo

bull Labial-Dental ndash ldquofrdquo ldquovrdquo

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Functional Importance

bull Another key factor to consider prior to reconstruction is the patientrsquos dentition

bull Edentulous patients pose an important challenge to reconstruction as only a mild degree of microstomia may be acceptable if dentures are worn

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Lip Cancer Staging and Treatment

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Lip Cancer Facts

bull Lip Cancer Incidence ndash 1-2 1

bull Most Common Oral Cavity Cancer

bull Risk Factors

ndash Prolonged Sun Exposure

ndash Male

ndash Pipe-smokingTobacco Chewing

ndash Alcohol consumption

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Lip Cancer

bull gt 90 is on red lip

bull 90 is on Lower Lip

bull 90 is Squamous Cell Carcinoma

bull Basal Cell Carcinoma occurs more commonly on Upper Lip

bull Excellent 5-year prognosis if lt 2 cm

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Lip Cancer

bull Squamous Cell Carcinoma ndash Mainly on Red Lip

bull Basal Cell Carcinoma ndash Mainly on Cutaneous White Lip

bull Rarer Types ndash Adenocarcinoma ndash secondary to minor salivary gland

presence

ndash Melanoma

ndash Lymphoma

ndash Sarcoma

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Lip Cancer

bull Upper Lip spreads to ipsilateral lymph nodes ndash Levels I ndash III

ndash Embryologic fusion in the midline prevents contralateral spread

bull Lower Lip spreads to ipsilateral and contralateral lymph nodes ndash Levels I - III

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Staging of Lip Cancer

bull T1 primary tumor lt2 cm

bull T2 primary tumor 2ndash4 cm

bull T3 primary tumor gt4 cm

bull T4 primary tumor invades adjacent structures (eg through cortical bone skin through floor of mouth)

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Treatment of Lip Cancer

bull Surgical Treatment is Mainstay

ndash Need 05 cm margins around tumor

bull Neck Dissection is often performed in conjunction especially if lower lip cancer

ndash Elective Supraomohyoid neck dissection for N0 necks

ndash Levels I-IV neck dissection for N1-N3 disease

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Radiation Therapy for Lip Cancer

bull Radiation Therapy

ndash May be used as primary treatment if T1 or non-operable patient

ndash Also used for

bull post-operative XRT for advanced stages

bull close margins

bull extracapsular extension

bull perineuralintravascular invasion

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Reconstruction

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Upper Lip Algorithm

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Lower Lip Algorithm

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Reconstruction Options

bull Small Defect

ndash Wedge Excision ndash Primary closure

ndash Local V-Y flaps can also be used for very small defects

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Full Thickness Excision Wedge Resection

bull Best suited for Lesions smaller than frac12 the lip

bull Can be closed as a V or W

bull Good functional and aesthetic outcome

bull Key is to re-approximate the vermillion border appropriately

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Full Thickness Excision Wedge Resection

Pictures courtesy of Dr Etai Funk

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Reconstruction Options

bull Large Defect

ndash Mucosal Advancement Flap

ndash Abbeacute Flap

ndash Estlander-Abbeacute Flap

ndash Karapandzic Flap

ndash Gilles Fan Flap (Nasolabial)

ndash Radial Forearm Free Flap

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Mucosal Advancement Flap

bull For use only in lesions of the red lip

bull Favored method for restoration of the vermillion

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Mucosal Advancement Flap bull Key Surgical Step

ndash Undermine labial mucosa deep to minor salivary glands and superficial to the posterior aspect of the orbicularis oculi

From Baker ndash Local Flaps in Facial Reconstruction

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Mucosal Advancement Flap

bull Concerns

ndash Advanced mucosa may display a deeper red color than natural vermillion

ndash Difficult to approximate vermillion line if lip skin is involved

ndash Contracture of flap can lead to inversion of lip

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Mucosal Advancement Flap

Pictures Courtesy of Dr Athre

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Abbeacute Flap

bull Flap is based on the principle of creating a pedicle from the lip without the lesion to the area of the defect

bull Based of the arterial supply of the labial artery ndash either superior or inferior

bull Ideal for lesions involving 13 ndash 23 of the lip

bull Lesions must not involve the commissure

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Abbeacute Steps (Cross Lip Flap)

bull Surgical Steps ndash 1 Draw defect on affected lip

ndash 2 Draw the flap on the opposite lip to be half the width of the defect

ndash 3 Make the full-thickness incision

ndash 4 Rotate the flap 180 degrees

ndash 5 Suture flap with each individual layer

ndash 6 Dress wound to minimize tension

ndash 7 Divide pedicle at 14-21 days

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Abbeacute Flap

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Abbeacute Flap

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Abbeacute Flap

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Estlander Flap

bull Similar to Abbeacute Flap

bull Key is that the Estlander Flap involves the commissure

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Estlander Flap

Pictures courtesy of Dr Patt

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Estalander Flap

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Estlander Flap

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Estlander Flap

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Karapandzic Flap

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Karapandzic

bull Indications

ndash Defects less than frac12 of upper lip

ndash Defects less than 23 of lower lip

ndash Full thickness defects

ndash Best suited for rectangular defects of the central lower lip

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Karapandzic

bull Key Surgical Steps

ndash Superiorly continue the incisions into the nasolabial fold

ndash Raise only skin and mucosa

ndash May selectively cut portions of the orbicularis oris near the original commissure

bull Advantage

ndash Preserves perioral sensation and function of the orbicularis oris by saving CN V3 and VII

bull Disadvantage

ndash Risk of Microstomia (directly proportional to size of defect)

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Karapandzic Flap

Pictures Courtesy of Dr Moody and Dr Lies

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Nasolabial Transpositional Flap

bull Aka Gilles Fan Flap

bull Rotation-Advancement Flap

bull Rotate the flap around the commissure to create a neo-commissure

bull Useful with upper lip lesions

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Gillies Flap

bull Surgical Steps ndash 1 For lower lip start with full thickness incision

medial to defect

ndash 2 Then continue the full thickness incision laterally and around the commissure

ndash 3 Then follow the melolabial fold

ndash 4 Then carry the incision down to the superior vermillion border

ndash 5 Advance flap and suture individual layers together

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Nasolabial Flap

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Nasolabial Flap

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Radial Forearm Free Flap bull Selected for Large Full-

Thickness Defects

bull Can be performed with the Palmaris Longus Tendon

bull Skin Paddle is used to cover both the lip skin and oral mucosal defect

bull Palmaris Longus Tendon is transected within 5 cm of either end of the flap

bull Secure the Palmaris Longus Tendon into the Orbicularis Oris Muscle

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Radial Forearm Free Flap

Pictures courtesy of Dr Athre

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Upper Lip Algorithm

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Lower Lip Algorithm

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Pictures

Thanks to

- Dr Athre

- Dr Lies and Dr Moody

- Dr Funk

- Dr Patt

Other pictures and drawings were taken from Baker

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7

Bibliography

bull Papel I et al Facial Plastic and Reconstructive Surgery Chapter 51 Lip Reconstruction Thieme Publishing New York NY 2002 634-645

bull Baker SR et al Local Flaps in Facial Reconstruction Chapter 19 Reconstruction of the Lip Mosby Elsevier Philadelphia PA 2007 475-524

bull Dolan RW et al Facial Plastic Reconstructive and Trauma Surgery Chapter 7 Specialized Local Facial Flaps for the Eyelids and Lips Marcel Dekker Inc New York NY 2003 201-232

bull Pasha R et al Otolaryngology Head and Neck Surgery Clinical Reference Guide Chapter 5 Head and Neck Cancer Singular San Diego CA 2001 239-243

bull 1Moretti A et al Surgical Management of Lip Cancer Acta Otorhinolaryngol Ital 2011 February 31(1) 5ndash10 bull 2Schulte DL Sherris DA Kasperbauer JL The anatomical basis of the Abbeacute flap Laryngoscope 2001

Mar111(3)382-6 bull McCarn KE Park SS Lip reconstruction Otolaryngol Clin North Am 2007 Apr40(2)361-80 bull Jeng SF Kuo YR Wei FC Su CY Chien CY Total lower lip reconstruction with a composite radial forearm-palmaris

longus tendon flap a clinical series Plast Reconstr Surg 2004 Jan113(1)19-23 bull Abbeacute RA A new plastic operation for the relief of deformity due to double hairlip Med Rec 188953447 bull Estlander JA Eine Methods ans der einen Lippe substanzverluste der anderen zu ersetzen Arch Klin Chir 187214

622 bull Karapandzic M Reconstruction of lip defects by local arterial flaps Br J Plast Surg 19742793-7 bull Freedman A M and Hidalgo D A Full-thickness cheek and lip reconstruction with the radial forearm free flap

Ann Plast Surg 25 287 1990 bull Daya M Nair V Free radial forearm flap lip reconstruction a clinical series and case reports of technical

refinements Ann Plast Surg 2009 Apr62(4)361-7