Lip

Reconstruction Steven Taylor, MD

Gregory Renner, MD

September 18, 2013

Overview

History

Anatomy

Causes for reconstruction

Reconstruction goals

Basic reconstructive options

Cases

References

This is not an all encompassing

presentation of repairs of lip

reconstruction.

Thank you Dr Renner for the procurement

of patient pictures and assistance in this

presentation.

History

Earliest known cheiloplasty was around

1000 BC, mentioned in the Indian sacred

texts of Susruta

http://en.wikipedia.org/wiki/File:Shushrut_statue.jpg

History

First mentioned repair in the Western

world was with Celsus in 25 AD.

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

History

Louis- 1768

Wedge excision with direct closure of margins

von Burrow- 1838

Small triangles removed for flap advancement

Serre- 1842

First to describe repair of the oral commissure

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524. Upper left picture: http://www.lipreconstruction.com/history

History

Robert Abbe- 1898.

Lip switch flap

Actually described by Sabttini 60 yrs earlier

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524. Upper left picture: http://www.lipreconstruction.com/history

History

Jacob Estlander- 1872

Full thickness triangular flap for lateral

defect repair.

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524. Upper left picture: http://www.lipreconstruction.com/history

History

“We can say without exaggeration that

the basis of almost every reconstructive

procedure in use today was established in

the mid-1800’s.”

Ricardo Mazzola

Over 300 options for lip reconstruction

have been described

Mazzola RF, Lupo G. Evolving Concepts in Lip Reconstruction. Clin Plastic Surgery. 11:583-617, 1984.

Anatomy

3 main units Cutaneous

Vermillion

Mucosal

Left: Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524. Right: McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Anatomy Cutaneous

Upper lip Borders

Superior- Nasal sill and columella

Lateral- Nasolabial fold

Inferior- vermilion lip

3 cosmetic units: 2 lateral and 1 medial Lateral units are bordered by the nasolabial groove

laterally and by the philtral crests medially

Medial philtral subunit is composed of the 2 convex philtral crests and the central philtral groove

Cupid's bow - downward projection of the philtral unit

White roll - light linear projection that circumferentially outlines the upper and lower lip Border of the cutaneous and vermilion lip

Anatomy

Cutaneous

Lower lip

Borders

Superior- vermillion

Lateral- Extension of nasolabial folds

Inferior- Mental crease

One aesthetic unit

Left: http://emedicine.medscape.com/article/1127307-overview#showall

Anatomy

Upper: McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380. Lower: http://en.wikipedia.org/wiki/File:Mouth.jpg. Accessed 9/10/2013

Anatomy

Vermillion

Modified mucosal membrane that lacks

pilosebaceous units, eccrine glands, and

salivary glands

Extensive superficial vasculature in this area

gives the vermillion its pink red color

Anatomy

Mucosal lip

Abuts the teeth and contains minor salivary

glands

Red line

Transition zone between the vermilion lip

and the mucosal lip

Anatomy

Muscles

Orbicularis Oris

Primary lip muscle

No bone

attachment

Acts as a sphincter for oral closure

http://emedicine.medscape.com/article/1288447-overview#showall

Anatomy

Lip Elevators

Levator Labii

Superioris Alaeque

Nasi

Levator Labii

Superioris

Zygomaticus major

Zygomaticus minor

Levator anguli oris

http://emedicine.medscape.com/article/1288447-overview#showall

Anatomy Lid depressors

Depressor anguli oris

Depressor labii inferioris

Lip Protrusion

Mentalis

http://emedicine.medscape.com/article/1288447-overview#showall

Anatomy Sensory

CN V Upper lip- infraorbital

nerve Lower lip- Mental

nerve

Motor CN VII

Buccal branch- orbicularis oris and elevators

Marginal branch- Orbicularis oris and depressors

http://emedicine.medscape.com/article/1288447-overview#showall

Anatomy

Blood supply

Superior and

inferior labial

arteries

Branch of Facial

artery

Arteries found

between Orbicularis

oris and submucosa

http://emedicine.medscape.com/article/1288447-overview#showall

Anatomy

Lymphatics

Primarily submental

and submandibular

Ferris RL, Gillman GS. Cancer of the Lip. Expert Consult. Ch 24. Accessed from online source 9/11/2013.

Aesthetic Subunits

Left: http://emedicine.medscape.com/article/1127307-overview#showall Right: J Oral Maxillofac Surg 61:1207-1211, 2003, An overview of facial aesthetic units.

Causes for Reconstruction

Malignancy

SCC most common neoplasm of the lips

>80% lip cancers

Lower Lip>> Upper lip

SCC at commissure or upper lip considered

more aggressive

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Causes for Reconstruction Other malignancies

Basal Cell Carcinoma More common at Upper lip

Melanoma

Microcystic adnexal carcinoma Yellow plaques, paresthesisas (perineural inv)

Locally invasive with high recurrence rate

Merkel cell carcinoma Neural Crest cells

Rapid growth

High rate of recurrence and metastasis

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Causes for Reconstruction

Other etiologies

Granulomatous cheilitis

Infection

Hemangiomas

Trauma

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Functions of the lips

Appearance

Speech

Swallowing/Nutrition

Emotional expression

Tactile information

Whistling, Blowing, Kissing

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Goals of Reconstruction Adequate excision of the lesion

Restore function oral sphincter competency

Minimize microstomia Allows access for dental/medical procedures

Need for dentures

Preserve or restore expressive & sensory functions

Normalize appearance Minimize scarring

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Goals of Reconstruction

Thorough approximation of muscles

Reduce contracture and “notching”

Maintain lip height

Respect aesthetic subunits

Important to properly align the vermillion

and white roll

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Goals of Reconstruction

Scar camoflouage

Mental crease

Philtral ridge

Melolabial fold

Upper: McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Lower: http://en.wikipedia.org/wiki/File:Mouth.jpg. Accessed 9/10/2013

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Repair

Over 300 repairs have been described

When possible, use the axiom

“Use of lip to repair the lip defect”

Reconstruction Ladder

Image from http://www.jaaos.org/content/15/5/290/F4.expansion

Repair

3 layer closure (mucosa, muscle, skin)

Mucosa to wet line

Muscle

White roll

Vermillion

Skin

Repair

Vermillion defects

Defects less than 1/3 of either lip

Defects wider than 1/3 of lower lip

Defects wider than 1/3 of upper lip

Commissure defects

_______________________

Total lip defects

Defects beyond the lips

Repair

Vermillion defects

Defects less than 1/3 of either lip

Defects wider than 1/3 of lower lip

Defects wider than 1/3 of upper lip

Commissure defects

_______________________

Total lip defects

Defects beyond the lips

Repair

Muscle Sparing

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Labial Mucosal Advancement Flap

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Repair

Other options include

V-Y flap

Cross lip vermillion flap

Tongue flap

Apron flap from the opposite mucosa

Full thickness vermillion advancement flap

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Repair

Vermillion defects

Defects less than 1/3 of either lip

Defects wider than 1/3 of lower lip

Defects wider than 1/3 of upper lip

Commissure defects

_______________________

Total lip defects

Defects beyond the lips

Repair

Defects less than 1/3 of either lip

Primary Closure

Wedge Excision (V- lip)

W-plasty

Bilateral Advancement flap

Photos courtesy of Gregory Renner, MD

V – Lip Repair

Photos courtesy of Gregory Renner, MD

W – Lip Repair

Photos courtesy of Gregory Renner, MD

W – Lip Repair

Photos courtesy of Gregory Renner, MD

Opposing Advancement Flaps

Photos courtesy of Gregory Renner, MD

Repair Primary Closure

Able to use for about defects <3cm stretched lip length

Potential Complications Microstomia

Accomodation for dentures needs to be considered

Sensory deficit May lead to problems with competence

Too much wound tension

Repair

Vermillion defects

Defects less than 1/3 of either lip

Defects wider than 1/3 of lower lip

Defects wider than 1/3 of upper lip

Commissure defects

_______________________

Total lip defects

Defects beyond the lips

Repair

Defects wider than 1/3 of lower lip

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Abbe flap (Sabattini)

Medial lesions

Pedicled off the labial artery

Flap smaller than defect

Division of pedicle after ~3 weeks

Abbe Flap

Photos courtesy of Gregory Renner, MD

Estlander Flap

Incorporates the

reconstructed oral

commissure

Based off labial

artery

For lateral defects

Creates blunting of

the oral commissure

Estlander Flap

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Karapandzic Flap

Preserves neurovascular bundle

Incisions made are not full thickness

Defects up to 2/3 lip length

May lead to microstomia

Can blunt the oral commissure

Upper: http://emedicine.medscape.com/article/1288447-overview#showall. Accessed 9/10/2013. Lower: Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Karapandzic Flap

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Large defects of the Lower Lip

Webster-Bernard

Burrows triangles

Lower Lip

Melolabial flap

Photos courtesy of Gregory Renner, MD

Repair

Vermillion defects

Defects less than 1/3 of either lip

Defects wider than 1/3 of lower lip

Defects wider than 1/3 of upper lip

Commissure defects

_______________________

Total lip defects

Defects beyond the lips

Upper Lip

May use Cross lip flaps

Estlander

Abbe flap

Melolabial flaps

Temporoparietal Flap

Melolabial Flap

Photos courtesy of Gregory Renner, MD

Upper Lip

Temporoparietal Flap

No muscle, but gravity aids in competence

Anticipate contraction and make the flap

slightly larger.

May use skin graft underneath the flap to

recreate the oral mucosa.

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Repair

Vermillion defects

Defects less than 1/3 of either lip

Defects wider than 1/3 of lower lip

Defects wider than 1/3 of upper lip

Commissure defects

_______________________

Total lip defects

Defects beyond the lips

Commissure defects

Difficult to recreate

Estlander

Karapandzic

Zisser Flap

Zisser Flap

Remove lesions

Buccal mucosa to recreate the

commissure

http://mingaonline.uach.cl/fbpe/img/cuadcir/v18n1/figura52.gif

Cases

Case #1

Recurrent SCC invading lower lip

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Case #1

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Case #2

Closmann JJ, et al. Reconstruction of Perioral Defects Following Resection for Oral Squamous Cell Carcinoma. J Oral Maxillofac Surg 64:367-374, 2006.

Closmann JJ, et al. Reconstruction of Perioral Defects Following Resection for Oral Squamous Cell Carcinoma. J Oral Maxillofac Surg 64:367-374, 2006.

Case #3

85 y F T2N0M0 SCC L lower lip

Closmann JJ, et al. Reconstruction of Perioral Defects Following Resection for Oral Squamous Cell Carcinoma. J Oral Maxillofac Surg 64:367-374, 2006.

Closmann JJ, et al. Reconstruction of Perioral Defects Following Resection for Oral Squamous Cell Carcinoma. J Oral Maxillofac Surg 64:367-374, 2006.

Case #4

2 cm defect of upper lip

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

Conclusions

There are multiple techniques for

managing lip reconstruction.

Abbe, Estlander and primary closure are

most common.

As much as possible, use lip to repair lip.

References Mona Lisa picture from

http://en.wikipedia.org/wiki/File:Mona_Lisa.jpg. Accessed 9/11/2013.

www.Lipreconstruction.com

http://www.slideshare.net/ronaldagador/lip-reconstruction

Baker, Shan. Local Flap in Facial Reconstruction. 2nd ed. Mosby. Ch. 19. Pgs 475-524.

Mazzola RF, Lupo G. Evolving Concepts in Lip Reconstruction. Clin Plastic Surgery. 11:583-617, 1984.

McCarn KE, Park SS. Lip Reconstruction. Otolaryngol Clin N Am. 40 (2007) 361–380.

http://emedicine.medscape.com/article/1288447-overview#showall. Accessed 9/10/2013.

Closmann JJ, et al. Reconstruction of Perioral Defects Following Resection for Oral Squamous Cell Carcinoma. J Oral Maxillofac Surg 64:367-374, 2006.