HISTORICAL PERSPECTIVE Lip reconstruction

HISTORICAL PERSPECTIVE

Lip reconstruction for large defects of the lower and upper lip continues to be a formidable challenge. The first written description of lip reconstruction was by Susruta in 1000 BC, but an ancient Hindu description of facial, lip, and nasal reconstruction with a forehead flap is reported as early as 3000 BC.¹ Sabatini first described lip reconstruction using a cross-lip flap in 1837,² but a subsequent modification of this technique by Abbe and Estlander resulted in their names being ascribed to this method of reconstruction. Bernard and Burow later described a method of lip reconstruction for total and subtotal defects using bilateral full-thickness advancement flaps to the cheeks that were brought to the midline to fashion a new lip.^3,4 Full-thickness triangles were excised in the location of the nasal alar fold to alleviate puckering that resulted from tissue excess in that location. In the 1920s, Gillies described a classic fan flap using a full-thickness pedicle that allows redistribution of the remaining lip during the reconstructive effort and emphasized the use of a similar or like tissue.⁵ This concept was further modified by Karapandzic in 1974, who made incisions through the skin and mucosa at a distance equal to the depth of the defect, but with primary emphasis on preservation of the underlying musculature and neurovascular structures.⁶ More contemporary refinements for reconstruction of large lip defects by Burget and Menick include the importance of the subunit principle as it applies to the upper lip for an optimal aesthetic result.⁷ Microvascular reconstruction using radial forearm free flap and temporal scalp free flap have been used for large and total defects of the lip and their use may become more popular as more surgeons are trained in microvascular techniques and refinement procedures to maximize the functional and aesthetic outcomes.⁸

Evaluation of the patient in need of lip reconstruction requires a clear understanding of the lip anatomy, aesthetics, and function. In this chapter, a systematic approach will be emphasized based on the anticipated or presenting size and location of the lip defect for a given patient.

ANATOMICALCONSIDERATIONS

The primary objective of a reconstructive effort is an aesthetic result that approaches a normal appearance. Functional considerations, including oral competence, articulation, speech, and the role of the lips in mastication, must be kept in mind during reconstruction of large lip defects.

Anatomically, the lips extend vertically from the subnasale to the chin and horizontally from the oral commissure to oral commissure. Both upper and lower lips consist of a separate red lip and white lip component separated by a vermilion border.

The upper lip is a curved “M”-shaped structure with the highest points of the vermilion border just located at the philtral ridges. The philtral ridge extends bilaterally from the highest point of the vermilion border to the base of the columella, and between the lines is a central depression in the upper lip. The complexity of the surface topography, its lines and shadows, results in two medial and lateral subunits of the upper lip, first described by Ulloa-Gonzales and subsequently emphasized by Burget and Menick as illustrated in Fig. 59-1. A reconstructive effort of the upper lip in which the surgical defect is simply filled without regard to the subunit principle is perceived by the observer as a patch. Aesthetically, for the lip to look normal, the observer’s eye should perceive it as normal. The perception of normal is more accurately described as the absence of abnormal because the “mind’s eye” of the observer ignores the defect it would see and focuses on the absence of aberrance. During lip reconstruction, one should attempt to duplicate appropriate height, projection, and the relationship of white to red lip. In addition, because regional or distant tissue is a different color, the use of local tissue with local flaps generally provides a superior result. The lower lip anatomy is considerably less complex and more forgiving of reconstructive effort. However, the same general principles apply for an optimal aesthetic result.

Functionally, the lips act as a sphincter to assist in phonation, mastication, and speech. Anatomical structures that are important to the function of the lips and oral sphincter include the perioral facial musculature, the neurovascular anatomy, and the muscular modiolus, all of which are located between the mucosal surface and the cutaneous surface of the lips. The muscular modiolus is a fibrous structure located at the oral commissure bilaterally and is a site of insertion of the oral sphincter musculature as illustrated in Fig. 59-2. The most successful functional reconstruction will address not only the integrity of the muscular oral sphincter, but also the importance of the orientation, position, and function of the muscular modiolus within the oral sphincter.

TECHNIQUES OF RECONSTRUCTION

Although traumatic defects are routinely encountered, the most common defect challenging the facial plastic surgeon is a result of oncologic excision. Squamous cell carcinomas (SCCs) are the most common malignant neoplasm of the red lip (95%). Furthermore, lower lip SCCs outnumber upper lip SCCs (90% versus 10%), probably related to a more direct sun exposure encountered by the lower lip. However, in the author’s experience, most basal cell carcinomas of the upper lip arise from the cutaneous white upper lip.

Reconstructive procedures can be classified as:

1. Minor reconstruction
   1. Vermillion defects
   2. Small full-thickness defects (less than 30% horizontal lip)
   1.  
      1. Combination of previous
   2. Major reconstruction
      1. Medium-size defects (30-60% horizontal lip)
      1. Subtotal/total lip reconstruction
         1. Large defects (greater than 60% horizontal lip)
         1. Hessler F. Commentarii et Annotationes in Susrutae Ayurvedam Enlager. Enke 1855;12.
         1. Sabatini P. Cennestorico dell’origine e progressi della rhinoplastica e cheiloplastica. Bologna, Italy: Belle Arti, 1838.
         1. Abbe RA. A new plastic operation for the relief of deformity due to double hairlip. Med Rec 1889;53:447.
         1. Estlander JA. Eine Methods ans der einen Lippe Substanzverluste der anderen zu ersetzen. Arch Klin Chir 1872;14:622.
         1. Gilles HD. Plastic surgery of the face. London: Hodder & Stoughton Ltd, 1920.
         1. Karapandzic, M. Reconstruction of lip defects by local arterial flap. Br J Plast Surg 1974;27:93-97.
         1. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg 1985;76:239-247.
         1. Coppit GL, Lin DT, Burkey BB. Current concepts in lip reconstruction. Current Opin Otolaryngol Head Neck Surg 2004;12:281-287.
         1. Bernard C. Cancer de la levre inferieure: resauration a laide de deux lambeaux gwaadrilatere. Querison Bull Mem Svc Chir Paris. 1853;3:357.
         1. Burow CA. Beschreibung einer neunen Transplantations-Method (Method der seitlichen Dreiecke) zum Wiedersatz verlorengegangener Teile des Gesichts. Berlin: Nauck, 1855.
         1. Kroll SS. Staged sequential flap reconstruction for large lower-lip defects. Plast Reconstr Surg 1990;88:620-625.
         1. Williams EF, Setzen G, Mulraney MJ. Modified Bernard-Burow advancement and cross-lip flap for total lip reconstruction. Arch Otolaryngol Head Neck Surg 1996;122:1253-1258.
         1. Gaylon SW, Frodel JL. Lip and perioral defects. Otolaryngol Clin North America 2001;34:3:647-666.

      i. Lower lip

      ii. Upper lip

      MINOR RECONSTRUCTION Vermilionectomy

      Vermilionectomy is indicated in the patient with chronic actinic cheilitis or microinvasive SCC. Actinic cheilitis is almost exclusively seen in the lower lip and can persist for several months or years before progressing to SCC. A positive diagnosis is considered an indication for surgical treatment because of the long-term risk for invasive carcinoma. In the compliant patient where there is no concern regarding appropriate follow-up, the author advocates an ablation procedure with the CO₂ laser. Local anesthetic is infiltrated, and a laser resurfacing mode is used at the same parameters one would utilize to treat eyelid skin. Two or three passes are performed, and the appropriate short- and long-term follow-up recommended. In the author’s experience with a compliant patient, this approach is very successful, and it is more cosmetically acceptable than the traditional vermilionectomy and lip advancement procedure.

      Technique A vermilionectomy procedure is the time-honored and traditional procedure for actinic cheilitis or carcinoma in situ, especially in the patient for whom reliable follow-up might be a concern. A surgical marking pen is used to delineate the vermilion border from oral commissure to oral commissure. A fusiform-type excision of the vermilion is planned and a posterior incision is placed parallel to the anterior vermilion border incision. The lip is infiltrated with the appropriate amount to lidocaine with 1:100,000 epinephrine. Incisions are made and the vermilion is excised in a submucosal plane as illustrated in Figure 59-3. A submucosal dissection is carried from the posterior incision toward the gingival-buccal sulcus approximately two times the width of the fusiform excision from anterior to posterior. Posterior red lip is advanced in a meticulous repair that is performed along the vermilion with a 5-0 chromic suture. Two back-cuts from each oral commissure toward the sulcus may be necessary to facilitate advancement. It is important that the vermilion border is repaired without tension on the incision line.

      Wedge Excision and Primary Repair

      A wedge or full-thickness excision is indicated with invasive SCC of the lower lip. A full-thickness wedge excision and repair can be utilized for surgical defects measuring up to one third the size of the horizontal lip. The length of the lower lip generally measures 7 to 7.5 cm, allowing a surgical defect of approximately 2.5 cm. However, one should exercise judgment in the patient at the upper limit of an acceptable excision for primary repair. In a patient with less tissue elasticity or one in whom repair will result in a significant and noticeable discrepancy of the upper and lower lip, it may be advisable to reconstruct using a cross-lip flap.

      Technique A surgical marking pen is used to plan for the reconstruction. It is generally recommended that the vermilion border be marked adjacent to the line of resection as local anesthetic, edema, and the blanching effect of epinephrine often make a precise repair at the vermilion border difficult. The line of resection through the red lip should be perpendicular to the long axis of the red lip and allowed to converge beginning on the white lip as illustrated in Figure 59-4. The apex of the wedge should not extend beyond the mental crease or melolabial crease. Incorporation of an M-plasty in the repair is advised for larger wedge resections as it prevents the incision from crossing the lip-chin junction and assists in irregularizing a longer incision. The repair is begun by placing a 6-0 nonabsorbable, monofilament suture at the vermilion border (Prolene, nylon). Two or three interrupted sutures should then be placed in the orbicularis muscle with a longer lasting absorbable, monofilament polyglycolic suture (4-0 PDS, macron). A 4-0 chromic suture is used for the intraoral red lip, and the author prefers a 5-0 chromic suture for the exposed red lip repair. The skin should be closed with a 6-0 nonabsorbable, monofilament suture (Prolene, nylon). Combined Defects

      Occasionally, a patient presents with a discrete lower-lip lesion amenable to excision with a full-thickness repair. However, on inspection the remaining red lip has the clinical appearance of a severe actinic cheilitis, placing the patient at high risk for subsequent carcinoma of the lip. In this patient population, a full-thickness incision and repair should be performed in conjunction with vermilionectomy and lip advancement for the remaining red lip.

      Major Reconstruction Medium Sized Defects: Cross-Lip Flap

      Surgical defects measuring between 30 and 60% of the horizontal lip are best reconstructed with a staged cross-lip flap, as first described by Sabatini and further modified by Abbe and Estlander. In general, this corresponds to a surgical defect between 2.5 and 4.5 cm. The cross-flap reconstruction has the benefit of reconstructing a relatively large full-thickness lip defect with tissue of similar texture, complexion, thickness, and muscular activity. Electromyography studies at one year following reconstruction have confirmed the ability of the transferred orbicularis muscle to reinnervate successfully and function as an animated segment.⁷ Sensory function may also return after several months. In addition, the cross-lip reconstruction successfully redistributes the remaining upper and lower lip discrepancy to the deficient lip with a minimal effect on the muscular modiolus in orientation of the remaining musculature of the oral sphincter. Because of the complexity of the upper lip anatomy as compared with the lower lip anatomy, the primary consideration of a cross-lip flap reconstruction is generally the effect the reconstruction will have on the upper lip anatomy.

      Lower Lip

      The approach to lower lip defects of 30 to 60% with a cross-lip flap is fairly straightforward, with primary emphasis placed on how taking the upper lip donor flap will affect the upper lip aesthetically.

      Technique After a wedge resection of the lower lip has been performed, a triangular full-thickness flap is designed on the upper lip. Traditionally, a cross-lip flap is designed at a width of one half to two thirds of the horizontal lip surgical defect, as illustrated in Figure 59-5. A full-thickness incision is carried approximately 2 to 3 mm to the vermilion border, and a meticulous dissection through the orbicularis muscle allows preservation of the labial artery. Burget emphasizes the importance of the blood supply provided by the vermilion mucosa and stresses the importance of preserving approximately 5 mm of mucosa in addition to the labial artery, which is included in the pedicle. Division and inset of the flap should occur at 14 to 21 days, and no attempt is made to test the flap with a tourniquet as suggested by some authors.

      In the fastidious patient with a larger defect (60 to 70% lower lip), one should consider bilateral cross-lip flaps to fill the lower lip defect as shown in Figure 59-6. This approach not only keeps the incision lines at the junction of the aesthetic subunits of the upper lip, but it also distributes the loss between the upper lip lateral subunits rather than recruiting all tissue from one side and causing a noticeable upper lip asymmetry.

      Upper Lip

      Upper lip defects pose a greater challenge for an optimal reconstruction because of the surface topography, complexity of the anatomy, and potential for distorting the upper lip subunits, thus creating a noticeable asymmetry.

      Technique In defects that result in more than 50% loss of the subunit, the reconstructive surgeon should excise the remaining normal tissue and replace the entire subunit from the lower lip, as shown in Figure 59-7. The template from the contralateral normal subunit is outlined on the upper lip, and a similar technique is used for developing, transposing, and resecting the cross-lip flap. The contralateral normal lip is utilized for developing a template because the presence of local anesthetic, tumor, and edema will result in a less accurate template if one uses the involved lip and subunit. Subtotal/Total Lip Reconstruction

      Surgical defects measuring greater than 70 to 80% of the lip continue to be a formidable challenge. In the 1920s, Gillies first described the classic fan flap using a full-thickness pedicle that allows redistribution of the remaining lip as illustrated in Figure 59-8. Karapandzic further modified this concept with an incision through both the skin and mucosa, with emphasis placed on preservation of the underlying musculature, as shown in Figure 59-9. Both techniques are important for historical purposes but have shortcomings with regard to an optimal aesthetic and functional reconstruction as previously discussed. In a more recent report, Kroll described a similarly staged procedure that uses the Bernard-Burow modification of the Karapandzic fan flap (Fig. 59-10) followed by a cross-lip flap at a different operative setting.^9-11 In principle, this accomplishes the same goal of reconstructing the missing lip with like tissue. This approach addresses the problem of lip tissue discrepancy between the lip that is reconstructed and the remaining lip by redistributing lip tissue in an area where it is needed. Williams et al further described the simultaneous use of a modified Bernard-Burow cheek advancement flap and a cross-lip flap for total lower or upper lip defects.¹² We believe that the modified cheek flap offers several advantages over sequential reconstruction described by Kroll. The extended intraoral incisions described allow for considerable advancement of the cheek into the surgical defect while preserving the neurovascular structures of the remaining lip. Furthermore, the procedure offers a theoretical advantage of less postoperative microstomia because it recruits new lip tissue into the perioral area rather than rearranging or sharing the remaining lip.

      Large Defects Subtotal/Total Lower Lip Defects Technique Total lower defects are full-thickness defects that extend from oral commissure to oral commissure or past the oral commissure to include a portion of the cheek, as detailed in Figure 59-11. During the first stage of reconstruction, the lateral aspect of the lip is reconstructed using a modification of the Bernard-Burow flap. Incisions only through the mucosa are created in the gingival-buccal sulcus from the surgical defect posterior to the angle of the mandible. Next, a horizontally oriented parallel incision is made through the mucosa only from the oral commissure posteriorly so that it is at least 1 cm from the opening of Stenson’s duct. An inferiorly based mucosal flap is created at the anterior aspect of this incision to be used for creation of the lateral oral commissure in red lip. Finally, a Burow’s triangle full-thickness skin is excised from the most lateral aspect, allowing advancement.

      These surgical maneuvers allow mobilization of the cheek for recruitment in the lower lip reconstruction. At this time, a midline cross-flap is developed and rotated into the central aspect of this large central defect. A three-layered, full-thickness defect closure is now performed between the laterally advanced lower lip and the transposed central cross-lip flap. A new oral commissure is created by rotation and inset of the mucosal flap. At 2 weeks, a delayed section of the cross-lip flap is performed (Fig. 59-12).

      Subtotal/Upper Lip Defects Technique For upper lip defects, the modified Bernard-Burow cheek advancement is performed in a similar fashion. In addition, it may be necessary to excise a perialar crescent of skin bilaterally. When used in conjunction with bilateral cheek advancement, the suture lines will be placed where the eye expects to see a shadow and will thus look more normal. In contrast to reconstruction of the lower lip, it is more important to emphasize and employ the subunit principle as previously described. Post-Operative Considerations

      Post-operative edema is an unavoidable aspect of lip reconstruction that should be discussed with the patient prior to the procedure. Based on the author’s experience, the edema gradually resolves by between 12 and 18 months (Figure 59-13). The patient should be counseled on performing oral exercise as much as possible in the post-operative period. These exercises help to re-establish neuronal connections and lymphatic channels that can improve the functional result and help decrease edema, respectively.

      Asymmetry of the oral commisure or microstomia can result from surgical defects of the lips and present an aesthetic and functional dilemma.¹³ Cross-lip flaps involving the commissure can result in blunting at the commissure. These problems can be addressed with a commissuroplasty, involving excision of a triangular piece of cutaneous skin at both commissures with mucosal advancement to the apex. Care must be taken to have precise alignment of the commissure at the appropriate level. This can be done as an office procedure under local. Commissuroplasty is considered no sooner than 9 months after the lip reconstruction procedure.

      REFERENCES

      FIGURE LEGENDS

      Figure 59-1 Medial and lateral upper lip subunit.

      (Corresponds to Figure 51-1 in 2^nd edition)

      Figure 59-2 Periorbital musculature and muscular modiolus.

      (Corresponds to Figure 51-2 in 2^nd edition)

      Figure 59-3 Vermilionectomy technique.

      (Corresponds to Figure 51-3 in 2^nd edition)

      Figure 59-4 Wedge excision and primary full-thickness repair.

      (Corresponds to Figure 51-4 in 2^nd edition)

      Figure 59-5 Cross-lip flap technique.

      (Corresponds to Figure 51-5 in 2^nd edition)

      Figure 59-6 Modified bilateral cross-lip flap for the lower lip.

      (Corresponds to Figure 51-6 in 2^nd edition)

      Figure 59-7 Modified cross-lip flap for the upper lip with emphasis on the subunit principle. (Corresponds to Figure 51-7 in 2^nd edition) Figure 59-8 Gillies fan flap technique. (Corresponds to Figure 51-8 in 2^nd edition) Figure 59-9 Karapandzic flap technique. (Corresponds to Figure 51-9 in 2^nd edition) Figure 59-10 Bernard-Burow flap technique. (Corresponds to Figure 51-10 in 2^nd edition) Figure 59-11 Modified Bernard-Burow cheek advancement with simultaneous cross-lip flap. (Corresponds to Figure 51-11 in 2^nd edition)

      Figure 59-12 Intraoperative (A), immediate postoperative (B) and 1-year (C) result of a surgical defect extending from left and commissure to include entire lower lip, right oral commissure, and right cheek repaired with a modified Bernard-Burow cheek advancement with a simultaneous cross-lip flap.

      (Corresponds to Figure 51-12 in 2^nd edition)

      Figure 59-13 This patient underwent lip reconstruction with right cross-lip and cheek advancement flaps. Three-month post-operative result (A) , demonstrating significant upper lip edema. Twenty-three month post-operative result (B) with vast improvement in edema as well as a good functional result (C) , (D) .

   i. Upper lip

   ii. Lower lip

i. Lower lip

ii. Upper lip