Different approaches of lip reconstruction

1. PRESENTER
DR. A.F.M. SHAKILUR RAHMAN
FCPS PART-2 TRAINEE
DEPT. OF ORAL & MAXILLOFACIAL
SURGERY.
DHAKA DENTAL COLLEGE & HOSPITAL.

2. LIP
RECONSTRUCTION
BASED ON DEFECT
SIZE

3. INTRODUCTION
 The principles of management of lip cancer require
resection with negative margins and reconstruction
of the defect to restore form and function.
 Whether the defect is acquired by ablation or
trauma, is based upon the size, location, and
integrity of the local anatomy.

4. Defects Less than One-Third
of the Lip
Option-
 Wedge Excision with Primary Closure.
- “V”, “W”, Pentagon, Shield excision.
 Lateral (Rectangular) Advancement Flaps.

5. Defects One-Third to
Two- Thirds of the Lip
Lip-Switch Flaps(Cross-Lip Flaps)
1. Abbe flap
2. Estlander flap
3. Stein flap
 Johanson Stair-Step Flap.
 Fernandes flap.

6. Defects Half to Two-Thirds
of the Lip
Karapandzic Flap.
Webster-Modified Bernard Flap.
Gillies “Fan” Flap.
McGregor Flap.

7. Defects Greater Than
Two- Thirds of the Lip
Free flaps -
1. Radial forearm free flap.
2. Antero-lateral thigh flap.
 Bilateral Gillie’s fan flap.
 McGregor flap.
 Karapandzic flap.

8. Vermilionectomy or Lip Shave
 a. Incision line- vermilion border
anteriorly, Wet- dry line –
posteriorly .
 b. The vermilion is excised in a
submucosal plane.
 c. Resected vermilion specimen.
 d. The lip mucosa may be
undermined in a submucosal plane
(between the submucosa and
orbicularis oris muscle). The
mucusa is advanced anteriorly and
sutured to the skin with interrupted
5-0 prolene suture, which are later
removed after one week.

9. “V” Excision
 ( a ) Squamous cell carcinoma of
lower lip with actinic changes of
remainder of lip vermilion.
 ( b ) Excision margins are marked
out with a vermilionectomy
incorporated into the resection.
 (c) Excised specimen with suture
marking orientation.
 (d) The orbicularis oris muscle is
reapproximated primarily with 3-0
vicryl suture.
 (e) The reconstruction is completed
by reapproximating the skin.and lip
mucosa, and then advancing the
lip mucosa anteriorly to the skin
edge.

10. “W” Excision
 ( a ) The incision is marked out. A
vermilionectomy is incorporated into the
resection.
 ( b ) Completed resection, which
produced a full-thickness defect.
 ( c ) The orbicularis oris muscle is
reapproximated first, followed by
primary closure of the skin and
mucosa. The lip mucosa is then
advanced anteriorly to the skin edge.
 ( d ) Healed wound. Note the new lower
lip “vermilion” is thinned due to scar
contracture and the inward rolling of the
lower lip skin.

11. Shield Excision Pentagonal Excision

12. Lateral advancement flap
 a ) The lesion is excised in a full-
thickness fashion and the wound
edges are advanced medially.
Burow’s triangles (of skin and
subcutaneous tissue) may be
incorporated into the resection to
prevent bunching of the tissue
during wound advancement and
closure.
 ( b ) The wound is closed in three
layers and results in a T-shaped
scar

13. Abbe flap
 ( a ) The full-thickness triangular excision of
the upper lip is marked out, followed by the
incision of the lower lip. The lower lip incision
is also made in a full-thickness fashion,
however it stops at the vermillion border to
preserve the vascular pedicle, which is
typically based medially. Here, the base of
lower lip flap is made almost equal to the
width of the defect to help preserve
symmetry of the more conspicuous upper
lip. The base can also be made smaller to
“share” the tissue loss between both lips.
This is more important when rotating upper
lip flaps into lower lip defects.
 ( b ) The lower lip flap is then rotated
superiorly and inset into the upper lip defect.
The lower lip defect is closed primarily.
 ( c ) After three to four weeks of healing, the
vermillion tissue pedicle is divided and inset

14. Estlander flap
 a ) The full-thickness excision of the lower
lip and incision of the upper lip are
marked out. The upper lip flap is made
approximately one-half the width of the
lower lip defect. The upper lip incision
ends at the vermilion border to preserve
the medially-based pedicle based on the
superior labial artery.
 ( b ) The flap is rotated inferiorly and inset
into the lower lip defect. Note that the
commissure will always be blunted with
this flap.
 ( c ) Here a lower lip flap is used to
reconstruct an upper lip defect. Note that
its base is made equal the defect width to
preserve upper lip symmetry.
 ( d ) The flap is rotated superiorly and
inset.

15. Stein flap
 (a) The Stein flap uses two symmetrical
triangular flaps from the central upper lip
to reconstruct a defect of the central
lower lip. The incisions are placed at the
philtral columns.
 ( b ) The flaps are rotated and inset into
the lower lip defect. Note that the patient
now has two laterally-based vermilion
pedicles.
 ( c ) Like the Abbe flap, once sufficient
collateral circulation has formed, the
vermillion pedicles are divided and inset.

16. Johanson flap-
 (a ) Pre-operative photo of
squamous cell carcinoma of lower
lip.
 ( b ) Excision and fl ap design is
marked.
 ( c ) The lesion is excised in a full-
thickness fashion and combined
with a vermilionectomy.
 (d) Excisions of skin and
subcutaneous tissue are made
below each step and the skin flaps
are undermined laterally.
 ( e) The wound is primarily-closed
in a layered fashion and the
mucosa is advanced and
reapproximated to the skin edge to
close the vermilionectomy defect.
 ( f ) Healed wound a few weeks
after suture removal. The scar will
continue to fade and flatten with
time

17. Fernandes flap
 a ) Excision and flap design are
marked.
 ( b ) A full-thickness defect is
created, and skin and
subcutaneous tissue are excised to
allow medial flap advancement.
 ( c ) The wound is closed in layers
and the scar is placed at the
labiomental crease .

18. Karapandzic flap-
 (a ) Excision and flap design are
marked. The incision is carried
along the labiomental crease and
then turns superiorly to follow the
nasolabial creases.
 ( b ) Large lower lip defect.
 (c) The flaps are advanced
medially and the defect is closed
in a layered fashion.

19. Gillies fan flap
 ( a ) A curvilinear incision is
extended laterally and then
superiorly to follow the naso-labial
fold.
 ( b ) A full-thickness flap is then
raised and rotated medially to bring
lip and cheek tissue to the defect.
 ( c )Because the Gillies flap rotates
tissue around the corner of the
mouth, it will result in blunting of the
oral commissure.

20. Webstar Bernard flap
 (a )Excision and flap design are
marked. Crescent triangular
excisions of skin and subcutaneous
tissue are created at the nasolabial
and labiomental folds bilaterally to
allow for medial advancement of
the flaps.
( b ) Final reconstruction