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Lip reconstruction
- 1. Lip Anatomy andReconstruction
- 2. Lip Reconstruction • Lipsprovide important aesthetic (ie. Mick Jagger) and functional role (both sphincteric and fine motor movements) • The vermilion is highly sensitive to temperature, touch and pain • Aims of reconstruction are to restore function, maintain sensation and avoid cosmetic deformity
- 3. Lip Reconstruction • Mostlip reconstructions will be performed for lip cancer
- 4. • Which lipis SCCA most commonly found?
- 5.
- 6. • Which lipis BCCA most commonly found?
- 7. Lip Reconstruction • Traumaticinjury to the lips is more challenging • Meticulous cleansing with minimal debridement to preserve as much tissue as possible usually allows for primary closure • Critical landmarks (vermilion border, philtrum, commissures) are realigned first • Closure proceeds: muscle layer, mucosa, skin • Flaps may be needed for closure or revision, but are usually done as a delayed procedure
- 8. • Injury toMarginal Mandibular Nerve? • Which side is injured? • Right side is higher than left at rest.
- 9. Lip Anatomy • the facial artery supplies the superior and inferior labial arteries, which anastamose to provide a dual blood supply to each lip • the arteries lie between the orbicularis oris and the oral mucosa
- 10. • What islymphatic drainage of lips?
- 12. • What arethe only muscles which are not supplied on the undersurface?
- 13. • 3 deep perioral muscles: • Mentalis • Levator Anguli Oris • Buccinator
- 14. • What isfunction of superficial portion of orbicularis oris? • Fine movements • What is function of deep? • sphincteric
- 15. • 8) Levator labii superioris, 9) Levator anguli oris, 10) Levator labii superioris alaeque nasi, 11) Orbicularis oris, 12) Mentalis, 13) Depressor labii inferioris, 14) Depressor anguli oris, 15) Platysma, 16) Masseter, 17) Zygomaticus major, 18) Zygomaticus minor, 19) Temporalis, 20) Lateral pterygoid, 21) Medial pterygoid, 22) Buccinator.
- 16. • 3 layersof muscles • Group I: Orbicularis oris, buccinator, levator anguli oris, depressor anguli oris, zygomaticus major, risorius • Group II: Levator labii superioris, levator labii superioris alaeque nasi, zygomaticus minor • Group III: Depressor labii inferiorius, mentalis, platysma
- 17. Lip Anatomy • orbicularis oris is solely responsible for lip closure, oral competence • The orbicularis is manipulated by superior elevator muscles and inferior depressor muscles: coordinate fine motor movement • Modiolus is area of muscle integration at each commissure
- 18. • How doyou perform a lip block?
- 19. • Palpate infraorbitalforamen • Draw line down vertically from pupil to infraorbital ridge • 4-7 mm below orbital rim perpendicular from medial limbus of iris
- 20. Mental Nerve • Locatedbetween 2 second mandibular bicuspid with 6-10mm of lateral visibility • Frequently visible
- 21. Lip Anatomy • Motorinnervation to the orbicularis oris is via the buccal branch of CN VII • The marginal mandibular nerve supplies the depressor muscles • These nerves run deep to the muscles • The trigeminal nerve supplies sensation to the upper lip via the superior labial nerve, a branch of the infraorbital nerve, and the lower lip via the mental nerve
- 22. Lip • Vermillion- Borderbetween skin of face and lip • Wet lip (mucous membrane)-nonkertanized • Dry lip (exterior lip)-kertanized • Red lip • White lip
- 23. Lip Anatomy • The most important aesthetic landmark is the white roll • For optimal cosmesis, the nasolabial and labiomental creases should not be violated
- 24. Lip Anatomy • The upper lip is divided into aesthetic subunits which should be considered in reconstructive planning • The lower lip has only one subunit
- 25. • Oral commissure involved? • Eastlander • Not involved? • Abbe
- 26. • How wideshould the Abbe flap be? • ½ the size of the defect
- 27. • Disadvantage of Abbe flap • Risk of microstomia • 2-staged procedure • Risk of patient tearing flap by opening mouth too wide
- 28. • Primary complicationof Eastlander flap • Microstomia
- 29. • Major advantageof Karpandzic circumoral rotation flap?
- 30. • Orbicularis oculipreserved
- 31. Vermilion Reconstruction • The vermilion can be reconstructed with a buccal mucosal advancement flap
- 32. Vermilion Reconstruction • advancement of a musculovermilion flap, raised deep to the labial artery • for defects of lower lip up to 1/3 (maybe 1/2) of lip
- 33. Vermilion Reconstruction • A V-Y advancement flap of muscle and mucosa can restore volume in a notch deformity
- 34.
- 35. Wedge excisions withprimary closure • wedge resections should not violate nasolabial or nasomental crease • Burow’s triangles will allow for medial lip advancement
- 36. Medium Lower LipDefects • Abbe flap converts medium defect to a small one • not for commissure defects • 2-stage (2-3 weeks) • no new lip tissue (must be enough remaining to prevent microstomia • flap can be based on either side
- 37. Abbe Flap • Flap½ size of defect taken full thickness • Leave Pedicled at Vermillion Border • 2nd stage at 3 weeks
- 38.
- 40. Medium Lower LipDefects • Estlander Flap can be used for commissure defects • No new lip tissue created • Single stage • Rounded commissure • Good oral competence
- 41.
- 43. Medium Lower LipDefects • Karapandzic Flap does not bring in new lip tissue • good for medial or lesions with commissure involvement • preserves neurovascular supply • microstomia more problematic with patients who wear dentures
- 44.
- 46. Medium Lower LipDefects • Bernard-Burow’s procedure generated new lip tissue to prevent microstomia • The advanced tissue lacks sensation and sphincteric function • Burow’s triangles are skin and subq tissue only • buccal mucosa advanced for vermilion
- 47.
- 48. Large Lower LipDefects • Karapandzic flap may be used in lesions up to 80% of lip, may cause microstomia • Bernard-Burow’s procedure provides new lip tissue, but sensation and competence problems can lead to drooling • Free flap may be needed in massive defects or those with insufficient lip or cheek tissue for reconstruction
- 49. • Best toaddress each subunit individually for large lip defects
- 50. Radial Forearm andFibular Free Flaps
- 51.
- 52. Upper Lip Reconstruction •Special considerations include presence of central structures (cupid’s bow, philtrum) • In men, facial hair aids in hiding scars • In men, nonhair-bearing flaps brought into hear-bearing areas can be noticeable • The upper lip is less important in oral competence • more lower lip tissue can be “borrowed” for upper lip reconstruction
- 53. Small upper lipdefects • lateral defects can be closed primarily • taper incision into nasolabial fold
- 54. Small Upper LipDefects • Perialar crescentric excisions can be used for central defects • Loss of Cupid’s bow, philtrum can be disguised with mustache
- 55. Small upper lipdefects • A nasolabial flap can be used in upper lip defects that spare the vermilion • The flap contains skin and subQ tissue • The donor site is closed along the nasolabial fold
- 56. Medium Upper LipDefects • When centrally located, a combined Abbe flap with perialar crescentric excisions
- 57. Medium Upper LipDefects • Karapandzic or Estlander flaps can also be used depending on commissure involvement
- 58. Large Upper LipDefects • Unilateral Gilles flap can bring in new lip tissue • Motor and sensory function may not be restored
- 59. Large Upper LipDefects • Upper lip Bernard- Burow’s procedure brings in new lip tissue • Sensation and motor function may not be restored • rarely, total upper lip reconstruction will require a distant or free flap
- 60. Commissureoplasty • Can correct microstomia or asymmetry of the commissures • orbicularis oris deficiency can result leading to oral incompetence
- 61. Microstomia • Electrical • Earlyointment • Early debridement not advised due to necrosis of muscle and soft tissue which extends beyond which is visible
- 62.
- 63. Lips • Define beautyin the lips • Lip Shapes • Natural Lips
- 64. Lips • Injectable fillers • Soft lip injection • Lasts 4-6 months • Fat transfer offers longer lasting results in some patients but some unpredictability
- 65. How to makeyour lips fuller without a procedure? • Lip plumpers • Drink a lot of water
- 66. Do Lip PlumpersWork? • Study by Dr. Most at U of Washington • Used Lip Explosion • 14 patients used for three months • No measurable difference • Only one patient thought would use the product again
- 67. Lip Augmenation • Fattransfer • Implants (Gore-Tex, Alloderm) • Surgical Advancements
- 68. Surgical Advancment • V-Yincision • 2:1 relationship exists b/t Y limb and lip height
- 70.