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Lip reconstruction


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Chicago Facial Plastic Surgeon Dr. Anil Shah discusses lip reconstruction.

Lip reconstruction

  1. 1. Lip Anatomy and Reconstruction
  2. 2. Lip Reconstruction • Lips provide 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. 3. Lip Reconstruction • Most lip reconstructions will be performed for lip cancer
  4. 4. • Which lip is SCCA most commonly found?
  5. 5. • Lower Lip
  6. 6. • Which lip is BCCA most commonly found?
  7. 7. Lip Reconstruction • Traumatic injury 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. 8. • Injury to Marginal Mandibular Nerve? • Which side is injured? • Right side is higher than left at rest.
  9. 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. 10. • What is lymphatic drainage of lips?
  11. 11. • What are the only muscles which are not supplied on the undersurface?
  12. 12. • 3 deep perioral muscles: • Mentalis • Levator Anguli Oris • Buccinator
  13. 13. • What is function of superficial portion of orbicularis oris? • Fine movements • What is function of deep? • sphincteric
  14. 14. • 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.
  15. 15. • 3 layers of 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
  16. 16. 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
  17. 17. • How do you perform a lip block?
  18. 18. • Palpate infraorbital foramen • Draw line down vertically from pupil to infraorbital ridge • 4-7 mm below orbital rim perpendicular from medial limbus of iris
  19. 19. Mental Nerve • Located between 2 second mandibular bicuspid with 6-10mm of lateral visibility • Frequently visible
  20. 20. Lip Anatomy • Motor innervation 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
  21. 21. Lip • Vermillion- Border between skin of face and lip • Wet lip (mucous membrane)-nonkertanized • Dry lip (exterior lip)-kertanized • Red lip • White lip
  22. 22. Lip Anatomy • The most important aesthetic landmark is the white roll • For optimal cosmesis, the nasolabial and labiomental creases should not be violated
  23. 23. Lip Anatomy • The upper lip is divided into aesthetic subunits which should be considered in reconstructive planning • The lower lip has only one subunit
  24. 24. • Oral commissure involved? • Eastlander • Not involved? • Abbe
  25. 25. • How wide should the Abbe flap be? • ½ the size of the defect
  26. 26. • Disadvantage of Abbe flap • Risk of microstomia • 2-staged procedure • Risk of patient tearing flap by opening mouth too wide
  27. 27. • Primary complication of Eastlander flap • Microstomia
  28. 28. • Major advantage of Karpandzic circumoral rotation flap?
  29. 29. • Orbicularis oculi preserved
  30. 30. Vermilion Reconstruction • The vermilion can be reconstructed with a buccal mucosal advancement flap
  31. 31. 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
  32. 32. Vermilion Reconstruction • A V-Y advancement flap of muscle and mucosa can restore volume in a notch deformity
  33. 33. Lower Lip Reconstruction
  34. 34. Wedge excisions with primary closure • wedge resections should not violate nasolabial or nasomental crease • Burow’s triangles will allow for medial lip advancement
  35. 35. Medium Lower Lip Defects • 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
  36. 36. Abbe Flap • Flap ½ size of defect taken full thickness • Leave Pedicled at Vermillion Border • 2nd stage at 3 weeks
  37. 37. Abbe Flap
  38. 38. Medium Lower Lip Defects • Estlander Flap can be used for commissure defects • No new lip tissue created • Single stage • Rounded commissure • Good oral competence
  39. 39. Estlander Flap
  40. 40. Medium Lower Lip Defects • 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
  41. 41. Karapandzic Flap
  42. 42. Medium Lower Lip Defects • 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
  43. 43. Bernard-Burow’s Procedure
  44. 44. Large Lower Lip Defects • 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
  45. 45. • Best to address each subunit individually for large lip defects
  46. 46. Radial Forearm and Fibular Free Flaps
  47. 47. Upper Lip Reconstruction
  48. 48. 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
  49. 49. Small upper lip defects • lateral defects can be closed primarily • taper incision into nasolabial fold
  50. 50. Small Upper Lip Defects • Perialar crescentric excisions can be used for central defects • Loss of Cupid’s bow, philtrum can be disguised with mustache
  51. 51. Small upper lip defects • 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
  52. 52. Medium Upper Lip Defects • When centrally located, a combined Abbe flap with perialar crescentric excisions
  53. 53. Medium Upper Lip Defects • Karapandzic or Estlander flaps can also be used depending on commissure involvement
  54. 54. Large Upper Lip Defects • Unilateral Gilles flap can bring in new lip tissue • Motor and sensory function may not be restored
  55. 55. Large Upper Lip Defects • 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
  56. 56. Commissureoplasty • Can correct microstomia or asymmetry of the commissures • orbicularis oris deficiency can result leading to oral incompetence
  57. 57. Microstomia • Electrical • Early ointment • Early debridement not advised due to necrosis of muscle and soft tissue which extends beyond which is visible
  58. 58. Microstomia Surgical • Commisureoplasty
  59. 59. Lips • Define beauty in the lips • Lip Shapes • Natural Lips
  60. 60. Lips • Injectable fillers • Soft lip injection • Lasts 4-6 months • Fat transfer offers longer lasting results in some patients but some unpredictability
  61. 61. How to make your lips fuller without a procedure? • Lip plumpers • Drink a lot of water
  62. 62. Do Lip Plumpers Work? • 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
  63. 63. Lip Augmenation • Fat transfer • Implants (Gore-Tex, Alloderm) • Surgical Advancements
  64. 64. Surgical Advancment • V-Y incision • 2:1 relationship exists b/t Y limb and lip height
  65. 65.