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

1. Lip Anatomy and Reconstruction

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. Lip Reconstruction
• Most lip reconstructions will be performed
for lip cancer

4. • Which lip is SCCA most commonly found?

5. • Lower Lip

6. • Which lip is BCCA most commonly found?

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. • Injury to Marginal 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 is lymphatic drainage of lips?

12. • What are the only muscles which are not
supplied on the undersurface?

13. • 3 deep perioral muscles:
• Mentalis
• Levator Anguli Oris
• Buccinator

14. • What is function 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 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

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 do you perform a lip block?

19. • Palpate infraorbital foramen
• Draw line down vertically from pupil to
infraorbital ridge
• 4-7 mm below orbital rim perpendicular
from medial limbus of iris

20. Mental Nerve
• Located between 2 second mandibular
bicuspid with 6-10mm of lateral visibility
• Frequently visible

21. 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

22. Lip
• Vermillion- Border between 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 wide should 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 complication of Eastlander flap
• Microstomia

29. • Major advantage of Karpandzic circumoral
rotation flap?

30. • Orbicularis oculi preserved

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. Lower Lip Reconstruction

35. Wedge excisions with primary
closure
• wedge resections
should not
violate nasolabial
or nasomental
crease
• Burow’s
triangles will
allow for medial
lip advancement

36. 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

37. Abbe Flap
• Flap ½ size of defect taken full thickness
• Leave Pedicled at Vermillion Border
• 2nd stage at 3 weeks

38. Abbe Flap

40. Medium Lower Lip Defects
• Estlander Flap can be
used for commissure
defects
• No new lip tissue
created
• Single stage
• Rounded commissure
• Good oral competence

41. Estlander Flap

43. 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

44. Karapandzic Flap

46. 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

47. Bernard-Burow’s Procedure

48. 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

49. • Best to address each subunit individually for
large lip defects

50. Radial Forearm and Fibular Free Flaps

51. Upper Lip Reconstruction

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 lip defects
• lateral defects can be
closed primarily
• taper incision into
nasolabial fold

54. Small Upper Lip Defects
• Perialar crescentric
excisions can be used
for central defects
• Loss of Cupid’s bow,
philtrum can be
disguised with
mustache

55. 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

56. Medium Upper Lip Defects
• When centrally
located, a combined
Abbe flap with
perialar crescentric
excisions

57. Medium Upper Lip Defects
• Karapandzic or Estlander
flaps can also be used
depending on commissure
involvement

58. Large Upper Lip Defects
• Unilateral Gilles flap
can bring in new lip
tissue
• Motor and sensory
function may not be
restored

59. 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

60. Commissureoplasty
• Can correct
microstomia or
asymmetry of the
commissures
• orbicularis oris
deficiency can result
leading to oral
incompetence

61. Microstomia
• Electrical
• Early ointment
• Early debridement not advised due to
necrosis of muscle and soft tissue which
extends beyond which is visible

62. Microstomia Surgical
• Commisureoplasty

63. Lips
• Define beauty in 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 make your lips fuller
without a procedure?
• Lip plumpers
• Drink a lot of water

66. 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

67. Lip Augmenation
• Fat transfer
• Implants (Gore-Tex, Alloderm)
• Surgical Advancements

68. Surgical Advancment
• V-Y incision
• 2:1 relationship exists b/t Y limb and lip
height

70. www.shahmd.com