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lip reconstruction

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lip reconstruction

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  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
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  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
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lip reconstruction

  1. 1. LIP RECONSTRUCTION Dr. Sumer Yadav Mch – Plastic and reconstructive surgery sumeryadav2004@gmail.com
  2. 2.  Lips are vital portions of an individualsLips are vital portions of an individuals face and personality that provide visualface and personality that provide visual contact to our fellow man and conveycontact to our fellow man and convey feelings and emotions at a glancefeelings and emotions at a glance  Formation of speechFormation of speech  Maintain oral secretions as a dam &Maintain oral secretions as a dam & prevent drooling.prevent drooling.  Ingestion of food and drinks.Ingestion of food and drinks. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  3. 3. Onco-surgeon’s definition, by AJCOnco-surgeon’s definition, by AJC Begins at the junction of the vermilionBegins at the junction of the vermilion border with skin and extends upto theborder with skin and extends upto the portion of lip that comes in contact withportion of lip that comes in contact with the opposite lipthe opposite lip Surgeon’s definition.Surgeon’s definition. Extends from one naso-labial fold to otherExtends from one naso-labial fold to other and includes entire area below noseand includes entire area below nose including vermilion & intraorally toincluding vermilion & intraorally to gingivo-labial sulcusgingivo-labial sulcus sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  4. 4. Topography of lipsTopography of lips 1.1. philtral columnsphiltral columns 2.2. Philtral groovePhiltral groove 3.3. Cupid’s bowCupid’s bow 4.4. White roll upperWhite roll upper liplip 5.5. TubercleTubercle 6.6. CommissureCommissure 7.7. vermilionvermilion sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  5. 5. 1000B.C.1000B.C. SushrutaSushruta First mention of labial repairFirst mention of labial repair 1597A.D.1597A.D. TagliacozziTagliacozzi Upper and lower lip repair by distal arm flapUpper and lower lip repair by distal arm flap 17681768 LouisLouis First wedge excisionFirst wedge excision 18341834 DieffenbachDieffenbach Lower lip repair with inferiorly based flapsLower lip repair with inferiorly based flaps 18381838 SabbattiniSabbattini Full thickness switch flap from lower to upperFull thickness switch flap from lower to upper liplip 18451845 DieffenbachDieffenbach Nasolabial flap for upper lip repairNasolabial flap for upper lip repair 18571857 Von BrunsVon Bruns Nasolabial flaps for lower lip defectNasolabial flaps for lower lip defect 18721872 EstlanderEstlander Lateral triangular upper lip flap for lower lip.Lateral triangular upper lip flap for lower lip. 19091909 LexerLexer Tongue flaps for lip reconstructionTongue flaps for lip reconstruction 19541954 schuchardtschuchardt Sliding inferiorly based cheek flapsSliding inferiorly based cheek flaps 19691969 BakamjianBakamjian Deltopectoral flap for lower lip defects.Deltopectoral flap for lower lip defects. 19741974 KarapandzicKarapandzic Emphasis on oral sphincter reconstructionEmphasis on oral sphincter reconstructionsumeryadav2004@gmail.comsumeryadav2004@gmail.com
  6. 6. Perioral musculaturePerioral musculature  Orbicularis oris:Orbicularis oris: Horizontal – purse stringing, Compress lips together.Horizontal – purse stringing, Compress lips together. ObliqueOblique –– evert lip.evert lip.  Elevators:Elevators: Levator labii superiorisLevator labii superioris Zygomaticus majorZygomaticus major Levator anguli orisLevator anguli oris  Mentalis – elevation and protrusion of central aspect of lower lipMentalis – elevation and protrusion of central aspect of lower lip  Depressors:Depressors: Depressor labii inferioris (Quadratus)Depressor labii inferioris (Quadratus) Depressor anguli oris (triangularis)Depressor anguli oris (triangularis) sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  7. 7. PERIORALPERIORAL MUSCULATUREMUSCULATURE sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  8. 8. NEURO- ANATOMYNEURO- ANATOMY  Motor:Motor: Buccal branch – elevators & orbicularis orisBuccal branch – elevators & orbicularis oris Facial nerveFacial nerve Marginal mandibular – depressorsMarginal mandibular – depressors  Sensory:Sensory: MaxillaryMaxillary –– Infraorbital nerve – upper lipInfraorbital nerve – upper lip TrigeminalTrigeminal Mandibular – inferior alveolar – mental nerveMandibular – inferior alveolar – mental nerve - lower lip- lower lip sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  9. 9. NEURO- ANATOMYNEURO- ANATOMY sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  10. 10. Vascular anatomyVascular anatomy  Through facial artery viaThrough facial artery via Superior & inferior labial artery.Superior & inferior labial artery.  Labial arteries, after piercing orbicularis oris – lie betweenLabial arteries, after piercing orbicularis oris – lie between the muscle and the mucosa.the muscle and the mucosa.  Facial artery tortuous in this region – gained length forFacial artery tortuous in this region – gained length for pedicled flaps.pedicled flaps. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  11. 11. Etiologies of lipEtiologies of lip defectsdefects  CongenitalCongenital  TraumaTrauma  BurnsBurns  Vasculitis, HaemangiomasVasculitis, Haemangiomas  NeoplasmNeoplasm  Infectious diseasesInfectious diseases sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  12. 12. Lip injuries – theLip injuries – the differencesdifferences  UNDERLYING NONGIVING TEETHUNDERLYING NONGIVING TEETH  TYPE OF HUMAN BITETYPE OF HUMAN BITE  GOOD VASCULARITYGOOD VASCULARITY  MINIMAL SCARRINGMINIMAL SCARRING  GOOD ELASTICITYGOOD ELASTICITY sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  13. 13. UPPER ~ LOWER LIPUPPER ~ LOWER LIP DEFECTSDEFECTS  Central philtral column with two equalCentral philtral column with two equal sidessides  Lower lip has no definative centralLower lip has no definative central structure hence it may sustain greaterstructure hence it may sustain greater loss without distortion.loss without distortion. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  14. 14. CLASSIFICATION OF LIPCLASSIFICATION OF LIP DEFECTSDEFECTS  Upper lipUpper lip 1.1. Vermilion defectsVermilion defects 2.2. Defects of < 30%Defects of < 30% 3.3. Defects of > 30%Defects of > 30% 4.4. Midline philtral defectsMidline philtral defects  Lower lipLower lip 1.1. Vermilion defectsVermilion defects 2.2. Defects of < 30%Defects of < 30% 3.3. Defects of 30 to 65%Defects of 30 to 65% 4.4. Defects of > 65%Defects of > 65% sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  15. 15. Principles of reconstructionPrinciples of reconstruction  Preserve sensation of the lipsPreserve sensation of the lips  Maintain oral competenceMaintain oral competence  Continuity of vermillion borderContinuity of vermillion border  Sufficient oral access (not too small,Sufficient oral access (not too small, microstoma)microstoma)  Adequate lip appearanceAdequate lip appearance sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  16. 16. GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS  For upper lip reconstruction, lower lip can be used , butFor upper lip reconstruction, lower lip can be used , but vice versa is avoided.vice versa is avoided.  Defect of 30% of the upper or lower lip can be closedDefect of 30% of the upper or lower lip can be closed primarily – great elasticity of lips.primarily – great elasticity of lips.  For defects greater than 30% tissue must be added orFor defects greater than 30% tissue must be added or shared from opp. normal lip.shared from opp. normal lip.  For 60% or greater defects other adjacent or distantFor 60% or greater defects other adjacent or distant flaps may be needed.flaps may be needed.  White roll or muco-cutaneous or vermilion border mustWhite roll or muco-cutaneous or vermilion border must be aligned properly.be aligned properly.  For incisions that cross vermilion border should do soFor incisions that cross vermilion border should do so at 90 deg.at 90 deg.  Good muscle approximation is must for competency ofGood muscle approximation is must for competency of oral stoma and prevents further scar widening.oral stoma and prevents further scar widening. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  17. 17. VERMILIONVERMILION DEFECTSDEFECTS sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  18. 18. Primary repairPrimary repair  Meticulous reattachment of laceratedMeticulous reattachment of lacerated tissue.tissue.  Save as much as possibleSave as much as possible  Thorough washing is must with mildThorough washing is must with mild antiseptic solution.antiseptic solution.  Best results when performed with in firstBest results when performed with in first few hours after injury.few hours after injury. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  19. 19. Primary closurePrimary closure sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  20. 20. Small vermilionSmall vermilion defectsdefects  V-y closure ofV-y closure of small lip defectsmall lip defect using a slidingusing a sliding flap.flap.  V-y closure of aV-y closure of a defect using twodefect using two sliding flaps.sliding flaps. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  21. 21. Wedge shaped defectsWedge shaped defects  Defects excisedDefects excised  Superiorly &Superiorly & inferiorly basedinferiorly based mucosalmucosal triangles are cuttriangles are cut  Muscle layerMuscle layer closed &closed & mucosalmucosal triangles aretriangles are transposed.transposed. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  22. 22. Large superficial vermilionLarge superficial vermilion defectsdefects  Mucosal slidingMucosal sliding flap.flap.  The intact lipThe intact lip mucosa ismucosa is mobilized,mobilized, advanced toadvanced to cover thecover the defect.defect. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  23. 23. Kawamoto’s VermilionKawamoto’s Vermilion switchswitch  Upper lipUpper lip deficiencies maydeficiencies may often be treatedoften be treated by transverselyby transversely oriented flapsoriented flaps  Divided after 10-Divided after 10- 14 days14 days sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  24. 24. Vermilion advancement ofVermilion advancement of Goldstein (1984)Goldstein (1984)  MyomucosalMyomucosal advancementadvancement flaps.flaps.  Vermilion defectsVermilion defects involving uptoinvolving upto one third ofone third of length can belength can be repaired withoutrepaired without any deformityany deformity sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  25. 25. Vermilion defectsVermilion defects (more than 1/3)(more than 1/3)  Mucosal flap from anterior margin ofMucosal flap from anterior margin of tongue, based on right or left side istongue, based on right or left side is swung into the defect- flap division afterswung into the defect- flap division after 2 wks.2 wks.  ventral papillary surface for females,ventral papillary surface for females, takes lipstick colors.takes lipstick colors. Tongue flapTongue flap sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  26. 26. Total vermilionectomy defectsTotal vermilionectomy defects  Mucosa of oral vestibule mobilized –Mucosa of oral vestibule mobilized – advanced over raw surface & sutured.advanced over raw surface & sutured.  May cause thinning of lip, inward pullingMay cause thinning of lip, inward pulling of hair bearing skin, tense free lip margin.of hair bearing skin, tense free lip margin. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  27. 27. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  28. 28. Lip reductionLip reduction  Mucosa & someMucosa & some muscle tissue aremuscle tissue are excised intraorallyexcised intraorally from protuberantfrom protuberant lips and closurelips and closure done.done. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  29. 29. Augmentation of upperAugmentation of upper liplip  A bipedicled flap is cut from lower lipA bipedicled flap is cut from lower lip and upper lip incisedand upper lip incised  Flap is transferred to the upper lipFlap is transferred to the upper lip and donor defect is closed.and donor defect is closed.  Flap is divided after 2 wks.Flap is divided after 2 wks. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  30. 30. Vermilion defectsVermilion defects  Small defects – wedge excisionSmall defects – wedge excision - v-y advancement flaps- v-y advancement flaps  Less than 1/3 – Mucosal slide flapsLess than 1/3 – Mucosal slide flaps - Muco-muscular advancement- Muco-muscular advancement flapsflaps  1/3 to 2/3 defects – Vermilion switch1/3 to 2/3 defects – Vermilion switch - Tongue flaps- Tongue flaps - Buccal mucosal- Buccal mucosal advancement flapsadvancement flaps  Total defects – Tongue flapsTotal defects – Tongue flaps - Buccal mucosal advancement flaps- Buccal mucosal advancement flaps sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  31. 31. UPPERUPPER LIPLIP RECONSTRUCTIONRECONSTRUCTION sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  32. 32. Upper lip reconstructionUpper lip reconstruction (median scars, and defects)(median scars, and defects)  Crescent shapedCrescent shaped excisions madeexcisions made lateral to alar groove,lateral to alar groove, scar excised, lip isscar excised, lip is mobilized & broughtmobilized & brought down normaldown normal position.position.  Z-plasty added toZ-plasty added to adjust the position ofadjust the position of vermilion.vermilion. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  33. 33. Upper lip reconstructionUpper lip reconstruction (median scars, and distortion of(median scars, and distortion of vermilion)vermilion)  Scar is excised andScar is excised and releasing incisionsreleasing incisions are made inare made in nasolabial folds.nasolabial folds.  Tumor or scarTumor or scar excised and scar isexcised and scar is dispersed by Z plastydispersed by Z plasty sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  34. 34. Upper lip reconstructionUpper lip reconstruction (larger scars and contractures)(larger scars and contractures)  Large burn scarsLarge burn scars and contracturesand contractures covered with fullcovered with full thickness postthickness post auricular grafts.auricular grafts. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  35. 35. Three-layered Abbe flapThree-layered Abbe flap  Three layered Abbe’s flapThree layered Abbe’s flap incised out from lower lipincised out from lower lip  Rotation of flap into theRotation of flap into the upper lip defect.upper lip defect.  Modification of Abbe’s flapModification of Abbe’s flap with different shapes ofwith different shapes of incisionsincisions  The flap is divided 20 daysThe flap is divided 20 days later.later. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  36. 36. Double Abbey’s flapDouble Abbey’s flap  By Wexler & DingmanBy Wexler & Dingman  May be used to close 75% central defects ofMay be used to close 75% central defects of lower lip.lower lip.  Causes definite shortening of lipCauses definite shortening of lipsumeryadav2004@gmail.comsumeryadav2004@gmail.com
  37. 37. Estlander flap (1872)Estlander flap (1872)  Similar to Abbe flap atSimilar to Abbe flap at commissure.commissure.  Wedge shaped flap based onWedge shaped flap based on inferior labial artery, is rotatedinferior labial artery, is rotated around angle of mouth into thearound angle of mouth into the defect.defect.  About 16-20 days later theAbout 16-20 days later the pedicle is divided, triangularpedicle is divided, triangular mucosal flaps are mobilizedmucosal flaps are mobilized  Z- plasty is added for closureZ- plasty is added for closure of donor site.of donor site. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  38. 38. UPPER LIP DEFECTUPPER LIP DEFECT sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  39. 39. Intra-operatively afterIntra-operatively after debridementdebridement sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  40. 40. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  41. 41. Nasolabial flapsNasolabial flaps  Bilateral nasolabial flaps for total near-Bilateral nasolabial flaps for total near- total upper lip defects.total upper lip defects.  Recreates upper lip anatomyRecreates upper lip anatomy  Inferiorly based for hairless skin inInferiorly based for hairless skin in femalesfemales  Superiorly based for hairy skin in males.Superiorly based for hairy skin in males.  Use of levator anguli oris in distallyUse of levator anguli oris in distally based.based.  Restores sensations, restores oralRestores sensations, restores oral sphincter, provides satisfactory totalsphincter, provides satisfactory total upper lip reconstruction with Abbe’s flapupper lip reconstruction with Abbe’s flapsumeryadav2004@gmail.comsumeryadav2004@gmail.com
  42. 42. Central Upper lip reconstructionCentral Upper lip reconstruction  Method byMethod by CelsusCelsus & Bruns& Bruns  Two-layer crescentTwo-layer crescent shaped incisionshaped incision made lateral to themade lateral to the alar groove andalar groove and extended alongextended along nasal base.nasal base. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  43. 43. Celsus method combined withCelsus method combined with an Abbe flapan Abbe flap  Large defects of upper lip can be reduced by CelsusLarge defects of upper lip can be reduced by Celsus method and then closed by using Abbe flap.method and then closed by using Abbe flap. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  44. 44. Neurovascular islandNeurovascular island flapflap  Three layered flapThree layered flap is advanced on ais advanced on a neurovascularneurovascular pediclepedicle  Repaired in v-yRepaired in v-y advancementadvancement manner.manner. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  45. 45. Neurovascular myocutaneousNeurovascular myocutaneous island flapisland flap  The flap cut in threeThe flap cut in three layers, preserving itslayers, preserving its neurovascular pedicleneurovascular pedicle  Flap advanced into upperFlap advanced into upper lip defect and burrow’slip defect and burrow’s triangles excised.triangles excised.  Mucosal flaps from oralMucosal flaps from oral vestibule – to lateral lipvestibule – to lateral lip defect.defect.sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  46. 46. Gillies fan flapGillies fan flap  Three layered nasolabial flap cutThree layered nasolabial flap cut around ala, nourished by labialaround ala, nourished by labial vessels.vessels.  Gillies flap is usually cut in twoGillies flap is usually cut in two layers & mucosa is mobilizedlayers & mucosa is mobilized toward midlinetoward midline  Flap contains orbicularis orisFlap contains orbicularis oris muscle, it is dissected bluntly tomuscle, it is dissected bluntly to preserve the superior and inferiorpreserve the superior and inferior labial vessels.labial vessels.  Lateral Z-plasty gives sufficientLateral Z-plasty gives sufficient mobility.mobility. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  47. 47. Upper lip recostruction of weerdaUpper lip recostruction of weerda  Left side is reconstructed with a twoLeft side is reconstructed with a two layer bilobed flap.layer bilobed flap.  Cheek flap is advanced on the right side.Cheek flap is advanced on the right side. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  48. 48. Defect in nasal vestibule orDefect in nasal vestibule or upper lipupper lip  An inferiorly based nasolabial flap canAn inferiorly based nasolabial flap can be used to repair a defect in the upperbe used to repair a defect in the upper lip or nasal vestibule.lip or nasal vestibule. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  49. 49. Burrow’s cheekBurrow’s cheek advancement flapadvancement flap  Crescent shaped skin excision is made in alarCrescent shaped skin excision is made in alar groove.groove.  The cheek is advanced and all defects areThe cheek is advanced and all defects are closed.closed. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  50. 50. Modified cheekModified cheek advancementadvancement  Flap is cut and the cheek is mobilized byFlap is cut and the cheek is mobilized by a crescent shaped excision in the areaa crescent shaped excision in the area of the alar groove & lateral noseof the alar groove & lateral nose sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  51. 51. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  52. 52. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  53. 53. Hair- bearing skinHair- bearing skin flapsflaps  Island temporal hair bearing scalp flapIsland temporal hair bearing scalp flap  Sub-mental skin flaps (unilateral orSub-mental skin flaps (unilateral or bilateral pedicle flaps)bilateral pedicle flaps)  Cervical skin flaps (unilateral or bilateralCervical skin flaps (unilateral or bilateral pedicle flaps)pedicle flaps)  Cheek advancement flapsCheek advancement flaps sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  54. 54. Wilson’s hair bearing scalp &Wilson’s hair bearing scalp & glabouros forehead flapsglabouros forehead flaps  Based on superficial temporal artery.Based on superficial temporal artery.  Hair bearing scalp for skin cover & foreheadHair bearing scalp for skin cover & forehead skin for the lining –skin for the lining – Groucho Marx Moustache.Groucho Marx Moustache.  Bipedicled tongue flap for vermilion.Bipedicled tongue flap for vermilion.  Abbe’s flap for philtral reconstruction.Abbe’s flap for philtral reconstruction. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  55. 55. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  56. 56. Tzur’s Hair bearing neckTzur’s Hair bearing neck flapflap • Delayed bipedicled neck flap may provide hairy skin • An inferior extension of glaborous skin provides lining. • Flap can be taken from Submental region. • Can be done in female patients. • Provides normal looking hair in proper direction. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  57. 57. Upper lip defectsUpper lip defects  Upto 1/4Upto 1/4thth loss – Primary repair.loss – Primary repair. - Wedge excision- Wedge excision Philtrum – Abbe’s flapPhiltrum – Abbe’s flap  ¼ to 2/3 loss – Abbe’s flap¼ to 2/3 loss – Abbe’s flap - Cheek advancement- Cheek advancement - Estlander’s flap- Estlander’s flap - Zisser-Madden’s flap- Zisser-Madden’s flap - Gille’s fan flap- Gille’s fan flap - Celsus Flaps- Celsus Flaps - Neurovascular island flap- Neurovascular island flap  Total loss – B/L nasolabial flapTotal loss – B/L nasolabial flap - B/L Cheek advancement flaps.- B/L Cheek advancement flaps. - Tzur’s hair bearing submantal flap- Tzur’s hair bearing submantal flap - wilson’s hair bearing scalp flap- wilson’s hair bearing scalp flap sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  58. 58. LOWERLOWER LIPLIP RECONSTRUCTIONRECONSTRUCTION sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  59. 59. Primary closurePrimary closure  25-30% in young patients and up to 33%25-30% in young patients and up to 33% in elderly patients can be resected.in elderly patients can be resected.  Lip asymmetry & loss of circumference isLip asymmetry & loss of circumference is functional and aesthetically normal.functional and aesthetically normal.  When lateral resection carried outWhen lateral resection carried out denervation of central orbicularis oris-denervation of central orbicularis oris- neurotization – satisfactory function.neurotization – satisfactory function. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  60. 60. Scarred lower lipScarred lower lip  Scar excised &Scar excised & wounds closed inwounds closed in multiple Z- plasties.multiple Z- plasties. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  61. 61. Modifications of wedgeModifications of wedge excisionexcision  Small defects of lowerSmall defects of lower lip can be repaired by v-lip can be repaired by v- y technique.y technique.  Excess tissue should beExcess tissue should be provided to vermilion toprovided to vermilion to prevent formation ofprevent formation of new defect.new defect.  Should not crossShould not cross labiomental fold-labiomental fold- hypertrophic scarhypertrophic scar occurs.occurs. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  62. 62. Modifications of wedgeModifications of wedge excisionexcision  Wider excisionWider excision possible uptopossible upto 2cms. By2cms. By excising in thisexcising in this mannermanner sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  63. 63. Modifications of W-Modifications of W- plastyplasty  Modifications in W-Modifications in W- plasty do not crossplasty do not cross labio-mental foldlabio-mental fold thus preventthus prevent hypertrophichypertrophic scarring.scarring. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  64. 64. Lip stumps mobilizationLip stumps mobilization  The central growth isThe central growth is excised (for up to 40-excised (for up to 40- 50% of defects)50% of defects)  The stumps areThe stumps are mobilized by excisingmobilized by excising burrow’s trianglesburrow’s triangles lateral to the upperlateral to the upper lip and the chin.lip and the chin.  SCHUCHARDTSCHUCHARDT’s’s flap if upper lipflap if upper lip incision are not doneincision are not done  Causes decreasedCauses decreased oral circumferenceoral circumferencesumeryadav2004@gmail.comsumeryadav2004@gmail.com
  65. 65. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  66. 66. uu sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  67. 67. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  68. 68. Post electrical burnPost electrical burn injury lip defectinjury lip defect sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  69. 69. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  70. 70. Johanson’s step ladderJohanson’s step ladder techniquetechnique  Two to four steps areTwo to four steps are to be designed.to be designed.  For up to 2/3 defects.For up to 2/3 defects.  Good sensation,Good sensation, muscle continuity &muscle continuity & function.function.  Scars areScars are conspicuous,conspicuous, tightness oftightness of reconstructed lipreconstructed lip occurs.occurs. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  71. 71. Estlander flap (1872)Estlander flap (1872)  Three layeredThree layered triangular flap outtriangular flap out lined in upper-liplined in upper-lip  Lateral limb extendsLateral limb extends to the commissureto the commissure along the nasolabialalong the nasolabial fold.fold.  Flap is rotated intoFlap is rotated into the defect, bringingthe defect, bringing the lateral vermilionthe lateral vermilion downward & mediallydownward & medially  sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  72. 72. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  73. 73. Causes shortening of mouth Opening with deviation of Angle. Following commissuroplasty. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  74. 74.  ModifiedModified Estlander flapEstlander flap for large centralfor large central defects.defects.  ModificationModification preservingpreserving angle of mouth.angle of mouth. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  75. 75. Gillies fan flapGillies fan flap (1957)(1957)  For largeFor large mediolateral defectsmediolateral defects not involvingnot involving commissurescommissures  Flap is basically aFlap is basically a large Eastlander flaplarge Eastlander flap that is rotated aroundthat is rotated around orbicularis oris &orbicularis oris & possibly maintainingpossibly maintaining its neurovascularits neurovascular supply.supply.  Z- plasty at cornersZ- plasty at corners increases the extent.increases the extent.  Causes distortion ofCauses distortion of sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  76. 76. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  77. 77. Universal method of Bernard,Universal method of Bernard, Grimm & FriesGrimm & Fries  For subtotal defectsFor subtotal defects  Lateral cheek is mobilizedLateral cheek is mobilized by cutting burrow’sby cutting burrow’s triangles.triangles.  Cheek U flap isCheek U flap is deepithelized anddeepithelized and resurfaced with mucosalresurfaced with mucosal flap from cheek.flap from cheek. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  78. 78. Meyer’s modificationMeyer’s modification  Triangles are cutTriangles are cut lateral to upper liplateral to upper lip & cheek mucosa& cheek mucosa is incised &is incised & mobilized.mobilized.  Mucosa turnedMucosa turned over to the lateralover to the lateral reconstructed lip.reconstructed lip.  Distortion of oralDistortion of oral commissure andcommissure and loss of oralloss of oral circumferencecircumferencesumeryadav2004@gmail.comsumeryadav2004@gmail.com
  79. 79. Karapandzic flapKarapandzic flap  For midline defects of lower lip.For midline defects of lower lip.  Safe, lips as donor tissue soSafe, lips as donor tissue so better results.better results.  No droling as adequate muscleNo droling as adequate muscle function and fibre direction isfunction and fibre direction is maintained.maintained.  Contraindicated if no donorContraindicated if no donor tissue available, ablation of bothtissue available, ablation of both facial artery & ant. br. of nasalfacial artery & ant. br. of nasal septal artery, upper lipseptal artery, upper lip irradiation and commissureirradiation and commissure involvement.involvement. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  80. 80.  Gillies;Gillies; distorts thedistorts the commissure.commissure.  KarapandzicKarapandzic;; intactintact neurovascular pedicle,neurovascular pedicle, oral apperture narrowedoral apperture narrowed  McGregor;McGregor; pivots aroundpivots around commissure, lesscommissure, less distorting, new vermilliondistorting, new vermillion & changed direction of& changed direction of fibres.fibres.  Nakajima;Nakajima; similar tosimilar to McGregor’s but facialMcGregor’s but facial vessels are spared.vessels are spared. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  81. 81. Fugimori’s Gate flapsFugimori’s Gate flaps • Used for total lower lip reconstruction. • Mucosal flaps provide vermilion coverage. • Facial vessels are left intact. • Revisional surgeries are often required • More chances of upper lip denervation. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  82. 82. Bakamjian’s Deltopectoral flapBakamjian’s Deltopectoral flap  Can be used afterCan be used after radical excision ofradical excision of lower lip andlower lip and surrounding tissue.surrounding tissue.  Blood supply by 2Blood supply by 2ndnd && 33rdrd intercostal vessels.intercostal vessels.  Averages 25 cm longAverages 25 cm long & 12 cm wide.& 12 cm wide.  Pivot point –Pivot point – emergence of 2emergence of 2ndnd intercostal vessels.intercostal vessels.  Denervated lower lipDenervated lower lipsumeryadav2004@gmail.comsumeryadav2004@gmail.com
  83. 83. PlatysmaPlatysma Musculocutaneous flapsMusculocutaneous flaps  Skin flap island designed on the lateral aspect of neckSkin flap island designed on the lateral aspect of neck above clavicle.above clavicle.  Turnover platysma muscle flap superiorly basedTurnover platysma muscle flap superiorly based pivoting along mandible including skin island in distalpivoting along mandible including skin island in distal third for resurfacing intraoral mucosa.third for resurfacing intraoral mucosa.  Careful dissection along medial border to avoidCareful dissection along medial border to avoid damage to submental branches of facial artery.damage to submental branches of facial artery.  Tone of transplanted muscle sufficient to prevent labialTone of transplanted muscle sufficient to prevent labial ectropion.ectropion.  Injury to 11Injury to 11thth nerve & mandibular branch of facial arenerve & mandibular branch of facial are potentially disastrous.potentially disastrous. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  84. 84. Lower lipLower lip  Less than 1/3 loss – Primary closureLess than 1/3 loss – Primary closure -- wedge excision v or w shaped closurewedge excision v or w shaped closure  1/3 to 2/3 loss – Schuchard’s1/3 to 2/3 loss – Schuchard’s - Johanson’s step ladder flap- Johanson’s step ladder flap - Abbe’s flap- Abbe’s flap - Estlander- Estlander - Bernard’s flap- Bernard’s flap - Webster- Bernard flap- Webster- Bernard flap - Bandoneon’s technique- Bandoneon’s technique - Gille’s fan flap- Gille’s fan flap - Karapandzic flap- Karapandzic flap - Mcgregor’s flap- Mcgregor’s flap - Nakajima’s flap- Nakajima’s flap - Depressor anguli oris flap- Depressor anguli oris flap  Total loss - Fujimori’s gate flapTotal loss - Fujimori’s gate flap - Meyer- Bernard flap- Meyer- Bernard flap - B/L McGregor flaps- B/L McGregor flaps - B/L Depressor anguli oris flap- B/L Depressor anguli oris flap - B/L Steeple flap for lower lip reconstruction- B/L Steeple flap for lower lip reconstruction - Bakamjian’s Deltp-pectoral flaps- Bakamjian’s Deltp-pectoral flaps - Platysmal flaps- Platysmal flaps sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  85. 85. COMMISSURECOMMISSURE RECONSTRUCTIONRECONSTRUCTION sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  86. 86. Oral fissure elongationOral fissure elongation Ganzer methodGanzer method  Elliptical triangle isElliptical triangle is excised, incisionexcised, incision is made aroundis made around the vermilionthe vermilion without dividing itwithout dividing it  Entire vermilion isEntire vermilion is advanced laterallyadvanced laterally and sutured intoand sutured into the defect.the defect.sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  87. 87. Elongation of oralElongation of oral fissurefissure  Triangle of epithelium isTriangle of epithelium is excised down toexcised down to mucosa, which is intact.mucosa, which is intact.  The existingThe existing commissure is excisedcommissure is excised  T-shaped incisions inT-shaped incisions in exposed mucosa & theexposed mucosa & the three mucosal flaps arethree mucosal flaps are turned out & sutured.turned out & sutured. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  88. 88. Lifting angle ofLifting angle of mouthmouth  Z-plasty used to raiseZ-plasty used to raise angle of mouthangle of mouth sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  89. 89. Reconstruction by method ofReconstruction by method of BrusatiBrusati  The commissure isThe commissure is excised & Burrow’sexcised & Burrow’s triangles are excised.triangles are excised.  U-shaped cheek flap isU-shaped cheek flap is advanced into theadvanced into the defect.defect.  Small area at of flap atSmall area at of flap at commissure is excisedcommissure is excised and mucosa isand mucosa issumeryadav2004@gmail.comsumeryadav2004@gmail.com
  90. 90.  Reconstruction ofReconstruction of vermilion by dual V-vermilion by dual V- Y advancement flap.Y advancement flap.  Buccal mucosaBuccal mucosa turned inside out.turned inside out.  Loss of muscle atLoss of muscle at commissure causescommissure causes oral incompetence.oral incompetence. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  91. 91. Method of Fries and BrusatiMethod of Fries and Brusati  The incisions areThe incisions are placed on aplaced on a semicircular segmentsemicircular segment in cheek above andin cheek above and below.below.  Secondary defectsSecondary defects closed by excision ofclosed by excision of Burrow’s triangles.Burrow’s triangles.  The commissure isThe commissure is restored by suturingrestored by suturing small triangularsmall triangular mucosal flapsmucosal flaps advanced over de-advanced over de- sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  92. 92.  Low cheek rotationLow cheek rotation combined with ancombined with an Estlander flap.Estlander flap.  Disadv. –Disadv. – Shortening of lipsShortening of lips with oralwith oral incompetence.incompetence. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  93. 93. Large full thicknessLarge full thickness reconstruction of commissurereconstruction of commissure and lipand lip  Defect excised andDefect excised and EssarEssar cheek rotation flapcheek rotation flap outlined.outlined. Incision is made below theIncision is made below the lower lip & skin mobilized.lower lip & skin mobilized.  All defects closed and scarsAll defects closed and scars are dispersed with Z-plastiesare dispersed with Z-plasties in RSTLsin RSTLs  Residual defects in oralResidual defects in oral portion of cheek can beportion of cheek can be covered with tongue flap.covered with tongue flap.  Though lip length is someThough lip length is some what preserved, oralwhat preserved, oral incompetence remains.incompetence remains. sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  94. 94. ReferencesReferences  Mathes – Plastic Surgery.Mathes – Plastic Surgery.  McCarthy – Plastic Surgery.McCarthy – Plastic Surgery.  Grabb’s – Encyclopedia of flaps.Grabb’s – Encyclopedia of flaps.  Grabb and Smith’s – Plastic Surgery.Grabb and Smith’s – Plastic Surgery.  Weerda’s – Reconstructive facial plasticWeerda’s – Reconstructive facial plastic surgery.surgery.  e- medicine – internet.e- medicine – internet.  Gray’s anatomy.Gray’s anatomy.  Gillies & Millard – The principles & Art ofGillies & Millard – The principles & Art of Plastic Surgery.Plastic Surgery.sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  95. 95. PERFECT SMILEPERFECT SMILE sumeryadav2004@gmail.comsumeryadav2004@gmail.com
  96. 96. sumeryadav2004@gmail.comsumeryadav2004@gmail.com

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