Partial or total reconstruction of the lip may arise in settings such as trauma, reconstruction of an ablative defect, and congenital settings. As carcinoma of the lip is the most common oral cavity malignancy (approximately 30%), it is crucial to have a clear plan for reconstruction. The major goals of lip reconstruction are to provide a functional and aesthetic outcome. To restore function, access to the oral cavity must be restored along with oral competency. Restoration of aesthetic appearance is equally important as the lips are a focal point for facial and verbal expression.

Defects of the lip are classified by thickness, location, and overall size. As these defects may involve skin, muscle, and mucosa, the treatment plan must be tailored to reconstruct each layer individually. The location is also critical as the vermilion border, philtral column, and commissure prove to be difficult areas to reconstruct. Finally, the size of the defect correlates with the ease (or difficulty) of reconstruction; in general, defects <30% can be closed with local advancement flaps; however, defects >60% often require complex or multiple options for closure.

There is an additional distinction between the reconstruction of the upper or lower lip. The two structures provide different degrees of function and aesthetics. Aesthetic restoration of the upper lip is more challenging as the result is more visible and the scars are less forgiving. Functional restoration of the upper and lower lip have different goals as both structures are dynamic independently. The lower lip functions in multiple axes in order to maintain oral competence; however, the upper lip function includes not only oral competency, but it also plays a role in phonation and speech.

Although there are many different options and specific eponyms associated with lip reconstruction, an understanding of the principles is far more important. As with any defect, the reconstructive “ladder” applies to lip reconstruction with respect to defect size, patient condition, and goals of the operation. The range of options span from wound healing by secondary intention, primary closure, skin grafting, composite grafting, local flaps, regional flaps, and free tissue transfer with incremental degrees of complexity based on the presenting defect.

Wound healing by secondary intention should not be an option in lip reconstruction except in the most dire of circumstances. Generally, healing by secondary intention will cause the formation of cicatrix, limiting mobility, speech, and oral competence. Split-thickness skin grafts provide temporary coverage of defects but have less than satisfactory aesthetic results in most areas of the lip and are clearly seen even years postoperatively. Full-thickness skin grafts are useful for secondary correction of lip contracture but, like split-thickness grafts, leave noticeable scarring.

The quality and texture of the lips are extremely difficult to recreate; therefore local flaps represent the best option for defects that cannot be closed primarily. Specialized structures of the lip such as the vermilion or mucosa are ideally reconstructed with available local tissue, as there are no adequate alternatives. Although local flaps provide suitable color match, adequate thickness of lip reconstruction, and generally acceptable scarring in the setting of trauma or tumor extirpation, there are several points of caution. The transposed segment may be somewhat
adynamic following transfer; additionally, secondary revision may be required due to the “pin-cushioning” effect of the differing levels of native tissue versus flap. Reconstruction of the commissure requires specialized local tissue rearrangement that is beyond the scope of this chapter (i.e., Z-plasties, V–Y advancement flaps).

Wound contracture can create further distortion after reconstruction and lead to poor functional and aesthetic outcomes. Scar contracture is problematic and even with ideal planning of scar location can compromise excellent results over time. Microstomia is another complication seen in lip reconstruction and should be avoided if possible. Finally, unlike other specialized structures of the face (ears, nose, eye), there are no prosthetics that can substitute reconstruction.

Before proceeding with any reconstructive procedure, it is important to discuss with the patient and family realistic expectations. As it is not possible in most circumstances to restore a perfectly normal lip, the surgeon must establish realistic goals. Along with informed consent, preoperative and postoperative photographic documentation is important for the medical record, especially in the setting of traumatic injuries that may lead to medicolegal review.