Lip Reconstruction



Lip Reconstruction


Bernard T. Lee

Samuel J. Lin



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.


Anatomy

The lips can be pictured as having a hexagonal shape with a superior and inferior border, and paired lateral borders both superiorly and inferiorly. These borders consist of a junction of specialized tissue, the vermilion, between the hair-bearing skin and mucosa. The superior border is in the form of the Cupid’s bow, a curvilinear shape with two apices. These two apices represent the lower junction to the philtral columns, which extend superiorly to the base of the nose. The vermilion–cutaneous border has a white roll that can be easily seen at Cupid’s bow. The vermilion is separated into dry and wet surfaces; the dry vermilion represents the red color of the external lip and the wet surface is the mucosal border where the upper and lower lips contact.

The muscular anatomy mainly consists of the elliptical orbicularis oris muscle, which encircles the lips as a sphincter. The muscle has eight segments, each in a fan-shaped distribution from the modiolus. In the upper lip, the orbicularis oris muscle inserts into the opposite philtrum and functionally compresses and everts the lip. Accessory muscles serve to elevate or depress the lips. The levator labii superioris, levator anguli oris, and the zygomaticus major and minor elevate the upper lip. The depressor labii inferioris and the depressor anguli oris muscle depress the lower lip; the latter also moves the commissure inferior and lateral. Finally, the mentalis muscle elevates and protrudes the central portion of the lower lip.

The buccal branch of the facial nerve innervates the orbicularis oris and elevator muscles. The marginal mandibular branch of the facial nerve innervates the lower lip depressors. The infraorbital nerve provides sensory innervation to the upper lip whereas the mental nerve supplies the lower lip. The main vascular supply to the lips is from branches of the facial artery as the superior and inferior labial arteries supply the upper and lower lips, respectively. The facial artery supplies the lateral nasal and angular arteries, both important for local flap blood supply.


Indications

The indications for lip reconstruction are straightforward as the most common etiology is from neoplasm or trauma. The most common tumor of the lips is squamous cell carcinoma, which affects the lower lips predominantly. The most common tumor of the upper lip is basal cell carcinoma. Complete excision of the tumor with clear margins is necessary prior to a complex reconstruction; Mohs’ micrographic surgery is preferred at many centers to achieve local control.

Lip reconstruction after trauma is most commonly seen after dog bites. These injuries are often complex and of full thickness. In the setting of a large composite amputated part, microsurgical replantation is indicated if the labial vessels can be identified. Pediatric burns to the commissure were previously common from children biting on electrical cords; however, these injuries are becoming exceedingly rare.



Upper Lip

Regional anesthesia for the upper lip can be performed with an infraorbital nerve block. The infraorbital nerve is located 7 mm below the infraorbital rim and at the midpupillary line lateral to the ala. A 25-gauge needle is introduced lateral to the alar base and directed superiorly toward the infraorbital foramen. An intraoral approach can also be used by injecting directly above the canine.








Table 1 Reconstruction of the Upper Lip






































Method Use Advantage Disadvantage Potential complications
Primary closure Defects up to 30% of lip No additional incisions May shorten lip Change in oral competence
A to T closure Superficial defects up to 30% Closure of defects adjacent to vermilion Only for small defects Vermilion notching
Perialar crescentic excision Lateral lip defects 30% to 60% Good scar location Can only be used for isolated defects at the lateral lip Vermilion notching
Abbe/Estlander Defects 30% to 60% of lip Potential for sensory restorationFull-thickness lip tissue transferRestoration of orbicularis oris Staged surgeryRelative microstomia Vascular compromiseVermillion notchingLip asymmetry
Karapandzic (reversed) Defects greater than 60% of lip Preservation of muscle and sensory function Microstomia Poor scar location









Table 2 Reconstruction of the Lower Lip


















































Method Use Advantages Disadvantages Potential complications
Primary closure Defects up to 30% No additional incisions May shorten lipVisible hypertrophic scar Change in oral competence
A to T closure Superficial defects Closure of defects adjacent to vermilion Only for small defects Vermilion notching
Abbe/Estlander Defects 30% to 60% Potential for sensory restorationFull-thickness lip tissue transferRestoration of orbicularis oris Staged surgeryRelative microstomiaTemporary denervation Vascular compromiseVermillion notchingLip asymmetry
Gillies fan Defects 30% to 60% Less microstomia Lack of motor and sensory function Oral incompetence
Karapandzic Defects 30% to 60% Preservation of muscle and sensory function MicrostomiaInversion of vermillion Poor scar location
Bernard–Burrow–Webster Up to total lip defect Good aesthetic resultPotential for preservation of muscle function Microstomia Postoperative droolingInsensate
Fujimori gate Up to total lip defect Closure of large defects Adynamic reconstruction Vascular compromise


Superficial Defects

Superficial defects of the upper lip are common from resection of basal cell carcinoma. Defects smaller than 1 cm in size are commonly closed primarily with judicious undermining. The direction of closure preferably creates a vertical incision to mask within the relaxed skin tension lines. Mucosal defects are often closed primarily or allowed to heal secondarily.

Options for closure of defects that are 1 to 2 cm in size are based on location. For lateral defects, a cheek advancement flap can facilitate closure as lateral tissue is recruited toward the midline. For medial defects adjacent to the philtrum, a perialar crescentic advancement flap is often used (Fig. 1). Lesions adjacent to the vermilion border are best reconstructed with an A to T closure. Defects located within the philtrum can be left to heal secondarily or reconstructed with a full-thickness skin graft. Finally, an inferiorly based nasolabial flap can provide coverage of large defects of the upper lip.

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Aug 2, 2016 | Posted by in GENERAL SURGERY | Comments Off on Lip Reconstruction

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