L i p Re c o n s t r u c t i o n

Mehdi B. Matin, DDS, Jasjit Dillon, DDS, MBBS, FDSRCS*

KEYWORDS
 Lip reconstruction  Partial-thickness defect  Full-thickness defect  Local and regional flap

KEY POINTS
 Small to moderate lip defects should be repaired with local and regional flaps.
 Local and regional flaps can provide both cosmetic and functional lip reconstruction.
 Microstomia is a common sequela in subtotal lip reconstruction.
 Microvascular reconstruction provides an excellent option for complex or total lip reconstruction;
however, it lacks the ability of providing any dynamic function.

INTRODUCTION published the first written description of lip recon-

struction. Early reports of lip reconstruction in the
The lips consist of 2 fleshy folds that surround Western literature date back to at least the first
the mouth in humans. They play a dynamic role century.1,8
in facial esthetics, human communications, and Many modern techniques are combinations and
oral functions, such as producing sounds, facial newer modification of methods first described by
expressions, and providing an oral seal.1–3 Dieffenbach, Sabatini, Abbe, and Estlander9–14
Defects may result from trauma, malignancy, over the past 2 centuries. In 1834, Dieffenbach9,10
and congenital disorders.4 These defects may first described the cheek advancement flap tech-
cause significant alterations of normal lip appear- nique based on an inferolateral pedicle. In 1838,
ance and function that profoundly impact Sabatini11 first described the cross-lip flap trans-
patients’ quality of life.5 Therefore presents sig- fer of the lower lip midline wedge to a philtral
nificant challenges for a surgeon to restore form defect. This technique was modified and further
and function of this complex vital anatomic unit. popularized by Abbe and Estlander.12,13 In 1853,
Although lip attempts to restore all of the above, Bernard15 explained his technique of full-
oral competence is probably the most thickness wedge excision and cheek advance-
important.6 ment for the repair of a lower lip defect. Earlier
Surgical management of patients in need of lip techniques, such as bilateral nasolabial flaps
reconstruction requires a clear understanding of (von Bruns16 1857) and fan flap (Gillies17 1920s)
the lip anatomy, aesthetics, and function7 as well using full-thickness flaps, led to denervation and
as extensive knowledge and background informa- did not allow for functional restoration.18 Later
tion of various techniques proposed to this date. Karapandzic19 improved Gillies’ technique with
This article is a comprehensive review of lip de- the preservation of underlying musculature and
fects reconstruction. neurovascular structures. The utilization of micro-
vascular free tissue transfer for total lip recon-
HISTORY struction was first reported by Harri and
colleagues in 1974.20,21 Later complex recon-
oralmaxsurgery.theclinics.com

The first evidence of lip reconstruction is found as structive options, such as functional gracilis trans-
far back as the Hindu and Sanskrit writings of Sus- fer, were elaborated to meet the requirements of
hruta. In 600 BC, Sushruta, an Indian surgeon, lip reconstruction20; and recently, successful

Disclosures: None.
Department of Oral & Maxillofacial Surgery, University of Washington, 1959 Northeast Pacific Street, HSB
Room B 241, Box 357134, Seattle, WA 98195, USA
* Corresponding author.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 26 (2014) 335–357

http://dx.doi.org/10.1016/j.coms.2014.05.013
1042-3699/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
336 Matin & Dillon

partial facial transplantation makes this technique

an increasingly more likely option for reconstruc-
tion in coming years.20,22,23

ANATOMIC CONSIDERATIONS
It is necessary to have an in-depth understanding
of anatomy in order to achieve superior outcomes
in lip reconstructive surgeries. Lips are located
within the observation of the lower face, and
even minor defects require meticulous reconstruc-
tion.5 The normal lip considerably varies in width,
length, and thickness among patients. The
anatomic boundaries of the lips extend vertically
from the subnasale to the chin and horizontally
from commissure to commissure.1,5,6,24
Anatomic development of the lips begins in the
early embryonic stage. The maxilla, mandible,
and both lips are derived from the first pharyngeal
arch. Upper lip development is from the fusion of
maxillary and medial nasal prominences with the
intermaxillary segment. The commissure is formed
by fusion of the lateral portion of the maxillary and
mandibular processes. Lower lip and mandible
Fig. 1. Lip cross section. ESG, eccrine sweat; ESL,
are derived from mandible process as a single external side of lip; HF, hair follicles; ISL, internal
structure.3 side of lip; LP, lamina propria; MM, the mucous mem-
The cross-sectional anatomy (Fig. 1) of the lips, brane (stratified squamous nonkeratinized epithe-
from superficial to deep, consists of skin (epi- lium); MO, muscularis orbicularis oris; MSG, minor
dermis, dermis, subcutaneous tissue), orbicularis salivary glands; SG, sebaceous glands (associated
oris muscle fibers, and submucosal and mucosal with hair follicles); VZL, vermillion (red) zone. (From
layers. Lips are surrounded by skin externally Arda O, Göksügür N, Tüzün Y. Basic histological struc-
and transition to internal mucosa at the mucocuta- ture and functions of facial skin. Clin Dermatol
2014;32(1):3–13; with permission.)
neous ridge or vermilion border, which is the most
distinguishing feature of the lip.1,24 A fine line of
pale skin, white roll, accentuates the color differ-
ence between the vermilion and skin. The mucosa crease forms an inverted U, which corresponds
of the vermilion is unique in that it lacks minor sali- to the depth of gingivolabial sulcus.
vary glands. The line separating this dry portion Adequate vascularization is a critical element of
from intraoral labial mucosa is called the wet line. flaps in reconstructive surgery.4 Both lips receive
The characteristic hue of the vermilion comes their blood supply from the facial branch of the
from a rich underlying vascular supply and thin external carotid artery via the superior and inferior
keratinized stratified squamous epithelium. This labial branches that course between the orbicula-
vascular bed and neural plexus makes the ris oris muscle fibers and the mucosa and just
vermilion highly sensate.25 deep to posterior vermilion line. According to
The upper lip consists of a middle and 2 lateral Neligan,25 the superior labial artery runs through
aesthetic subunits (Figs. 2 and 3), demarcated by the muscle in half of patients and has a tendency
the philtral ridges medially and the nasolabial folds to travel slightly higher in the central parts of the
laterally. The central concavity between vermilion upper lip. It anastomoses contralaterally and com-
and subnasale is called the philtral groove, which municates with the subdermal plexus.1,3 Venus
is limited bilaterally by philtral ridges.3,5 The cen- drainage runs with the arteries but, in the upper
tral depression of the upper vermilion is referred lip, can drain to the cavernous sinus via the
to as cupid’s bow. The lower lip is composed of ophthalmic vein, providing a route for labial infec-
a single subunit considerably less complex and tions to spread intracranially.3
more forgiving to reconstruct. It is separated Lymphatic drainage of the lips merges to 5 pri-
from the surrounding structures by a labiomental mary trunks. The upper lip, except the midline,
crease and melolabial fold. The labiomental drains ipsilaterally to the submandibular nodes
 Lip Reconstruction 337

Fig. 2. Anatomic landmarks of lip.

with some drainage to the periparotid nodes and muscles, except the mentalis, which receives su-
occasionally to the submental nodes. The lower perficial innervation.25–27
lip drains bilaterally to the submental nodes in Perioral musculature (Fig. 4) can be classified as
the center and submandibular nodes laterally.26 3 groups based on insertion into the commissure
Sensation of the upper and lower lips is provided (modiolus) and upper and lower lip. Table 1 shows
by the infraorbital branch of maxillary division the groups as well as the function of each mus-
and the mental branch of mandibular division of cle.26 The orbicularis oris principally composes
the trigeminal nerve, respectively.3 the body of the lip. Deep fibers provide the oral
The motor supply is derived primarily from cavity sphincter function, whereas the superficial
buccal and marginal mandibular branches of the fibers perform fine movements.27 In the cross sec-
facial nerve. These nerves enter deep into tion, the orbicularis oris is composed of a long,
vertical segment that curls outward at the superior
and inferior free margins to form a marginal protru-
sion. In the upper lip, the orbicularis oris fibers
decussate in the midline and have dermal inser-
tions approximately 4 to 5 mm lateral from the
midline. This serves to pull the skin medially at
these dermal insertion points, forming the philtral
columns. The central region (philtral groove) is
devoid of dermal attachments and is pulled into
a concave depression.26

PATHOLOGY AND EPIDEMIOLOGY

Cancer resection causes most lip defects;
however, trauma; burns; and certain disease pro-
cesses, such as granulomatous cheilitis, hemangi-
oma, nevi, melanotic macules, and noma, can
cause lip defects that require reconstructive sur-
gery. Unlike facial and lip skin where basal cell car-
cinoma (BCC) is the most common malignancy,
squamous cell carcinoma (SCC) constitutes 95%
of primary malignant lesions of the red lip followed
by BCC, melanoma, minor salivary gland malig-
Fig. 3. Aesthetic subunits of face. (From Patel KG, nancies, microcystic adnexal carcinoma, and Mer-
Sykes JM. Concepts in local flap design and classifica- kel cell carcinoma.3,28
tion. Oper Tech Otolaryngol–Head Neck Surg 2011; Lip cancer accounts for 25% of oral cavity ma-
22(1):13–23; with permission.) lignancies, and its incidence can be as high as
338 Matin & Dillon

Fig. 4. Perioral musculature. (Modified from Gillman GS, Gallo JF. Cosmetic uses of Botox and injectable fillers.
In: Bailey BJ, Johnson JT, Newlands SD, editors. Head & neck surgery–otolaryngology. 4th edition. Philadelphia:
Lippincott Williams & Wilkins; 2006.)

13.5 per 100,000 people.28 The risk factors for lip FUNCTIONAL AND ESTHETIC
cancer include sun exposure, smoking, alcohol CONSIDERATIONS
consumption, and fair complexion. It is 3 to 13
times more common in males.3,28–30 Lower lips Box 2 lists some of the most important functional
receive more ultraviolet exposure and are the and aesthetic goals of reconstructive surgeries.
most common site for lip cancers (89%); although Three-layered closure, reconstruction of orbicu-
rarer, carcinomas from upper lips (7%) and com- laris oris, and restoration of the continuity of
missures (4%) are more aggressive.3,28 the lips sphincter and labial vestibules are essen-
tial to restore ideal function. Microstomia is a
GENERAL CONSIDERATIONS common complication in lip reconstruction that
could affect function. In order to avoid microsto-
Management of lip defects with reconstructive mia, bringing new tissue to the lip might be
surgery requires restoration of labial/oral function necessary.1,3,6,27
and restoration of esthetics. There are several op- Topographic boundaries and aesthetic subunits
tions for defect reconstruction24,25,31 and will vary (see Figs. 2 and 3) must be recognized and
per patient (Box 1). respected.4 It is best to avoid crossing these

Table 1
Perioral musculature

Muscle Group Muscle Action

Group I: modiolus Orbicularis oris Presses the lips against the teeth
insertion Buccinator Presses the lips and cheek against the teeth
Levator anguli oris Elevates the commissure
Depressor anguli oris Depresses and moves the commissure laterally
Zygomaticus major Elevates and moves the commissure laterally
Risorius Draws the commissure laterally and smiling
Group II: upper lip Levator labii superioris Elevates the upper lip
insertion Levator labii superioris Dilates the nostril and elevates the upper lip
alaeque nasi
Zygomaticus minor Elevates and pulls the commissure laterally
Group III: lower lip Depressor labii inferioris Depresses the lower lip and pulls it slightly
insertion laterally
Mentalis Elevates the lower lip
Platysma Depresses the lips
 Lip Reconstruction 339

Box 1
RECONSTRUCTIVE STRATEGIES OF UPPER
Patient and defect factors affecting treatment AND LOWER LIPS
plan
Lip defects are classified based on anatomic loca-
 Patient factor tion, thickness, and size of the defect (Box 3).34
The main reconstructive options include second-
 Age
ary intention healing, skin grafts, primary closure,
 Prognosis local flaps, and free flaps. When considering
 General medical condition reconstruction of lip defect, the reconstruction lad-
 Patient compliance
der starts with the simplest procedures, moving up
to the most complex.32 Figs. 5–7 show the basic
 Comorbidities approach to lip defects from simple to complex.
 Cost and convenience of treatment This classification has limitations but helps to
 Defect/tumor factor have an organized approach to this problem.

 Size of tumor Vermilion Defects

 Histology of tumor
The vermilion is the most distinguishing feature of
 Extent of lip resection/defect the lip and consists of specialized stratified squa-
 Anticipation of esthetic and functional mous epithelium.34 The junction between the
outcome vermilion and white lip (white roll) is smooth and
 Availability of local tissue seamless; any abnormality is immediately obvious,
which makes vermilion reconstruction critical.
 History of prior treatment (eg, radiation
and surgery) Healing by secondary intention
Data from Refs.24,28,32 Small, partial-thickness defects of the lip isolated
to the vermilion or extending marginally to the
cutaneous lip that do not involve the underlying
orbicularis muscle may heal nicely through sec-
boundaries. When a defect involves a substantial ondary intention.3,35–38 Leonard and Hanke39 re-
portion of an esthetic subunit, better cosmetic re- ported re-epithelialization of such defects by
sults are achieved by reconstructing areas as 25 days on average, with good cosmetic results
complete units.3 without persistent visible scar. Wound contraction
is still a disadvantage and should be anticipated.40

Primary closure
Box 2 For a small vermilion defect in which the remaining
The most important reconstructive goals are
vermilion shape and contour is not distorted,
outlined as follows

 Functional goal
Box 3
 Maintenance of oral competence
Defect classification
 Sufficient oral access
 Anatomic location
 Preservation of sensation
 Skin
 Mobility
 Vermilion
 Phonation
 Skin and vermilion
 Aesthetic goal
 Thickness
 Restore or preservation of the anatomic
land marks  Partial thickness
 Reconstruction of facial subunits  Full thickness
 Adequate tissue match in terms of color  Size
and texture
 Small less than 30% of lip
 Lip symmetry and anatomic proportion
 Medium 30% to 60% of lip width
 Maintenance of lips relation
 Subtotal or total greater than 60% lip
Data from Refs.3,5,24,32,33 width
340 Matin & Dillon

that is pedicled on the underlying deep tissue.

The triangular-shaped island is advanced into
the adjacent recipient site, maintaining sufficient
deep-tissue attachments to ensure its viability.
The donor site is closed primarily in a Y configu-
ration. In some cases, horizontal movement is
used using a single or bilateral opposing island
flap.1,2

Mucosal advancement flap

Fig. 5. Superficial defects of the lip. The mucosal advancement flap is the most
favored and common method for vermilion defect
primary closure is the simplest reconstruction restoration.1,25,34 It is indicated for repairing small
technique.5,32,41 Small lesions and scar of the defects isolated to the vermilion, diffuse actinic
vermilion can be excised in fusiform fashion and cheilitis, and subsequent reconstruction of a ver-
closed primarily.42 Incisions should be placed in milionectomy of either lips.3,24
the radially oriented relaxing skin tension lines In this method, an incision is made along the
(RSTLs), and the mucocutaneous line should be vermilion border3; the labial mucosa is under-
avoided for optimal closure and cosmetic mined in a plane deep to minor salivary glands
result.2,27,42 and superficial to posterior surface of orbicularis
Primary closure may cause unpleasant redun- oris muscle. The mucosal lining of the vestibule
dant vermilion.5 In a recent study, it was observed is mobilized and advanced forward to resurface
that mucosal advancement flaps resulted in better the defect and remaining muscle (Fig. 9).1–3
maintenance of the vermilion width compared with Selective dissection techniques in an attempt to
primary closure.43 preserve the small neurovascular structure have
been described. This technique is a one-stage sur-
Mucosal V-Y advancement gery. Because the vermilion is modified mucosa,
Small defect or volume deficiency of the vermilion reconstruction with labial mucosa offers a very
may be restored using adjacent oral mucosa by close substitute1 with excellent aesthetic re-
V-Y advancement flaps movement (Fig. 8).1,2 sults.1,45,46 Most patients regain some degree of
Bocchi and colleagues44 reports good results sensation within months.1
with no complications, such as vascular compro- The disadvantages of this technique are distor-
mise, microstomia, retracted scars, or hypomobil- tion of the anterior vermilion line caused by wound
ity, in restoration of vermilion in 16 patients by this contraction, change in hair growth direction,1 thin-
technique. The advancement flap is created by a ning of the lip, mucosal retraction,3,24,32 decreased
V-shaped incision to the level of the orbicularis mucosal sensation,47–49 color mismatch,41,48
oris with the apex of incision positioned toward dryness, and excessive lip fullness from flap
the gingivolabial sulcus, creating an island flap overadvancement.4

Fig. 6. Lower lip defects.

 Lip Reconstruction 341

Fig. 7. Upper lip defects.

The limitations in this technique are the difficulty The flap is usually dissected and elevated in the
in reconstructing the fullness of the white roll plane superficial to the muscle; however, the mus-
because of scar contraction, difficulty in accu- cle and labial artery can be included. It is raised,
rately repositioning the anterior vermilion line rotated, and transferred across the oral aperture
when there is a skin defect adjacent to lip margin,1 and sutured into the opposing vermilion defect.
and the inability to restore muscle bulk in defects The donor site is closed primarily if it is the buccal
involving the orbicularis-oris muscle.5 vestibule or using a mucosal advancement at the
vermilion (Fig. 10).1,2,34 Division of the pedicle is
Mucosal cross lip flap performed after 2 to 3 weeks as the second stage.1
This flap is designed as a linear band of mucosa 2-stage surgery, patient discomfort and
harvested from the vermilion or labial mucosa of restricted mouth opening are the disadvantages
the opposing lip and is used to restore the vermilion of this technique. Multiple other techniques are
defect or add substance.1,2,34 It is designed as a available using tongue flaps, vermilion advance-
single pedicle flap or double pedicle (bucket ment flaps, facial artery musculomucosal flaps,
handle) for reconstruction of a larger defect.1 and cheek rotation flaps; but they are outside the

Fig. 8. Mucosal V-Y advancement. (From Weerda H. Reconstructive facial plastic surgery: a problem-solving
manual. 1st edition. New York: Thieme; 2001; with permission.)
342 Matin & Dillon

Fig. 9. (A–F) Mucosal advancement flap. (A) Outline of cheilitis and severe dysplasia. (B) Vermillion excision. (C)
Labial mucosal advancement. (D) Closure. (E) Six months postoperatively. (F) Diagrammatical depiction. (From [F]
Weerda H. Reconstructive facial plastic surgery: a problem-solving manual. 1st edition. New York: Thieme; 2001;
with permission.)

scope of this article, and readers are recommen- facilitates re-approximation, particularly when the
ded to review facial plastic surgery texts cited in vermilion is involved (Fig. 11).35,50 A recent anal-
the references for additional information. ysis shows excellent aesthetic and functional
results when upper lip cutaneous defects were
converted to full-thickness defects and repaired
Partial-Thickness Defect
by primary closure.51
These defects are limited to the tissue superficial
to the orbicularis oris muscle and usually cause Primary closure
no functional problem. The basic challenge for Small cutaneous defects in the lower lip and lateral
the surgeon is esthetics.34,41 subunit of the upper lip can be repaired by primary
A perilabial partial-thickness defect can be closure.5,33 Excellent cosmetic results may be
closed primarily or with a variety of transposition achieved by designing fusiform excisions parallel
flaps.27 When using local tissue for reconstruction, to RSTLs, confined within the boundaries of the
only the skin and subcutaneous tissue is used and facial aesthetic subunits.1,34
underlying muscles remain intact.27 It is also An M-plasty at the end of the excision is useful to
preferred to confine tissue movement within the avoid extension of the incision beyond the aesthetic
aesthetic region unless it causes distortion.1 Con- borders. If the lesion crosses the vermilion, the inci-
version of partial-thickness defect to full thickness sion must cross the mucocutaneous line at 90 .31 In
 Lip Reconstruction 343

Fig. 10. Mucosal cross lip flap. The arrow shows the bipedicle flap being transferred to the upper lip. (From
Weerda H. Reconstructive facial plastic surgery: a problem-solving manual. 1st edition. New York: Thieme;
2001; with permission.)

horizontal lesions, a Z-plasty may be used to The flap is dissected down to the orbicularis oris
disperse wounds and scars (Fig. 12).2 muscle, maintaining a deep pedicle. The underly-
Cutaneous defects less than 50% of the width of ing facial musculature should not be violated.
philtrum may be reconstructed by primary closure; The flap is then advanced into the excision site
however, it can cause flattening of cupid’s bow or and the donor site is closed in a V-Y fashion.34
an upward pull of the vermilion caused by wound Some remaining normal skin may be removed in
contraction.1 order to position the final scar into the nasal
base or aesthetic boundaries.33
Island advancement flap Intralabial transposition flap, labial rotational
Small to medium cutaneous defects involving late- and advancement flap, melolabial transposition
ral lips can be repaired by a subcutaneous island flap, and chin and submandibular transposition
pedicled flap (Fig. 13).33,52–56 These flaps are best flap are also possible options but are outside the
to repair defects adjacent to the vermilion line.34 scope of this article; readers are recommended

Fig. 11. (A–C) Primary closure of vermilion with conversion of partial thickness. (A) Partial-thickness dog bite.
(B, C) Tissue undermined and closed primarily.
344 Matin & Dillon

Fig. 12. Primary closure. (From Weerda H. Reconstructive facial plastic surgery: a problem-solving manual. 1st
edition. New York: Thieme; 2001; with permission.)

to review facial plastic surgery texts cited in the a reasonable substitute and multilayer repair.1
references for additional information. These defects have traditionally been classified
according to the size and location of the defect.34
Full-Thickness Defect
Small full-thickness defects: primary closure
Full-thickness defect reconstruction of the lips re- Full-thickness defects that involve less than 30%
quires replacement of skin, muscle, mucosa, or (up to 50%27,34) of the stretched lower lip width or

Fig. 13. Island advancement flap. (A) BCC upper lip. An 86-year-old man with multiple prior surgeries. (B) BCC
demarcated with flaps outlined. (C) BCC excised. (D) Advancement flaps raised bilaterally. (E) Closure. (F) Six
months postoperatively. Patient pleased with no desire for creation of cupid’s bow.
 Lip Reconstruction 345

25% of the upper lip width,25 not including most of notched or retracted vermilion.1,32 Aesthetic
the philtral subunit, can be removed by wedge wound closure can be achieved by undermining
excision or its variants and repaired by primary the skin and mucosal edge of the wound and
layered closure3,24,57 without causing significant closure of epithelium with slight skin ever-
microstomia.32 The size rules are especially appli- sion.1,32,33,59 A Z-plasty may be combined with
cable to elderly patients with greater tissue laxity.34 design or performed as a secondary procedure.
A recent study by Soliman and colleagues58 A V-shape (wedge) excision (Fig. 14) is the most
shows superior functional and aesthetic results common and simplest method to repair small lip
obtained with primary closure. The investigators defects and malignancies.1,3 The wedge resection
suggested that local flaps are often overused. is designed with the incisions perpendicular to the
They advocate primary closure of defects that red lip, tapered as they enter the white lip.5 The
comprise 40% of the upper lip and 50% of the excision is parallel to RSTLs, which are oriented
lower lip. vertically in the central portion and skewed in the
Optimal primary repair of full-thickness defects lateral region of lip.1,27
requires the approximation of at least 4 tissue Calhoun60 has reported that classic V excision
layers: mucosa, muscle, subcutaneous tissue, can cause a noticeable step-off in the vermilion-
and skin epithelium.1 The anterior vermilion line is cutaneous junction. He showed that a slight angu-
the principal landmark of the lip, and its location lation of the lateral incision allows for precise
at the edge of the wound needs to be identified matching of the vermilion-cutaneous junction.6
and marked before incision to avoid distortion dur- The apex of the wedge should not exceed 30
ing injection and dissection. Meticulous closure of and not cross the mental crease to avoid a con-
the vermilion is critical, both anteriorly and poste- spicuous cutaneous deformity and scar. If both
riorly, to prevent asymmetry.27 Early approxima- of these conditions cannot be met, another modi-
tion of the vermilion border is recommended as a fication, such as a W- or U-shape design, should
guide for closure of the other layers and maximizes be used.3,27 A vermilionectomy can be performed
the cosmetic outcome.1,27 Precise anastomosis of at the same time as the wedge excision (Fig. 15).
the orbicularis oris muscle ends is important to Attention should be given to the alignment of the
reconstitute the oral sphincter and prevent vermilion and orbicularis muscle.

Fig. 14. (A–F) Wedge excision upper lip with primary closure. (E, F) Patient 3 months postoperatively.
346 Matin & Dillon

Fig. 15. (A–E) Primary closure. Combination of V-shape (wedge) excision and vermilionectomy. (Courtesy of
David E. Urbanek, DMD, MS, and Jonathan S. Bailey, DMD, MD, FACS, Carle Foundation Hospital, Urbana, IL.)

A W-shaped (Fig. 16) excision is a modification upper lip defects at the philtrum and cupid’s
of a wedge excision that allows greater resection bow.33 Again, a vermilionectomy can be incorpo-
and preserves the integrity of the aesthetic sub- rated into the excision.
unit24 without extending the incisions beyond the
mental or melolabial creases.1,27 The excision is Medium full-thickness defects of lip
planned, with the apices of the W oriented away Medium-sized defects (30%–60% of lip length)
from the vermilion border with each angle less represent the most complex challenges in surgical
than 30 .3 In laterally located defects, the angle planning.27 Although primary closure of this de-
formed by the lateral subunit should be larger fects of this size is feasible, it is not recommended
and more obliquely oriented to properly align the because of secondary wound tension and micro-
closure and achieve a more natural-appearing stomia.41 These defects require some form of local
scar.1,24,27,47 flap to borrow tissue from the opposing lip or adja-
W-plasty can be used for moderate-sized de- cent tissue.4,6
fects up to one-third of the lower lip width.3 Depending on the site of the defect, 2 major tech-
Aesthetic results in the upper lip are often less niques are available to reconstruct these defects:
satisfactory, in part, because of the specific
aesthetic subunits and that the upper lip is able I. Lip switch/cross lip flap (3 most common are
to withstand less tissue loss. Less satisfactory the Abbe, Estlander, and Stein)
aesthetic result is particularly noticeable in mid- II. Circumoral advancement or rotational flap
 Lip Reconstruction 347

Fig. 16. (A) SCC lower lip. (B) W-wedge excision. (C) Closure. (D) Six months postoperatively.

(I.A) Abbe flap Cross-lip transfer of full-thickness also be designed to accommodate different varia-
tissue was described first by Sabattini (1838) and tions, such as W shape or rectangle, depending on
later by Abbe in 1898.11,12,61,62 It is designed as the defect situation. This flap is designed conven-
a rotational or lip switch flap from the opposite tionally as the same height and half of the width of
lip, based on the labial artery, which is preserved the defect1,62 to achieve a proportional reduction
on one side to serve as a pedicle of the interpo- in size of both lips.27 However, the size of the flaps
lated flap. There is no associated vein, and venous may range from one that is the size of a given
drainage is provided by small veins that parallel defect to one that fills only a small portion of the
the course of the artery.1,3,27,47 defect.1 The flap is created by a full-thickness inci-
Although this flap was initially designed to cor- sion with preservation of the labial artery on the
rect midline defects of the upper lip,48 it has medial or lateral pedicle within the vermilion.
been used for reconstruction of full-thickness de- Approximately 5 mm of vermilion mucosa should
fects affecting 30% to 60%5 of the width of either be preserved for adequate blood supply.5 The
lip medial to the commissure (Fig. 17).1,2,5 pedicle should be place at the defect midpoint.
The donor site is traditionally designed similar to The flap is rotated 180 as it is inserted into the
the V-shaped full-thickness excision; but it can opposing lip defect and closed in multiple layers.

Fig. 17. Abbe flap. (From Weerda H. Reconstructive facial plastic surgery: a problem-solving manual. 1st edition.
New York: Thieme; 2001; with permission.)
348 Matin & Dillon

The donor site is repaired primarily. Patients are can be modified to lie within the melolabial crease
placed on a liquid or soft diet for the period of to reduce scarring.1,4
vascular ingrowth. In approximately 3 weeks, the The major disadvantages of this flap are a blunt-
pedicle on the vermilion is divided and the flap ed oral commissure1 and prolonged denervation
inset.1,4,34 (lasting 6–18 months).3 The blunted commissure
A cross-lip flap can be combined with unilateral frequently diminishes over time,25 and revision
or bilateral advancement flaps to reconstruct ma- commissuroplasty is rarely required.4,24,68
jor tissue loss.1 Bilateral Abbe flaps are advised
(I.C) In 1848, Stein described a method of recon-
for large central defects of the lower lip to avoid
upper lip asymmetry.5 structing the lower lip with 2 flaps from the center
In this technique, the defect is repaired with of the upper lip hinged on the labial vessels.69
similar tissue; the orbicularis oris muscle is recon- The Stein flap is essentially a double Abbe flap. It
structed; the continuity of the circumoral sphincter has 2 smaller symmetric flaps that form the central
is reestablished24; and the commissure is not portion of the upper lip to reconstruct the lower lip.
violated. Adequate sensory and voluntary motor This flap is a complicated and less-favored flap.
function is regained.63–67 (II.A) Bilateral lip advancement Full-thickness de-
The major disadvantages are damage to the ar- fects, measuring up to one-half of the lower lip,6,33
tery on elevation of the flap, relative microstomia, may be reconstructed with unilateral or bilateral lip
2-stage surgery, risk of injuring the flap by opening advancement (Fig. 19).1,3,6,27
the mouth, prolonged phase of denervation, and In this technique, the wide, rectangular wedge
thickened appearance caused by scar and trap- of the tissue is excised. Unilateral or bilateral full-
door deformity. thickness advancement flaps are created by an
The Stein flap is essentially a double Abbe flap. inferior arc shape releasing the incision along the
It has 2 smaller symmetric flaps that form the cen- labiomental crease.3 The resultant flaps are
tral portion of the upper lip to reconstruct the lower advanced medially around the mental prominence
lip. This flap is a complicated and less-favored to close the defect. Incisional release at the
flap. commissure or removal of crescents around the
mental prominence incision may be necessary to
(I.B) Estlander This design was described by Est- mobilize the flap.3
lander in 1872.67 It is a cross-lip flap. It is similar In the upper lip, soft tissue attachment to the un-
to the Abbe flap but has its point of rotation at derlying bony skeleton limits compensatory move-
the commissure (Fig. 18). It is designed for re- ment of the remaining lip. A perialar excision as
pairing a defect involving the oral commissure described by Webster70 minimizes this effect by
of either lips and transfers a full-thickness lip allowing the lateral lip elements to be advanced.
flap around the oral commissure on a small Central upper lip defects up to two-thirds of the
medially vascular pedicle containing the labial lip width may be reconstructed with perialar cres-
artery.1,27,61,67 In contrast to the Abbe flap, it is centic advancement flaps combined with an Abbe
a single-stage reconstruction.4,33,67 flap to restore the philtral subunit.6,20 Although
The flap design is similar to the Abbe flap; its this technique causes lip tightness, this improves
dimension is equivalent in height and half the width over time and provides a satisfactory cosmetic
of the defect. It is usually designed as a triangle but result.27

Fig. 18. Estlander. (From Weerda H. Reconstructive facial plastic surgery: a problem-solving manual. 1st edition.
New York: Thieme; 2001; with permission.)
 Lip Reconstruction 349

Fig. 19. Bilateral lip advancement (lower lip)/Fernandes flap. (A) Flap design. (B) Full-thickness defect, with exci-
sion of skin and subcutaneous tissue for advancement of flaps. (C) Closed in layers; scar in labiomental crease.
(Courtesy of Phillip Pirgousis, MBBS, BDS, FRCS, FRACDS, University of Florida College of Medicine-Jacksonville,
Jacksonville, FL, and Rui Fernandes MD, DMD, FACS, University of Florida College of Medicine-Jacksonville,
Jacksonville, FL.)

(II.B) Stair step design Johanson and colleagues71 used unilaterally for lateral defects or bilaterally to
proposed the stair-step design flap in 1974 for a close central defects.73
defect that is too wide to close directly but not Several advantages of this technique are mini-
wide enough to require transfer tissue by other mized scar contracture,1 unchanged muscle fibers
flap designs (Fig. 20). This design is ideally suited direction, preserved innervation and vascularity of
for smaller defects but is capable of reconstructing the flap owing to its broad pedicle, and intact
a defect involving one-half to two-thirds of the commissures.3
lower lip.24,33 The main drawback is a geometric scar that is
In this method, the lower lip lesion is resected us- unnatural to the lower face and does not follow
ing a rectangular-shaped excision. A series of 2 to 4 the mental crease.1,33
of connected bilateral small rectangular are excised
(skin and subcutaneous tissue only) in a downward (II.C) Gillies fan flap This flap is a rotation-
diagonal fashion at a 45 angle, following the advancement flap that was initially described by
aesthetic border of the chin.24,72 At the termination Gillies and Millard in 1957.17
of the incisions, bilateral, small triangles are It is a modification of the technique described
excised. This design allows the advancement of by von Bruns74 and is designed to transfer the
the flap in the direction of the defect. As the lip seg- remaining lip segment from one side of a defect
ments are advanced, the series of rectangular and together with the lateral portion of the opposing
terminal triangles are closed, creating a stair-step lip1,27 around the commissure in the same
wound closure line. This advancement flap can be fashion as Estlander.24,25,75 It is based on the
350 Matin & Dillon

Fig. 20. Stair step flap. (A) Flap design. (B) Tumor excision and flap raised with excision of skin and subcutaneous
tissue at each step. (C) Closure in layers. (D) Three weeks postoperatively. Scar will flatten and fade with time.
(Courtesy of David E. Urbanek, DMD, MS, and Jonathan S. Bailey, DMD, MD, FACS, Carle Foundation Hospital,
Urbana, IL.)

superior labial artery27 and has a narrow without compromising the superior labial artery.
pedicle.1 Then the flap is rotated and advanced to close
This composite flap is created by full-thickness the defect, and the layer closure is performed
lip incisions from the inferior aspect of the defect, (Fig. 21).
which extends laterally around the commissure The advantages of this technique are more
and superiorly into the melolabial fold,4,40 essen- available tissue from the nasolabial region, one-
tially paralleling the orbicularis-oris. A secondary stage reconstruction surgery, and maintained
incision is made toward the superior vermilion orbicularis-oris continuity. The primary limitations

Fig. 21. Gillies fan flap. 1 and 2, Z-plasty is incorporated to the facilitated movement of the flap. (From Weerda H.
Reconstructive facial plastic surgery: a problem-solving manual. 1st edition. New York: Thieme; 2001; with
permission.)
 Lip Reconstruction 351

of this approach are microstomia, blunted com- (II.E) Karapandzic flap The circumoral
missure, and vermilion deficiency.25 Because the advancement-rotation flap initially described by
orbicularis is not fully dissected, full function and von Bruns in 1857 (Fig. 22).24 He used a full-
sensation may not return and oral incompetence thickness flap to rotate the upper lip and perioral
may also result3,4,24; however, partial reinnervation tissue down and around to reconstruct the lower
seems to occur in 12 to 18 months.24,47,76,77 lip defect, which resulted in denervation of the
The Gillies flap can be used bilaterally or in orbicularis oris muscle.24,74
combination with other flaps to restore large full- In 1974, Karapandzic19,24,78 modified von
thickness lip defects of up to 80% of the lip. Bruns’ technique. In his modification, the inci-
Z-plasty may be incorporated to the facilitated sional design was identical to the original tech-
movement of the flap.2 nique; but a full-thickness flap was not created,
and the neurovascular supply of the lip was pre-
(II.D) McGregor flap McGregor has modified the served via meticulous dissection,6,24 so optimal
Gillies technique to reconstruct upper lip defects.1 oral competence, sensory, and function were
It is a rectangular composite flap, based on the preserved.
labial artery, created by a full-thickness lip incision The flap is created by circumoral incisions
and transfers the tissue from the melolabial region extended bilaterally from the base of the defect
to the defect of the upper lip. to the upper lips by placing incisions in the mental
It is indicated for reconstruction of lateral upper and nasolabial crease.24 The thickness of the
lip defect when there is not sufficient tissue without flaps should be maintained relatively constant
recruitment of cheek tissue. This technique fails to throughout their length. Neurovascular bundles
reconstruct the muscle of the sphincter and the are identified, bluntly dissected, and preserved.
vermilion. It needs to be combined by other tech- The dissection of peripheral muscle fibers allows
niques such as mucosal advancement to recon- advancement without dissection of the mucosa.25
struct the vermilion. It can be used bilaterally for The mucosa is incised only if needed.4 The flap is
large upper lip full- thickness defects.1 advanced, and the layer closure is performed.

Fig. 22. Karapandzic flap. (A) Flap design. Along labiomental crease. (B) Resulting lip defect. (C) Flaps medially
advanced and closed in layers. (Courtesy of David E. Urbanek, DMD, MS, and Jonathan S. Bailey, DMD, MD,
FACS, Carle Foundation Hospital, Urbana, IL.)
352 Matin & Dillon

This method is usually used to reconstruct de- This technique was originally described as full-
fects involving up to two-thirds of the lower lip thickness excisions but was later modified and
and, to a lesser degree, the upper lip. Some inves- performed as cutaneous and mucosal excisions
tigators state it can be designed bilaterally to and flap dissection to minimize disruption of
reconstruct defects of up to 80% of the total lip the facial structure28,33 and preserve sensory
length.24,25,47,76,79,80 It is useful in cases whereby innervation.
radiation had been previously used and blood sup- It is technically difficult, and oral function is fair
ply is compromised.6 at best.1 It fails to restore the vermilion and needs
The technique has predictable results, with su- to be combined with other techniques, such as a
perior function, sensation, and cosmetic out- buccal mucosal flap or tongue flap, to reconstruct
come.4,24 It causes blunting of the commissure the missing vermilion.4 This technique is better
and some degree of microstomia4,24; however, suited for upper lip reconstruction because of
secondary correction of the mouth opening is less risk for the development of postoperative
seldom needed.33 oral incompetence.

Large full-thickness defect Webster technique In 1960, Webster and col-

Total lip reconstruction presents the biggest func- leagues81 described the modification of Bernard–-
tional and cosmetic reconstruction challenge for von Burrow for the reconstruction of the lower lip
surgeons.4,27 The defects usually involve the lower by using a more linear horizontal advancement of
lip. Defects greater than two-thirds of the lip need the cheek, placing scar lines in natural facial skin
transfer of adjacent cheek tissue or tissue from creases and avoiding the violation of the aesthetic
distant sites to prevent microstomia.1 If there is a region of the chin (Fig. 24).1 Webster and col-
lack of residual lip tissue, microvascular free tissue leagues recommended placement of triangular
transfer must be considered.4 Potential complica- excisions along the nasolabial fold with excision
tions of total lip reconstruction include hypertro- only through skin and subcutaneous tissue. This
phic scarring, disfigurement, loss of sensation, design minimizes the tendency for vertical defi-
microstomia, loss of oral competence, and loss ciency of the lower lip1,81 and provides better
of natural gingivobuccal sulcus. These complica- muscle function.
tions can make denture placement challenging.
Distant flap Distant flaps are used if adjacent local
Bilateral cheek advancement flaps (Bernard–von tissue is unavailable owing to trauma or extensive
Burow) Bernard (1852)16 and von Burow15 (1853) disease involvement.3,82 Flaps from the scalp and
separately described bilateral horizontal cheek forehead and submandibular, deltopectoral,
advancement. pectoralis-major, sternocleidomastoid, and cervi-
This advancement is performed by a horizontal codeltopectoral flaps have been described in liter-
full- or partial-thickness incision4 extended later- ature.27,33,47,83 These flaps provide tissue for
ally from the commissure and excision of the skin wound closure and lip restoration; but compared
and subcutaneous triangles (von Burow trian- with local techniques, they are not capable of
gles33) at the superior and inferior margin of the restoring adequate function and satisfactory
flap to facilitate advancement. cosmetics.27,33
Upper lip reconstruction is accomplished with
the excision of 4 triangles and lower lip reconstruc- Microvascular reconstruction Microvascular re-
tion with the excision of 3 triangles (Fig. 23).27 The construction allows for single-stage reconstruction
remaining orbicularis muscle is freed up to allow of large defects27 with high success rates and
for flap advancement.1 good functional and cosmetic results (Fig. 25).84,85

Fig. 23. Bilateral cheek advancement flaps (Bernard–von Burow). (From Coppit GL, Lin DT, Burkey BB. Current
concepts in lip reconstruction. Curr Opin Otolaryngol Head Neck Surg 2004;12:281–7; with permission.)
 Lip Reconstruction 353

Fig. 24. (A–D) Webster Technique. (A) Large SCC. (B) Resection with flap design. The crescents are areas of skin
and subcutaneous tissue that will be excised for flap advancement. (C) Closure: note the microstomia that will
improve with time. (D) Postoperative results a few weeks later. (Courtesy of David E. Urbanek, DMD, MS, and
Jonathan S. Bailey, DMD, MD, FACS, Carle Foundation Hospital, Urbana, IL.)

The most commonly used free flap to recon- and temporal scalp free flap for upper lip defects
struct total or near-total lip defect is the radial fore- have also been described.89
arm free flap. It may also be transferred along with
the palmaris longus tendon, which anchors to the Commissuroplasty Finally, the Estlander cross-lip
orbicularis muscle and/or modiolus to function as flap and other methods can cause blunting and
a sling between 2 commissures and to provide distortion of lip commissures and shortening of
static support for oral competence.4,28,33,86 It the oral fissure that require secondary
may also be fashioned to the nasolabial or malar correction.1,2
periosteum. Alternatively, the flexor carpi radialis The simplest method of commissureplasty
tendon or a nonvascularized folded fascia lata (Converse 1959, Weerda 1983)2,90 involves mak-
graft can be used as a sling over which the radial ing a horizontal full-thickness incision at the level
forearm flap is draped.33 This flap may be trans- of the blunted commissure, in the direction of the
ferred as a sensate free flap by performing anasto- oral fissure, which extends laterally to the point
mosis of the lateral antebrachial cutaneous nerve corresponding in position of the contralateral
to the mental nerve to restore some competence normal commissure. The epithelium above and
and sensation, which was first described by Sakai below the incision is removed; the labial mucosa
and colleagues in 1989.87 is then mobilized and advanced forward on each
Free flaps not only provide reconstruction of soft side of the incision to restore a vermilion
tissue but can also provide bone if there is bone surface.47,91
involvement with an osteofasciocutaneous flap.27 Gillies and Millard17 (1957) described excising a
Fibula flap or iliac crest flap based on deep triangular segment of skin lateral to the rounded
circumflex iliac vessels offer the best reconstruc- commissure, raising and rotating a vermilion flap
tion method for the anterior mandible defect.33 from the lower (or upper) lip to reconstruct the
Other microvascular approaches including the opposite vermilion and mobilizing a mucosal flap
gracilis free flap88 for total lower lip reconstruction to form the vermilion of the other lip.2
354 Matin & Dillon

Fig. 25. (A–D) Radial forearm free flap. (A) Large SCC lower lip. Note induration and ulceration. (B) Planned exci-
sion. (C) Resection including entire periosteum and right mental nerve. (D) Final reconstruction 3 weeks postop-
eratively. (Courtesy of Brian Schmidt MD, DDS, PhD, FACS.)

SUMMARY 2. Weerda H. Reconstructive facial plastic surgery: a

problem-solving manual. 1st edition. Thieme; 2001.
Lips are complex and highly functional compo- 3. McCarn KE, Park SS. Lip reconstruction. Otolar-
nents that are located in an esthetic area of the yngol Clin North Am 2007;40:361–80.
face. The complexity of the lip structure leads to 4. Anvar BA, Evans BC, Evans GR. Lip reconstruc-
a complex functional unit that is critical in main- tion. Plast Reconstr Surg 2007;120(4):57e–64e.
taining one’s quality of life. 5. Ishii LE, Byrne PJ. Lip reconstruction. Facial Plast
The unique anatomy and the location of the lips Surg Clin North Am 2009;17(3):445–53.
bring specific challenges to the reconstructive sur- 6. Cupp CL, Larrabee WF. Reconstruction of the lip.
geon. Cancer lesions, trauma, or burns cause most Oper Tech Otolaryngol–Head Neck Surg 1993;
common defects of the lips. Repairing these defects 4(1):46–53.
requires a clear understanding of anatomy, pathol- 7. Williams EF, Hove C. Lip reconstruction. Chapter 51.
ogy, patients’ factors, and surgical techniques. In: Paper ID, Holt GR, Larrabee WF, et al, editors.
Size, location, and thickness of the lesion are the Facial plastic and reconstructive surgery. 2nd edi-
most important determining factors to choose the tion. New York: Thieme; 2002.
proper surgical approach. Smaller defects can be 8. Hauben DJ. Sushruta Samhita (Sushruta’s collec-
repaired by primary reconstruction, followed by a tion) (800-600 B.C ?) Pioneer of plastic surgery.
local flap from the remaining labial or adjacent tis- Acta Chir Plast 1984;26:65–8.
sue. Larger defects may need a distant tissue flap 9. Dieffenbach JF. Die operative chirurgie, vol. 1.
or free flap. The ultimate goal in lip reconstruction Leipzig (Germany): Brockhaus; 1845. p. 423.
is to reach a high level of esthetics while attempt- Medscape.
ing to maintain normal function. 10. Dieffenbach JF. Chirurgische Erfahrungen, ben-
sonders uber die Wiederherstellung Zerstoerter
REFERENCES Theile des Menschlichen Koerpers nach Neuen
Methoden. Berlin: TCF Enslin; 1829. p. 34.
1. Renner GJ. Reconstruction of the lip 475-524. In: Medscape.
Baker SR, editor. Local flaps in facial reconstruc- 11. Sabattini P. Cenno storico dell-origine e progresso
tion. 2nd edition. Philadelphia: Mosby; 2007. della rinoplastica e cheiloplastica seguito dalla
 Lip Reconstruction 355

descrizione di queste operazioni sopra un solo in- retrospective epidemiological study. Aust Dent J
dividuo. Bologna: Balla Arti; 1838. Medscape. 2009;54:130–5.
12. Abbe R. A new plastic operation for the relief of 30. Molnar L, Ronay P, Tapolcsanyi L. Carcinoma of the
deformity due to double harelip. Med Rec 1898; lip. Analysis of the material of 25 years. Oncology
53:447. Medscape. 1974;29:101–21.
13. Estlander JA. Methode d’autoplastie de la joue ou 31. Wilson JS, Walker EP. Reconstruction of the lower
d’une levre par un lambeau emprunte a l’autre lip. Head Neck Surg 1981;4:29–44.
levre. Rev Mens Med Chir 1877;1:344. Medscape. 32. Lubek JE, Ord RA. Lip reconstruction. Oral Maxillo-
14. Estlander JA. Eine Methode, aus der einen Lippe facial Surg Clin North Am 2013;25:203–14.
Substanzverluste der anderen zu ersetzen. Archiv 33. Vuyk HD, Leemans CR. Lip reconstruction. In:
fur klinische Chirurgie 1872;14:622. Vuyk HD, Lohuis PJ, editors. Facial plastic and
15. Bernard C. Cancer de la levre inferieure opere par reconstructive surgery. 1st edition. London: Hodder
un procede nouveau. Bull Mem Soc Chir Paris Arnold; 2006.
1853;3:357. 34. Harris L, Higgins K, Enepekides D. Local flap
16. Mazzola RF, Lupo G. Evolving concepts in lip reconstruction of acquired lip defects. Curr Opin
reconstruction. Clin Plast Surg 1984;11(4): Otolaryngol Head Neck Surg 2012;20:254–61.
583–617. 35. Pepper JP, Baker SR. Local flaps: cheek and lip
17. Gillies HD, Millard DR Jr. Principles and art of plas- reconstruction. JAMA Facial Plast Surg 2013;
tic surgery. Boston: Little Brown; 1957. 15(5):374–82.
18. Sajjadian A, Narayan D. Lip reconstruction proce- 36. Gloster HM Jr. The use of second-intention healing
dure. Medscape. Available at: http://emedicine. for partial-thickness Mohs defects involving the
medscape.com/article/1288447-overview#a0101. vermilion and/or mucosal surfaces of the lip.
19. Karapandzic M. Reconstruction of lip defects by J Am Acad Dermatol 2002;47(6):893–7.
local arterial flaps. Br J Plast Surg 1974;27(1): 37. Becker GD, Adams LA, Levin BC. Outcome anal-
93–7. ysis of Mohs surgery of the lip and chin: comparing
20. Carty MJ, Pribaz JJ. Lip and cheek reconstruction. secondary intention healing and surgery. Laryngo-
In: Siemionow MZ, Eisenmann-Klein M, editors. Plas- scope 1995;105(11):1176–83.
tic and reconstructive surgery, London: Springer 38. Zitelli JA. Wound healing by secondary intention. A
specialist surgery series. 2010. cosmetic appraisal. J Am Acad Dermatol 1983;
21. Harii K, Ohmori K, Torii S. Free gracilis muscle trans- 9(3):407–15.
plantation, with microneurovascular anastomoses 39. Leonard AL, Hanke CW. Second intention heal-
for the treatment of facial paralysis. A preliminary ing for intermediate and large postsurgical de-
report. Plast Reconstr Surg 1976;57(2):133–43. fects of the lip. J Am Acad Dermatol 2007;
22. Devauchelle B, Badet L, Lengele B, et al. First hu- 57(5):832–5.
man face allograft: early report. Lancet 2006;368: 40. McCarn KE, Park SS. Lip reconstruction. Facial
203–9. Plast Surg Clin North Am 2005;13(2):301–14.
23. Dubernard JM, Lengele B, Morelon E, et al. Out- 41. Malard O, Corre P, Jégoux F, et al. Surgical repair
comes 18 months after the first human partial of labial defect. Eur Ann Otorhinolaryngol Head
face transplantation. N Engl J Med 2007;357(24): Neck Dis 2010;127(2):49–62.
2451–60. 42. Galyon SW, Frodel JL. Lip and perioral defects.
24. Neligan PC. Cheek and lip reconstruction. In: Neli- Otolaryngol Clin North Am 2001;34:647–66.
gan PC, editor. Plastic surgery. vol. 6. 3rd edition. 43. Sand M, Altmeyer P, Bechara FG. Mucosal
25. Neligan PC. Strategies in lip reconstruction. Clin advancement flap versus primary closure after ver-
Plast Surg 2009;36:477–85. milionectomy of the lower lip. Dermatol Surg 2010;
26. Jahan-Parwar B, Meyers AD, et al. Lips and Perio- 36:1987–92.
ral Region Anatomy, Medscape. Available at: http:// 44. Bocchi A, Baccarani A, Bianco G, et al. Double
emedicine.medscape.com/article/835209-overview V-Y advancement flap in the management of
#aw2aab6b5. lower lip reconstruction. Ann Plast Surg 2003;
27. Coppit GL, Lin DT, Burkey BB. Current concepts in 51:205.
lip reconstruction. Curr Opin Otolaryngol Head 45. Manstein CH. Vermilionectomy and mucosal ad-
Neck Surg 2004;12:281–7. vancement. Plast Reconstr Surg 1997;100(5):1363.
28. Shah JP, Patel SG, Singh B. Lips Chapter 7. In: 46. Ay A, Aytekin A. Meshing technique in mucosal
Shah JP, Patel SG, Singh B, editors. Jatin shah’s advancement flaps for vermilionectomy defects.
head and neck surgery and oncology. 4th edition. Plast Reconstr Surg 2003;112:1739–40.
Philadelphia: Mosby; 2012. 47. Renner G. Reconstruction of the lip. In: Baker SR,
29. Abreu L, Kruger E, Tennant M. Lip cancer in Swanson N, editors. Local flaps in facial recon-
Western Australia, 1982-2006: a 25-year struction. New York: Mosby; 1995. p. 345–96.
356 Matin & Dillon

48. Krunic AL, Weitzul S, Taylor RS, et al. Advanced 67. Estlander J. Eine methode aus er einen ippe sub-
reconstructive techniques for the lip and perioral stanzverluste der anderen zu ersetzein. Arch Klin
area. Dermatol Clin 2005;23:43–53, v–vi. Chir 1872;14:622 [Reprinted in English in Plast Re-
49. Neligan P, Gullane P, Werning J. Lip reconstruction. constr Surg 1968;42:361–6].
In: Werning J, editor. Oral cancer. New York: 68. Kroll S. Lip reconstruction. In: Kroll SS, editor.
Thieme Medical Publishing Inc; 2006. p. 180–93. Reconstructive plastic surgery for cancer. St Louis
50. Baker SR. In: Baker SR, editor. Flap classification (MO): Mosby Year Book; 1996. p. 201–9.
and design: local flaps in facial reconstruction. 2nd 69. Stein SA. Lip repair (cheiloplasty) performed by a
edition. St Louis (MO): CV Mosby; 2007. p. 71–106. new method. Hosp-Meddel 1848;1:212. [Reprinted
51. Godek CP, Weinzweig J, Bartlett SP. Lip recon- in Plast Reconstr Surg 53:332, 1974.]
struction following Mohs’ surgery: the role for com- 70. Webster J. Crescentic peri-alar cheek excision for
posite resection and primary closure. Plast upper lip flap advancement with a short history of up-
Reconstr Surg 2000;106(4):798–804. per lip repair. Plast Reconstr Surg 1955;16:434–64.
52. Skouge JW. Upper lip repair - the subcutaneous 71. Johanson B, Aspelund E, Breine U, et al. Surgical
pedicle flap. J Dermatol Surg Oncol 1990;16:63–8. treatment of non-traumatic lower lip lesions with
53. Griffin GR, Weber S, Baker SR. Outcomes following special reference to the step technique: a follow
V-Y advancement flap reconstruction of large upper up on 149 patients. Scand J Plast Reconstr Surg
lip defects. Arch Facial Plast Surg 2012;14(3):193–7. 1974;8:232–40.
54. Rustad TJ, Hartshorn DO, Clevens RA, et al. The 72. Sullivan D. “Staircase” closure of lower lip defects.
subcutaneous pedicle flap in melolabial recon- Ann Plast Surg 1978;1:392–7.
struction. Arch Otolaryngol Head Neck Surg 73. Zide BM. Deformities of the lip and cheeks. In:
1998;124(10):1163–6. McCarthy JG, editor. Plastic surgery, vol. 3. Phila-
55. Zook EG, Van Beek AL, Russell RC, et al. V-Y delphia: W.B.Saunders; 1990. p. 2009–56.
advancement flap for facial defects. Plast Reconstr 74. Hauben DJ. Victor von Bruns (1812-1883) and his
Surg 1980;65(6):786–97. contributions to plastic and reconstructive surgery.
56. Herbert DC, Harrison RG. Nasolabial subcutane- Plast Reconstr Surg 1985;75(1):120–7.
ous pedicle flaps. Br J Plast Surg 1975;28(2):85–9. 75. McGregor IA. Reconstruction of the lower lip. Br J
57. Langstein H, Robb G. Lip and perioral reconstruc- Plast Surg 1983;36(1):40–7.
tion. Clin Plast Surg 2005;32:431–45. 76. Ducic Y, Athre R, Cochran CS, et al. The split orbi-
58. Soliman S, Hatef DA, Hollier LH Jr, et al. The ratio- cularis myomucosal flap for lower lip reconstruc-
nale for direct linear closure of facial Mohs’ defects. tion. Arch Facial Plast Surg 2005;7:347–52.
Plast Reconstr Surg 2011;127:142–9. 77. Rea JL, Davis WE, Rittenhouse LK, et al. Reinner-
59. McGregor IA. Lips. In: McGregor IA, Howard DJ, vation of an Abbe-Estlander and a Gillies fan flap
editors. Rob & Smith’s operative surgery. 4th edition. of the lower lip: electromyographic comparison.
Part I: head and neck. Oxford (United Kingdom): Arch Otolaryngol 1978;104:294–5.
Butterworth-Heinemann; 1992. p. 105–23. 78. Ethunandan M, Macpherson DW, Santhanam V.
60. Calhoun K. Reconstruction of small and medium Karapandzic flap for reconstruction of lip defects.
sized defects of the lower lip. Am J Otol 1992;13: J Oral Maxillofac Surg 2007;65(12):2512–7.
16–22. 79. Williams E, Hove C. Lip reconstruction. In: Papel I,
61. Mazzola RF, Hueston JT. A forgotten innovator in editor. Facial plastic and reconstructive surgery.
facial reconstruction: Pietro Sabattini. Plast Re- New York: Thieme; 2002. p. 634–45.
constr Surg 1990;85(4):621–6. 80. Eguchi T, Nakatsuka T, Mori Y, et al. Total recon-
62. Agostini T. The Sabattini-Abbé flap: a historical struction of the upper lip after resection of a malig-
note. Plast Reconstr Surg 2009;123(2):767. nant melanoma. Scand J Plast Reconstr Surg Hand
63. Smith JW. Anatomical and physiologic acclimatiza- Surg 2005;39:45.
tion of tissue transplanted by the lip switch tech- 81. Webster RC, Coffey RJ, Kelleher RE. Total and par-
nique. Plast Reconstr Surg 1960;26:40. tial reconstruction of the lower lip with innervated
64. Thompson N, Pollard AC. Motor function in Abbe musclebearing flaps. Plast Reconstr Surg 1960;
flaps: a histochemical study of motor reinnervation 25:360–71.
in transplanted muscle tissue of the lip in man. Br J 82. Calhoun KH. Reconstruction of subtotal and total
Plast Surg 1961;14:66. defects of the lips. In: Calhoun KH, Stiernberg CM,
65. Burget G, Menick F. Aesthetic restoration of one- editors. Surgery of the lip. New York: Thieme;
half of the upper lip. Plast Reconstr Surg 1986; 1992. p. 24–34.
78:583–93. 83. Ducic Y, Smith JE. The cervicodeltopectoral flap for
66. Abbe R. A new plastic operation for the relief of single-stage resurfacing of anterolateral defects of
deformity due to double harelip. Plast Reconstr the face and neck. Arch Facial Plast Surg 2003;5:
Surg 1968;42:481–3. 197–201.
 Lip Reconstruction 357

84. Jeng SF, Kuo YR, Wei FC, et al. Total lower lip 88. Lengele BG, Testelin S, Bayet B, et al. Total lower
reconstruction with a composite radial forearm- lip functional reconstruction with a prefabricated
palmaris longus tendon flap: a clinical series. Plast gracilis muscle free flap. Int J Oral Maxillofac
Reconstr Surg 2004;113:19–23. Surg 2004;33:396.
85. Ozdemir R, Ortak T, Kocer U, et al. Total lower lip 89. Chang KP, Lai CS, Tsai CC, et al. Total upper lip
reconstruction using sensate composite radial reconstruction with a free temporal scalp flap:
forearm flap. J Craniomaxillofac Surg 2003;14: long-term follow-up. Head Neck 2003;25:602.
393–405. 90. Converse JM. Technique of elongation of the oral
86. Sadove RC, Luce EA, McGrath PC. Reconstruction fissure and restoration of the angle of the mouth.
of the lower lip and chin with the composite radial In: Kazanjian and Converse’s The Surgical Treatment
forearm palmaris longus free flap. Plast Reconstr of Facial Injuries. Baltimore: Williams and Wilkins;
Surg 1991;88:209. 1959. p. 795.
87. Sakai S, Soeda S, Endo T, et al. A compound radial 91. Anderson R, Kurtay M. Reconstruction of the
artery forearm flap for the reconstruction of lip and corner of the mouth. Plast Reconstr Surg 1971;47:
chin defect. Br J Plat Surg 1989;42:337–8. 463.