Lip Reconstruction

Donald Baumann, M.D.,1 and Geoffrey Robb, M.D.1

ABSTRACT

Lip reconstruction poses a particular challenge to the plastic surgeon in that the
lips are the dynamic center of the lower third of the face. Their role in aesthetic balance,
facial expression, speech, and deglutination is not replicated by any other tissue substitute.

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The goals of lip reconstruction are both functional and aesthetic, and the surgical
techniques employed are often overlapping. This discussion will focus on lip defects
with significant tissue loss that require flap reconstruction. Flaps described include
Webster-Bernard cheek advancement flaps, Abbe cross-lip flaps, Karapandzic rotation
advancement flaps, and single and dual free-flap lip reconstructions. The principles and
techniques described are broadly applicable to other flap designs that are required to meet
both the aesthetic and functional goals of lip reconstruction.

KEYWORDS: Lip reconstruction, Webster-Bernard flap, Abbe flap, Karapandzic flap,

free flap

L ip reconstruction poses a particular challenge to modifications associated with them. This can be quite
the plastic surgeon in that the lips are the dynamic center confusing and often a source of miscommunication.
of the lower third of the face. Their role in aesthetic Surgical techniques to reconstruct the lips can be differ-
balance, facial expression, speech, and deglutination is entiated by three main criteria: Is the reconstruction
not replicated by any other tissue substitute. The goals of dynamic or static? Is the orbicularis oris muscle sphincter
lip reconstruction are both functional and aesthetic, and reestablished or is tissue interposed within it? Is the
the surgical techniques employed are often overlapping. donor tissue from the remaining lip, local cheek tissue, or
The aesthetic goals of lip reconstruction are to provide distant tissue? These aspects of flap design must be
adequate replacement of external skin while maintaining considered as they impact the ultimate aesthetic and
the aesthetic balance of the vermiliocutaneous junction functional outcome. As an example, a dynamic recon-
and lip aesthetic units. The functional goals of lip struction with remaining lip tissue that re-creates the
reconstruction are to maintain intraoral mucosal lining orbicularis sphincter will likely be superior in terms of lip
and to preserve the surface area of the oral aperture. The appearance and orbicularis function to a static recon-
competence of the orbicularis muscle sphincter must also struction that uses remote tissue interposed between the
be maintained, as this is critical to achieving a functional remaining orbicularis muscle.
recovery.1,2 Ideally, cutaneous sensation is preserved or This discussion will focus on representative flaps
reestablished to provide proprioceptive feedback for from each category above. Webster-Bernard cheek
speech, animation, and management of secretions. advancement flaps, Abbe cross-lip flaps, Karapandzic
There have been countless flaps described to rotation advancement flaps, and free-flap reconstructions
reconstruct the lips with numerous eponyms and will be presented. The principles described are broadly

1
Department of Plastic Surgery, The University of Texas M. D. Soft Tissue Facial Reconstruction; Guest Editor, James F. Thornton,
Anderson Cancer Center, Houston, Texas. M.D.
Address for correspondence and reprint requests: Donald Semin Plast Surg 2008;22:269–280. Copyright # 2008 by Thieme
Baumann, M.D., Assistant Professor, Department of Plastic Surgery, Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
The University of Texas M. D. Anderson Cancer Center, 1515 USA. Tel: +1(212) 584-4662.
Holcombe Boulevard, Unit 443, Houston, TX 77030 (e-mail: DOI 10.1055/s-0028-1095886. ISSN 1535-2188.
[email protected]).
269
270 SEMINARS IN PLASTIC SURGERY/VOLUME 22, NUMBER 4 2008

applicable to other flap designs and modifications of the and skin. The mucosa must be aligned and everted to
above flaps that are used in lip reconstruction. provide a watertight mucosal seal. The deep and super-
ficial fibers of the orbicularis muscle must be reapproxi-
mated to allow tension-free muscle coaptation and avoid
ANATOMY attenuation or muscle dehiscence. Incisions that cross
Lip reconstruction requires familiarity with the surface the white roll should be oriented perpendicularly to
anatomy, underlying muscular anatomy, and neurovas- allow precise realignment of the while roll to avoid
cular anatomy of the lower face. The upper lip is a noticeable vermiliocutaneous mismatch or notch.
composed of the philtrum and tubercle centrally, the Subtle misalignment of the lip can be aesthetically
paired philtral columns laterally, and the white roll of the distracting, even in the absence of significant soft tissue
vermiliocutaneous junction. The orbicularis oris muscle loss. This remainder of this discussion will focus on lip
maintains oral competence by acting as a circumoral defects with significant tissue loss that require flap
sphincter. Its horizontal fibers link the modiolus and reconstruction.
philtral columns producing a tightening of the upper lip.
Oblique fibers between the commissure and nasal floor
act to evert the upper lip. The orbicularis is acted upon CHEEK ADVANCEMENT FLAPS: WEBSTER-

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by the surrounding elevating and depressing mimetic BERNARD FLAP
musculature. The levator labii superioris, levator anguli The Webster-Bernard flap is used to reconstruct the
oris, and the zygomaticus major and minor elevate the lower lip by advancing cheek tissue and the remaining lip
upper lip, and the mentalis, depressor labii inferioris, and tissue medially.3 This technique is well suited for sub-
the depressor anguli oris draw the lip inferiorly. total defects of the lower lip where the commissure is
The blood supply to the lips is derived from the preserved (Fig. 1). Cheek skin is recruited to add length
facial artery with the inferior labial artery supplying the to the lip repair to lessen the degree of microstomia.
lower lip and the superior labial artery and branches Simultaneous vermilion reconstruction can be accom-
from the angular artery supplying the upper lip. Motor plished with this technique through mucosal eversion.4
innervation arises from the buccal and marginal man- In planning the flap design, the length of each
dibular branches of the facial nerve; sensory innervation cheek limb equals half of the horizontal lip defect.
of the upper lip is from the infraorbital nerve V2 and the Triangular curvilinear upper and lower incisions are
mental nerve V3 supplies the lower lip. planned along the nasolabial and labiomental creases.
The lip vermilion separates the skin of the exter- Burow’s triangles are excised from the upper incisions.
nal lip and the mucosa of the inner lip. It is composed The lower incision can often be advanced without the
of keratinizing glabrous epithelium with numerous need for resection of the Burow’s triangles due to
sebaceous glands. The transitional area between the the laxity of the skin of the chin-cheek junction. The
keratinizing epithelium of the vermilion and the non- incisions are performed through the subcutaneous tissue
keratinizing epithelium of the labial mucosa is densely and muscle to the level of the mucosa. The mucosa is
innervated with mucocutaneous end organs. incised medially but need not be incised laterally as this
will stretch with tissue advancement. This allows pres-
ervation of intraoral lining. Medially, the mucosa is
DEFECTS incised superior to the skin flap design to allow mucosa
The etiologies of lip defects are quite diverse including, to be delivered anteriorly and everted to create the
oncologic resection, traumatic avulsion, burns and con- vermilion of the reconstructed lip. The medial edges of
genital deformities. Defects of the lower lips are more each flap are inset with a three-layer closure. Realign-
often encountered due to the higher incidence of lower ment of the native lip vermilion is accomplished by an
lip cancers. Defects of up to 30% of the transverse width overlapping vermilion advancement to prevent central
of the lip in adults can typically be closed primarily notching at the junction of the two flaps.
without significant decrease in oral opening. Defects of The Webster-Bernard flap provides reliable
the vermilion may require sacrifice of adjacent skin of the resurfacing of large lip defects with adjacent cheek
prolabium or mentum to allow a vertical realignment of skin. Adding local tissue to the lip reduces the incidence
all lip elements without redundancy. This may be de- of microstomia. Its potential disadvantages include
signed as a V or an inverted V for narrow defects. Wider notching of the central lip incision and effacement of
defects may require the skin excess to be resected in a the gingivobuccal sulcus.5 It also is an adynamic recon-
curvilinear alar groove or labiomental pattern allowing struction, and when used in the lower lip, it requires care
the remaining lateral lip or lip-cheek junction to advance in setting tension of lower lip to maintain oral compe-
medially. tence. Care should be taken when planning this flap
Full-thickness defects require meticulous atten- in patients who have had previous facial surgery and
tion to obtain a three-layer closure of mucosa, muscle, previous neck dissections as previous incisions and facial
 LIP RECONSTRUCTION/BAUMANN, ROBB 271

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Figure 1 Squamous cell carcinoma of the lower lip reconstructed with the Webster-Bernard flap. (A) Preoperative view.
(B) Total lower lip defect; note the commissures are preserved. (C) Planned markings for bilateral cheek advancement with
the Webster-Bernard flap. (D) Flaps mobilized; note the extent of mucosa recruited for creation of the vermilion. (E) Flap inset.
(F–I) Twelve-month follow-up.

artery ligation can alter the reliability of the cutaneous Dissection is performed to release muscle fibers
circulation. and suspensory ligaments while taking great care to
preserve the inferior and superior labial artery branches
and the buccal motor nerve branches to the orbicularis as
ROTATION ADVANCEMENT LIP FLAP: they enter the muscle at its lateral extent (Fig. 2). Bipolar
KARAPANDZIC FLAP cautery and a nerve stimulator facilitate the intramus-
The Karapandzic flap was designed to reestablish the cular dissection. Minimal incision of the underlying
circumoral sphincter by rotating and advancing the mucosa is performed, as the mucosal laxity will allow
remaining innervated orbicularis oris muscle.6 In theory, advancement for closure. The overall lip circumference is
the lip is rebuilt with innervated-like tissue. However, reduced to close the defect with a corresponding decrease
the net circumference of the lip is reduced. The in stoma surface area. Critical microstomia is the limit of
Karapandzic flap can be used to resurface up to near- the flap design. Lesser degrees of microstomia can be
total defects of both the upper and lower lips, though addressed secondarily with cross-lip flaps to transfer
superiorly based flaps for lower lip defects are more relative lip excess to areas of deficiency.
common. The key to flap design is to assess the vertical The Karapandzic flap can provide a dynamic
height of the defect and translate that dimension to the functional reconstruction with smaller innervated flaps
width of the flap. This allows a curvilinear incision to be preserving better function. Although the flaps remain
plotted upwards toward the alar base. These incisions innervated, the tension created by flap advancement in
can fall within the nasolabial fold or parallel to it with the face of larger tissue loss reduces the lower lip to a
acceptable donor-site scarring. tightened band.7 Subtle dynamic motion is replaced by
272 SEMINARS IN PLASTIC SURGERY/VOLUME 22, NUMBER 4 2008

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Figure 2 T2 N0 squamous cell carcinoma subtotal lower lip defect reconstructed with a Karapandzic flap. (A) Extirpative
defect. Right commissure marked. (B) Flap design along nasolabial fold. (C) Flaps mobilized. Neurovascular pedicle isolated and
preserved. (D) Flap inset. (All photos copyright # 2007, Matthew Hanasono, M.D.)

tethered scar. As with cheek advancement flaps, efface- with both the central and lateral lower lip serving as a
ment of the anterior gingivobuccal sulcus may require donor site. However, when the upper lip is used as donor
revising and deepening with a skin graft to improve tissue, the central philtral region is preserved given the
salivary competence. delicate aesthetic balance of the central upper lip. The
lateral upper lip serves as a donor site more commonly
for transfer to the lower lip. Defects that are well suited
CROSS-LIP FLAP: ABBE FLAP to Abbe flaps are central full-thickness defects that do
The cross-lip flap, or Abbe flap, is a staged flap based on not involve the commissure.8 One advantage of the
the labial artery. The Abbe flap is well suited for both cross-lip flap is the ability to replace a vertical segment
upper and lower lip reconstructions. It is more com- of both vermilion and cutaneous lip tissue. An inferiorly
monly used as a lower lip flap transferred to the upper lip based Abbe flap can be extended to also include skin
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Figure 3 Recurrent squamous cell carcinoma of nasal vestibule and upper lip treated previously with radiation. (A) View of
planned resection of nasal vestibule, septum, and upper lip. (B) Abbe flap with addition of mental skin to resurface defect of
nasal floor. (C) Width of flap design was based on wider tissue requirement of nasal floor than of upper lip defect. (D) Result at
2 weeks before flap division. (E) Three-month follow up. (F) Lateral view; projection of the central lip preserved. (All photos
copyright # 2007, Roman Skoracki, M.D.)

from the chin to resurface a defect extending into the tains the oral opening as wide as possible. Flap division is
nasal floor (Fig. 3). performed at 3 weeks. A compliant patient is paramount
The defect is assessed and the flap is designed to to the success of this flap as diet, speech, and social-
be half as wide as the defect to allow for balanced upper ization are altered during the staged reconstruction.
and lower lip lengths after flap transposition. The flap Abbe flaps are also useful options for revising lip
survives on an axial blood supply and can be reliably reconstructions as secondary lip-balancing procedures. If
narrowed allowing the flap to pivot and rotate into the there is a relative deficiency in lip length after a cir-
defect. In selecting which side of the lip to set the base of cumoral lip reconstruction, an Abbe flap can be inter-
the flap, the pivot point is placed closest to the commis- posed to the shortened lip segment restoring balance.
sure to allow a more proximal blood supply and a more The main disadvantages are the intervening period of lip
lateral pivot point. This allows a maximal distance from adhesion and the potential imbalance of the vermilion
the opposite commissure to the flap pedicle and main- and white roll on either side of the two suture lines.
274 SEMINARS IN PLASTIC SURGERY/VOLUME 22, NUMBER 4 2008

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Figure 4 T4 N0 squamous cell carcinoma of nasal cavity, columella, and upper lip. (A) Extirpative defect after total
rhinectomy, palatectomy, bilateral maxillectomies, and resection of upper lip resulting in large confluent oro-nasal cavity.
(B) Palate and upper lip reconstructed with folded radial forearm flap. The flap was oriented such that the radial and ulnar borders
were inset posteriorly allowing the pedicle to travel laterally to the left facial vessels. A palmaris sling anchored to the zygomatic
bone supported the flap. (All photos copyright # 2007, Donald Baumann, M.D.)

FREE-FLAP RECONSTRUCTION OF LARGE and, depending on body habitus, have the ability to be
LIP DEFECTS folded and contoured re-creating the internal and ex-
Free-flap reconstruction is often required for large-scale ternal lining of the lip. When additional flap volume is
defects with associated loss of mucosa, cheek, nasal, and required, the anterolateral thigh flap (ALT) with or
chin skin that exceed the availability of local soft tissue. without the vastus lateralis muscle is well suited to
This can be due to paucity of available soft tissue, reconstruct defects of the central and lower face. The
previous radiation therapy, or previous surgery (Fig. 4). ALT flap is ideal for large through-and-through cheek
While free-tissue transfer can provide an abundance of defects with lip involvement when two skin islands are
soft tissue, care must be taken in selecting a donor required13,14 (Fig. 6). An advantage of internal mam-
site with an appropriate match in color, texture, and mary artery perforator, lateral arm, and parascapular
pliability. flaps is color match with facial tissues; however, pedicle
The radial forearm flap has been used extensively length must also be taken into account when selecting
because of its thin profile, long pedicle, and reasonable these donor sites for lip reconstruction.
color match9,10 (Fig. 5). Parascapular flaps have also Accurate assessment of three-dimensional tissue
been used preferentially in facial reconstruction because loss and required volume for reconstruction is para-
of their excellent color match with facial skin.11 With mount to the success of a lip reconstruction. Lip defects
the advent of perforator flaps, the thoracodorsal artery often appear more dramatic than they are in actuality
perforator flap, internal mammary artery perforator because of the displacement of wound edges due to the
flap, anterolateral thigh flaps, and lateral arm flaps lateral pull of the facial muscles. The first step in
have become options for facial reconstruction available deciding on flap dimension is to reestablish the resting
to the reconstructive microsurgeon.12 Perforator flaps tension of the edges of the lip defect. The other lip can
allow tissue to be thinned based on a preferential be used as a guide to reestablish the aesthetic dimension
cutaneous blood supply and in theory are fascial and of the lip. Next, an Esmarch template is fashioned and
muscle sparing thus reducing donor-site morbidity. sewn to the remaining lip elements and folded to
These flaps typically provide reasonable color match account for the three-dimensional tissue requirements
 LIP RECONSTRUCTION/BAUMANN, ROBB 275

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Figure 5 Eight-month follow-up after radial forearm free-flap reconstruction of lower lip defect. (A) Lip in repose. Flap was
supported with fascia lata sling anchored to the modiolus. Of note, the palmaris tendon was absent. (B) Lip circumference
symmetrically preserved. (C) Healed donor site. (All photos copyright # 2007, Roman Skoracki, M.D.)

Figure 6 Recurrent squamous cell carcinoma after previous reconstruction with vertical rectus abdominus myocutaneous
flap and radiation therapy. (A) Preoperative appearance. Note the tethered scar retraction and lateral displacement of the
commissure. Intraoral soft tissues are also contracted and fixed. (B) Full-thickness cheek defect including the lateral element of
the upper and lower lips and commissure. (C) Reconstruction with dual paddled anterolateral thigh flap and fascia lata sling
anchored to the zygomatic bone. The upper and lower lip elements were advanced to create a new commissure supported by
the underlying ALT flap. (D) Follow-up at 8 weeks. (E) Improved mouth opening. (F) Reconstructed commissure maintains
anatomic position upon mouth opening. (All photos copyright # 2007, Donald Baumann, M.D.)
276 SEMINARS IN PLASTIC SURGERY/VOLUME 22, NUMBER 4 2008

of the defect. Precision is required in determining the to avoid a previously operated neck or primarily radi-
length of the external skin deficit given the delicate ated neck. Recipient vessels are reached through a
balance of lip aesthetic units. The mucosal requirement subcutaneous tunnel. The tunnel must be designed to
can be slightly overestimated to allow excess tissue to allow the pedicle to travel in a direct path avoiding
deepen the gingivobuccal sulcus and limit intraoral scar kinks, twists, or compression.
contracture. The inset of a thinned perforator flap is performed
Next, recipient vessels must be selected. The by folding the flap on itself to create internal mucosal
facial vessels are of adequate caliber and readily acces- lining and external cutaneous coverage. Alternatively, if
sible at the angle of the mandible. An anastomosis at the flap cannot be folded, the cutaneous portion can be
this level requires a pedicle length of 8 cm, which is used for intraoral lining, and the external portion of the
readily available with any flap design. If the facial flap can be covered with a skin graft. The flap design
vessels are too small or unavailable due to previous should plan for pedicle orientation in the coronal plane to
surgery, then recipient vessels must be sought elsewhere avoid the pedicle being folded on itself and compressed in
in the external carotid system. One advantage in select- the sagittal plane. The flap inset is guided by aligning
ing recipient vessels for a lip reconstruction is that external lip structures and interposing flap skin island
either side of the neck can be used allowing the surgeon under slight tension. This is done to establish the resting

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Figure 7 T4 N0 squamous cell carcinoma of the mandible eroding through to external skin and undermining the lower lip. (A)
Preoperative appearance. (B) Defect after hemimandibulectomy and resection of lower lip and chin-cheek skin. The defect
required intraoral bone and soft tissue reconstruction that was provided by a fibula osteocutaneous flap. A radial forearm flap
provided external skin coverage. (C) Radial forearm skin island. (D) Fibula inset and radial forearm flap revascularized. Lip
reconstruction was planned with a unilateral Karapandzic flap. (E) Intraoperative result after flap inset. (F) Result at 4 weeks.
Reconstructed right lower lip is well supported by the soft tissue framework below; however, the shortened lip length has led to
reduction in oral opening. (G) Result at 8 months after completion of radiation therapy. Note the improved contour of radial
forearm flap. (All photos copyright # 2007, Matthew Hanasono, M.D.)
 LIP RECONSTRUCTION/BAUMANN, ROBB 277

tone of the lip to prevent ptosis and salivary incompe- If the central mimetic musculature or distal facial
tence. Attention to deepening the anterior gingivobuccal nerve branches have been resected, the reconstructed lip
sulcus will improve the patient’s ability to manage secre- must be supported with either a static or dynamic sling.
tions, tolerate liquids, and avoid drooling. Static sling free-flap reconstruction requires suspension

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Figure 8 Exophytic squamous cell carcinoma of mandible and lower third of the face. (A) Preoperative appearance.
(B) Extirpative defect including angle-to-angle mandibulectomy, resection of floor of mouth, lower lip, chin and neck skin.
This defect required a dual free-flap reconstruction, bone and soft tissue intraoral reconstruction, and a large soft tissue flap for
external neck and chin coverage. Given the extent of lip and intraoral resection, there were limited options for the lip
reconstruction. The fibula skin island was used for resurfacing of the lower lip in addition to intraoral coverage. (C) Harvest of
fibula with large skin paddle. (D) Fibula inset with soft tissue platform for lip reconstruction. (E) Intraoperative result with ALT
flap resurfacing the chin and cheek and neck skin. (All photos copyright # 2007, Matthew Hanasono, M.D.)
278 SEMINARS IN PLASTIC SURGERY/VOLUME 22, NUMBER 4 2008

of the lateral element of the lip with rolled fascia grafts or REVISIONS
prosthetic or bioprosthetic materials. The vector can be Most lip reconstructions require revision after a period of
set using either the modiolus or zygomatic body as a interim healing and completion of adjuvant therapy. The
point of fixation depending on the presence or absence of advanced tumor stage of larger lip defects often requires
the facial nerve function. Bony anchors offer stable radiation therapy for oncologic control. Radiation ther-
fixation and enable fine-tuning of the vector of lip apy inevitably alters the aesthetic outcome resulting in
elevation. hyperpigmentation, fibrosis, edema, and pin-cushioning.
The previously discussed aesthetic benefits of When evaluating a patient for a lip revision, it is
radial forearm flaps and perforator flaps including thin important to consider the appearance and function of
tissue mass, pliability, and color match are offset by the the lip as well as the patient’s goals. The lip must be
lack of functional dynamic motion. These flap donor viewed in relation to its subunits: external skin of the
sites all lack motor innervation and voluntary tightening mentum and prolabium, vermilion, commissure, and
of the lip. All lower lip static reconstructions are essen- mucosa. Options for vermilion revisions include facial
tially tension bands that relax with time and lose aspects artery musculomucosal flaps,21 mucosal advancement
of their barrier function. Dynamic slings can also be flaps, commissureplasties, and tongue flaps. Intraoral
incorporated into free-flap lip reconstructions to im- scar release and skin grafting to deepen the gingivobuc-

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prove the degree of voluntary control of commissure cal sulcus can provide dramatic improvement in the
position and lip tone. Techniques that use both free flaps ability to manage secretions and liquids. Full-thickness
for lip resurfacing and temporalis muscle turn-down skin grafts can be used to resurface the aesthetic units of
flaps for lip elevation have been described for this the lip and chin. In men, asymmetries in the recon-
purpose.15 This technique may prevent ptosis of the structed upper lip can be camouflaged by resurfacing the
lateral lip, but with time the degree of function achieved lip with a hair-bearing temporoparietal fascial flap.22
does not compare with the native lip’s mobility. These revisional efforts can have a significant impact on
Often, total lip defects are accompanied by large- the patient’s sense of body image and their ability to
scale resections of surrounding tissue including the nasal resume their personal and professional lives.
floor, nose, mandible, floor of mouth, chin, cheek, and
neck. These complex volumetric and topographic defects
often require tissue replacement in excess of that avail- CONCLUSION
able with any one flap. Dual free-flap reconstructions can In planning a lip reconstruction, all aspects of flap design
be employed to reconstruct these extensive intraoral and must be considered as they impact the ultimate aesthetic
extraoral defects.16 These flaps may be used to provide a and functional outcome. A dynamic reconstruction with
platform to support the lip reconstruction by a local flap remaining lip tissue can provide superior results in terms
or they might provide the lip reconstruction itself17 of lip appearance and function in smaller lip defects.
(Figs. 7 and 8). Reconstruction of large-scale defects often requires free-
The next step in refining free-tissue lip recon- tissue transfer that provides static support of the lip.
struction is to develop flaps that can meet both the Further refinements in free-flap design are needed to
aesthetic and functional demands of the lip. The aes- provide dynamic reconstructions that re-create the func-
thetics have been refined through our current flap tion of the lip and preserve oral competence.
selection. However, the need for voluntary controlled
intrinsically dynamic flap designs has not been met.18
These characteristics are not readily available in any ACKNOWLEDGMENTS
given flap donor site. However, as dual free-flap recon- The authors acknowledge their colleagues Matthew
struction for complex head and neck reconstruction has Hanasono, M.D., and Roman Skoracki, M.D., who
become more commonplace, extensive total lower lip contributed their cases to this work.
defects may be amenable to a dual-flap trilaminar
dynamic reconstruction. As an example, innervated a
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13. Yildirim S, Gideroglu K, Aydogdu E, Avci G, Akan M, artery musculomucosal flap. Plast Reconstr Surg 2000;105:
Akoz T. Composite anterolateral thigh-fascia lata flap: a 864–872
good alternative to radial forearm-palmaris longus flap for 22. Kim JC, Hadlock T, Varvares MA, Cheney ML. Hair-
total lower lip reconstruction. Plast Reconstr Surg 2006;117: bearing temporoparietal fascial flap reconstruction of upper
2033–2041 lip and scalp defects. Arch Facial Plast Surg 2001;3:170–177
280 SEMINARS IN PLASTIC SURGERY/VOLUME 22, NUMBER 4 2008

Editor’s Comments incision closure. The resulting lip is functional, but

admittedly unbalanced. Overall, we still feel this provides
Drs. Baumann and Robb have written an outstanding the best functional resection option.
review of their reconstructive management of large lip Also, for upper lip skin only defects, peri-alar
defects. crescentric advancement flap can provide color
They reflect the current consideration that the matched coverage of up to 35% defects in selected
upper limits of a lip defect to be closed primarily is patients.
limited to 30%.
However, we have found that in selected patients James F. Thornton, M.D.
defects up to 45% can be closed with a ‘‘V’’ wedge

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Figure 1 Interoperative/postoperative views of a nearly 50% lower lip defect closed by wedge excision/closure.

Figure 2 30% skin only upper lip defect reconstructed with a peri-alar crescentric advancement flap.