Novel Flaps for Lip Reconstruction

A. J. Kaufman, MD¹ and T. E. Rohrer, MD²

1. David Geffen School of Medicine at UCLA, Los Angeles, USA and Private Practice, Center for Dermatology Care, Thousand Oaks and Santa Barbara, USA
2. Boston University School of Medicine, Boston, USA and Private Practice, Skin Care Physicians, Chestnut Hill, USA

ABSTRACTkau

Reconstruction of the lips requires careful attention to aesthetic and functional goals. We describe our approach to lip repair and present novel methods to maintain symmetry and function, and optimize cosmetic results.

Key Words:
Lip repair, vermillion

Reconstruction of the lips is a challenging task for the dermatologic surgeon. From a functional standpoint, the lips serve a critical role in speech, eating, and demonstrative emotions. Aesthetically, there are numerous subtle, but very important, variations in contour, color, and texture. With no underlying bony or cartilaginous framework, they are extremely sensitive to distortion. The lips are a focus of facial beauty, and their central location does not permit concealment of unsightly scars or asymmetrical results.

As with most repairs on the face, repair along relaxed skin tension lines and within cosmetic subunits optimizes cosmetic outcome. Cosmetic subunits of the upper lip include two lateral segments and one central or philtral unit. While the lower lip is a single unit, it is helpful to consider whether the defect is more central or lateral. Another cosmetic subunit to consider is the vermillion, and defects involving only the vermillion should be reconstructed within that cosmetic subunit whenever possible.

Categorization into partial or full-thickness defects also identifies ideal reconstructive methods. Defects that involve a full-thickness portion of the lip (i.e., skin, muscle, and mucosa) require full-thickness repair. The size of the surgical defect also impacts
alternatives for repair. The dermatologic surgeon should strive to keep incision lines within or parallel to relaxed skin tension lines and place incisions at the boundaries between cosmetic units or subunits whenever possible.

We will describe our approach to reconstruction of the lips and some novel methods of repair. As mentioned, the first step is to consider the location of the defect and what tissue has been lost.

Partial Thickness Surgical Defects

Vermillion

Small superficial defects limited to the vermillion may be allowed to heal by secondary intention with good results;¹ however, larger or deeper defects or wounds near the vermillion border risk distortion if allowed to heal in this manner. Full-thickness grafts from the labial or buccal mucosa may be used, but often develop trapdoor deformity or mismatch color, texture, and thickness with the surrounding vermillion.

For defects approaching 50% of the vermillion width or greater, a complete vermillionectomy and mucosal advancement flap repair may be performed (Figures 1A–C). By removing the entire vermillion the risk of subsequent malignancy from adjacent actinic cheilitis is lessened, and the uniform repair and scarring help maintain symmetry of the lip. Like other repairs of the perioral area, mucosal advancement flaps should be marked out prior to the injection of local anesthesia. Mucosal advancement flaps are undermined below the level of the minor salivary glands, but above the orbicularis muscle. They are dissected back to a point where there is minimal closure tension at the vermillion border, and then closed by the rule of halves with absorbable and nonabsorbable sutures. While useful for large defects, mucosal advancement flaps have potential disadvantages. Advancement of mucosa to reconstruct vermillion often decreases the anterior-posterior dimension of the lip and can give a more rounded and reddish color to the reconstructed vermillion. Patients also frequently complain of persistent hypoesthesia, and men may note redirection of beard hair upward, causing irritation to the upper lip.

Another approach to vermillion repair for defects that are < 40% of the vermillion width is a bilateral vermillion rotation flap (Figures 2A–C).² This flap utilizes adjacent vermillion to rotate centrally. The arcs of the rotation flap are drawn along the vermillion border with the redundant triangle of skin (dog ear) removed posteriorly. Back cuts are made at the oral commissures to permit rotation of the flaps and minimize pivotal restraint. Like the mucosal advancement flap, the bilateral vermillion rotation flap is undermined in a plane between the minor salivary glands and orbicularis muscle. This flap maintains the anterior-posterior dimension of the lip, avoids redirection of beard hairs, and decreases the risk of persistent hypoesthesia. This flap is an excellent alternative for repair of medium-sized defects in patients with less actinic damage to the adjacent vermillion.

Figure 1A: Vermillion defect prior to reconstruction.	Figure 1B: Residual dry vermillion is removed (vermillionectomy), and defect repaired with mucosal advancement flap.	Figure 1C: Healed result.
Figure 2A: Medium-size vermillion defect prior to repair.	Figure 2B: Bilateral vermillion rotation flap completed by incision along vermillion border bilaterally to oral commissures with backcuts to permit rotation. Undermine widely deep to salivary glands on the labial mucosa and rotate and secure flaps centrally. Central tricone excised at end.	Figure 2C: Short-term healed result.

Cutaneous Lip, Lateral

In many instances, surgical defects in the lateral cutaneous lip may be closed in a simple, linear fashion along the relaxed skin tension lines radiating from the lip. Although M-plasties can be performed to shorten the length and keep the repair from crossing the vermillion border, violating the vermillion border with a linear closure is generally not an aesthetic problem at all, as long as the vermillion border is properly aligned during closure. It is certainly better to violate the border than leave an elliptical closure too short and create a protrusion of tissue or tricone on the lip. Also, remember that elliptical excisions may push tissue at the poles outward. This force on the lip can create a displeasing downward displacement of the lip and should be watched for and avoided during closure. To reduce motion and tension on the wound during healing, a novel trick is to use a small amount of botulinum toxin injected around the perioral area (i.e., place 0.5–1 unit in four sites circumferentially around the vermillion border) during the immediate postoperative period.³

For defects too large for side-to-side repair, advancement flaps are the most useful repair for partial-thickness defects of the lateral cutaneous lip. The procedure works well for the upper and lower lip due to the abundant reservoir of cheek and jowl tissue. Advancement flaps are generally drawn along the vermillion border with redundant tissue or tricone excised (superiorly on the upper lip and inferiorly on the lower lip) along relaxed skin tension lines radiating from the lip. Since a pure advancement flap has unequal lengths being drawn together (X vs. X + the length of the defect), there is significant potential for tissue distortion if this is not accounted for. Burrow’s triangles or crescents should be taken to minimize this difference and the risk of vermillion distortion. Advancement flaps are generally undermined in the deep subcutaneous fat above the orbicularis muscle. When defects are located in the superior aspect of the upper cutaneous lip, the flap may be drawn, extending along the nasal sill with a crescent taken lateral to the ala and the redundancy taken inferiorly along a relaxed skin tension line radiating from the lip. When designing and executing advancement flaps in the upper lip, care should be taken not to flatten or pull the philtral crests asymmetrically. Pulling the philtrum too far to one side creates an aesthetically unpleasing effect.

Another option for lateral defects of the upper or lower lip is the inferior-based rotation flap (Figure 3A–C). One of the benefits of this repair in this location is that the arc of the incision is kept at the junction between cosmetic units, the melolabial fold on the upper lip and the labiomental crease on the lower lip. One of the basic tenets of reconstructive surgery, keeping an incision line at the junction between cosmetic units or subunits, helps to hide some of the incision lines in this repair.

In a similar fashion the island pedicle flap is useful for defects of the lower lip and the upper lip. This is another example where at least half of the incision from the flap is hidden along the melolabial fold and more along the nasal sill. Great care must be taken to adequately undermine and dissect this flap to assure minimal tension on the mobile vermillion border.

Transposition flaps may be useful for partial thickness defects of the lateral upper or lower lip, especially in instances where an advancement flap does not provide adequate tissue or mobility. One of the advantages of this flap is that part of the incision can be hidden along the melolabial or labiomental folds. However, a distinct disadvantage is the tendency to trapdoor, especially on the more mobile upper lip.

Cutaneous Lip, Medial

Defects in the central area of the lower lip and defects of the upper lip too large for repair with a unilateral procedure can be reconstructed using a bilateral advancement flap (Figures 4A–C). Large amounts of tissue can be recruited from the cheeks for repair, especially in elderly individuals. However, in men the reconstructed upper lip may lack beard hair. The key to successful aesthetic repair is to keep incision lines at cosmetic unit/subunit boundaries and avoid deviation of the lip (eclabium). Undermining in these large random flaps should be carried out in a plane that is superficial to the underlying facial musculature. Avoid trauma to neurovascular structures.

For defects of the philtrum, several options are available. For defects < 50% of the philtral width, a complex repair works well. Defects 50%–100% of the philtral width can be reconstructed using an island pedicle flap, keeping the incisions along the philtral ridges, intersecting to a point at the base, or extending far up the nasal columella if necessary (Figures 5A–C). In this regard, the incision lines are kept at the junction of cosmetic subunits (philtral ridges) and similar vascularized tissue is utilized in the repair. If the defect extends to involve the vermillion, the defects should be repaired separately, using a mucosal advancement flap for the vermillion portion. Another option for defects involving most of the philtrum is to enlarge the defect to the full size of the philtrum and use a full-thickness skin graft. The obvious disadvantage to this option is the difference in skin characteristics, most obvious in men due to the lack of beard hair. In some rare instances, bilateral rhombic transposition flaps may be used to close philtral defects. The secondary defects of the rhombic flaps are taken along the philtral crests on each side of the philtrum and transposed into the defect.

Figure 3A: Partial-thickness defect of lateral upper cutaneous lip.	Figure 3B: Rotation flap completed keeping incision line in melolabial fold and tricone excised in same direction as perioral rhytides.	Figure 3C: Healed result.
Figure 4A: Partial-thickness defect of central upper cutaneous lip.	Figure 4B: Bilateral rotation flap to reconstruct defect. Incision lines are kept at junctions of cosmetic subunits (vermillion inferiorly, alar sill superiorly) and tissue superior to defect is sacrificed to better hide surgical scars.	Figure 4C: Healed result.
Figure 5A: Partial-thickness philtral defect involving cutaneous lip and vermillion.	Figure 5B: Repair with island pedicle flap for cutaneous lip and mucosal advance- ment flap for vermillion. Remember to consider repair of separate subunit defects separately.	Figure 5C: Healed result.

An excellent flap for closure of small defects on or just above the vermillion border involving both the cutaneous lip and vermillion lip is the Cupid’s bow repair as described by Mellette.4 The flap is drawn similar to a mucosal advancement flap, but incorporates a bow shape, mimicking the patient’s Cupid’s bow in the upper cutaneous lip. A disadvantage of this flap is the upward pull of the vermillion lip. If it is a relatively small defect, the slight pull can give a pleasant increase in upper lip fullness. Unfortunately, there is a limit to the amount of pull that is aesthetically acceptable and the flap is thereby limited to small defects in patients that would like a more full upper lip.

Full-Thickness Surgical Defects

Full-thickness surgical defects involve loss of various degrees of cutaneous, muscular, and mucosal lip. Defects up to 25% of the upper lip and one-third of the lower lip can be closed in a wedge-excision fashion. The key to success with this and other full-thickness repairs is careful and complete repair of the mucosa, orbicularis, and skin, and accurate approximation of the vermillion border.

Larger defects necessitate repair with a “lip switch” staged procedure or a repair that moves tissue around the oral commissures. Fortunately, with the growth of Mohs micrographic surgery and its resultant tissue preservation and higher cure rates, the need for these larger repairs is less for the dermatologic surgeon. The original “lip switch” flap was described by Sabatinni, and later by Abbe, as a staged procedure where donor tissue is transposed from the unaffected lip across the oral aperture to the surgical defect, maintaining an intact vascular pedicle.5 The transposed flap should approximate one-half the size of the defect and should not exceed one-third of the donor lip width. After vascular ingrowth has developed within the flap from the recipient site, the pedicle is severed and inset. This flap may be used for defects up to 50% of the lip width, but disadvantages include prolonged denervation with incomplete recovery, risk of the trapdoor phenomenon, inconvenience of a transoral pedicle, and the need for two or more procedures. Other alternatives are available that avoid some of the disadvantages of a “lip switch” procedure. The Estlander flap moves tissue around the commissure in a single-stage procedure, though blunting of the oral commissure, necessitating revision surgery, is not uncommon. A circumferential incision permits the Karapandzic flap or Gillie’s flap to move donor tissue around the oral commissures, and is able to repair defects up to two-thirds of the lip.6 By maintaining an innervated and vascularized pedicle, there is good potential to maintain motor and sensory function. On the downside, there is frequent distortion of the oral commissures, requiring commissuroplasty, and the circumferential incision gives some patients a “clown-like” appearance.

Conclusion

The perioral area is a focal point of both spoken and nonspoken communication and an area of great aesthetic importance. Its mobile nature and varied contours make it a reconstructive challenge. However, as in reconstruction in any area of the face, by understanding the anatomy (superficial and deep), keeping tension off the free margin (the vermillion lip), and placing incision lines in cosmetic unit junctions and/or along relaxed skin tension lines, aesthetically pleasing reconstruction can be consistently achieved. Given its place as a central focus of facial beauty, successful reconstruction of the perioral area is immensely rewarding.

References

1. Gloster HM. The use of second-intention healing for partial-thickness Mohs defects involving the vermillion and/or mucosal surfaces of the lip. J Am Acad Dermatol 47(6):893-7 (2002 Dec).
2. Kaufman AJ. Bilateral vermillion rotation flap. Dermatol Surg 32(5):721-5 (2006 May).
3. Bansal C, Omlin KJ, Hayes CM, Rohrer TE. Novel cutaneous uses for Botulinum toxin type A. Cosmet Dermatol (in press 2006).
4. Paniker PU, Mellette JR. A simple technique for repair of Cupid’s bow. Dermatol Surg 29(6):636- 40 (2003 Jun).
5. Clarkson P. Use of the Abbe flap in the primary repair of the double cleft lip. Br J Plast Surg 7(2):175-8 (1954 Jul).
6. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 27(1):93-7 (1974 Jan).