lip and cheek reconstruction

Lip and Cheek Reconstruction

Drs. N. Afridi and G. Sparkes

Lip reconstruction

Lip function

– Oral competence– Deglutition– Articulation– Expression of emotion– Symbol of beauty

Lip reconstruction

Anatomy– Topographic landmarks

Lip reconstruction

Anatomy– Muscles

Lip reconstruction

Anatomy– Motor Innervation

• Facial nerve VII– Buccal

• Elevators of commissures and orbicularis oris– Marginal mandibular

• Lip depressors

– Sensory innervation • Trigeminal nerve V

– Mental nerve terminal branch of inferior alveolar nerve• Lower lip

– Infraorbital nerve• Upper lip

Lip reconstruction

Anatomy– Vascular supply

• Derived from the facial arteries– Superior and inferior labial branches

– Travel tangentially deep to the orbicularis oris muscles

– Lymphatic drainage• Primarily submental and submandibular nodes

– Upper lip and lateral lower lip

• Submandibular chain

– Central lower lip

• Submental nodal area

• Crossover common

Lip reconstruction

Approach– Evaluate

• Size and location of the defect• Etiology of the lesion• Patient age and gender

Lip reconstruction

Surgical goals

– Complete skin cover and oral lining– Semblance of a vermilion– Adequate stomal diameter– Sensation– Competent oral sphincter

Lip reconstruction

Vermilion– Modified mucosal surface– Most visible component of the lips– Sensory unit of the lips

• Temperature• Light touch• Pain

– Scars well hidden at vermilion– Avoid crossing vermilion cutaneous junction

• Incisions should cross at 90 degrees

– 1 mm discrepancy in outline of white roll visible at 3 feet

Lip reconstruction

Vermilion reconstruction– Lower vermilion most affected

• Target of solar radiation injury

– Premalignant lesions• Actinic cheilitis or leukoplakia• Total vermilionectomy (lip shave)

– Resection from white roll to contact area with opposite lip

– Primary closure possible• Tension and dehiscence• Flattening of lip

Lip reconstruction

Vermilion reconstruction– Buccal mucosal advancement flap

• Relaxing incision on mucosa at deep buccal sulcus

• Mucosa elevated deep to salivary glands and superficial to orbicularis oris muscle

Lip reconstruction

Vermilion reconstruction– Tongue flaps

• Two stage procedures• Tongue mucosa

– Red with poor cosmetic match– Feminizing effect in men

• Unpleasant experience for patients

Lip reconstruction

Vermilion reconstruction– Vermilion muscle advancement flap

• Defect less than 1/3 lower vermilion• Based on axial labial artery

Lip reconstruction

Vermilion reconstruction– Lip switch (Kawamoto)

• Correction of large vermilion volume deficiency

• Hemifacial atrophy• Transverse centrally based flap• Turn 180 degrees• Pedicle divided

– 10-14 days

Lip reconstruction

Lower lip– Advantage over upper lip

• Increased soft tissue laxity• No dominant central structure

– Philtrum– Nose

– Disadvantage• Effect of gravity on repair• Greater need for tone to prevent drooling and

oral incompetence

Lip reconstruction

Lower lip reconstruction– Primary closure

• V or W wedge resection– Can provide inadequate margin at lower portion of

resection

• Shield or double or single barrel excision• Avoid crossing the labiomental fold

– Improves aesthetic result

– Grafts• Unreliable survival of composite grafts

– Average width 1 cm

Lip reconstruction

Lower lip reconstruction– Orbicularis oris flap

• Rectangular excision of lower lip lesion

• V-Y advancement– Bipedicled

orbicularis oris

• Vermilion reconstruction

– Labial mucosa advancement flap

• Preserves muscle integrity and nerve supply

Lip reconstruction

Lower lip reconstruction– Rectangular flaps

• Lower lip rectangular flaps

– Labiomental region

– Rotated medially

• Vermilion– Bilateral buccal

mucosa flaps

Lip reconstruction

Lower lip reconstruction– Step method

• Horizontal component of step excisions

– ½ width of defect

• Vertical dimension – 8-10 mm

• 2 to 4 steps are made

• Can be used to close defects up to 2/3 of lip length

Lip reconstruction

Lower lip reconstruction– Abbe flap

• Lip switch– Two stage procedure– 14-21 days of lip apposition before pedicle division

• Indications– Medium sized defects– Defect not involving commissure– Cooperative patients

• EMG studies– Return of muscle function to flap at recipient site

Lip reconstruction


• Flap design– Junction of middle and lateral 1/3s of upper lip– Away from philtral columns and commissure– Paper template useful– Medial or lateral pedicle– Distal flap

• Tapered to nasolabial fold• Rectangle

– Maximum flap size• 2 to 3 cm

Lip reconstruction


• Flap elevation– White roll marked– Full thickness division of non pedicle side

• Locate exact position of labial artery• Allows precise dissection on pedicle side

– Vascular pedicle should have soft tissue support

• Post operative– Liquid and soft diet– Antiseptic rinses– Pedicle division at 2 to 3 weeks

Lip reconstruction


• Bilateral extraphiltral cross lip flaps

Lip reconstruction

Lower lip reconstruction– Estlander flap

• Laterally based lip switch• Pivots at corner of mouth• Indications

– Defect at commissure

• Advantages– Maintains continuity of orbicularis oris– Oral competence

• Disadvantages– Poor commissure definition– Needs secondary revision

Lip reconstructionLower lip reconstruction

– Estlander flap• Flap design

– Full thickness – Medial based flap of lateral lip– Supplied by contralateral labial artery– ½ size of lower lip defect– Distal edge of flap tapered to nasolabial fold

Lip reconstruction

Lower lip reconstruction– Estlander flap

• Modified Estlander– Transposition of

flaps– Preserves

commissure

• Estlander flap with medial advancement of lateral lip

– Large central defects


– Fan flap• Indications

– Total or near total lower lip reconstruction– Gillies fan flap

• Modification of Estlander flap• Preservation of portion of oral sphincter• EMG confirmed nerve regeneration

Lip reconstruction

Lower lip reconstruction– Karapandzic flap

• Indications– Modification of Gillies fan flap– Defects not requiring new lip tissue– Central

• 3.5 to 7.0 cm defects– Lateral with commissure involvement– Preservation of neurovascular supply– Oral sphincter function maintained

Lip reconstruction


• Advantages– Sensation and sphincter function

• Preferable to Bernard Burow’s repair– Single stage procedure and less risk of flap loss

• Compared to Abbe flap

• Disadvantages– Microstomia– Inferior aesthetic result– Circumoral scarring noticeable

Lip reconstruction


• Flap design– Vertical height of defect

• Determines width of flap– Width maintained to alar bases– Full thickness incision medially– Laterally at level of commissures

• Incision to subcutaneous tissue– Labial arteries and buccal branches dissected and

preserved– Central defect equal mobilization– Lateral defect contralateral mobilization greater

Lip reconstruction

Lower lip reconstruction– Depressor anguli oris flap

• Innervated motor and sensory flap• Muscle, skin, buccal mucosa

– Marginal mandibular VII and mental branch V– Based superiorly at oral commissure– Limited to lateral lower lip reconstruction

• Reach of mental nerve restricts– Bilateral flaps can be raised

Lip reconstruction

Lower lip reconstruction– Bernard Burow’s procedure

• 1st described– Full thickness excision 4 triangles

• Two have caudal base at commissure


– Bernard Burow’s procedure• Modifications (Webster)

– Excise skin and subcutaneous tissue– Leave muscle intact– Base triangle in nasolabial fold– Paramental triangular flaps

Lip reconstruction


• Indications– Need for new lip tissue– Avoidance of microstomia

• Advantages– Brings new tissue from cheek– Commissure better reconstructed

• Disadvantages– Incomplete recovery of sensation– Vermilion color mismatch– Oral incontinence and drooling

Lip reconstruction


• Flap design– Excision of lower lip lesion– Triangles of skin and subcutaneous tissue

• Excised at nasolabial fold– Buccal mucosa undermined– All layers advanced and approximated

Lip reconstruction

Lower lip reconstruction– Dieffenbach flap

• Historical interest• Wide inferiorly based rectangular cheek flaps• Functionally impaired lip• Long cheek scars

Lip reconstruction

Lower lip reconstruction– Nasolabial flaps

• Inferiorly based• Pivot on the commissures• Mucosa lining flaps

– Everted to recreate vermilion

Lip reconstruction

Lower lip reconstruction– Free flaps

• Radial forearm most common– Ease of dissection– Two team approach– Thin, pliable, hairless and good colour match

• Can integrate palmaris longus tendon– Attach to modiolus as a sling

• Avoid oral incompetence– Can attach to malar eminence with microplate

Lip reconstruction

Lower lip reconstruction– Rational approach

• Based on extent of defect– Small (less than 1/3)

• Primary closure– Medium (1/3 to 2/3)

• Karapandzic• Estlander• Abbe• Bernard Burow’s

– Large (greater than 2/3)• Bernard Burow’s• Karapandzic• Free flap

Lip reconstruction

Upper lip– Defects less common– Unique features to consider

• Nose • Columella• Cupid’s bow• Philtrum

– Men• Hairbearing – nasolabial and cheek flaps obvious• Can disguise scars in a mustache

– Oral competence less significant

Lip reconstruction

Upper lip– Aesthetic subunits

• Lateral– Philtral column– Nostral sill– Alar base– Nasolabial crease

• Medial– One half of philtrum

• Popularized by Burget and Menick – Design Abbe flaps exactly to match subunit

Lip reconstruction

Upper lip reconstruction– Primary closure

• Most satisfactory results• Lateral defects

– Taper incision into nasolabial fold

Lip reconstruction

Upper lip reconstruction– Perialar crescentic skin excisions

• Area excised conforms to alar margin– Skin and subcutaneous tissue only

• Release of upper buccal sulcus

Lip reconstruction

Upper lip reconstruction– Nasolabial flaps

• Skin and subcutaneous tissue from nasolabial fold

• For upper lip without vermilion defect• Donor site closed primarily

Lip reconstructionUpper lip reconstruction

– Abbe flap• Lip switch from lower lip• Can be combined with perialar crescentic

excision flaps

Lip reconstruction

Upper lip reconstruction– Reverse Karapandzic flap

• Inferiorly based• Carry circumoral incision to commissure

Lip reconstruction

Upper lip reconstruction– Reverse fan flap

Lip reconstruction

Upper lip reconstruction– Reverse Estlander

flap

Lip reconstruction

Upper lip reconstruction– Superiorly based lower cheek flaps

Lip reconstruction

Upper lip reconstruction– Inverted Bernard Burow’s flap

• Upper lip defect replaced with midcheek tissue

• Skin and subcutaneous tissue Burow’s triangles excised lateral to the lower lip and alar base

• Orbicularis muscle not violated• Vermilion reconstructed with buccal mucosa

Lip reconstruction

Upper lip reconstruction– Bilateral levator

anguli oris flap• Innervated• Bilateral and

combined with Abbe flap

– Can be used for total lip reconstruction

Lip reconstruction

Upper lip reconstruction– Rational approach to upper lip

reconstruction• Small (less than 1/3)• Medium (1/3 to 2/3)• Large (greater than 2/3)

Lip reconstruction

Upper lip reconstruction– Small defects

• Primary closure• Perialar crescentic skin excisions

Lip reconstruction

Upper lip reconstruction– Medium defects

• Central – Primary closure with perialar crescentic skin excisions

– Greater than ½

• Perialar crescentic with Abbe flap

– Karapandzic

• Lateral– Commissure not involved

• Abbe flap

– Commissure involved

• Estlander flap

Lip reconstruction

Upper lip reconstruction– Large defects

• Adequate cheek tissue– Inverted Bernard Burow’s procedure– Bilateral levator anguli oris combined with Abbe

flap

• Inadequate cheek tissue– Distant pedicle flap– Free flap

Lip reconstruction

Upper lip reconstruction– Hair bearing skin

• Forehead flap• Scalp flap• Unipedicled submandibular flap• Bipedicled submental flap• Temporal island scalp flap

– Temporoparietal fascia flap– Cutaneous island at vertex of skull– Pivot point at tragus– Tunneled under cheek– Emerges at nasolabial fold

Lip reconstruction

Commissure reconstruction– Microstomia

• Lip vermilion 1st choice

– Advanced or transposed full thickness flap

• Buccal mucosa– Alternative

Lip reconstruction

Commissure reconstruction– Macrostomia

• Congenital macrostomia– Lateral orofacial cleft between maxillary and

mandibular components 1st branchial arch– Incomplete orbicularis oris ring– Upper lip orbicularis

• Contiguous with zygomaticus– Lower lip orbicularis

• Contiguous with risorius

Lip reconstruction

Commissure reconstruction– Macrostomia

• Congenital macrostomia– Operative correction

• Commissure positioning• Reconstruction of muscle ring• Upper lip orbicularis fibers placed anterior to

lower lip orbicularis

Cheek reconstruction

Introduction– Aesthetic units

• Zone I– Suborbital

• Zone II– Preauricular

• Zone III– Buccomandibular

– Includes oral lining in full thickness defects

Cheek reconstructionZone I

– Boundaries• Medial: nasolabial line

• Lateral: anterior sideburn

• Inferior: gingival sulcus

• Superior: lower eyelid

– Subunits • A, B & C

• Subunit C consists of lower eyelid skin at junction with cheek skin

• Orbicularis and zygomaticus origin

• VII deep to zygomaticus


Zone I– Skin grafts

• Split thickness skin grafts– Unfavorable contraction– Ectropion and lid malposition

• Full thickness skin grafts– Preauricular, postauricular, supraclavicular region– Better suited lower eyelid (subunit C)– Less contraction– Subunit A and B – patchy result– Poor contour replacement if defect >5mm depth


Zone I– Local flaps

• Rhomboid flap– 8 flap options– Donor site scar

• Direction of relaxed skin tension lines– Base flap inferiorly

• Decreased edema• Minimize trapdoor effect


Zone I– Local flaps

• Swing side plasty– Reduces size of

defect

– Minimize flap ischemia by rounding tip

• Avoid narrow distal tip


Zone I– Cervicofacial flap

• More extensive zone I defects• Subcutaneous plane

– Extensive dissection unreliable vascularity– Transection of transverse branch facial artery

• Deep plane– Beneath SMAS (subplastymal in neck)– Facial nerve injury significant risk– Useful in smokers and larger flaps

• Anchoring sutures– Anterior zygomatic arch and orbital rim

• Tissue expansion– Congenital nevi


Zone II– Superolateral

junction of helix and cheek

– Medially to malar eminence

– Inferior to mandible– Covers

parotid/masseteric fascia


Zone II– Skin grafts

• Skin laxity in zone II• Common donor site• Use of skin graft rare

– Camouflaged easily with hair


Zone II– Local flaps

• Rhomboid or modified rhomboid• Small cheek rotation advancement flaps• Subcutaneous pedicle flaps


Zone II– Vertical or posterior cheek advancement

• Facelift procedure• Subcutaneous• Deep plane

– Beneath SMAS

Cheek reconstructionZone II

– Cervical flaps• Can include platysma with cheek flap

– Avoid deep plane– Start subcutaneous– Transect platysma 4 cm below mandibular border

Cheek reconstructionZone II

– Cervicopectoral flap• Best for large defects• Medially based flap

– Anterior thoracic perforators of internal mammary


Zone II– Deltopectoral flap

• Medially based• Reliable • Good skin match from shoulder and upper

arm

– Pectoralis major flap– Latissimus dorsi flap


Zone III– Similar to zone II– Issue of buccal

lining• Tongue flaps• Turnover or hinge

flaps• Folded skin flaps• Free flaps

– Radial forearm

– TFL

Lip reconstruction

Anatomy– Muscles

• Orbicularis oris– Closes the oral sphincter– Primarily horizontal fibers - compress lips

• Originate lateral to the commissures• Mingle with cranial VII muscles at modiolus• Cross the lip• Decussate in the midline• Insert into opposite philtral column

– Oblique fibers - evert lip• Arise from modiolus• Travel upward and medial• Insert at the anterior nasal spine, nasal septum,

and anterior nasal floor

Lip reconstruction

Anatomy– Muscles

• Major elevators upper lip – Levator labii superioris (LLS)

• Originates from orbital margin• Curves around the alar base• Inserts into ipsilateral orbicularis oris and

philtral column– Zygomaticus major

• extends from malar eminence inserts in modiolus

– Levator anguli oris• arises just below the lateral edge of the LLS

Lip reconstruction

Anatomy– Muscles

• Nasalis muscle– Three components– Arise from bone below the piriform aperture– Depressor septi muscle is the most medial of the

three. This paired muscle arises from the periosteum over the central and lateral incisors to insert cephalad into the footplates of the medial crura (Fig. 2). Its function is primarily the depressing of the tip of the nose and secondarily the lifting of the upper central lip. The nasalis muscle alar part sends fibers to the ala and the nasalis transversus part to the nasal dorsum19.

Lip reconstruction

Anatomy– Muscles

• Mentalis muscle – Paired

– Function primarily in the elevation and protrusion of the central aspect of the lower lip. They arise from about 2 cm of alveolar periosteum just below the vestibular sulcus and descend obliquely to insert into the skin of the chin.

– Loss of these muscles below the labiomental area following resection, mucosal scarring, or inadequate muscle suture technique results in lip incompetence and lower incisor “show”

Lip reconstruction

– The depressor labii inferioris (quadratus) arises from the lower border of the mandible between the symphysis and the mental foramen. The fibers pass upward and medially, intermingling superiorly and more medially with the orbicularis oris. This muscle displaces the lower lip inferiorly. The depressor anguli oris (triangularis) arises inferior to the quadratus muscle and continues upward to the modiolus. At its origin, the muscle mingles with the platysma fibers. It functions to help draw the angle of the mouth downward and laterally17.

lip and cheek reconstruction

Documents

cheek reconstruction

lower lip

subcutaneous

upper lip

cheek reconstruction

abbe flap

nasolabial

cheek reconstructionzone