lip reconstruction

LIP RECONSTRUCTION

Dr. Sumer YadavMch – Plastic and reconstructive surgery

sumeryadav2004@gmail.com

Lips are vital portions of an individuals Lips are vital portions of an individuals face and personality that provide visual face and personality that provide visual contact to our fellow man and convey contact to our fellow man and convey feelings and emotions at a glancefeelings and emotions at a glance

Formation of speechFormation of speech Maintain oral secretions as a dam & Maintain oral secretions as a dam &

prevent drooling.prevent drooling. Ingestion of food and drinks.Ingestion of food and drinks.

sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Onco-surgeon’s definition, by AJCOnco-surgeon’s definition, by AJC Begins at the junction of the vermilion border Begins at the junction of the vermilion border

with skin and extends upto the portion of lip with skin and extends upto the portion of lip that comes in contact with the opposite lipthat comes in contact with the opposite lip

Surgeon’s definition.Surgeon’s definition.Extends from one naso-labial fold to other Extends from one naso-labial fold to other

and includes entire area below nose and includes entire area below nose including vermilion & intraorally to gingivo-including vermilion & intraorally to gingivo-labial sulcus labial sulcus

Topography of lipsTopography of lips

1.1. philtral columnsphiltral columns2.2. Philtral groovePhiltral groove3.3. Cupid’s bowCupid’s bow4.4. White roll upper White roll upper

liplip5.5. TubercleTubercle6.6. CommissureCommissure7.7. vermilionvermilion

1000B.C.1000B.C. SushrutaSushruta First mention of labial repairFirst mention of labial repair

1597A.D.1597A.D. Tagliacozzi Tagliacozzi Upper and lower lip repair by distal arm flapUpper and lower lip repair by distal arm flap

17681768 Louis Louis First wedge excisionFirst wedge excision

18341834 DieffenbachDieffenbach Lower lip repair with inferiorly based flapsLower lip repair with inferiorly based flaps

18381838 SabbattiniSabbattini Full thickness switch flap from lower to upper Full thickness switch flap from lower to upper lip lip

18451845 Dieffenbach Dieffenbach Nasolabial flap for upper lip repairNasolabial flap for upper lip repair

18571857 Von BrunsVon Bruns Nasolabial flaps for lower lip defectNasolabial flaps for lower lip defect

18721872 EstlanderEstlander Lateral triangular upper lip flap for lower lip.Lateral triangular upper lip flap for lower lip.

19091909 LexerLexer Tongue flaps for lip reconstructionTongue flaps for lip reconstruction

19541954 schuchardtschuchardt Sliding inferiorly based cheek flapsSliding inferiorly based cheek flaps

19691969 Bakamjian Bakamjian Deltopectoral flap for lower lip defects.Deltopectoral flap for lower lip defects.

19741974 KarapandzicKarapandzic Emphasis on oral sphincter reconstructionEmphasis on oral sphincter reconstructionsumeryadav2004@gmail.comsumeryadav2004@gmail.com

Perioral musculaturePerioral musculature Orbicularis oris: Orbicularis oris: Horizontal – purse stringing, Compress lips together. Horizontal – purse stringing, Compress lips together.

ObliqueOblique – – evert lip.evert lip.

Elevators:Elevators:Levator labii superioris Levator labii superioris Zygomaticus majorZygomaticus majorLevator anguli oris Levator anguli oris Mentalis – elevation and protrusion of central aspect of lower lip Mentalis – elevation and protrusion of central aspect of lower lip Depressors:Depressors:Depressor labii inferioris (Quadratus)Depressor labii inferioris (Quadratus)Depressor anguli oris (triangularis)Depressor anguli oris (triangularis)

PERIORAL MUSCULATUREPERIORAL MUSCULATURE

NEURO- ANATOMYNEURO- ANATOMY Motor: Motor: Buccal branch – elevators & orbicularis orisBuccal branch – elevators & orbicularis orisFacial nerveFacial nerve Marginal mandibular – depressorsMarginal mandibular – depressors

Sensory:Sensory: MaxillaryMaxillary – – Infraorbital nerve – upper lipInfraorbital nerve – upper lip

Trigeminal Trigeminal Mandibular – inferior alveolar – mental nerve Mandibular – inferior alveolar – mental nerve

- lower lip - lower lip

NEURO- ANATOMYNEURO- ANATOMY

Vascular anatomyVascular anatomy

Through facial artery via Through facial artery via Superior & inferior labial artery.Superior & inferior labial artery. Labial arteries, after piercing orbicularis oris – lie between Labial arteries, after piercing orbicularis oris – lie between

the muscle and the mucosa.the muscle and the mucosa. Facial artery tortuous in this region – gained length for Facial artery tortuous in this region – gained length for

pedicled flaps. pedicled flaps. sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Etiologies of lip defectsEtiologies of lip defects CongenitalCongenital TraumaTrauma Burns Burns Vasculitis, HaemangiomasVasculitis, Haemangiomas Neoplasm Neoplasm Infectious diseasesInfectious diseases

Lip injuries – the differencesLip injuries – the differences

UNDERLYING NONGIVING TEETHUNDERLYING NONGIVING TEETH TYPE OF HUMAN BITETYPE OF HUMAN BITE GOOD VASCULARITYGOOD VASCULARITY MINIMAL SCARRINGMINIMAL SCARRING GOOD ELASTICITYGOOD ELASTICITY

UPPER ~ LOWER LIP UPPER ~ LOWER LIP DEFECTSDEFECTS

Central philtral column with two equal Central philtral column with two equal sidessides

Lower lip has no definative central Lower lip has no definative central structure hence it may sustain greater structure hence it may sustain greater loss without distortion. loss without distortion.

CLASSIFICATION OF LIP CLASSIFICATION OF LIP DEFECTSDEFECTS

Upper lipUpper lip1.1. Vermilion defectsVermilion defects2.2. Defects of < 30% Defects of < 30% 3.3. Defects of > 30%Defects of > 30%4.4. Midline philtral defectsMidline philtral defects

Lower lipLower lip1.1. Vermilion defectsVermilion defects2.2. Defects of < 30% Defects of < 30% 3.3. Defects of 30 to 65%Defects of 30 to 65%4.4. Defects of > 65%Defects of > 65%

Principles of reconstructionPrinciples of reconstruction

Preserve sensation of the lips Preserve sensation of the lips Maintain oral competence Maintain oral competence Continuity of vermillion border Continuity of vermillion border Sufficient oral access (not too small, Sufficient oral access (not too small,

microstoma) microstoma) Adequate lip appearance Adequate lip appearance

GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS For upper lip reconstruction, lower lip can be used , but For upper lip reconstruction, lower lip can be used , but

vice versa is avoided. vice versa is avoided. Defect of 30% of the upper or lower lip can be closed Defect of 30% of the upper or lower lip can be closed

primarily – great elasticity of lips.primarily – great elasticity of lips. For defects greater than 30% tissue must be added or For defects greater than 30% tissue must be added or

shared from opp. normal lip.shared from opp. normal lip. For 60% or greater defects other adjacent or distant For 60% or greater defects other adjacent or distant

flaps may be needed. flaps may be needed. White roll or muco-cutaneous or vermilion border must White roll or muco-cutaneous or vermilion border must

be aligned properly.be aligned properly. For incisions that cross vermilion border should do so For incisions that cross vermilion border should do so

at 90 deg. at 90 deg. Good muscle approximation is must for competency of Good muscle approximation is must for competency of

oral stoma and prevents further scar widening.oral stoma and prevents further scar widening.sumeryadav2004@gmail.comsumeryadav2004@gmail.com

VERMILION VERMILION

DEFECTSDEFECTS

Primary repairPrimary repair Meticulous reattachment of lacerated Meticulous reattachment of lacerated

tissue.tissue. Save as much as possibleSave as much as possible Thorough washing is must with mild Thorough washing is must with mild

antiseptic solution.antiseptic solution. Best results when performed with in first Best results when performed with in first

few hours after injury. few hours after injury.

Primary closurePrimary closure

Small vermilion defectsSmall vermilion defects V-y closure of V-y closure of

small lip defect small lip defect using a sliding using a sliding flap.flap.

V-y closure of a V-y closure of a defect using two defect using two sliding flaps.sliding flaps.

Wedge shaped defects Wedge shaped defects Defects excisedDefects excised Superiorly & Superiorly &

inferiorly based inferiorly based mucosal triangles mucosal triangles are cut are cut

Muscle layer Muscle layer closed & mucosal closed & mucosal triangles are triangles are transposed. transposed.

Large superficial vermilionLarge superficial vermiliondefectsdefects

Mucosal sliding Mucosal sliding flap.flap.

The intact lip The intact lip mucosa is mucosa is mobilized, mobilized, advanced to advanced to cover the cover the defect. defect.

Kawamoto’s Vermilion Kawamoto’s Vermilion switch switch

Upper lip Upper lip deficiencies may deficiencies may often be treated often be treated by transversely by transversely oriented flaps oriented flaps

Divided after 10-Divided after 10-14 days 14 days

Vermilion advancement of Vermilion advancement of Goldstein (1984)Goldstein (1984)

Myomucosal Myomucosal advancement advancement flaps.flaps.

Vermilion defects Vermilion defects involving upto involving upto one third of one third of length can be length can be repaired without repaired without any deformity any deformity

Vermilion defects Vermilion defects (more than 1/3)(more than 1/3)

Mucosal flap from anterior margin of tongue, Mucosal flap from anterior margin of tongue, based on right or left side is swung into the based on right or left side is swung into the defect- flap division after 2 wks.defect- flap division after 2 wks.

ventral papillary surface for females, takes ventral papillary surface for females, takes lipstick colors. lipstick colors.

Tongue flapTongue flap

Total vermilionectomy defectsTotal vermilionectomy defects

Mucosa of oral vestibule mobilized – Mucosa of oral vestibule mobilized – advanced over raw surface & sutured.advanced over raw surface & sutured.

May cause thinning of lip, inward pulling May cause thinning of lip, inward pulling of hair bearing skin, tense free lip margin.of hair bearing skin, tense free lip margin.

Lip reductionLip reduction

Mucosa & some Mucosa & some muscle tissue are muscle tissue are excised intraorally excised intraorally from protuberant from protuberant lips and closure lips and closure done.done.

Augmentation of upper lipAugmentation of upper lip

A bipedicled flap is cut from lower lip and A bipedicled flap is cut from lower lip and upper lip incisedupper lip incised

Flap is transferred to the upper lip and Flap is transferred to the upper lip and donor defect is closed.donor defect is closed.

Flap is divided after 2 wks. Flap is divided after 2 wks.

Vermilion defectsVermilion defects Small defects – wedge excisionSmall defects – wedge excision - v-y advancement flaps- v-y advancement flaps Less than 1/3 – Mucosal slide flapsLess than 1/3 – Mucosal slide flaps - Muco-muscular advancement - Muco-muscular advancement

flaps flaps 1/3 to 2/3 defects – Vermilion switch1/3 to 2/3 defects – Vermilion switch - Tongue flaps- Tongue flaps - Buccal mucosal - Buccal mucosal

advancement flaps advancement flaps Total defects – Tongue flapsTotal defects – Tongue flaps - Buccal mucosal advancement flaps - Buccal mucosal advancement flaps

UPPER UPPER LIP LIP

RECONSTRUCTIONRECONSTRUCTION

Upper lip reconstructionUpper lip reconstruction(median scars, and defects)(median scars, and defects)

Crescent shaped Crescent shaped excisions made lateral excisions made lateral to alar groove, scar to alar groove, scar excised, lip is excised, lip is mobilized & brought mobilized & brought down normal position.down normal position.

Z-plasty added to Z-plasty added to adjust the position of adjust the position of vermilion.vermilion.

Upper lip reconstructionUpper lip reconstruction(median scars, and distortion of (median scars, and distortion of vermilion)vermilion)

Scar is excised and Scar is excised and releasing incisions releasing incisions are made in are made in nasolabial folds.nasolabial folds.

Tumor or scar Tumor or scar excised and scar is excised and scar is dispersed by Z plastydispersed by Z plasty

Upper lip reconstructionUpper lip reconstruction(larger scars and contractures)(larger scars and contractures)

Large burn scars Large burn scars and contractures and contractures covered with full covered with full thickness post thickness post auricular grafts.auricular grafts.

Three-layered Abbe flapThree-layered Abbe flap

Three layered Abbe’s flap Three layered Abbe’s flap incised out from lower lipincised out from lower lip

Rotation of flap into the Rotation of flap into the upper lip defect.upper lip defect.

Modification of Abbe’s flap Modification of Abbe’s flap with different shapes of with different shapes of incisionsincisions

The flap is divided 20 days The flap is divided 20 days later.later.

Double Abbey’s flapDouble Abbey’s flap

By Wexler & DingmanBy Wexler & Dingman May be used to close 75% central defects of lower lip.May be used to close 75% central defects of lower lip. Causes definite shortening of lip Causes definite shortening of lip

Estlander flap (1872)Estlander flap (1872) Similar to Abbe flap at Similar to Abbe flap at

commissure.commissure. Wedge shaped flap based on Wedge shaped flap based on

inferior labial artery, is rotated inferior labial artery, is rotated around angle of mouth into the around angle of mouth into the defect.defect.

About 16-20 days later the About 16-20 days later the pedicle is divided, triangular pedicle is divided, triangular mucosal flaps are mobilizedmucosal flaps are mobilized

Z- plasty is added for closure Z- plasty is added for closure of donor site.of donor site.

UPPER LIP DEFECTUPPER LIP DEFECT

Intra-operatively after Intra-operatively after debridementdebridement

Nasolabial flapsNasolabial flaps Bilateral nasolabial flaps for total near-total Bilateral nasolabial flaps for total near-total

upper lip defects.upper lip defects. Recreates upper lip anatomyRecreates upper lip anatomy Inferiorly based for hairless skin in femalesInferiorly based for hairless skin in females Superiorly based for hairy skin in males.Superiorly based for hairy skin in males. Use of levator anguli oris in distally based.Use of levator anguli oris in distally based. Restores sensations, restores oral Restores sensations, restores oral

sphincter, provides satisfactory total upper sphincter, provides satisfactory total upper lip reconstruction with Abbe’s flap for philtral lip reconstruction with Abbe’s flap for philtral defects.defects.

Insensate, no functional oral commissure.Insensate, no functional oral commissure.sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Central Upper lip reconstructionCentral Upper lip reconstruction

Method by Method by Celsus Celsus & Bruns & Bruns

Two-layer crescent Two-layer crescent shaped incision shaped incision made lateral to the made lateral to the alar groove and alar groove and extended along extended along nasal base. nasal base.

Celsus method combined with an Celsus method combined with an Abbe flapAbbe flap

Large defects of upper lip can be reduced by Celsus Large defects of upper lip can be reduced by Celsus method and then closed by using Abbe flap.method and then closed by using Abbe flap.

Neurovascular island flapNeurovascular island flap Three layered flap Three layered flap

is advanced on a is advanced on a neurovascular neurovascular pediclepedicle

Repaired in v-y Repaired in v-y advancement advancement manner.manner.

Neurovascular myocutaneous Neurovascular myocutaneous island flap island flap The flap cut in three layers, The flap cut in three layers,

preserving its neurovascular preserving its neurovascular pediclepedicle

Flap advanced into upper lip Flap advanced into upper lip defect and burrow’s triangles defect and burrow’s triangles excised.excised.

Mucosal flaps from oral Mucosal flaps from oral vestibule – to lateral lip vestibule – to lateral lip defect.defect.

Gillies fan flapGillies fan flap Three layered nasolabial flap cut Three layered nasolabial flap cut

around ala, nourished by labial around ala, nourished by labial vessels.vessels.

Gillies flap is usually cut in two Gillies flap is usually cut in two layers & mucosa is mobilized layers & mucosa is mobilized toward midlinetoward midline

Flap contains orbicularis oris Flap contains orbicularis oris muscle, it is dissected bluntly to muscle, it is dissected bluntly to preserve the superior and inferior preserve the superior and inferior labial vessels.labial vessels.

Lateral Z-plasty gives sufficient Lateral Z-plasty gives sufficient mobility. mobility.

Upper lip recostruction of weerdaUpper lip recostruction of weerda

Left side is reconstructed with a two Left side is reconstructed with a two layer bilobed flap.layer bilobed flap.

Cheek flap is advanced on the right side.Cheek flap is advanced on the right side.

Defect in nasal vestibule or Defect in nasal vestibule or upper lipupper lip

An inferiorly based nasolabial flap can An inferiorly based nasolabial flap can be used to repair a defect in the upper be used to repair a defect in the upper lip or nasal vestibule. lip or nasal vestibule.

Burrow’s cheek Burrow’s cheek advancement flapadvancement flap

Crescent shaped skin excision is made in alar Crescent shaped skin excision is made in alar groove.groove.

The cheek is advanced and all defects are The cheek is advanced and all defects are closed.closed.

Modified cheek advancementModified cheek advancement

Flap is cut and the cheek is mobilized by Flap is cut and the cheek is mobilized by a crescent shaped excision in the area a crescent shaped excision in the area of the alar groove & lateral noseof the alar groove & lateral nose

Hair- bearing skin flaps Hair- bearing skin flaps Island temporal hair bearing scalp flapIsland temporal hair bearing scalp flap Sub-mental skin flaps (unilateral or Sub-mental skin flaps (unilateral or

bilateral pedicle flaps)bilateral pedicle flaps) Cervical skin flaps (unilateral or bilateral Cervical skin flaps (unilateral or bilateral

pedicle flaps)pedicle flaps) Cheek advancement flaps Cheek advancement flaps

Wilson’s hair bearing scalp & Wilson’s hair bearing scalp & glabouros forehead flapsglabouros forehead flaps

Based on superficial temporal artery.Based on superficial temporal artery. Hair bearing scalp for skin cover & forehead Hair bearing scalp for skin cover & forehead

skin for the lining – skin for the lining – Groucho Marx Moustache.Groucho Marx Moustache. Bipedicled tongue flap for vermilion.Bipedicled tongue flap for vermilion. Abbe’s flap for philtral reconstruction.Abbe’s flap for philtral reconstruction.

Tzur’s Hair bearing neck Tzur’s Hair bearing neck flapflap

• Delayed bipedicled neck flap may provide hairy skin• An inferior extension of glaborous skin provides lining.• Flap can be taken from Submental region.• Can be done in female patients.• Provides normal looking hair in proper direction.

Upper lip defectsUpper lip defects Upto 1/4Upto 1/4thth loss – Primary repair. loss – Primary repair. - Wedge excision- Wedge excision Philtrum – Abbe’s flapPhiltrum – Abbe’s flap ¼ to 2/3 loss – Abbe’s flap¼ to 2/3 loss – Abbe’s flap - Cheek advancement- Cheek advancement - Estlander’s flap- Estlander’s flap - Zisser-Madden’s flap- Zisser-Madden’s flap - Gille’s fan flap- Gille’s fan flap - Celsus Flaps- Celsus Flaps - Neurovascular island flap- Neurovascular island flap Total loss – B/L nasolabial flapTotal loss – B/L nasolabial flap - B/L Cheek advancement flaps. - B/L Cheek advancement flaps. - Tzur’s hair bearing submantal flap- Tzur’s hair bearing submantal flap - wilson’s hair bearing scalp flap- wilson’s hair bearing scalp flap

LOWER LOWER LIP LIP

RECONSTRUCTION RECONSTRUCTION

Primary closurePrimary closure 25-30% in young patients and up to 33% 25-30% in young patients and up to 33%

in elderly patients can be resected.in elderly patients can be resected. Lip asymmetry & loss of circumference is Lip asymmetry & loss of circumference is

functional and aesthetically normal.functional and aesthetically normal. When lateral resection carried out When lateral resection carried out

denervation of central orbicularis oris- denervation of central orbicularis oris- neurotization – satisfactory function. neurotization – satisfactory function.

Scarred lower lipScarred lower lip Scar excised & Scar excised &

wounds closed in wounds closed in multiple Z- plasties.multiple Z- plasties.

Modifications of wedge Modifications of wedge excisionexcision

Small defects of lower Small defects of lower lip can be repaired by v-lip can be repaired by v-y technique.y technique.

Excess tissue should be Excess tissue should be provided to vermilion to provided to vermilion to prevent formation of new prevent formation of new defect. defect.

Should not cross Should not cross labiomental fold- labiomental fold- hypertrophic scar hypertrophic scar occurs.occurs.

Modifications of wedge Modifications of wedge excisionexcision

Wider excision Wider excision possible upto possible upto 2cms. By 2cms. By excising in this excising in this manner manner

Modifications of W- plasty Modifications of W- plasty Modifications in W- Modifications in W-

plasty do not cross plasty do not cross labio-mental fold labio-mental fold thus prevent thus prevent hypertrophic hypertrophic scarring.scarring.

Lip stumps mobilizationLip stumps mobilization The central growth is The central growth is

excised (for up to 40-excised (for up to 40-50% of defects)50% of defects)

The stumps are The stumps are mobilized by excising mobilized by excising burrow’s triangles burrow’s triangles lateral to the upper lip lateral to the upper lip and the chin.and the chin.

SCHUCHARDTSCHUCHARDT’s’s flap if flap if upper lip incision are upper lip incision are not donenot done

Causes decreased oral Causes decreased oral circumference and tight circumference and tight lip. lip. sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Post electrical burn injury Post electrical burn injury lip defectlip defect

Johanson’s step ladder techniqueJohanson’s step ladder technique

Two to four steps are to Two to four steps are to be designed.be designed.

For up to 2/3 defects.For up to 2/3 defects. Good sensation, muscle Good sensation, muscle

continuity & function.continuity & function. Scars are conspicuous, Scars are conspicuous,

tightness of tightness of reconstructed lip reconstructed lip occurs.occurs.

Estlander flap (1872)Estlander flap (1872) Three layered triangular flap Three layered triangular flap

out lined in upper-lipout lined in upper-lip Lateral limb extends to the Lateral limb extends to the

commissure along the commissure along the nasolabial fold.nasolabial fold.

Flap is rotated into the Flap is rotated into the defect, bringing the lateral defect, bringing the lateral vermilion downward & vermilion downward & mediallymedially

Revision of rounded Revision of rounded commissure may be required commissure may be required as a secondary procedure as a secondary procedure

Causes shortening of mouth Opening with deviation ofAngle.

Following commissuroplasty.

Modified Modified Estlander flap Estlander flap for large central for large central defects.defects.

Modification Modification preserving preserving angle of mouth.angle of mouth.

Gillies fan flap (1957)Gillies fan flap (1957) For large mediolateral For large mediolateral

defects not involving defects not involving commissures commissures

Flap is basically a Flap is basically a large large Eastlander flapEastlander flap that is that is rotated around rotated around orbicularis oris & orbicularis oris & possibly maintaining its possibly maintaining its neurovascular supply.neurovascular supply.

Z- plasty at corners Z- plasty at corners increases the extent.increases the extent.

Causes distortion of Causes distortion of commissure & commissure & shortening of lower lip. shortening of lower lip. sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Universal method of Bernard, Universal method of Bernard, Grimm & FriesGrimm & Fries

For subtotal defectsFor subtotal defects Lateral cheek is mobilized Lateral cheek is mobilized

by cutting burrow’s by cutting burrow’s triangles.triangles.

Cheek U flap is Cheek U flap is deepithelized and deepithelized and resurfaced with mucosal resurfaced with mucosal flap from cheek.flap from cheek.

Meyer’s modificationMeyer’s modification Triangles are cut Triangles are cut

lateral to upper lip & lateral to upper lip & cheek mucosa is cheek mucosa is incised & mobilized.incised & mobilized.

Mucosa turned over Mucosa turned over to the lateral to the lateral reconstructed lip.reconstructed lip.

Distortion of oral Distortion of oral commissure and commissure and loss of oral loss of oral circumferencecircumference

Karapandzic flapKarapandzic flap

For midline defects of lower lip.For midline defects of lower lip. Safe, lips as donor tissue so Safe, lips as donor tissue so

better results.better results. No droling as adequate muscle No droling as adequate muscle

function and fibre direction is function and fibre direction is maintained. maintained.

Contraindicated if no donor Contraindicated if no donor tissue available, ablation of both tissue available, ablation of both facial artery & ant. br. of nasal facial artery & ant. br. of nasal septal artery, upper lip septal artery, upper lip irradiation and commissure irradiation and commissure involvement.involvement.

Gillies;Gillies; distorts the distorts the commissure.commissure.

KarapandzicKarapandzic;; intact intact neurovascular pedicle, neurovascular pedicle, oral apperture narrowedoral apperture narrowed

McGregor;McGregor; pivots around pivots around commissure, less commissure, less distorting, new vermillion distorting, new vermillion & changed direction of & changed direction of fibres.fibres.

Nakajima;Nakajima; similar to similar to McGregor’s but facial McGregor’s but facial vessels are spared.vessels are spared.

Fugimori’s Gate flapsFugimori’s Gate flaps

• Used for total lower lip reconstruction. • Mucosal flaps provide vermilion coverage. • Facial vessels are left intact.• Revisional surgeries are often required• More chances of upper lip denervation.

Bakamjian’s Deltopectoral flapBakamjian’s Deltopectoral flap Can be used after radical Can be used after radical

excision of lower lip and excision of lower lip and surrounding tissue.surrounding tissue.

Blood supply by 2Blood supply by 2ndnd & 3 & 3rdrd intercostal vessels.intercostal vessels.

Averages 25 cm long & 12 Averages 25 cm long & 12 cm wide.cm wide.

Pivot point – emergence of Pivot point – emergence of 22ndnd intercostal vessels. intercostal vessels.

Denervated lower lip Denervated lower lip reconstruction tend to sag reconstruction tend to sag by its own weight.by its own weight.

Platysma Musculocutaneous Platysma Musculocutaneous flapsflaps

Skin flap island designed on the lateral aspect of neck Skin flap island designed on the lateral aspect of neck above clavicle.above clavicle.

Turnover platysma muscle flap superiorly based Turnover platysma muscle flap superiorly based pivoting along mandible including skin island in distal pivoting along mandible including skin island in distal third for resurfacing intraoral mucosa.third for resurfacing intraoral mucosa.

Careful dissection along medial border to avoid Careful dissection along medial border to avoid damage to submental branches of facial artery.damage to submental branches of facial artery.

Tone of transplanted muscle sufficient to prevent labial Tone of transplanted muscle sufficient to prevent labial ectropion.ectropion.

Injury to 11Injury to 11thth nerve & mandibular branch of facial are nerve & mandibular branch of facial are potentially disastrous. potentially disastrous.

Lower lipLower lip Less than 1/3 loss – Primary closure Less than 1/3 loss – Primary closure - -

wedge excision v or w shaped closurewedge excision v or w shaped closure 1/3 to 2/3 loss – Schuchard’s1/3 to 2/3 loss – Schuchard’s - Johanson’s step ladder flap- Johanson’s step ladder flap - Abbe’s flap- Abbe’s flap - Estlander- Estlander - Bernard’s flap- Bernard’s flap - Webster- Bernard flap- Webster- Bernard flap - Bandoneon’s technique- Bandoneon’s technique - Gille’s fan flap- Gille’s fan flap - Karapandzic flap- Karapandzic flap - Mcgregor’s flap- Mcgregor’s flap - Nakajima’s flap - Nakajima’s flap - Depressor anguli oris flap- Depressor anguli oris flap Total loss - Fujimori’s gate flapTotal loss - Fujimori’s gate flap - Meyer- Bernard flap- Meyer- Bernard flap - B/L McGregor flaps- B/L McGregor flaps - B/L Depressor anguli oris flap - B/L Depressor anguli oris flap - B/L Steeple flap for lower lip reconstruction- B/L Steeple flap for lower lip reconstruction - Bakamjian’s Deltp-pectoral flaps- Bakamjian’s Deltp-pectoral flaps - Platysmal flaps- Platysmal flaps

COMMISSURE COMMISSURE

RECONSTRUCTIONRECONSTRUCTION

Oral fissure elongationOral fissure elongationGanzer methodGanzer method

Elliptical triangle is Elliptical triangle is excised, incision is excised, incision is made around the made around the vermilion without vermilion without dividing itdividing it

Entire vermilion is Entire vermilion is advanced laterally advanced laterally and sutured into the and sutured into the defect.defect.

Elongation of oral Elongation of oral fissurefissure

Triangle of epithelium is Triangle of epithelium is excised down to excised down to mucosa, which is intact.mucosa, which is intact.

The existing The existing commissure is excisedcommissure is excised

T-shaped incisions in T-shaped incisions in exposed mucosa & the exposed mucosa & the three mucosal flaps are three mucosal flaps are turned out & sutured.turned out & sutured.

Lifting angle of mouthLifting angle of mouth

Z-plasty used to raise Z-plasty used to raise angle of mouthangle of mouth

Reconstruction by method of Reconstruction by method of BrusatiBrusati

The commissure is The commissure is excised & Burrow’s excised & Burrow’s triangles are excised.triangles are excised.

U-shaped cheek flap is U-shaped cheek flap is advanced into the defect.advanced into the defect.

Small area at of flap at Small area at of flap at commissure is excised commissure is excised and mucosa is advanced and mucosa is advanced into it. into it.

Reconstruction of Reconstruction of vermilion by dual V-vermilion by dual V-Y advancement flap.Y advancement flap.

Buccal mucosa Buccal mucosa turned inside out.turned inside out.

Loss of muscle at Loss of muscle at commissure causes commissure causes oral incompetence. oral incompetence.

Method of Fries and BrusatiMethod of Fries and Brusati The incisions are placed The incisions are placed

on a semicircular on a semicircular segment in cheek above segment in cheek above and below.and below.

Secondary defects Secondary defects closed by excision of closed by excision of Burrow’s triangles.Burrow’s triangles.

The commissure is The commissure is restored by suturing restored by suturing small triangular mucosal small triangular mucosal flaps advanced over de-flaps advanced over de-epithelized flaps.epithelized flaps.

Low cheek rotation Low cheek rotation combined with an combined with an Estlander flap.Estlander flap.

Disadv. – Disadv. – Shortening of lips Shortening of lips with oral with oral incompetence.incompetence.

Large full thickness reconstruction Large full thickness reconstruction of commissure and lipof commissure and lip

Defect excised and Defect excised and Essar Essar cheek rotation flapcheek rotation flap outlined. outlined. Incision is made below the Incision is made below the lower lip & skin mobilized.lower lip & skin mobilized.

All defects closed and scars All defects closed and scars are dispersed with Z-plasties are dispersed with Z-plasties in RSTLsin RSTLs

Residual defects in oral Residual defects in oral portion of cheek can be portion of cheek can be covered with tongue flap.covered with tongue flap.

Though lip length is some Though lip length is some what preserved, oral what preserved, oral incompetence remains.incompetence remains.

ReferencesReferences Mathes – Plastic Surgery.Mathes – Plastic Surgery. McCarthy – Plastic Surgery.McCarthy – Plastic Surgery. Grabb’s – Encyclopedia of flaps.Grabb’s – Encyclopedia of flaps. Grabb and Smith’s – Plastic Surgery.Grabb and Smith’s – Plastic Surgery. Weerda’s – Reconstructive facial plastic Weerda’s – Reconstructive facial plastic

surgery.surgery. e- medicine – internet. e- medicine – internet. Gray’s anatomy.Gray’s anatomy. Gillies & Millard – The principles & Art of Plastic Gillies & Millard – The principles & Art of Plastic

Surgery. Surgery. sumeryadav2004@gmail.comsumeryadav2004@gmail.com

PERFECT SMILEPERFECT SMILE

lip reconstruction

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