White roll- junction of vermillion and cutaneous surface
Vermillion – the red/pink dry part of lip seen outside
Vermillion is widest in central lip
Philtrum columns are formed by C/L orbicularis oris fibers.
Philtrum columns slightly diverge as then come down.
White roll created by pars marginalis fibers of orbicularis oris.
Upper lip elevators-
- Z. major
- Z. minor
- LLS AN
[levator labii superioris anguli nasalis, levator labii superioris anguli, levator anguli oris]
Retractors and depressor of lower lip-
- Depressor labii
- Depressor anguli oris
Lower lip elevator– Mentalis (makes pout)
Nasolabial crease formed by-
- Z. major
- Pars marginalis
- Pars peripherlais
Marginalis anterior to peripherialis [Peripheralis- Posterior]
Marginalis mostly deep to vermillion area
Peripheralis mostly deep to cutaneous portion of lip
Muscular sling that presses lip against gingiva and teeth is formed by-
- Pharyngeal constrictor
Facial artery courses through a plane which between two muscle layers.
Muscles anterior/superficial to artery are-
- Z major,
- Superficial lamina of orbicularis oris (OO)
Muscles that are deep to the artery are-
- Deep lamina of OO
Facial artery branches approx- 1.5cm lateral to oral commissure
Into – superior labial and inferior labial a.
Superior labial- found within 10mm of lip margin
Inferior labial- found within 4-13 mm of lip margin
Labial artery lies within or posterior to orbicularis oris muscle but Never anterior to it.
Zygomatic and buccal branch – lip elevators and retractors
Marginal mandibular- lip depressor
V2 –infraorbital & V3 mental branch of trigeminal nerve
Etiology of lip defect –
Most common cause is – Carcinoma lip. MC type of cancer is Squamous cell ca.
96% lip cancer occur in lower lip
96% is SCC type.
96% of patients are male.
Reconstruction – defect wise
Defect by definition does not crosses white roll.
So, reconstruction should – Avoid crossing white roll.
Simplest method—undermining of adjacent oral mucosa with defect closure by advancement.
Wilson & Walker – laterally based bipedical mucosal flap
For Full-thickness defect of vermillion –
-lateral vermillion musculomucosal advancement flap (based on labial artery)
-musculocutaneous flap composed of intraoral mucosa and orbicularis advanced from sulcus in V-Y fashion
Other regional flaps-
Unipedicle vermillion lip switch flap from opposite lip -divided after 10-14 days
Random musculomucosal flap
FAMM flap (facial artery myomucosal flap) – buccinators muscle based on facial artery
Tongue flap (from lateral/lower surface) – two stage procedure cumbersome.
Partial thickness defect-
Skin graft not routinely used/required
Except, central philtral defect- full thickness graft used instead of STSG.
Small full thickness defect-
Lower lip- up to 40% defect
Upper lip- up to 25 % defect
Large full thickness defect-
Two resources to recruit extra tissue to fill the defect – opposite lip & adjacent cheek.
Orbicularis oris- better competent stoma. Microstomia a risk.
Cheek- microstomia less common, functionally and aesthetically inferior outcome
Large central upper lip defect-
Abbe flap (based on inferior labial artery) –> flap division after 2-3 weeks
Abbe flap with perioral crescent
Large central lower lip defect-
Modified Bernard (Webster- Bernard)
|Musculocutaneous rotation advancement flap
First 1cm incision full thickness- after that only skin and muscle divided, mucosa is intact
Burrow’s triangle excised
|Lateral advancement flap
First 1cm full thickness incision after that only skin and mucosa intraorally
Burrow’s triangle excised
Interdigitating nasolabial flap
Partial thickness random flap
Full-thickness “Gate-flap”- based on facial a
Full thickness flap denervates upper lip.
Large lateral and commissure defect-
Medially based rotation advancement flap from upper lip to lower lip
Reverse Estlander- from lower lip to upper lip
Gillies-fan flap- rotational advancement flap. A quadrilateral flap
McGregor & Nakajima modified fan flap –
- Pivotal flap
- Stoma size unchanged
- Need for vermillion reconstruction
Need second stage of flap division
U/L Nasolabial flap
Total lip reconstruction-
B/L Bernard or Nasolabial flap
Submental flap (flap based on submental branch of facial artery)
Radial forearm free flap (RAFF)
Karapandzic – will cause microstomia, so not preferred.
RAFF is the best choice for total lip reconstruction.
Palmaris longus tendon can be harvested along with the flap to be weaved into remaining OO muscle or into modulus.
Lip replantation –
Most commonly – by traumatic amputation by dog bite.
Every attempt should be made for reimplant as the aesthetic and functional outcome is better than free tissue transfer.
Main obstacle in reimplant of lip is – poorly formed labial vein.
|Defect size||Defect location||Reconstructive option|
|Up to 25% – upper lip
Up to 40% – lower lip
|25-80 %||Upper lateral lip or lower lateral lip||Lip switch (Estlander/Abbe) or
Unilateral Karapandzic/ Bernard/ Nasolabial flap
|Central lower lip||Bilateral Karapandzic/ Bernard|
|Central upper lip||Abbe flap +/- perioral crescent|
|>80%||Bilateral Bernard/ Nasolabial flap or
Free tissue transfer – RAFF
(further reading – Grabb and Smith Plastic surgery 7th Ed. chapter 34)