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LIP RECONSTRUCTION
Dr.Akasha Ambar
PGR-PRS
BVH BWP
FUNCTIONS
– Oral competence
– Chewing and entrance of digestive tract
– Articulation
– Expression of emotions
– Aesthetic ...
ANATOMY
Levator labii superioris
alaeque nasi muscle
Levator labll superlorls muscle
Minor zygomatic muscle
Major zygomatic muscle...
Muscles Of Lip & Perioral Region
ORBICULARIS ORIS
• Two components
– Pars marginalis
– Pars peripheralis
• Function
• Modiolus
– Complex interdigitation of...
Arrangement Of Facial Muscles
1st layer Depressor anguli oris, zygomaticus minor,
orbicularis oris
2nd layer Platysma, ris...
VASCULAR SUPPLY
– blood supply
• Derived from the facial arteries
– Superior and inferior labial branches
– Facial vein (n...
NERVE SUPPLY
– Motor Innervation
• Facial nerve VII
– Buccal,zygomatic
» Lip elevators & retractors
– Marginal mandibular
...
DEFECTS
• Etiology
• Developmental
– Abnormal Development
• Acquired
– Cancer(most common; 96% Lower Lip)
• SCC >>> BCC, v...
Lip Reconstruction
• Approach
– Evaluate
• Size and location of the defect
• Etiology of the lesion
• Patient age and gend...
Goals of reconstruction
• competent oral sphincter
• Sufficient sized stoma
• Sensation
• Three-layered closure
– Reconsti...
VERMILION
• Regional anesthesia
• Tattooing vermilion with methylene blue
before local anesthetic infilteration
• Sutures ...
Breaking up the linear scar
by introducing a vertical
element to an excision will
allow for more precise
closure as the ve...
VERMILION
• Vermilionectomy/shave defects: primary
closure after undermining and advancing
adjacent mucosa
– Inward pullin...
(A) An area of vermilion is marked for excision
(B) The vermilion has been excised and a mucosal flap raised from the bucc...
VERMILLION
• Wilson & walker
– Laterally based bipedicle mucosal flap
– From gingivobuccal sulcus
• Skin grafting/secondar...
VERMILION
• Full thickness vermilion defects/not extending beyond
white roll
• Lateral vermllion musculomucosal advancemen...
• Unipedicle vermilion lip switch
flap(Kawamoto)
• If ipsilateral vermilion or mucosa unavailable
• 2-staged
OTHER OPTIONS
• mucosal V-Y advancement flap
• Random mucosal flaps from angle of mouth
– Rotation 120°, 1cm wide
– Lower ...
• Facial artery musculomucosal flap(FAMM)
• Flaps from ventral/lateral surface of the
tongue
Superficial/Partial Thickness Defects
• Primary closure
– Circular: vertical closure
– Conversion into full thickness by w...
• Resection of a central segment of the upper lip is shown. A “T”
excision is performed with a Webster crescentic perialar...
Partial-thickness defect involving the philtrum, Cupid's bow, and vermilion.
Advancement flap of right cutaneous lip with ...
Small Full Thickness Defects
• Primary closure
– 25% UL, 40% LL
• Vermillion notching-eversion
• V-plasty or double limb z...
Large Full Thickness Defects
• Donors:
– tissue from other lip
• Aesthetically superior,all components(like with like),
co...
Central Lip Defects Reconstruction
• :
– Abbe flap :Large central upper lip defects
– not ideal for Lower lip
– Alternativ...
Schematic of an Abbé flap from the lower
lip to the upper.
Note that width of the Abbé flap is half the
width of the defec...
Full-thickness defect involving central and left upper lip.
Schematic of an Abbe flap.
Central Abbe flap with bilateral up...
KARAPANDZIC FLAP
• Musculocutaneous rotation advancement flap
• Preserves neurovascular supply
• Semicircle with radius co...
Full-thickness defect involving lower lip. Schematic of a bilateral Karapandzic flap.
Schematic of a reverse bilateral Kar...
lower later lip defect.
Unilateral Karapandzic flap with full-thickness lip
advancement flap
Modified Bernard Operation
• Original bernard cheiloplasty described in 1853 for lower lip
Modified Bernard Operation
• Webster modification
• Laterally based horizontal advancement flap
• Mucosa and skin incision...
Full-thickness defect involving central and lateral lower lip. Schematic of a bilateral modified
Bernard flap. A stair-ste...
NASOLABIAL FLAPS
• Partial or full thickness,bilateral flaps
• Full thickness; facial artery
• No tissue loss
Large Lateral & Commissural Defects
• Estlander flap
• Gillies flap
• Abbe estlander flap
• Others:
– Unilateral nasolabia...
Estlander flap
• Medially based rotation advancement flap
• Upper to lower lip
• Reverse estlander flap
• Techniques simil...
Reverse Estlander flap with cheek advancement
flap and excision of perialar crescent
Gillies Fan Flap
• Rotation advancement flap
• Modification of estlander
• Quadrilateral with an arc of rotation that of a...
A schematic of the Gillies fan flap is shown. Note the releasing
incisions on the upper lip that allow the flap to rotate ...
Stair Step Closure
• Medium defects(upto two-thirds of the lower lip) where
abbe or estlander cannot be used
• excision of...
Schematic of a step flap reconstruction. Note that the steps are excised to allow the flaps to
advance. Note also that the...
Total Lip Reconstruction
• Regional tissues in adequate
• Karapandzic flap(microstomia)
• Bilateral nasolabial or estlande...
Near total lower lip defect with involvement of adjacent chin soft tissue
Proposed resection
Folded radial forearm flap wi...
Total lower lip and chin defect following arteriovenous malformation (AVM) excision.
Template for folded radial forearm fl...
Defect size Defect location Reconstrcution
Upper lip up to 25%
Lower lip up to 40%
Lip switch(e.g., Ealander/Abbe)
Or unil...
Lip Replantation
• Dog bites
• Microsurgical repair of labial arteries
• Venous anastomosis difficult; leech therapy
• Blo...
COMPLICATIONS
• Bleeding
• Flap loss
• Wound dehicence
• Microstomia
• Denervation
• Oral incompetence
Post Operative Care
• General care of wound
• Avoid congestion
• Oral hygiene
• Feeding liquids(straw use)
THANKS
Lip reconstruction
Lip reconstruction
Lip reconstruction
Lip reconstruction
Lip reconstruction
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Lip reconstruction

  1. 1. LIP RECONSTRUCTION Dr.Akasha Ambar PGR-PRS BVH BWP
  2. 2. FUNCTIONS – Oral competence – Chewing and entrance of digestive tract – Articulation – Expression of emotions – Aesthetic role
  3. 3. ANATOMY
  4. 4. Levator labii superioris alaeque nasi muscle Levator labll superlorls muscle Minor zygomatic muscle Major zygomatic muscle Risorius muscle Orbicularis orb muscle Orbicularis oris muscle Depressor anguli oris muscle Depressor labii muscle Pharyngeal constrictors buccinators
  5. 5. Muscles Of Lip & Perioral Region
  6. 6. ORBICULARIS ORIS • Two components – Pars marginalis – Pars peripheralis • Function • Modiolus – Complex interdigitation of perioral muscles
  7. 7. Arrangement Of Facial Muscles 1st layer Depressor anguli oris, zygomaticus minor, orbicularis oris 2nd layer Platysma, risorius, zygomaticus major, Depressor labii inferioris, levator labii superioris and LLS Alaeque nasi 3rd layer Orbicularis oris, levator labii superioris 4th layer Mentalis, levator anguli oris, oris, buccinator
  8. 8. VASCULAR SUPPLY – blood supply • Derived from the facial arteries – Superior and inferior labial branches – Facial vein (not single/plexiform venous channels) – Lymphatic drainage • Primarily submental and submandibular nodes – Upper lip and lateral lower lip » Submandibular chain – Central lower lip » Submental nodal area
  9. 9. NERVE SUPPLY – Motor Innervation • Facial nerve VII – Buccal,zygomatic » Lip elevators & retractors – Marginal mandibular » Lip depressors – Sensory innervation • Trigeminal nerve V – Mental nerve terminal branch of inferior alveolar nerve(V3) » Lower lip – Infraorbital nerve(V2) » Upper lip
  10. 10. DEFECTS • Etiology • Developmental – Abnormal Development • Acquired – Cancer(most common; 96% Lower Lip) • SCC >>> BCC, verrucous ca, adenocarcinoma – Trauma,infections (noma,vasculitis), vascular anomalies, burn injuries
  11. 11. Lip Reconstruction • Approach – Evaluate • Size and location of the defect • Etiology of the lesion • Patient age and gender
  12. 12. Goals of reconstruction • competent oral sphincter • Sufficient sized stoma • Sensation • Three-layered closure – Reconstitution of orbicularis oris – Complete skin cover and oral lining • Accurate alignment of vermillion. • Maintenance of relationship between upper and lower lips. • Optimization of cosmesis.
  13. 13. VERMILION • Regional anesthesia • Tattooing vermilion with methylene blue before local anesthetic infilteration • Sutures above/below white roll – Repairs should not cross white roll • Smaller defects: primary closure , secondary healing
  14. 14. Breaking up the linear scar by introducing a vertical element to an excision will allow for more precise closure as the vermilion borders can be accurately approximated (marked with dots). Furthermore, the resulting scar will not be linear and will therefore be less likely to contract
  15. 15. VERMILION • Vermilionectomy/shave defects: primary closure after undermining and advancing adjacent mucosa – Inward pulling of lip, flattening and loss of pout – Portion of muscle taken to avoid this
  16. 16. (A) An area of vermilion is marked for excision (B) The vermilion has been excised and a mucosal flap raised from the buccal mucosa (C) The mucosal flap advanced and sutured to white lip to recreate mucocutaneous junction (D) Postoperative appearance showing good restoration of vermilion
  17. 17. VERMILLION • Wilson & walker – Laterally based bipedicle mucosal flap – From gingivobuccal sulcus • Skin grafting/secondary healing of donor site
  18. 18. VERMILION • Full thickness vermilion defects/not extending beyond white roll • Lateral vermllion musculomucosal advancement flap(Goldstein’s) • Musculomucosal advancement flap from sulcus
  19. 19. • Unipedicle vermilion lip switch flap(Kawamoto) • If ipsilateral vermilion or mucosa unavailable • 2-staged
  20. 20. OTHER OPTIONS • mucosal V-Y advancement flap • Random mucosal flaps from angle of mouth – Rotation 120°, 1cm wide – Lower lip vermilion
  21. 21. • Facial artery musculomucosal flap(FAMM) • Flaps from ventral/lateral surface of the tongue
  22. 22. Superficial/Partial Thickness Defects • Primary closure – Circular: vertical closure – Conversion into full thickness by wedge excision,closure • Local flaps – Cheek or adjacent lip tissue – Advancement/transposition – V-Y flap, nasolabial flap • Skin grafts(less frequent use) – Full thickness
  23. 23. • Resection of a central segment of the upper lip is shown. A “T” excision is performed with a Webster crescentic perialar excision allowing for advancement of the lip elements.
  24. 24. Partial-thickness defect involving the philtrum, Cupid's bow, and vermilion. Advancement flap of right cutaneous lip with V-Y advancement for vermilion reconstruction. Skin graft reconstruction of Cupid's bow
  25. 25. Small Full Thickness Defects • Primary closure – 25% UL, 40% LL • Vermillion notching-eversion • V-plasty or double limb z plasty • Abbe flap for upper central defects Fllared W Single barrel Double barell
  26. 26. Large Full Thickness Defects • Donors: – tissue from other lip • Aesthetically superior,all components(like with like), competent stoma,balances lip length discrepancies • microstomia – adjacent cheek • Aesthetically inferior • No microstomia, not 3 layered tissue
  27. 27. Central Lip Defects Reconstruction • : – Abbe flap :Large central upper lip defects – not ideal for Lower lip – Alternatives: • Bilateral karapandzic • Modified bernard • nasolabial flaps
  28. 28. Schematic of an Abbé flap from the lower lip to the upper. Note that width of the Abbé flap is half the width of the defect, while the height of the flap is same as the height of the defect. The pedicle will be planned at a point opposite the mid-portion of the defect and will end-up at the medial end of the defect following rotation of the flap
  29. 29. Full-thickness defect involving central and left upper lip. Schematic of an Abbe flap. Central Abbe flap with bilateral upper lip advancement flaps and excision of perialar crescents
  30. 30. KARAPANDZIC FLAP • Musculocutaneous rotation advancement flap • Preserves neurovascular supply • Semicircle with radius corresponding to defect height
  31. 31. Full-thickness defect involving lower lip. Schematic of a bilateral Karapandzic flap. Schematic of a reverse bilateral Karapandzic flap.
  32. 32. lower later lip defect. Unilateral Karapandzic flap with full-thickness lip advancement flap
  33. 33. Modified Bernard Operation • Original bernard cheiloplasty described in 1853 for lower lip
  34. 34. Modified Bernard Operation • Webster modification • Laterally based horizontal advancement flap • Mucosa and skin incisions only,muscle cut in initial 1 cm of incision • Burrows triangle excision
  35. 35. Full-thickness defect involving central and lateral lower lip. Schematic of a bilateral modified Bernard flap. A stair-step incision in the mucosa to include extra tissue for vermilion reconstruction.Right unilawal Bernard flap with left unilateral Karapandzic flap
  36. 36. NASOLABIAL FLAPS • Partial or full thickness,bilateral flaps • Full thickness; facial artery • No tissue loss
  37. 37. Large Lateral & Commissural Defects • Estlander flap • Gillies flap • Abbe estlander flap • Others: – Unilateral nasolabial,karapandzic or bernard flaps – Stair step technique
  38. 38. Estlander flap • Medially based rotation advancement flap • Upper to lower lip • Reverse estlander flap • Techniques similar to abbe’s flap • Commisurotomy or commisuroplasty required
  39. 39. Reverse Estlander flap with cheek advancement flap and excision of perialar crescent
  40. 40. Gillies Fan Flap • Rotation advancement flap • Modification of estlander • Quadrilateral with an arc of rotation that of a fan • Disadavntage: vermilion reconstruction
  41. 41. A schematic of the Gillies fan flap is shown. Note the releasing incisions on the upper lip that allow the flap to rotate and advance
  42. 42. Stair Step Closure • Medium defects(upto two-thirds of the lower lip) where abbe or estlander cannot be used • excision of 2–4 small rectangles arranged in a stair-step fashion • Decending from medial to lateral at a 45° angle from either side of the base of defect • width of each step approximately one-half of its height • a triangle is excised with its apex located inferiorly • Full thickness excision
  43. 43. Schematic of a step flap reconstruction. Note that the steps are excised to allow the flaps to advance. Note also that the scar remains above the mental crease.
  44. 44. Total Lip Reconstruction • Regional tissues in adequate • Karapandzic flap(microstomia) • Bilateral nasolabial or estlander(laxity) • Submental flap – Submental artery – Island flap • Free tissue transfer – Very large defects – Combined chin and lip defects – Radial forearm free flap – Palmaris longus tendon as free graft( longitudinal skin island) or composite graft( transverse skin island) – Vermilion reconstruction; FAMM flap • Partial face transplantation • Composite tissue allotransplantation
  45. 45. Near total lower lip defect with involvement of adjacent chin soft tissue Proposed resection Folded radial forearm flap with palmaris tendon graft Early postoperative result
  46. 46. Total lower lip and chin defect following arteriovenous malformation (AVM) excision. Template for folded radial forearm flap. Antegrade bilateral FAMM flaps for vermilion reconstruction. Four-year postoperative result.
  47. 47. Defect size Defect location Reconstrcution Upper lip up to 25% Lower lip up to 40% Lip switch(e.g., Ealander/Abbe) Or unilateral kalapandzic Bernard/nasolabial flap0 Bilateral Benard/nasolabial flaps Or free tissue transfer Abbe+/- perialar crescents Bilateral karapandzic/ bernard 25-80% >80% Primary closure Reconstructive algorithm for full-thickness defects
  48. 48. Lip Replantation • Dog bites • Microsurgical repair of labial arteries • Venous anastomosis difficult; leech therapy • Blood transfusions and hospital stay Near total upper lip amputation. This 17-year-old male had the majority of his upper lip amputated by a dog. The part was replanted but swelling prevented immediate inset and venous congestion necessitated leech therapy. After serial inset,the anatomic landmarks were restored,and at 6 months full function and sensation.
  49. 49. COMPLICATIONS • Bleeding • Flap loss • Wound dehicence • Microstomia • Denervation • Oral incompetence
  50. 50. Post Operative Care • General care of wound • Avoid congestion • Oral hygiene • Feeding liquids(straw use)
  51. 51. THANKS
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