lip reconstruction

LIP RECONSTRUCTION
Dr. Sumer Yadav
Mch – Plastic and reconstructive surgery
sumeryadav2004@gmail.com

 Lips are vital portions of an individualsLips are vital portions of an individuals
face and personality that provide visualface and personality that provide visual
contact to our fellow man and conveycontact 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 vermilionBegins at the junction of the vermilion
border with skin and extends upto theborder with skin and extends upto the
portion of lip that comes in contact withportion of lip that comes in contact with
the opposite lipthe opposite lip
Surgeon’s definition.Surgeon’s definition.
Extends from one naso-labial fold to otherExtends from one naso-labial fold to other
and includes entire area below noseand includes entire area below nose
including vermilion & intraorally toincluding vermilion & intraorally to
gingivo-labial sulcusgingivo-labial sulcus

Topography of lipsTopography of lips
1.1. philtral columnsphiltral columns
2.2. Philtral groovePhiltral groove
3.3. Cupid’s bowCupid’s bow
4.4. White roll upperWhite roll upper
liplip
5.5. TubercleTubercle
6.6. CommissureCommissure
7.7. vermilionvermilion

1000B.C.1000B.C. SushrutaSushruta First mention of labial repairFirst mention of labial repair
1597A.D.1597A.D. TagliacozziTagliacozzi Upper and lower lip repair by distal arm flapUpper and lower lip repair by distal arm flap
17681768 LouisLouis 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 upperFull thickness switch flap from lower to upper
liplip
18451845 DieffenbachDieffenbach 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 BakamjianBakamjian 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 superiorisLevator labii superioris
Zygomaticus majorZygomaticus major
Levator anguli orisLevator anguli oris
 Mentalis – elevation and protrusion of central aspect of lower lipMentalis – 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)

PERIORALPERIORAL
MUSCULATUREMUSCULATURE

NEURO- ANATOMYNEURO- ANATOMY
 Motor:Motor:
Buccal branch – elevators & orbicularis orisBuccal branch – elevators & orbicularis oris
Facial nerveFacial nerve
Marginal mandibular – depressorsMarginal mandibular – depressors
 Sensory:Sensory:
MaxillaryMaxillary –– Infraorbital nerve – upper lipInfraorbital nerve – upper lip
TrigeminalTrigeminal
Mandibular – inferior alveolar – mental nerveMandibular – inferior alveolar – mental nerve
- lower liplower lip

NEURO- ANATOMYNEURO- ANATOMY

Vascular anatomyVascular anatomy
 Through facial artery viaThrough facial artery via
Superior & inferior labial artery.Superior & inferior labial artery.
 Labial arteries, after piercing orbicularis oris – lie betweenLabial 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 forFacial artery tortuous in this region – gained length for
pedicled flaps.pedicled flaps. sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Etiologies of lipEtiologies of lip
defectsdefects
 CongenitalCongenital
 TraumaTrauma
 BurnsBurns
 Vasculitis, HaemangiomasVasculitis, Haemangiomas
 NeoplasmNeoplasm
 Infectious diseasesInfectious diseases

Lip injuries – theLip injuries – the
differencesdifferences
 UNDERLYING NONGIVING TEETHUNDERLYING NONGIVING TEETH
 TYPE OF HUMAN BITETYPE OF HUMAN BITE
 GOOD VASCULARITYGOOD VASCULARITY
 MINIMAL SCARRINGMINIMAL SCARRING
 GOOD ELASTICITYGOOD ELASTICITY

UPPER ~ LOWER LIPUPPER ~ LOWER LIP
DEFECTSDEFECTS
 Central philtral column with two equalCentral philtral column with two equal
sidessides
 Lower lip has no definative centralLower lip has no definative central
structure hence it may sustain greaterstructure hence it may sustain greater
loss without distortion.loss without distortion.

CLASSIFICATION OF LIPCLASSIFICATION OF LIP
DEFECTSDEFECTS
 Upper lipUpper lip
1.1. Vermilion defectsVermilion defects
2.2. Defects of < 30%Defects of < 30%
3.3. Defects of > 30%Defects of > 30%
4.4. Midline philtral defectsMidline philtral defects
 Lower lipLower lip
1.1. Vermilion defectsVermilion defects
2.2. 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 lipsPreserve sensation of the lips
 Maintain oral competenceMaintain oral competence
 Continuity of vermillion borderContinuity of vermillion border
 Sufficient oral access (not too small,Sufficient oral access (not too small,
microstoma)microstoma)
 Adequate lip appearanceAdequate lip appearance

GENERAL CONSIDERATIONSGENERAL CONSIDERATIONS
 For upper lip reconstruction, lower lip can be used , butFor 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 closedDefect 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 orFor 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 distantFor 60% or greater defects other adjacent or distant
flaps may be needed.flaps may be needed.
 White roll or muco-cutaneous or vermilion border mustWhite roll or muco-cutaneous or vermilion border must
be aligned properly.be aligned properly.
 For incisions that cross vermilion border should do soFor incisions that cross vermilion border should do so
at 90 deg.at 90 deg.
 Good muscle approximation is must for competency ofGood muscle approximation is must for competency of
oral stoma and prevents further scar widening.oral stoma and prevents further scar widening.

VERMILIONVERMILION
DEFECTSDEFECTS

Primary repairPrimary repair
 Meticulous reattachment of laceratedMeticulous reattachment of lacerated
tissue.tissue.
 Save as much as possibleSave as much as possible
 Thorough washing is must with mildThorough washing is must with mild
antiseptic solution.antiseptic solution.
 Best results when performed with in firstBest results when performed with in first
few hours after injury.few hours after injury.

Primary closurePrimary closure

Small vermilionSmall vermilion
defectsdefects
 V-y closure ofV-y closure of
small lip defectsmall lip defect
using a slidingusing a sliding
flap.flap.
 V-y closure of aV-y closure of a
defect using twodefect using two
sliding flaps.sliding flaps.

Wedge shaped defectsWedge shaped defects
 Defects excisedDefects excised
 Superiorly &Superiorly &
inferiorly basedinferiorly based
mucosalmucosal
triangles are cuttriangles are cut
 Muscle layerMuscle layer
closed &closed &
mucosalmucosal
triangles aretriangles are
transposed.transposed.

Large superficial vermilionLarge superficial vermilion
defectsdefects
 Mucosal slidingMucosal sliding
flap.flap.
 The intact lipThe intact lip
mucosa ismucosa is
mobilized,mobilized,
advanced toadvanced to
cover thecover the
defect.defect.

Kawamoto’s VermilionKawamoto’s Vermilion
switchswitch
 Upper lipUpper lip
deficiencies maydeficiencies may
often be treatedoften be treated
by transverselyby transversely
oriented flapsoriented flaps
 Divided after 10-Divided after 10-
14 days14 days

Vermilion advancement ofVermilion advancement of
Goldstein (1984)Goldstein (1984)
 MyomucosalMyomucosal
advancementadvancement
flaps.flaps.
 Vermilion defectsVermilion defects
involving uptoinvolving upto
one third ofone third of
length can belength can be
repaired withoutrepaired without
any deformityany deformity

Vermilion defectsVermilion defects
(more than 1/3)(more than 1/3)
 Mucosal flap from anterior margin ofMucosal flap from anterior margin of
tongue, based on right or left side istongue, based on right or left side is
swung into the defect- flap division afterswung into the defect- flap division after
2 wks.2 wks.
 ventral papillary surface for females,ventral papillary surface for females,
takes lipstick colors.takes 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 pullingMay 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 & someMucosa & some
muscle tissue aremuscle tissue are
excised intraorallyexcised intraorally
from protuberantfrom protuberant
lips and closurelips and closure
done.done.

Augmentation of upperAugmentation of upper
liplip
 A bipedicled flap is cut from lower lipA bipedicled flap is cut from lower lip
and upper lip incisedand upper lip incised
 Flap is transferred to the upper lipFlap is transferred to the upper lip
and donor defect is closed.and 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
flapsflaps
 1/3 to 2/3 defects – Vermilion switch1/3 to 2/3 defects – Vermilion switch
- Tongue flaps- Tongue flaps
- Buccal mucosal- Buccal mucosal
advancement flapsadvancement flaps
 Total defects – Tongue flapsTotal defects – Tongue flaps
- Buccal mucosal advancement flaps- Buccal mucosal advancement flaps

UPPERUPPER
LIPLIP
RECONSTRUCTIONRECONSTRUCTION

Upper lip reconstructionUpper lip reconstruction
(median scars, and defects)(median scars, and defects)
 Crescent shapedCrescent shaped
excisions madeexcisions made
lateral to alar groove,lateral to alar groove,
scar excised, lip isscar excised, lip is
mobilized & broughtmobilized & brought
down normaldown normal
position.position.
 Z-plasty added toZ-plasty added to
adjust the position ofadjust the position of
vermilion.vermilion.

(median scars, and distortion of(median scars, and distortion of
vermilion)vermilion)
 Scar is excised andScar is excised and
releasing incisionsreleasing incisions
are made inare made in
nasolabial folds.nasolabial folds.
 Tumor or scarTumor or scar
excised and scar isexcised and scar is
dispersed by Z plastydispersed by Z plasty

(larger scars and contractures)(larger scars and contractures)
 Large burn scarsLarge burn scars
and contracturesand contractures
covered with fullcovered with full
thickness postthickness post
auricular grafts.auricular grafts.

Three-layered Abbe flapThree-layered Abbe flap
 Three layered Abbe’s flapThree layered Abbe’s flap
incised out from lower lipincised out from lower lip
 Rotation of flap into theRotation of flap into the
upper lip defect.upper lip defect.
 Modification of Abbe’s flapModification of Abbe’s flap
with different shapes ofwith different shapes of
incisionsincisions
 The flap is divided 20 daysThe 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 ofMay be used to close 75% central defects of
lower lip.lower lip.
 Causes definite shortening of lipCauses definite shortening of lipsumeryadav2004@gmail.comsumeryadav2004@gmail.com

Estlander flap (1872)Estlander flap (1872)
 Similar to Abbe flap atSimilar to Abbe flap at
commissure.commissure.
 Wedge shaped flap based onWedge shaped flap based on
inferior labial artery, is rotatedinferior labial artery, is rotated
around angle of mouth into thearound angle of mouth into the
defect.defect.
 About 16-20 days later theAbout 16-20 days later the
pedicle is divided, triangularpedicle is divided, triangular
mucosal flaps are mobilizedmucosal flaps are mobilized
 Z- plasty is added for closureZ- plasty is added for closure
of donor site.of donor site.

UPPER LIP DEFECTUPPER LIP DEFECT

Intra-operatively afterIntra-operatively after
debridementdebridement

Nasolabial flapsNasolabial flaps
 Bilateral nasolabial flaps for total near-Bilateral nasolabial flaps for total near-
total upper lip defects.total upper lip defects.
 Recreates upper lip anatomyRecreates upper lip anatomy
 Inferiorly based for hairless skin inInferiorly based for hairless skin in
femalesfemales
 Superiorly based for hairy skin in males.Superiorly based for hairy skin in males.
 Use of levator anguli oris in distallyUse of levator anguli oris in distally
based.based.
 Restores sensations, restores oralRestores sensations, restores oral
sphincter, provides satisfactory totalsphincter, provides satisfactory total
upper lip reconstruction with Abbe’s flapupper lip reconstruction with Abbe’s flapsumeryadav2004@gmail.comsumeryadav2004@gmail.com

Central Upper lip reconstructionCentral Upper lip reconstruction
 Method byMethod by CelsusCelsus
& Bruns& Bruns
 Two-layer crescentTwo-layer crescent
shaped incisionshaped incision
made lateral to themade lateral to the
alar groove andalar groove and
extended alongextended along
nasal base.nasal base.

Celsus method combined withCelsus method combined with
an Abbe flapan Abbe flap
 Large defects of upper lip can be reduced by CelsusLarge 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 islandNeurovascular island
flapflap
 Three layered flapThree layered flap
is advanced on ais advanced on a
neurovascularneurovascular
pediclepedicle
 Repaired in v-yRepaired in v-y
manner.manner.

Neurovascular myocutaneousNeurovascular myocutaneous
island flapisland flap
 The flap cut in threeThe flap cut in three
layers, preserving itslayers, preserving its
neurovascular pedicleneurovascular pedicle
 Flap advanced into upperFlap advanced into upper
lip defect and burrow’slip defect and burrow’s
triangles excised.triangles excised.
 Mucosal flaps from oralMucosal flaps from oral
vestibule – to lateral lipvestibule – to lateral lip
defect.defect.sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Gillies fan flapGillies fan flap
 Three layered nasolabial flap cutThree layered nasolabial flap cut
around ala, nourished by labialaround ala, nourished by labial
vessels.vessels.
 Gillies flap is usually cut in twoGillies flap is usually cut in two
layers & mucosa is mobilizedlayers & mucosa is mobilized
toward midlinetoward midline
 Flap contains orbicularis orisFlap contains orbicularis oris
muscle, it is dissected bluntly tomuscle, it is dissected bluntly to
preserve the superior and inferiorpreserve the superior and inferior
labial vessels.labial vessels.
 Lateral Z-plasty gives sufficientLateral Z-plasty gives sufficient
mobility.mobility.

Upper lip recostruction of weerdaUpper lip recostruction of weerda
 Left side is reconstructed with a twoLeft 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 orDefect in nasal vestibule or
upper lipupper lip
 An inferiorly based nasolabial flap canAn inferiorly based nasolabial flap can
be used to repair a defect in the upperbe used to repair a defect in the upper
lip or nasal vestibule.lip or nasal vestibule.

Burrow’s cheekBurrow’s cheek
advancement flapadvancement flap
 Crescent shaped skin excision is made in alarCrescent shaped skin excision is made in alar
groove.groove.
 The cheek is advanced and all defects areThe cheek is advanced and all defects are
closed.closed.

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

Hair- bearing skinHair- bearing skin
flapsflaps
 Island temporal hair bearing scalp flapIsland temporal hair bearing scalp flap
 Sub-mental skin flaps (unilateral orSub-mental skin flaps (unilateral or
bilateral pedicle flaps)bilateral pedicle flaps)
 Cervical skin flaps (unilateral or bilateralCervical skin flaps (unilateral or bilateral
pedicle flaps)pedicle flaps)
 Cheek advancement flapsCheek 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 & foreheadHair 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 neckTzur’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

LOWERLOWER
LIPLIP

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 isLip asymmetry & loss of circumference is
functional and aesthetically normal.functional and aesthetically normal.
 When lateral resection carried outWhen 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 inwounds closed in
multiple Z- plasties.multiple Z- plasties.

Modifications of wedgeModifications of wedge
excisionexcision
 Small defects of lowerSmall defects of lower
lip can be repaired by v-lip can be repaired by v-
y technique.y technique.
 Excess tissue should beExcess tissue should be
provided to vermilion toprovided to vermilion to
prevent formation ofprevent formation of
new defect.new defect.
 Should not crossShould not cross
labiomental fold-labiomental fold-
hypertrophic scarhypertrophic scar
occurs.occurs.

Modifications of wedgeModifications of wedge
excisionexcision
 Wider excisionWider excision
possible uptopossible upto
2cms. By2cms. By
excising in thisexcising in this
mannermanner

Modifications of W-Modifications of W-
plastyplasty
 Modifications in W-Modifications in W-
plasty do not crossplasty do not cross
labio-mental foldlabio-mental fold
thus preventthus prevent
hypertrophichypertrophic
scarring.scarring.

Lip stumps mobilizationLip stumps mobilization
 The central growth isThe central growth is
excised (for up to 40-excised (for up to 40-
50% of defects)50% of defects)
 The stumps areThe stumps are
mobilized by excisingmobilized by excising
burrow’s trianglesburrow’s triangles
lateral to the upperlateral to the upper
lip and the chin.lip and the chin.
 SCHUCHARDTSCHUCHARDT’s’s
flap if upper lipflap if upper lip
incision are not doneincision are not done
 Causes decreasedCauses decreased
oral circumferenceoral circumferencesumeryadav2004@gmail.comsumeryadav2004@gmail.com

uu

Post electrical burnPost electrical burn
injury lip defectinjury lip defect

Johanson’s step ladderJohanson’s step ladder
techniquetechnique
 Two to four steps areTwo to four steps are
to be designed.to be designed.
 For up to 2/3 defects.For up to 2/3 defects.
 Good sensation,Good sensation,
muscle continuity &muscle continuity &
function.function.
 Scars areScars are
conspicuous,conspicuous,
tightness oftightness of
reconstructed lipreconstructed lip
occurs.occurs.

Estlander flap (1872)Estlander flap (1872)
 Three layeredThree layered
triangular flap outtriangular flap out
lined in upper-liplined in upper-lip
 Lateral limb extendsLateral limb extends
to the commissureto the commissure
along the nasolabialalong the nasolabial
fold.fold.
 Flap is rotated intoFlap is rotated into
the defect, bringingthe defect, bringing
the lateral vermilionthe lateral vermilion
downward & mediallydownward & medially


Causes shortening of mouth
Opening with deviation of
Angle.
Following commissuroplasty.

 ModifiedModified
Estlander flapEstlander flap
for large centralfor large central
defects.defects.
 ModificationModification
preservingpreserving
angle of mouth.angle of mouth.

Gillies fan flapGillies fan flap
(1957)(1957)
 For largeFor large
mediolateral defectsmediolateral defects
not involvingnot involving
commissurescommissures
 Flap is basically aFlap is basically a
large Eastlander flaplarge Eastlander flap
that is rotated aroundthat is rotated around
orbicularis oris &orbicularis oris &
possibly maintainingpossibly maintaining
its neurovascularits neurovascular
supply.supply.
 Z- plasty at cornersZ- plasty at corners
increases the extent.increases the extent.
 Causes distortion ofCauses distortion of

Universal method of Bernard,Universal method of Bernard,
Grimm & FriesGrimm & Fries
 For subtotal defectsFor subtotal defects
 Lateral cheek is mobilizedLateral cheek is mobilized
by cutting burrow’sby cutting burrow’s
triangles.triangles.
 Cheek U flap isCheek U flap is
deepithelized anddeepithelized and
resurfaced with mucosalresurfaced with mucosal
flap from cheek.flap from cheek.

Meyer’s modificationMeyer’s modification
 Triangles are cutTriangles are cut
lateral to upper liplateral to upper lip
& cheek mucosa& cheek mucosa
is incised &is incised &
mobilized.mobilized.
 Mucosa turnedMucosa turned
over to the lateralover to the lateral
reconstructed lip.reconstructed lip.
 Distortion of oralDistortion of oral
commissure andcommissure and
loss of oralloss of oral
circumferencecircumferencesumeryadav2004@gmail.comsumeryadav2004@gmail.com

Karapandzic flapKarapandzic flap
 For midline defects of lower lip.For midline defects of lower lip.
 Safe, lips as donor tissue soSafe, lips as donor tissue so
better results.better results.
 No droling as adequate muscleNo droling as adequate muscle
function and fibre direction isfunction and fibre direction is
maintained.maintained.
 Contraindicated if no donorContraindicated if no donor
tissue available, ablation of bothtissue available, ablation of both
facial artery & ant. br. of nasalfacial artery & ant. br. of nasal
septal artery, upper lipseptal artery, upper lip
irradiation and commissureirradiation and commissure
involvement.involvement.

 Gillies;Gillies; distorts thedistorts the
commissure.commissure.
 KarapandzicKarapandzic;; intactintact
neurovascular pedicle,neurovascular pedicle,
oral apperture narrowedoral apperture narrowed
 McGregor;McGregor; pivots aroundpivots around
commissure, lesscommissure, less
distorting, new vermilliondistorting, new vermillion
& changed direction of& changed direction of
fibres.fibres.
 Nakajima;Nakajima; similar tosimilar to
McGregor’s but facialMcGregor’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 afterCan be used after
radical excision ofradical excision of
lower lip andlower lip and
surrounding tissue.surrounding tissue.
 Blood supply by 2Blood supply by 2ndnd
&&
33rdrd
intercostal vessels.intercostal vessels.
 Averages 25 cm longAverages 25 cm long
& 12 cm wide.& 12 cm wide.
 Pivot point –Pivot point –
emergence of 2emergence of 2ndnd
intercostal vessels.intercostal vessels.
 Denervated lower lipDenervated lower lipsumeryadav2004@gmail.comsumeryadav2004@gmail.com

PlatysmaPlatysma
Musculocutaneous flapsMusculocutaneous flaps
 Skin flap island designed on the lateral aspect of neckSkin flap island designed on the lateral aspect of neck
above clavicle.above clavicle.
 Turnover platysma muscle flap superiorly basedTurnover platysma muscle flap superiorly based
pivoting along mandible including skin island in distalpivoting along mandible including skin island in distal
third for resurfacing intraoral mucosa.third for resurfacing intraoral mucosa.
 Careful dissection along medial border to avoidCareful 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 labialTone of transplanted muscle sufficient to prevent labial
ectropion.ectropion.
 Injury to 11Injury to 11thth
nerve & mandibular branch of facial arenerve & mandibular branch of facial are
potentially disastrous.potentially disastrous.

Lower lipLower lip
 Less than 1/3 loss – Primary closureLess 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

COMMISSURECOMMISSURE

Oral fissure elongationOral fissure elongation
Ganzer methodGanzer method
 Elliptical triangle isElliptical triangle is
excised, incisionexcised, incision
is made aroundis made around
the vermilionthe vermilion
without dividing itwithout dividing it
 Entire vermilion isEntire vermilion is
advanced laterallyadvanced laterally
and sutured intoand sutured into
the defect.the defect.sumeryadav2004@gmail.comsumeryadav2004@gmail.com

Elongation of oralElongation of oral
fissurefissure
 Triangle of epithelium isTriangle of epithelium is
excised down toexcised down to
mucosa, which is intact.mucosa, which is intact.
 The existingThe existing
commissure is excisedcommissure is excised
 T-shaped incisions inT-shaped incisions in
exposed mucosa & theexposed mucosa & the
three mucosal flaps arethree mucosal flaps are
turned out & sutured.turned out & sutured.

Lifting angle ofLifting angle of
mouthmouth
 Z-plasty used to raiseZ-plasty used to raise
angle of mouthangle of mouth

Reconstruction by method ofReconstruction by method of
BrusatiBrusati
 The commissure isThe commissure is
excised & Burrow’sexcised & Burrow’s
triangles are excised.triangles are excised.
 U-shaped cheek flap isU-shaped cheek flap is
advanced into theadvanced into the
defect.defect.
 Small area at of flap atSmall area at of flap at
commissure is excisedcommissure is excised
and mucosa isand mucosa issumeryadav2004@gmail.comsumeryadav2004@gmail.com

 Reconstruction ofReconstruction of
vermilion by dual V-vermilion by dual V-
Y advancement flap.Y advancement flap.
 Buccal mucosaBuccal mucosa
turned inside out.turned inside out.
 Loss of muscle atLoss of muscle at
commissure causescommissure causes
oral incompetence.oral incompetence.

Method of Fries and BrusatiMethod of Fries and Brusati
 The incisions areThe incisions are
placed on aplaced on a
semicircular segmentsemicircular segment
in cheek above andin cheek above and
below.below.
 Secondary defectsSecondary defects
closed by excision ofclosed by excision of
Burrow’s triangles.Burrow’s triangles.
 The commissure isThe commissure is
restored by suturingrestored by suturing
small triangularsmall triangular
mucosal flapsmucosal flaps
advanced over de-advanced over de-

 Low cheek rotationLow cheek rotation
combined with ancombined with an
Estlander flap.Estlander flap.
 Disadv. –Disadv. –
Shortening of lipsShortening of lips
with oralwith oral
incompetence.incompetence.

Large full thicknessLarge full thickness
reconstruction of commissurereconstruction of commissure
and lipand lip
 Defect excised andDefect excised and EssarEssar
cheek rotation flapcheek rotation flap outlined.outlined.
Incision is made below theIncision is made below the
lower lip & skin mobilized.lower lip & skin mobilized.
 All defects closed and scarsAll defects closed and scars
are dispersed with Z-plastiesare dispersed with Z-plasties
in RSTLsin RSTLs
 Residual defects in oralResidual defects in oral
portion of cheek can beportion of cheek can be
covered with tongue flap.covered with tongue flap.
 Though lip length is someThough lip length is some
what preserved, oralwhat 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 plasticWeerda’s – Reconstructive facial plastic
surgery.surgery.
 e- medicine – internet.e- medicine – internet.
 Gray’s anatomy.Gray’s anatomy.
 Gillies & Millard – The principles & Art ofGillies & Millard – The principles & Art of
Plastic Surgery.Plastic Surgery.sumeryadav2004@gmail.comsumeryadav2004@gmail.com

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