38

Lip Reconstruction
Babak J.Mehrara, M.D.,* and Barry M.Zide, M.D., D.M.D.
New York University Medical Center, New York, New York, U.S.A.

I. INTRODUCTION
1. Lip reconstruction is challenging for functional and aesthetic reasons. In addition,
minor lip defects are noticeable at conversational distances.
2. Thus, important goals in lip reconstruction include maintenance of oral competence as
well as aesthetic reconstruction of the lips and vermilion.

II. ANATOMY

The topography of the lips is an important consideration in reconstructive planning (Fig.

1). The area corresponding to the upper lip extends from one nasolabial fold to the other,
including the philtral columns, vermilion, and intraoral mucosa. The lower lip includes
the intraoral mucosa, vermilion, as well as the skin and soft tissues extending to the
labiomental fold.
 A. Musculature
1. Orbicularis oris
• Primary muscle responsible for maintenance of oral competence, hence known as the
oral sphincter.
• Muscle fibers originate at the modiolus laterally and decussate in the midline and at
the commissures.
• Orbicularis oris muscle consists of two anatomically distinct muscle groups: the
outer pars peripheralis and the pars marginalis (toward the vermilion).
2. Levator labii superioris
• Acts as the primary lip elevator in conjunction with levator labii superioris alaque
nasi.
• Originates from the anterior portion of the maxilla and inserts into the lower two-
thirds of the philtral columns superficial to the orbicularis oris muscle.
• This muscle, along with the orbicularis oris, provides the bulk of the lower philtral
columns.
 Lip reconstruction 28

3. Levator anguli oris: originates from the anterior portion of the maxilla and inserts on
the upper lateral lip and modiolus, thereby acting in conjunction with zygomaticus
major/minor muscles to elevate the commissures.
4. Zygomaticus major and minor
• Act to draw upper lips up and back.
• Originate from the zygoma and insert on the upper lateral lip and modiolus.
5. Mentalis
• Is the central lower lip elevator.
• Originates from the mandibular periosteum below the attached gingiva between the

* Current affiliation: Memorial Sloan-Kettering Cancer Center, New York, New York, U.S.A.

Figure 1 Topographic anatomy of the

lips: (1) philtral columns; (2) philtral
groove or dimple; (3) cupid’s bow; (4)
white roll; (5) tubercle; (6)
commissure; (7) vermilion; (8)
labiomental fold; (9) nasolabial fold.
(Adapted from Zide BM: Deformities
of the lips and cheek. In: McCarthy
JG, ed. Plastic Surgery. Philadelphia:
W.B.Saunders, 1990.)
lower lateral incisors and inserts into the entire chin pad.
• Contraction of this muscle elevates the chin pad and compresses it against the
mandible, thus forcing the central lip upward. It is the muscle that allows
“pouting.”
 Lip reconstruction 29

• The upper fibers maintain lip position.

6. Depressor anguli oris, depressor labii inferioris: represent the primary lower lip
depressors that originate from the mandibular border and insert into the lower
orbicularis of the lower lip.
 Lip reconstruction 30

B. Innervation
1. Motor
• Motor innervation of the lips is via the seventh cranial nerve (buccal and mandibular
branches).
• Orbicularis oris is innervated by the buccal branch only.
2. Sensory
• Sensory innervation of the upper lip is via the infraorbital branch of the fifth cranial
nerve (V2).
• Sensory innervation of the lower lip is via the mental branch of the fifth cranial
nerve (V3).

C. Blood Supply
1. The blood supply of the lips is derived from the paired labial arteries arising from the
facial arteries.
2. A rich anastomotic network surrounds the lips, thus enabling extensive dissections.
3. Local flaps based on the labial arteries represent the basis for many reconstructive
options.

D. Lymphatic Drainage
1. Lymphatic drainage of the lips occurs via the submandibular and submental lymph
nodes.

III. PATHOPHYSIOLOGY

The vast majority of lip defects are secondary to cancer ablation. In addition, lip defects
resulting from vascular malformations, trauma, and infectious complications are also
commonly encountered.

A. Characteristics
1. Neoplasms of the lip are primarily related to actinic damage, Most lip neoplasms
(approximately 95%) involve the lower lip since the upper lip is at least partially
shielded from sun exposure by the nose.
2. Lip cancers demonstrate strong sex bias, with males affected approximately 9 times
more frequently than females.
3. Upper and lower lips also differ in the incidence of different types of skin cancers.
Upper lip carcinomas are usually basal cell types, while lower lip carcinomas are
usually squamous cell carcinomas.
4. Fortunately, only a small minority (approximately 2–3%) of lower lip squamous cell
carcinomas tend to involve the commissures. These tumors tend to behave more
aggressively (up to 16% have evidence of metastasis on presentation) and are more
difficult to reconstruct.

B. Squamous Cell Carcinomas of the Lips

These tend to behave less aggressively than those involving oral mucous membranes.
1. Primary lip squamous cell carcinomas less than 1.5 cm in diameter should be excised
with a margin of 1.0 cm (unless Mohs’ chemosurgery is used). In addition, many
authors recommend evaluation of the remaining lip vermilion with lip shave and
histologic sampling to rule out premalignant or superficial malignancy.
2. Staging of squamous cell carcinomas is also important since the surgical stage has
been directly correlated with survival. In surgical staging of squamous cell
carcinomas, T1 represents a tumor <2 cm in greatest diameter, T2=2–4 cm, T3>4 cm,
and T4=local tissue invasion.

IV. RECONSTRUCTION

A. Basic Tenets
Reconstruction of lip defects is preferentially performed using:
1. Same lip
2. Opposite lip
3. Local skin (cheek, nasolabial fold, etc.)
4. Free flap

B. Upper Lip Reconstruction

Aesthetic reconstruction of the upper lip is more challenging than that of lower lip
defects, since care must be given to the reconstruction of the Cupid’s bow and philtral
columns. In addition, care must be taken to restore the shape and contour of the vermilion
with accurate alignment of the white roll. Functionally, however, upper lip defects are
less challenging than lower lip defects, since the lower lip primarily controls oral
competence. Techniques used for upper lip reconstruction are summarized in Figure 2.
 1. Partial-Thickness Defects
a. Partial-thickness defects can usually be closed by primary closure in the direction of
relaxed skin tension lines (i.e., vertically).
b. Larger defects may occasionally require full-thickness skin grafting, and results in
aesthetically pleasing results (for example, reconstruction of the entire philtral skin).
c. Conversion to full-thickness defects and coverage with lower lip flaps (e.g., Abbe
flaps).
d. Local tissue flaps are commonly used. Examples include nasolabial flaps and cheek
flaps. The use of local flaps may be problematic, however, since these flaps often
result in the obliteration of aesthetic units, especially with facial animation (e.g.,
during smiling). In addition, movement of hair-bearing skin in male patients can result
in noticeable scars.

2. Full-Thickness Defects
a. Defects <35% of Total Width:
• Usually can be closed primarily with good aesthetic results. Maximum defect size
that can be closed primarily depends on skin laxity. Care must be given to precise
alignment of white roll and muscle for optimum aesthetic and functional
reconstruction. Closure of medial defects may cause distortion of the philtral
columns.
• Abbe flaps (lip switch) and occasionally full-thickness grafts may be used for philtral
column reconstruction in central lip defects. This technique may improve aesthetic
outcome, especially in females, since the absence of philtral columns secondary to
primary closure cannot be hidden by facial hair.
b. Defects >30% of Total Width:
• Local tissue flaps: large upper lip defects may be reconstructed with bilateral flaps.

Abbe flaps (lip switch) may be used to reconstruct defects measuring up

to 50% of the total width. These flaps may be combined with local tissue
flaps, especially for reconstruction of philtral columns.
Nasolabial flaps/cheek advancement flaps rely on perialar tissue with
or without skin/soft tissue excisions to aid in tissue advancement. All
flaps usually require revisions, and patients should be so advised. If
excisions are limited to skin and limited subcutaneous tissues, these
procedures have the potential to preserve innervated muscle tissue to close
lip defects while maintaining sphincter function. However, original
descriptions of some of these procedures called for full-thickness
excisions that would denervate the lips. Examples of nasolabial/cheek
advancement flaps include:
• Bernard Von Burrow chelioplasty
• with verse lower cheek
Web direc flaps; (H) reverse
ster t Karapandzic flap.
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• (B) plastic surgery.)
Sch Abb Notes: (A) cuts
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flap swit perpendicular to
ch) vermilion border;
flap; (B) switch flaps
(C) best put in center
rever only. This size
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Gilli
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fan
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flap;
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Fig ster’
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 closed primarily with release as drawn;
(C) rarely used-see Yotsuyanagi; (D)
rarely done due to commissure
distortion. (From Yotsuyanagi T, et al.:
Functional and aesthetic reconstruction
using a naso labial orbicularis oris
myocutaneous flap for large defects of
the upper lip. Plast. Reconstr. Surg.
101:1624, 1998.)
Oral circumference flaps
• Gillies fan flap is a rotation advancement flap that moves lateral lip and commissure
medially. Results in distortion of commissure, often requiring a difficult commissure
revision. In addition, this flap is associated with microstomia when used as bilateral
flaps for the closure of large defects.
• McGregor flap is a modification of the Estlander flap (see below) and adds complete
vermilionectomy with rotation around the commissure. Maintains commissure in
position, but changes direction of muscle fibers with reosultant decreased sphinteric
action.
• Innervated composite flaps (e.g., Karapandzic flap, Nakajima flap) are best dissected
with loupe magnification to preserve facial nerve branches and vessels. Thus, motor
and sensory innervation of the orbicularis oris muscle are preserved, resulting in
improved sphincteric function. The use of these flaps in larger defects may result in
microstomia, thus complicating denture insertion and dental work. Microstomia is, to
some extent, responsive to stretching exercise or devices. In addition, the scars
associated with these flaps tend to be noticeable.

Combination flaps utilize combinations of above flaps to close larger

defects.
Distant flaps are used only if local tissues are not available. Distant
flaps are problematic because they are insensate and have no muscle
function. The most commonly described flap is the radial forearm flap. A
radial forearm flap may be suspended with palmaris longus tendon to aid
in oral competence.

C. Lower Lip Defects

These are encountered much more frequently than upper lip defects (due to increased
actinic damage—
Figure 3 Techniques for primary
closure of lower lip defects: (A) single
barrel excision; (B) double barrel
excision; (C) staircase/stepladder
method: Not a great result as steps are
often visible. (Adapted from Zide BM:
Deformities of the lips and cheek. In:
McCarthy JG, ed. Plastic Surgery.
Philadelphia: W.B.Saunders, 1990.)
 Figure 4 Techniques for closure of
large (>33% total width) lower lip
defects: (A) Schuchardt procedure; (B)
Webster modification of the Bernard
operation; (C) Gillies fan flap; (D)
Karapandzic flap (innervated); (E)
McGregor flap; (F) Nakajima flap.
(Adapted from Zide BM: Deformities
of the lips and cheek. In: McCarthy
JG, ed. Plastic Surgery. Philadelphia:
W.B.Saunders, 1990.)
see above). In addition, when lower lip reconstruction is performed, every effort should
be made to maintain oral competence. Techniques used for lower lip reconstruction are
summarized in Figures 3 and 4.
1. Defects less than 33% of total lower lip width can usually be closed primarily.
 • Techniques such as single barrel, double barrel, or stair-step excisions can be used
successfully (Fig. 3).
• V-shaped excisions are not recommended for tumor excision since tumor invasion
can occur laterally or downward.
• Flared W-plasty and barrel-shaped excisions avoid incisions across the labiomental
fold, thus resulting in more cosmetic appearance by avoiding hypertrophic scarring.
2. Defects measuring 33–65% of total width
• Local advancement flaps:

Cheek advancement.
Oral circumference advancement flaps (e.g., Schuchardt
advancement flaps, Webster-Bernard flaps, gate flaps).
Composite flaps (e.g., Gillies fan flap, McGregor flap, Karapandzic
flap).
Lip switch procedures (e.g., Abbe flap).
3. Defects measuring greater than 65% of total width are considered near-complete
reconstruction (>80% is considered total reconstruction).
• Bilateral Karapandzic flaps (approximately 80%)
• Bilateral McGregor/Nakajima flaps (approximately 90%)
• Webster-Bernard technique (approximately 100%)
• Combination procedures
• Distant flaps
• Microvascular tissue transfers

D. Defects Involving the Commissures

1. Can be treated similar to upper/lower defects.
2. Commissure reconstruction can be provided with Estlander or McGregor flaps.
3. Larger defects may be combined with other procedures.

E. Vermilion Defects

1. Key Points for Reconstruction

a. Always mark the white roll with blue dots into the dermis.
b. Always cross white roll at 90° angles.
c. Do not suture the white roll (results in prolonged erythema and resultant obliteration).
d. If possible, maintain incisions within the vermilion.
 2. Order or Preference for Vermilion Reconstruction
1. Advancement of same lip (V-Y advancement flaps or primary closure). Care must be
taken to reapproximate muscle fibers to prevent future scar contraction and dimpling.
2. Other lip vermilion (unipedicled or bipedicle flaps).
3. Mucosal advancement flap.
4. Tongue flaps.
5. FAMM flaps (facial artery musculomucosal flap).