AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The lips have important functional and aesthetic roles in daily living. They are the focal point of the lower face, with several aesthetic units intricately controlled by a complex series of muscles. Several key factors make reconstruction of the lip especially challenging. The lack of any substantial fibrous framework increases the risk of anatomic distortion through wound contraction and, hence, leads to poor functional and aesthetic outcomes. The quality (ie, color, texture, elasticity) of the skin and mucosa of the lips are difficult to match with distant flaps. Hence, local tissues provide the best results. However, with larger oncologic resections and more extensive traumas, an appropriate donor site might be difficult find. This is further complicated by the lack of any satisfactory prosthesis in aid of reconstruction.

Goals of reconstruction

Lip reconstruction is driven by restoration or preservation of function and aesthetics.

Functional considerations include oral continence, mobility that allows for sound formation and facial expression, adequate oral access, and sensation. Oral continence is critical in the ingestion of food and the confinement of salivary fluids within the oral cavity. The lips are also essential in forming many sounds, especially those of B, F, M, P, and V. Though microstomia may become an unavoidable adverse effect in some cases of lip reconstruction, it may cause functional impairment and should be avoided when possible. Furthermore, preservation of sensation is preferred both socially and functionally, as insensate lips are more prone to repeat injury.

Aesthetic considerations include appropriate symmetry and normal anatomic proportions, presence of a philtrum, normal oral commissures, and establishment of a vermilion-cutaneous white border. Refer to Image 1 for the aesthetic units of the lower face.

History of the Procedure

The first evidence of lip reconstruction is seen as far back as 3000 BC in Hindu writings, as well as in the Sanskrit writings of Susruta in 1000 BC. Many modern techniques are newer renditions of methods first described by Dieffenbach, Sabatini, Abbe, and Estlander in the 19th century.^{1, 2, 3, 4, 5, 6} In 1834, Dieffenbach first described the check advancement flap technique based on an inferior-lateral pedicle. In 1838, Sabattini first described the cross-lip flap transfer of a lower lip midline wedge to a philtral defect.³ This technique was modified and further popularized by Abbe and Estlander toward the end of the century.

To this day, the Abbe-Sabattini flap is commonly used in philtral reconstruction. Bernard⁷ and von Burow⁸ later described a bilateral full-thickness triangular cheek advancement flap that allowed for correction of total and subtotal lip defects. In the 1920s, Gillies described a fan flap technique using full-thickness pedicles; however, these flaps were denervated and did not allow for functional restoration.

Karapandzic improved on this technique with an oral circumference advancement flap with preservation of underlying musculature and neurovascular structures.⁹ Most recent techniques incorporate principles that attempt to maximize both functional and aesthetic outcomes.

Frequency

The frequency with which a reconstructive surgeon encounters the need for lip reconstruction is related to social and environmental issues of the practice setting. Since the most common causes of lip loss are trauma and oncologic resection, frequency is greater in trauma-related and oncologic practices. Earlier detection and attention to tumors, knowledge of sun protection, and better passenger protection in motor vehicle accidents have lessened the overall frequency of major lip reconstruction. The frequency of congenital deformities and major lip loss from gunshot injuries have not changed significantly.

Etiology

Oncologic excision, trauma, and congenital deformities are the major etiologies that require lip reconstruction.

More than 80% of cancers of the lip are of the squamous cell carcinoma type, perhaps due to tobacco use or anatomic exposure to solar radiation. Less commonly, other adenocarcinomas and mucoepidermoid tumors can be found. Cancer of the lip is considered a readily visualized cancer and, as such, has a relatively lower mortality rate than other head and neck cancers. In the past 25 years, the incidence of lip cancer has decreased dramatically, and new surgical and medical treatments have contributed to a nearly 38% decrease in mortality. However, the functional and aesthetic ramifications of local wide excision of cancer of the lip make reconstruction of the lip imperative to the complete treatment and restoration of health and functioning.

The lower lip is most commonly affected by squamous cell carcinoma, whereas most basal cell carcinomas affect the upper lip. Based on the type of cancer, the excisional margin size may be smaller, with squamous cell carcinomas requiring larger margins than basal cell carcinomas. For more information about skin cancers, visit Medscape's Skin Cancer Resource Center. For education on treating head and neck cancers presented at the 2007 meeting of the American Society of Clinical Oncology, see this Medscape CME activity.

Traumatic lesions of the lip are also common etiologies requiring reconstructive surgery. Frequently, gunshot wounds or motor vehicle accidents result in defects that affect functioning and aesthetic appearance of the lips. These injuries often require total or subtotal repair. Congenital defects such as cleft lip, vascular malformations, fistulae, and nevi frequently require lip reconstruction. These defects are not discussed in this article.

Pathophysiology

The tumor biology of cutaneous malignancy is relevant to the pathophysiology of much of lip reconstruction. This is discussed in Cancer, Skin. Other relevant pathophysiology is scar contracture, which is discussed in Wound Healing, Skin.

Clinical

Patients usually present for lip reconstruction immediately following lip loss. In oncologic lesions and hemangioma resections, the reconstruction is usually performed under the same anesthetic or after a short period needed for confirmation of completeness of cancer resection. In trauma, the reconstruction is also performed immediately after presentation or when the management of associated injuries allows anesthesia with maximum safety and when bacteriologic control of the wound is achieved. A short delay of a few days poses no particular barrier to successful reconstructions. However, long delays with wounds left open to heal by contraction and scar deposition substantially complicate subsequent reconstruction.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Indications for lip reconstruction are straightforward: they are the presence of a significant defect and available donor tissues. Contraindications arise when local control of the tumor cannot be achieved, which is a relatively rare occurrence. Unavailability of donor tissue generally does not prevent reconstruction but changes the technique to procedures that are more complex, that use donor tissue with less satisfactory properties, and that produce outcomes of lesser quality. Because many of the reconstructions can be performed under local or regional anesthetic, contraindications from systemic conditions such as advanced cardiopulmonary disease are rare.

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Superficial anatomy

The lower third of the face is dominated by the lips, which can be further divided into 3 components: cutaneous, vermilion, and mucosal (see Image 2).The cross-sectional anatomy of the lips consists of the epidermal, dermal, subcutaneous, muscular (orbicularis oris), submucosal, and mucosal layers. Neurovascular, lymphatic, and glandular structures mainly run between the muscular and submucosal layers. At the vermilion, a rich neural and vascular plexus lies beneath a layer of specialized squamous epithelium, making the vermilion highly sensate and giving it its characteristic red appearance.

The red-white vermilion-cutaneous border is best defined in the upper lip, creating a shape referred to as Cupid's bow, the center of which is contributed by the philtral ridges and groove. Though the lower lip does not have as well defined a central groove, many individuals have a minor central notch. The dry vermilion transitions into the wet vermilion, which, in turn, has a smooth transition into the mucosa of the internal lips.

Perioral surface anatomy, including the nasolabial and labiomental grooves, as well as individual-specific shadows and tension lines, is important in the design of flaps with imperceptible incisions.

Muscular anatomy

Relevant muscular anatomy along with origins, insertions, neural innervation, and action is summarized in Table 1 below and can be seen in Image 3:

Table 1. Muscles of Facial Expression

Neural anatomy

The motor innervation to the muscular anatomy is summarized in Table 1 above. The trigeminal nerve provides sensory innervation to the skin of the face. The maxillary division innervates the face below the level of the eyes and above the upper lip as the zygomaticotemporal, zygomaticofacial, and infraorbital nerves. The mandibular division innervates the face below the level of the lower lip via the buccal, auriculotemporal, and mental nerves. Refer to Image 4 for cutaneous innervation of the face and distribution of the facial nerve.

Vascular anatomy

The main vascular supply to the lips comes from branches of the facial artery. The superior and inferior labial arteries supply the upper and lower lip respectively. The arteries originate deep to orbicularis oris and depressor anguli oris, and form a vascular ring around the mouth penetrating the orbicularis oris near the angle of the mouth and continue to run between the muscle and mucous membrane. Here, they communicate with the septal artery near the philtral ridges. The facial artery also gives rise to lateral nasal and angular arteries. The facial artery runs deep to the zygomaticus and levator labii superioris muscles, at which point it branches into the angular artery, which is embedded in the labii superioris, and then continues as the lateral nasal artery. Venous supply of the face runs with named arteries. Being familiar with the vascular supply around the lips allows for appropriate flap selection and preservation of neurovascular pedicles. See Image 5.

Lymphatic anatomy

The lymphatic drainage of the lower face and lips plays a critical role in the spread of melanoma and squamous cell carcinoma. Both superficial and deep vessels of the central part of the lower lip drain to the submental lymph nodes, which, in turn, are drained by the submandibular and deep cervical lymph nodes. The upper lip, cheeks, side of the nose, and lateral portions of the lower lip are drained by the submandibular nodes. See Image 5.

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• Beyond standard anesthetic screening, no other laboratory studies are key to reconstruction. The only other relevant laboratories studies would be related to the underlying condition producing the lip loss defect or associated patient conditions.

Imaging Studies

• Imaging studies are rarely of use in lip reconstruction, as the surface and neuromuscular anatomy is directly accessible for evaluation. An arteriogram of the facial artery branches to the lips may be helpful in circumstances where trauma or resection has altered the vascular anatomy. This may also be useful in imaging vascular malformations involving the lips.

Histologic Findings

The relevant histologic findings address the oncologic issues of tumor resections and confirmation of margins. These are discussed in Cancer, Skin and Cancers of the Oral Mucosa.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical Therapy

No medical therapy exists for lip loss. Dental prosthetics are ineffective for lip restoration. However, they do have substantial value in replacing loss of maxillary or mandibular bony support for the lips in certain circumstances when these underlying structures are missing.

Preoperative Details

Preoperative considerations include determination of whether the conditions are appropriate for reconstruction, flap design along with appropriate markings, oral hygiene, preparation of surgical area, and communication of possible outcomes with the patient.

Oncologic resection is a major cause of lip defects. Hence, prior to reconstruction, pathology results on complete resection of tumor and clear surgical margins must be confirmed. When trauma is the etiology or accompanies the defect, it is imperative to allow recovery while keeping in mind the possibility of distortion of local anatomy and vascular supply.

Flap design includes assessing the size and shape of the defect and the availability of replacement tissue. As such, the location of the donor sight may vary (from local to distant flaps) based on defect size and whether the surrounding anatomy is preserved, since trauma is often extensive and may not be localized. Prior to administration of anesthetics, mark the cutaneous-vermilion border to aid in realignment and note relevant cosmetic landmarks such as folds, shadows, and tension lines. Oral hygiene should be optimized and hairs trimmed to decrease the chance of infection.

Since the obstacles of reconstruction may not be apparent prior to surgery, communicate to the patient or family the variability in functional and aesthetics outcomes. Doing so instills reasonable expectations that may make the postoperative period less difficult for the patient or the family.

Defect repair

Different defects require different repair techniques. Alternatively, different techniques may be appropriate for a particular defect. Tables 2 and 3 outline defect types, sizes, and locations and the appropriate techniques that may be used in repairing those defects. Details concerning specific techniques are discussed in the next section.

Intraoperative Details

Techniques

Primary closure

Primary repair involves reapproximation of defect edges and is generally reserved for smaller defects and involves consideration of several factors (see Image 6). Closure should occur along relaxed skin tension lines or, when possible, along folds (eg, nasolabial). If necessary, excessive tissue must be excised and the vermilion border must be realigned exactly to ensure appropriate aesthetic outcome. This is most often performed using a Burow wedge or V excision based on the vermilion with a 30-degree apex (or an A-to-T flap). This is also where preoperative markings greatly aid in repair. Repair options may include M-plasty or Z-plasty to release tension that would distort the shape of the mouth or the vermilion border.

Closure is generally done in 3 or 4 layers, making sure the knots are embedded to prevent surface irregularities, vermilion border and muscle approximation are precise, and wound edges are everted to prevent noticeable scar formation.

Cross-lip flap

Cross-lip flap reconstruction allows for repair of fairly large defects with tissue that is similar to the excised tissue. It allows for distribution of upper and lower lip discrepancy that would occur with primary closure. The technique allows for minimal disruption of muscle orientation in both donor and recipient sites. Though denervation of the orbicularis oris may occur, the orbicularis muscle reinnervates with adequate functioning with one-year postoperative electromyography. The disadvantage of this technique is that it reduces the oral circumference; microstomia becomes an important issue with increasingly large defects.

Abbe flap

Used for repair of defects near the oral commissure, the flap is planned about one-half the size of defect (see Image 7). One aspect of the flap is incised full-thickness, while the inferiormost aspect of the flap is only excised three-fourths full-thickness to create a pedicle that preserves the vascular supply (labial artery). Three-layer closure is performed, with emphasis on accurate alignment of the vermilion border. At 3 weeks, the pedicle is separated and the mucosa is repaired or allowed to heal as necessary.

Estlander flap

As the first step in commissure reconstruction, the Estlander flap allows for repair of defects at the oral commissures. With a base larger than that of the Abbe flap, the full-thickness incision is placed along the nasolabial fold (see Image 8). Upon realignment of the vermilion border, the mucosa may need to be advanced to match the thickness of the recipient site. A commissureplasty is then performed at 3 months to restore the normal appearance of the angle of the mouth. A modification to the Estlander flap is the reverse Abbe flap, which avoids revision commissureplasty by transposing instead of rotating the flap.

Gillies fan flap

An extension of the Estlander flap, the Gillies flap allows for subtotal or total lip reconstruction. This is accomplished through bilaterally expanding the tissue used to include areas lateral to the commissures. The flap is rotated to create new commissures while advanced medially to fill the defect (see Image 9). Though this method leads to denervation, it does preserve partial continuity of the musculature, which was shown by Gillies to regain eventual partial function through neurotization.¹⁰ However, sensory loss and vermilion deficiency continue to be disadvantages to this technique. Later, the Karapandzic flap improved on this technique by maintaining the neurovascular structures.

Karapandzic flap

Used primarily for midline medium-sized defects, the Karapandzic defect has also been used in total lower lip defects (see Image 10). Since this is an innervated flap with neurovascular structures intact, this method of repair allows for immediate muscle use as compared to cross-lip flap and fan flap techniques. The method involves the use of tissue surrounding the defect. Three-quarter–thickness incisions are made, and, with separation of muscle fibers allowing for advancement of the flap, the tissue around the defect is reapproximated. Perioral incisions extending along the nasolabial fold ease the advancement of the flap medially. Though a very useful technique, the drawback of this method is the considerable microstomia that may result.

Bernard-Burow flap

The Bernard-Burow flap allows reconstruction of larger lower lip defects using advancement of adjacent cheek tissue (see Image 11). The method involves transposition of triangular flaps with bases at the level of the commissures and flipping over of superior triangular flaps to reconstruct the vermilion using buccal mucosa. These earlier methods transected perioral musculature, which resulted in complete loss of muscle function.

The Webster modification of the Bernard-Burow flaps involves locating the triangular flaps along the nasolabial fold with excision only through skin and subcutaneous tissue to preserve the neuromuscular structures. The modification also calls for paramental Burow triangles that facilitate the advancement of cheek tissue. Williams introduced a combination Bernard-Burow and cross-lip flap that addresses the lip tissue discrepancy and allows for replacement of the philtral subunit in subtotal or total lip reconstruction. Though these methods allow for repair of large centrally located defects, the disadvantages include loss of motor and sensory function; however, typically, the tightness of the reconstruction may provide sufficient oral continence.

Perialar crescentic advancement flap

Essentially a modification of the Bernard-Burow flap, the perialar crescentic advancement flap alters the location of the scar so that it lies within the perialar and nasolabial folds, allowing for less distortion due to tension (see Image 12). The technique, used primarily for upper lip repair, involves a curvilinear incision that naturally follows the nasolabial fold and is generally 3 times larger than the diameter of the defect. It allows for musculocutaneous advancement of adjacent cheek tissue and may be combined with an Abbe flap to reconstruct central defects, as well.

Depressor anguli oris flap

First described by Tobin, this composite flap consists of muscle, skin, and buccal mucosa and maintains its motor and sensory innervation in the repair of lateral lower lip defects.¹¹ Based superiorly, the flap contains the marginal mandibular branch of the facial nerve (motor) and the mental branch of the trigeminal nerve (sensory). Bilateral flaps allow for repair of larger subtotal lower lip defects (see Image 13).

Nasolabial flap

These flaps, originally inferiorly based and rotated around the commissures as described by von Bruns, allow for total lower lip reconstruction (see Image 14). The technique uses bilateral nasolabial tissues and rotates them inferiorly and medially to re-form a complete lower lip. As with other procedures, the buccal mucosa is later used to form the vermilion. Fujimori and Meyer later describe modifications to this technique that allow for full-thickness island flap transfer via the angular vessels.^{12, 13} Nevertheless, the methods result in denervation with less than satisfactory oral sphincter function.

Regional and free flaps

When significant trauma or very large oncologic resections make the use of local tissues impossible, regional or distant flaps are necessary for lower face and lip reconstruction. Regional flaps include submandibular, anterior cervical, forehead, deltopectoral, and sternocleidomastoid musculocutaneous flaps. More recently, radial forearm free flaps employing microvascular techniques for extensive lower lip defects have been described.¹⁴ Though insensate and lacking motor functionality, various steps have been described to improve oral competence. For example, the tendon of the palmaris longus may be attached to the modiolus, thereby acting as a scaffold for the newly constructed lip.

Other microvascular developments include replantation of traumatic amputation of the upper or lip. This method also results in a denervated flap (though neurotization has been shown) and, when selected for appropriate cases, has been shown to have excellent cosmetic results.

Vermilionectomy and laser ablation

Actinic cheilitis and squamous cell carcinoma in situ (most commonly of the lower lip) are the primary indications for vermilionectomy or laser ablation. Two or three passes using a carbon dioxide laser allows for cosmetically superior removal of confirmed lesions. When indicated, a vermilionectomy is performed using a fusiform excision in a submucosal plane.

When more fullness is desired, a posterior musculomucosal flap is advanced, and the vermilion border is reapproximated, making sure no tension exists on the incision line. If incisions must cross the vermilion border, they should do so at 90 degrees to allow for exact realignment, since even a 1-mm discrepancy along the border is noticeable at 3 feet. Again, proper marking of the vermilion-cutaneous border is critical. Possible disadvantages to the lip shave technique include loss of lip pout and inward drawing of hair, which may lead to constant irritation of mucosa.

Secondary intention

Secondary intention involves the union of 2 granulating surfaces accompanied by suppuration and delayed closure. With the lips, the risk of scar formation with wound contraction is increased; as such, lesions allowed to heal by secondary intention must be appropriately selected. Granulation can be allowed after some Mohs surgeries, superficial defects of the vermilion (eg, after carbon dioxide treatment for actinic cheilitis), and superficial defects of the cutaneous portion of the lip (especially the lateral upper cutaneous lip adjacent to the alar-cheek junction). However, the risk of distortion through wound contraction, which increases with the increasing depth or width of the wound, must be considered.

Full-thickness skin grafts

Skin grafts are not commonly used in lip repair, as the risk of graft failure is higher because of the inability to immobilize the lips. Furthermore, matching the color and texture of the skin at donor and recipient sites is difficult. In men, lack of hair on the upper lip may be quite obvious. Inability to find a good match results in an unnatural and patchy appearance. Philtral defects may even be expanded to include the entire philtrum so that a full-thickness skin graft may be used in reconstruction with good cosmetic outcomes.

Postoperative Details

Postoperative care of patients who have undergone lip reconstruction involves appropriate wound care. Oral hygiene should be maintained with antiseptic mouthwash, a diluted hydrogen peroxide rinse, or both. Cutaneous suture lines should be cared for in the typical postoperative fashion by routinely cleansing with soap, hydrogen peroxide, or both, followed by the application of antibiotic ointment.

Excess tension on the repair should be avoided. This includes minimizing talking, minimizing facial expressions, and consuming only small bites of food. Initially, a liquid or soft food diet may be necessary, while those with extensive reconstructions may require placement of feeding tubes.

Sutures may be removed as early as 1 week postoperatively. Cross-lip pedicles may be separated at 3 weeks. The timing of revision or staged (eg, commissureplasty) surgeries varies based on the complexity of the reconstruction.

Follow-up

Perform periodic follow-up care at appropriate intervals to observe the natural return of function and to ensure that scar contracture does not distort the result. If either complication is noted, appropriate physical therapy and scar contraction treatment measures may be instituted. If the reconstruction was performed for oncologic purposes, the follow-up schedule should be tailored to detect potential recurrence.

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Cancer of the Mouth and Throat.

COMPLICATIONS

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Early complications

Given the rich vascular supply of the lips, meticulous intraoperative hemostasis is imperative to reduce the risk of postoperative hematoma formation and hemorrhaging. Conversely, the extensive vascular supply makes flap loss or necrosis less likely. However, pedicles must be handled with care, as kinking or damage to the vascular supply could increase the risk of flap loss. This is especially critical when the vascular supply has been compromised by extensive trauma.

Infection, suture abscess, sialocele, and fistula formation can be minimized with appropriate care of suture lines, appropriate preoperative oral hygiene, perioperative prophylactic antibiotics, and careful surgical technique.

Late complications

Aesthetic and functional loss can arise from scar formation and wound contracture, which can be prevented with eversion of the wound edges with subcutaneous sutures and epidermal vertical mattress sutures. They can also be treated with release and Z-plasty. Another potential complication is hypertrophic scar formation and pincushioning. This may be treated with intralesional corticosteroid injections but may require revision surgery.

With reconstructions due to oncologic resections, tumor recurrence is a dreaded complication. Hence, negative pathology must be confirmed prior to reconstruction.

OUTCOME AND PROGNOSIS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Careful selection of techniques appropriate to the defect, in addition to observing principles of preserving and restoring motor and sensory function, has substantially improved the results of contemporary reconstructions compared to those obtained historically. The development and recognition of the innervated composite flaps also has substantially enhanced outcome as compared with historic procedures, which often cut across valuable neuromuscular structures and impaired the quality of outcome.

FUTURE AND CONTROVERSIES

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Substantial opportunity exists for future contributions to the field, particularly in the case of massive lip loss in which no perioral tissues are available for reconstruction. The techniques for achieving best functional outcome when distant tissues must be imported by pedicle or microsurgical technique are incompletely defined at present. Currently, no available method achieves a high-quality aesthetic and functional result in total loss of both upper and lower lips. Those who discover effective reconstructive techniques for these massive defects will provide a most valuable contribution to reconstructive plastic surgery and the patients it serves.

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Aesthetic units of the face.
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Media file 2:  Superficial anatomy of the lower face.
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Media file 3:  Muscular anatomy of the face.
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Media file 4:  Cutaneous innervation of the face and facial nerve distribution.
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Media file 5:  Blood supply and lymphatic drainage of the face.
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Media file 6:  Wedge excision and primary closure.
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Media file 7:  Abbe flap technique.
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Media file 8:  Estlander flap technique.
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Media file 9:  Gillies fan flap technique.
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Media file 10:  Karapandzic flap technique.
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Media file 11:  Bernard-Burow flap technique.
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Media file 12:  A and B. Central upper lip defect reconstruction with the perialar skin crescent method that retains motor and sensory innervation to the advanced upper lip lateral elements and uses an Abbe flap for philtral reconstruction. Used with permission of WB Saunders Company.
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Media file 13:  Bilateral depressor anguli oris total lower lip reconstruction. A. Flap design shows the relationships of the incision, muscle, motor nerve (VII), and sensory nerve (V). B. Flap transposition reorients the depressor anguli oris to restore the lower lip oral sphincter. Vermilion is created by mucosal advancement. C. Flap insert and direct donor defect closure complete the reconstruction.
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Media file 14:  von Bruns nasolabial flap technique.
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Media file 15:  A and B. Lip reconstruction. Bilateral orbicularis oris composite flap reconstruction of a large central upper defect. The aesthetic qualities of this reconstruction are enhanced by an Abbe flap philtral reconstruction.
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Media file 16:  A bilateral levator anguli oris flap total upper lip reconstruction. A. Flap design shows the relationship of the incisions, muscle, and lower lip Abbe flap for philtral reconstruction. B. Flap transposition reorients the muscles to become the upper lip sphincter. Motor (buccal) and sensory (infraorbital) nerves entering the lateral flap border are carefully preserved in dissection and transfer. Mucosal advancement restores vermilion and an Abbe flap restores the philtrum. C. Donor defect is closed directly and the Abbe flap pedicle is divided at 2 weeks.
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Media file 17:  Left: A patient with midline and left lateral lesions each occupying less than one third of the lower lip. Right: Wedge excision of the lesions.
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Media file 18:  Left: W-closure with bilateral advancement flaps of midline defect along with mucosal advancement flap of left lateral defect. Right: Postoperative follow-up showing excellent aesthetic results.
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Media file 19:  Left: Excision of large lesion occupying greater than 85% of the upper lip. Center: Selection of regional temporal interpolated flap based on the temporal artery. In this case, significant involvement of the cheek as well as compromised vasculature secondary to Mohs surgery did not allow for an advancement flap such as the Karapandzic flap. Right: Postoperative follow-up showing good aesthetic reconstruction of the ala of the nose, upper and lateral lip, and cheek.
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Media file 20:  Left: A patient with a midline upper lip lesion. Right: Reconstruction of medium to large upper lip defect with a modified unilateral Karapandzic flap. The nasal defect was closed with an internal mucosal advancement flap, a cartilage graft from concha of the ear, and a paramedian forehead flap for external reconstruction.
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Media file 21:  Left: Mohs surgical excision of the upper lip lesion affecting the left ala of the nose and leaving a defect occupying approximately 50-60% of the upper lip. Right: Postoperative follow-up showing good aesthetic reconstruction of the left ala of the nose an upper lip.
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Media file 22:  Left: Superficial lower lip cancer. Center: Resection of cancer with margins including the entire segment of the dry and major segment of the wet portion of the lower lip. Right: Vermilion advancement flap after dissection intraorally to the gingivobuccal sulcus.
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Media file 23:  Left: Small lower left lip lesion. Center: Excision and primary closure. Right: Postoperative results.
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Media file 24:  Left: Full-thickness left upper lip defect. Center: Medial advancement of the upper lip along subunits lines leading to the final scar being placed along the philtral column of the upper lip. Right: Postoperative results.
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Media file 25:  Left: Near midline small upper lip defect. Right: Burow wedge excision with primary closure (A-to-T flap).
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Media file 26:  Upper left: Left upper lip defect (<1/3). Upper right: Medial advancement of the upper lip along subunits lines, leading to the final scar being placed along the philtral column of the upper lip. Lower left: Early postoperative follow-up. Lower right: Late postoperative follow-up.
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Media file 27:  Left: Right upper lip defect (~1/3). Right: Primary closure of defect.
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