Master Techniques in Otolaryngology - Head and Neck Surgery: Reconstructive Surgery, 1ed.

1. Management of the Major Lip Defect

William Lawson

Defects of the lips present the reconstructive surgeon with the complex problem of tissue restoration requiring both cosmetic and functional optimization. The etiology of lip defects is most commonly the result of trauma or the resection of malignant tumors. Aesthetically the lips are a focal point of facial balance and beauty. In this regard, the upper lip offers additional reconstructive difficulty because of the presence of a central dimple and its surrounding philtral columns. Functionally, the lips are of particular importance in facial expression, oral competence, and communication. The challenge of reconstituting aesthetic symmetry while maintaining functionality with large lip defects presents the reconstructive surgeons with a major challenge.

Historically, efforts at lip reconstruction were directed toward the repair of small defects. In particular, the cross-lip procedure in which a lower lip flap was transferred to the upper lip was described separately by Sabattini, Estlander, and Stein in Europe in the early 19th century. However, the technique was popularized by the American surgeon, Robert Abbe, and the flap continues to bear his name. This flap continues to be used to provide bulk and a functional component as they have been shown to have reinnervation in 6 to 12 months. Newer techniques were directed to the repair of subtotal lip defects by advancing or rotating full-thickness local flaps of adjacent cheek tissue by Gillies, Bernard, and von Burow in the period from 1850 to 1950 and by Karapandzic in 1974.

Regional flaps are not suitable for reconstruction of larger defects involving 80% or more of the lip horizontally and which extend past the labiomental sulcus in the vertical plane into the cheek and extend into the oral cavity and involve the maxilla because an adequate lip sulcus and oral aperture cannot be maintained. Thus, in recent times, nonregional tissue transfer has become the mainstay for total lip reconstruction. Some examples include the deltopectoral flap, sternocleidomastoid musculocutaneous flap, and the radial forearm free flap. Unfortunately, it is difficult to preserve sphincter competence with distant flaps, which has led to modifications in free tissue transfer to include the addition of vascularized palmaris longus tendon or tensor fascial lata grafts to contribute a static component to reconstruction. Furthermore, enhanced dynamic reconstruction options combining an innervated depressor anguli oris, temporalis, or masseter muscle flap transfer to a radial forearm free flap have been reported, demonstrating muscle activity on electromyography at 6-month postoperative follow-up.

Reconstruction of large defects of the upper lip including maintenance of oral competence and avoiding microstomia remains a technical challenge for the head and neck surgeon. The numerous techniques described for reconstruction of near-total full-thickness lip defects underscores the fact that while soft tissue replacement can be achieved, functional restoration is elusive. Flaps that recruit the remaining orbicularis oris provide the potential for motor and sensory function but are limited by the development of postoperative microstomia, which often requires secondary commissuroplasty to facilitate oral feeding, hygiene, and placement of dentures.

Alternatively, techniques that do not involve local musculocutaneous tissue transfer, such as local and regional cutaneous flaps or free microvascular tissue transfer reconstruction, allow for replacement of greater amounts of tissue for repair of defects but increase the likelihood of oral incompetence. Consequently, they find their greatest application in reconstruction of large composite lip perioral defects where a large volume of tissue is necessary.

The use of the nasolabial or melolabial transposition flap has been extensively described in lip reconstruction for both cutaneous and full-thickness defects. Its blood supply is from a random subdermal plexus of vessels, with contributions from the facial, infraorbital, and transverse facial arteries and can be superiorly or inferiorly based. Superiorly based flaps have been used for reconstruction of nose, cheek, lower eyelid, and central upper lip defects, while the inferiorly based flap is most commonly used for repair of the lateral upper and lower lip, oral commissure, and anterior oral cavity.

The fan flap reported by Gillies in 1957 is the prototypical rotation–advancement nasolabial flap for reconstruction of upper and lower lip defects. In its original form, it entailed full-thickness incision of the lip and cheek, with the flap based on a narrow vascular pedicle at the oral commissure. Gillies cautioned that the limit of correction was one-half of the upper lip because of the development of microstomia, lip eversion, and intraoral scarring. Having the pivot point at the oral commissure caused the distortion. Additionally, the through and through division of skin, muscle, and mucosa resulted in transection of the nerve supply and the creation of an adynamic lip segment. A later modification by McGregor created a rectangular flap also pedicled on the labial artery compared to Nakajima’s flap that had the facial artery as its vascular pedicle. Both employed fullthickness incisions to transfer cheek tissue to the lip.

While this flap design creates a potentially denervated and adynamic flap, there are reports of patients who regained sensory and motor function.

The patient’s history is an important aspect of the reconstructive planning. A history of prior surgery or radiotherapy may limit the options. In such cases, radiation and/or surgery can impair the use of local flaps because the blood supply may be compromised. In such cases, free tissue transfer may be indicated. Another aspect of the patient history that should be sought is a history of collagen vascular disease that may impair healing. When a careful preoperative history is obtained, the chances of an optimal outcome are maximized and the risks of complications are minimized.

Anatomically, the lips are a central feature of the lower third of the face. When approaching defects of either the upper or lower lip, a thorough evaluation of its location and extent visually and by palpation is critical in selecting the most appropriate reconstructive option. Defects can involve the upper or lower lip individually or may include a portion of each. They may also be either medially or more laterally based and can involve the oral commissure, which may significantly alter the reconstructive approach. Cancer involving the commissure has a propensity for cervical lymph node metastasis making careful evaluation of the neck mandatory. In addition to location, accurately evaluating the extent and depth of the defect on physical examination is of utmost importance. The lips are composed of skin, muscle, mucosa, and underlying skeletal bone of the maxilla, mandible, and alveolus that may be deficient to varying degrees. The tissue components involved will dictate the most suitable reconstructive technique or whether additional tissue will be indicated. A key aesthetic boundary is the vermilion border delineating the mucocutaneous junction of the lip, and if this landmark is violated, careful approximation can be planned. Defects may also extend across the nasolabial and labiomandibular creases to involve surrounding structures such as the base of the nose, cheek, and chin necessitating more complex reconstructive planning and techniques.

Defects of the lip most commonly result from trauma, congenital malformation, or malignancy. Traumatic injury to the upper and lower lip can often be repaired primarily after the freshening of wound edges and careful realignment of aesthetic boundaries, but more extensive soft tissue damage may call for the use of various locoregional flaps or even microvascular free tissue transfer. Congenital defects from unilateral and bilateral cleft lip with or without palatal involvement certainly may pose distinct challenges to the reconstructive surgeon but are not specifically addressed in this chapter.

The most frequent indication for reconstruction of major defects of the lip is following resection of skin cancer. Cutaneous malignancies including basal cell carcinoma, squamous cell carcinoma, and malignant melanoma are among the most prevalent cancers today. Due to their exposure to direct sunlight, the lips are particularly vulnerable to solar insults. This is especially true of the lower lip, which harbors the majority of suninduced cancers due to its more exposed position. Smoking and the use of tobacco-containing products can also increase the risk of developing lip cancer. Fortunately, its prominent location lends itself to manifesting visible signs and symptoms and therefore typically leads to earlier clinical detection and treatment. Still, some lesions may present in later stages due to patient neglect or misdiagnosis necessitating more aggressive surgical resection and therefore larger defects. Even with the advent of Mohs surgery, resulting defects are often larger than at first expected, and reconstruction of these complex postablative subtotal and total lip defects will be required.

There are no contraindications to the reconstruction of major lip defects other than the availability of suitable donor tissue and patient-related factors. Particularly, patients who are not candidates for microvascular free tissue transfer due to the presence of extensive peripheral vascular disease, active smoking, or other significant comorbidities may be better served with a less aggressive type of reconstruction despite the possibility of inferior aesthetic and functional outcomes. Recent advances in microvascular techniques and the use of two-team approaches have reduced surgical time so that performing a radial forearm free flap may actually be faster than the more complex locoregional reconstructive flaps in some settings. Additionally, a radical resection may not be reasonable in the presence of distant metastatic disease, although there may be a role for palliative debulking at the primary tumor site in some cases. Certainly, all local and patient-related factors must be carefully considered in open discourse between the patient and surgeon in order to select the most reasonable and appropriate treatment option.

Imaging Studies

Imaging studies, in general, are not necessary when evaluating more superficial lesions of the lip; however, there are instances in which a contrast-enhanced CT scan may be very useful. Examples include extensive tumors that involve neighboring structures, recurrent neoplasms, or those that are highly aggressive in nature (e.g., malignant melanoma). In addition to the primary site, it is prudent in such cases to evaluate for metastatic lymphadenopathy by cervical CT scan. Any lymph nodes detected can undergo fine needle aspiration (FNA) to determine whether they represent metastatic cancer or an inflammatory response to large lesions, which also tend to be superficially ulcerated and infected. CT scan may also help to determine the presence or extent of underlying bone involvement from deeply invasive lip lesions to allow for appropriate preoperative planning. For instance, if microvascular free tissue transfer is indicated, the most common flap used is the radial forearm flap, which typically requires only a reliable Allen test.

Although not as commonly used in major lip reconstruction, magnetic resonance angiography of the lower extremities would be indicated prior to harvesting of a fibular free flap. PET/CT is now routinely used for accurate staging of more extensive or aggressive malignancies to evaluate for distant metastases prior to any definitive surgical intervention.

Biopsy

Due to the readily accessible nature of the lips, biopsy of lesions is typically performed in an outpatient setting under topical or local anesthetic. When dealing with a possible cutaneous malignancy, it is important to perform either a small wedge excisional biopsy or an adequate punch biopsy in order to accurately determine the depth of the lesion, which has prognostic significance and may alter the subsequent surgical approach. A biopsy in the center of the lesion is preferable. Bleeding following biopsy is generally negligible and can be controlled with direct pressure, chemical cautery using silver nitrate sticks, dissolvable hemostatic agents, handheld electrocautery, or an absorbable suture used to approximate the edges of the defect. Histopathologic analysis will confirm the diagnosis and dictate whether further diagnostic studies or intervention is indicated.

Due to their aesthetic and functional importance, the lips are also amenable to Mohs excision to ensure clear margins while conserving the maximum amount of native tissue. If metastatic lymphadenopathy is suspected either clinically or radiographically, an FNA may also be performed in clinic by the surgeon or cytopathologist. Image-guided FNA may help in cases where cervical lymph nodes are not palpable.

Nasolabial (Melolabial) Transposition Flap

The advantages of the nasolabial flap for repair of the upper lip include its close proximity to the defect and adequate color match. Donor site morbidity is generally minimal due to the redundancy of tissue in the nasolabial fold, allowing for reasonable camouflage of the scar. However, drawbacks to the use of the nasolabial flap include the absence of function of the oral sphincter following reconstruction. Reconstitution of the oral mucosa is an important consideration when employing cutaneous flaps for lip reconstruction. Buccal mucosal advancement flaps have the advantage of providing like-appearing mucosa to recreate the vermilion border and of being sensate. The potential downside with the advancement of large amounts of buccal mucosa is the potential loss of lip fullness, lip inversion, and loss of the gingivobuccal sulcus.

Description of Technique: Nasolabial (Melolabial) Transposition Flap

The patient is placed under general anesthesia and may be intubated transorally; however, a nasotracheal tube secured superiorly away from the surgical field is preferable in order to avoid distortion of the tissues. The patient is then prepped and draped in standard sterile fashion with the lower two-thirds of the face and upper neck exposed. The flap is designed to incorporate the nasolabial fold and subalar crease to improve aesthetic results (Fig. 1.1). Surgical technique involves incisions based along the nasolabial folds. The flap is then raised in a plane deep to the skin and subcutaneous tissue and superficial to the facial musculature. The rotation point of the inferiorly based flap should be just superior and lateral to the oral commissure to minimize dog-ear formation. This case depicts the use of bilateral nasolabial flaps to reconstruct a large central defect of the upper lip extending to the base of the nose (Fig. 1.2A–C).

FIGURE 1.1 Diagram of bilateral nasolabial transposition flaps. The flaps are designed with incisions lying in the melolabial folds and flaps transposed over the adjacent alar bases to meet in the midline of the upper lip. A. Bilateral nasolabial flaps outlined. B. Flaps advanced and sutured together to create a new vermilion border and fill the defect.

FIGURE 1.2 A. Central defect of the upper lip involving entire philtrum and extending superiorly to the nasal base. Incisions are marked for bilateral nasolabial transposition flap reconstruction. B. Bilateral nasolabial transposition flaps are raised after incisions through the melolabial creases and excision of partial-thickness triangles inferiorly. Flaps are raised in a subcutaneous plane taking care not to violate the underlying mucosa. C. Flaps are advanced toward the midline and closed in layers with careful realignment of the vermilion border and subnasale. Note that bilateral incisions lie within the melolabial creases to help with eventual camouflage of the scar.

Reconstruction of a subtotal and total defect of the upper lip requires two local regional flaps. Bilateral nasolabial flaps provide ample tissue but, unfortunately, are adynamic. On the side of less involvement, the reverse Karapandzic flap is used to transfer innervated elements of the remaining orbicularis oris to restore some sphincteric function. The original fan flap has been modified by eliminating the through and through incision and instead creating two advancement-rotation flaps. The cutaneous–subcutaneous flap provides external coverage of the new lip, while the mucosal muscular flap replaces the internal lining of the lip and creates a new vermilion border. The skin component is preplanned while the internal component is created by making sequential mucosal incisions as necessary to achieve flap advancement and coverage. Moreover, this flap transfers with it the modiolus (which is 1.5 cm beyond the anterior commissure), which carries elevator and depressor muscles and the buccinator muscle providing some dynamic activity.

When nasolabial flaps are used, a new oral commissure is created unilaterally or bilaterally. The two flaps are advanced and sutured together, and the cheek flap is sutured to the opposite lip at the point where the new commissure is to be created. This entails a deep suture of 3-0 Vicryl. The skin is attached with a 5-0 nylon suture and 4-0 chromic sutures after the mucosal flap has been advanced to create a new vermilion border. Care must be taken to ensure that the new vermilion border is correctly realigned. Closure should be performed in three layers consisting of mucosa, subcutaneous tissue, and skin using 4-0 chromic, 3-0 Vicryl, and 5-0 nylon sutures, respectively. Steri-Strips can be used to reinforce the incision if under moderate tension; otherwise, bacitracin ointment may be applied following closure.

Circumoral Rotation–Advancement Flap: Karapandzic Flap

The Karapandzic flap is an advancement–rotation flap based on the superior and inferior labial arteries and nasoseptal artery branches. A distinguishing feature of this flap is the preservation of the neurovascular innervation of the orbicularis oris muscle during transfer to reconstitute a functional oral sphincter. This flap also transfers with it the modiolus of the lip, with its attached muscles and adjacent decussating fibers, which while producing misdirection of muscular fibers and proprioceptive elements, nevertheless recreates a functional oral unit. Its greatest application is with unilateral flaps to reconstruct small to moderate defects of the lower lip although a modification can be used for upper lip reconstruction (reverse Karapandzic). The Karapandzic flap is generally not used to reconstruct defects of the lateral lip and oral commissure.

Good functional outcomes have been reported in case series of patients undergoing Karapandzic reconstruction of lip defects with up to 75% of patients regaining normal postoperative speech and oral competence. When rotational flaps are used as the exclusive method of reconstruction in the repair of large defects, commissuroplasty and commissurotomy are necessary to correct the resultant severe microstomia. Other disadvantages relate to aesthetic concerns, including the potential for an unsightly perioral scar as well as rounding of the commissure.

Description of Technique: Karapandzic Flap

The patient is placed under general anesthesia and may be intubated transorally; however, a nasotracheal tube secured superiorly away from the surgical field is preferable. The patient is then prepped and draped in standard sterile fashion with the lower two-thirds of the face and upper neck exposed. Surgical technique involves bilateral circumoral incisions around the defect along the nasolabial folds from the lower to upper lip (Fig. 1.3). Blunt dissection is then carried out within the orbicularis oris to mobilize muscle fibers while preserving the major neurovasculature bundles typically located near the oral commissures. The mucosa should not be violated during the course of dissection until the flaps are completely raised and advanced together under appropriate tension. Care must be taken to ensure that the new vermilion border is correctly realigned. Closure should be performed in three layers consisting of mucosa, subcutaneous tissue, and skin using 4-0 chromic, 3-0 Vicryl, and 5-0 nylon sutures, respectively. Steri-Strips can be used to reinforce the incision if under moderate tension; otherwise, Bacitracin ointment may be applied following closure.

FIGURE 1.3 Diagram of proposed Karapandzic flap for repair of right subtotal defect of the lower lip. A. Bilateral circumoral incisions outlined. B. Orbicularis oris muscle bluntly dissected to expose nerve. C. Flaps advanced and vermilion border aligned. D. Completed layered closure.

Transoral Cross-Lip Flaps: Abbe and Estlander Flaps

The transoral cross-lip or lip-switch flaps were devised in the mid 1800s and are still used today for reconstruction of the lip (Figs. 1.4 and 1.5). They provide a reliable method of restoring medium-sized lip defects with or without oral commissure involvement and can also be used in combination with other locoregional flaps for subtotal and total lip reconstruction. Advantages include good color match and skin texture from the opposing lip as well as the ability to position the incision in a natural skin crease, which leads to more favorable scar formation. Drawbacks are the need for a two-stage procedure when using the Abbe flap for central lip defects, possible distortion of upper lip subunits when using this as a donor site for lower lip repair, and the potential need for a revision commissuroplasty with the Estlander flap. Overall, even 200 years after its initial development, the transoral cross-lip flap has endured the test of time and is still commonly employed in major lip repair by today’s reconstructive surgeons.

FIGURE 1.4 Abbe flap. A. Central area of resection of upper lip outlined. Area of lower lip to be transposed outlined. B. Lower lip donor flap sutured into upper lip defect. C. Pedicle divided after 2-3 weeks. (From Thorne CH (ed). Grabb and Smith’s Plastic Surgery, 7th ed.Philadelphia, PA: Lippincott Williams & Wilkins, 2014.)

FIGURE 1.5 Estlander flap. A. Donor flap from upper lip including the commissure is outlined for lateral defect. B. Flap transfered into long lip defect. Note rounding of commissure. (From Thorne CH (ed). Grabb and Smith’s Plastic Surgery, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2014.)

Description of Technique: Abbe and Estlander Flaps

The patient is placed under general anesthesia with a nasotracheal tube secured superiorly away from the surgical field; nasal intubation is preferred due to the need of the flap pedicle to cross over the lips. This procedure can also be done under local with IV sedation. The patient is then rotated 180 degrees and prepped and draped in standard sterile fashion with the lower two-thirds of the face and upper neck exposed. The flap should be designed to incorporate the nasolabial crease for improved cosmesis with its length approximating that of the defect. Incisions are made sharply through the skin and subcutaneous tissues taking care not to disrupt the vascular pedicle based either medially or laterally off the labial artery. After complete elevation, the flap may be rotated into the corresponding defect and closed in layers. Abbe flaps used to close more centrally based defects will require a second-stage procedure for pedicle division in 2 to 3 weeks, while the Estlander flap used to reconstruct the oral commissure laterally typically will not require a second surgery unless revision commissuroplasty is indicated. The incisions should be kept clean and moist with antibiotic ointment postoperatively, and patients should adhere to a modified diet until healing is complete.

Bilateral Cheek Advancement Flap: Bernard-Webster Flap

Lower lip subtotal defects can be reconstituted with a combined Karapandzic and Bernard-Webster–type flap to maximize dynamic function. With total defects of the lower lip, bilateral Bernard-Webster flaps are necessary for adequate tissue mass. The Bernard-Webster flap is a modification of the original Bernard-von Burow flap described in the 1850s used for reconstruction of total full-thickness defects of the upper or lower lip. The technique involves the excision of partial-thickness triangles from the nasolabial creases to facilitate advancement superiorly and inferiorly of the adjacent local tissue. Similar to the modified fan flap used for upper lip reconstruction, the Bernard-Webster flap is not created by full-thickness incisions through the adjacent cheek tissue but divided into an outer cutaneous and inner mucosal portion. While the outer component is preset, the intraoral component is incised incrementally to achieve adequate advancement and to resurface the mucosal aspect of the neolip and vermilion border.

Transferring the modiolus forward with its attached depressor and elevator muscles as well as the buccinator muscle adds a dynamic component and provides some sphincteric function. I modify this method further by making bilateral labiomandibular incisions rather than excising triangles in this region (Fig. 1.6).

FIGURE 1.6 Diagram of modified Bernard-Webster flap for reconstruction of total lower lip defect. Bilateral partial-thickness nasolabial triangles are excised along with labiomandibular incisions inferiorly.

Typically, the flap innervation is not preserved with this technique with possible functional postoperative deficits. For this reason, I prefer microvascular free flaps as a more reliable reconstruction option for larger defects; however, bilateral cheek advancement technique may still play a role in patients who cannot undergo free tissue transfer or when used in combination with related locoregional flaps.

Locoregional Flap Combinations

When one type of locoregional flap is insufficient to repair a larger lip defect, a combination of various reconstructive techniques may be employed. These may include the use of a modified Bernard-Webster flap with either a transoral cross-lip flap or a circumoral rotation–advancement flap such as the Karapandzic (Fig. 1.7A and B). This case illustrates the utility in performing a combined Abbe and Karapandzic flap to reconstruct a subtotal upper lip defect after excision of a recurrent cutaneous squamous cell carcinoma (Fig. 1.8A–D). Excellent postoperative outcomes have been demonstrated using these techniques especially when dynamic function is maintained through neurovascular preservation during flap dissection. If microvascular free tissue transfer is not available or is contraindicated, the use of combined locoregional flaps may provide an acceptable alternative to the repair of major lip defects.

FIGURE 1.7 A. Subtotal lower lip defect after excision of a cancer extending to the oral commissure on the left side. B. Combined Karapandzic and modified Bernard-Webster flaps are advanced together and carefully closed in layers. Note that resulting circumoral incisions lie in cosmetically acceptable areas of the nasolabial and labiomandibular folds.

FIGURE 1.8 A. Extensive upper lip defect after excision of recurrent squamous cell carcinoma. Defect involves entire left hemilip and extends across the philtrum and left nasolabial fold superiorly onto the cheek and alar base as well as within the left oral commissure. B.Incisions made for an inferiorly based Estlander flap along with a modified Karapandzic flap to repair defect of the left upper lip. C. Estlander flap rotated transorally into position to meet remainder of the upper lip. The Karapandzic flap will slide circumorally to close the Estlander donor site and oral commissure. Broad undermining is necessary to avoid excess tension on the wound and postoperative microstomia. D. Result after closure with combined Estlander and Karapandzic flaps for reconstruction of subtotal defect of the upper lip.

Microvascular Free Tissue Transfer

The application of microvascular free tissue transfer to subtotal and total reconstruction of the lip has been reported since the 1980s. Due to its thin skin paddle and pliability, the radial forearm flap remains the flap most commonly used to repair the lip although others such as the anterolateral thigh and fibula free flap have also been used. Free tissue transfer from distant sites is particularly advantageous when adjacent locoregional tissue flaps are not available, may be invaded with malignancy, or would result in significant deformity and microstomia. The ability to harvest large amounts of tissue allows for adequate filling of extensive defects but has also led to concerns that such reconstructions may be too bulky or adynamic and therefore aesthetically and functionally deficient. Further developments such as the incorporation of the palmaris longus tendon and fascia lata sling for static suspension as well as simultaneous free muscle transfer including the depressor anguli oris, temporalis, and masseter have improved overall outcomes for these patients. In the presence of composite bone defects, osteofasciocutaneous flaps such as the scapula, iliac crest, and fibula free flap may also be used. As the techniques of microvascular free tissue transfer and facial reanimation evolve, they will no doubt continue to play a large role in the reconstruction of major defects of the lip.

Description of Technique: Radial Forearm Free Flap with Palmaris Longus Tendon

The patient is placed under general anesthesia preferably with a nasotracheal tube secured superiorly away from the surgical field and appropriate lines and monitors are placed. The patient is then rotated 180 degrees and prepped and draped in standard sterile fashion with the lower two-thirds of the face and entire neck exposed along with the upper and lower extremity donor sites. A tourniquet is placed around the upper arm, which is laid outstretched on an arm board. Resection is then carried out with confirmation of clear margins by frozen section (Fig. 1.9A). When neck dissection is also performed, it is important to identify and preserve vasculature such as the facial artery and vein that can potentially be used for the microvascular anastomosis.

FIGURE 1.9 A. Total lower lip defect following excision of malignant melanoma. B. Radial forearm free flap harvested with palmaris longus tendon for total lower lip reconstruction with static reanimation sling. C. Immediate postoperative view after radial forearm flap anastomosis and insetting. Nylon sutures were used for the skin while Vicryl circumdental sutures were placed to secure the flap internally. D. 6-month postoperative result. Note the good color match and bulk to prevent oral incompetence and achieve excellent functional outcome.

In preparation for free flap harvesting, the forearm must be exsanguinated and the tourniquet inflated. The skin paddle should be appropriately measured based on the size of the corresponding lip defect keeping in mind that some flap reabsorption and wound contraction will be expected to occur over time. The forearm flap may be harvested in typical fashion with ligating of the radial artery, cephalic veins, and distal vena comitans. Vessels can be traced further proximally if additional length of the vascular pedicle is needed. In this case, a palmaris longus tendon was harvested along with the radial forearm free flap to create a static sling for the lower lip; fascial connections may remain attached or it can be separated for use as a free graft (Fig. 1.9B). Prior to detachment of the flap, the ulnar collateral circulation should be checked to ensure that the hand remains well perfused.

A subcutaneous tunnel is then made from the lip defect into the neck and widened sufficiently to permit easy passage of the vascular pedicle. The radial forearm flap is then inset into the defect using 3-0 Vicryl circumdental sutures placed intraorally. Microvascular anastomosis is next performed with the operating microscope using 8-0 nylon microsuture; in this case, the facial artery was used. The venous anastomosis was then carried out using a 3.5-mm coupling device to establish continuity between the confluence of the cephalic and radial veins with the common facial vein. At this point, the patency of both arterial and venous anastomoses should be confirmed as well as perfusion of the microvascular flap assessed. Clinically, the flap should be bleeding well upon gentle needle prick and have good color, warmth, and tone (Fig. 1.9C and D).

Closure of the neck is performed in a standard manner with particular care when overlying the vascular pedicle. The platysma is typically closed with interrupted 3-0 or 4-0 Vicryl sutures and skin reapproximated with 4-0 or 5-0 nylon. A number 10 Jackson-Pratt drain is placed in the neck to self-suction and brought out through a small stab incision just lateral to the closure; it should not directly overlie the anastomotic site. Bacitracin ointment and thin xeroform strips may be placed over the neck incision as well as sterile gauze and drain sponge.

Closure of the radial forearm donor site can be performed either during the microvascular anastomosis or simultaneous with closure of the neck wound. Careful attention should be paid to ensure adequate hemostasis prior to closure of the proximal forearm with 3-0 Vicryl sutures and a running 4-0 nylon suture along the skin; insertion of a drain is typically not required. A split-thickness (0.17 mm) skin graft can be harvested from the anterolateral thigh using a dermatome after measuring the appropriate size of the donor site defect. An epinephrine-soaked lap pad may be placed over the skin graft donor site for temporary hemostasis. The skin graft can then be laid onto the radial forearm defect, trimmed accordingly, and secured using 4-0 chromic sutures. A standard dorsal splint should then be placed for postoperative immobilization along with successive layers of web-roll, Kerlix, and ace bandage.

After closure, the patient may either be extubated or remain sedated overnight on the ventilator in an ICU setting depending on patient factors, surgeon preference, and institutional protocol.

Depending upon the extent of the lip defect and subsequent reconstruction, the patient is either maintained on a modified diet or kept NPO for approximately 5 to 7 days following surgery. In the latter case, a nasogastric tube may be placed and secured at the time of surgery to facilitate postoperative feeding. Following microvascular free tissue transfer, patients are generally kept in an inpatient setting for flap monitoring for a minimum of 3 to 5 days. Aspirin 81 mg is typically administered daily throughout the first postoperative month. All suture lines are meticulously cleaned and kept moist with bacitracin or petroleum ointment; sutures are removed within 5 to 7 days or longer if the patient has previously received radiation therapy or if wound tension is a concern.

Complications of major lip reconstruction may be classified as either anatomic or surgical. Certainly, aesthetic compromise is of great concern to the patient, and it is important to set reasonable expectations preoperatively through careful and honest patient counseling. Poor color match and contour of the flap, asymmetric healing, excess tissue bulk, scarring, and contracture all may occur with some degree of unpredictability. Incomplete deep volume may result in retraction and notching of the new lip at the point of junction of the flaps. These aesthetic issues can typically be managed more successfully in the postoperative setting when understood beforehand by the patient.

In addition to cosmesis, functional problems can include oral incompetence, dysarthria, and dysphagia that may result from microstomia and adynamic reconstruction. Oral competence may be compromised, and spoon-feeding may be required for several weeks. With the Karapandzic flap, some degree of microstomia and the need for commissuroplasty are to be anticipated. With nasolabial flaps, a new commissure is created. The upper lip has greater volume and distensibility than does the lower lip, and the correction of microstomia is necessary infrequently. The flap is elevated in a plane superficial to the mimetic muscle, and no significant facial nerve injury is incurred. Selecting the proper reconstructive method based on the size of the defect and using dynamic tissue when possible is critical to avoiding these postoperative problems.

Surgical complications at the primary site include infection, bleeding, hematoma, seroma, and wound breakdown. Additional risks inherent to microvascular free tissue transfer will become relevant when this reconstructive technique is employed. These include flap failure, donor site morbidity, and increased overall hospital stay and costs. Complications can be avoided or minimized by thorough preoperative planning, meticulous operative technique, and diligent postoperative care. Integral to this is explicit preoperative patient counseling with realistic expectations regarding the ultimate aesthetic and functional outcomes.

Despite over 200 years of advances in reconstructive techniques, the repair of major lip defects remains a formidable challenge to even the most experienced reconstructive surgeon. As defects progressively increase in size and complexity, the task of restoring a functional and aesthetically pleasing lip becomes ever more elusive. Certainly the advent of microvascular transfer along with free tissue grafting for static suspension has greatly enhanced our ability to provide coverage after extensive ablative surgery or trauma. Surprisingly, in spite of these technologic advances, age-old methods of lip reconstruction including variations of the circumoral rotation–advancement, transoral cross-lip, and bilateral cheek advancement flaps continue to be employed today. This not only speaks to the ingenuity of their original creators but also the truly dynamic challenge that subtotal and total lip reconstruction poses. Only by continued reconstructive creativity and progressive thinking will the primary goal of patient satisfaction with cosmetic and functional outcomes following major lip restoration ultimately be achieved.

• Proper evaluation of the upper and lower lip defect includes a careful analysis of its extent and location with a focus on aesthetic subunits, functional musculature, and tissue composition.

• Preoperative biopsy and imaging are important to confirm the diagnosis and accurately assess the extent of particularly large, aggressive, or recurrent cancer of the lip.

• Meticulous dissection of neurovascular structures and surrounding musculature is critical to maintaining a dynamic reconstructive result when utilizing complex locoregional flaps.

• Microvascular free tissue transfer provides a reliable and versatile option for reconstruction of subtotal and total lip defects.

• Combining microvascular techniques with concomitant tendon or fascial grafts as well as free muscle transfer may improve overall functional outcomes.

• Attempting to reconstruct subtotal and total lip defects with locoregional flaps may result in microstomia along with unacceptable aesthetic and functional outcomes for the patient.

• Patient comorbidities or malignancies that require active surveillance may preclude the use of microvascular free tissue transfer for reconstruction of major lip defects in favor of less aggressive options.

• Failing to establish realistic expectations through rigorous preoperative counseling may lead to patient dissatisfaction despite technically adequate reconstructive efforts.

• Standard head and neck surgical instruments

• Microsurgical instrumentation

• Operating microscope

I gratefully acknowledge the contributions of Andrew Klienberger and Vijay Mukija.

SUGGESTED READING

Renner GJ. Reconstruction of the lip. In: Baker SR, ed. Local flaps in facial reconstruction, 2nd ed. St. Louis, MO: Mosby/Elsevier, 2007;19:475–524.

Ferris RL, Gillman GS. Cancer of the lip. In: Myers EN, ed. Operative otolaryngology—head and neck surgery, 2nd ed. Philadelphia, PA: Saunders/Elsevier, 2008;24:183–193.

DeFatta RJ, Williams EF. Lip reconstruction. In: Papel ID, ed. Facial plastic and reconstructive surgery, 3rd ed. Stuttgart, NY: Thieme, 2009;61:841–854.