HEAD AND NECK
CHAPTER 34 RECONSTRUCTION OF ACQUIRED LIP DEFORMITIES
EVAN MATROS AND JULIAN J. PRIBAZ
The lips play an important role in both human physiology and culture. As the portal of entry for the gastrointestinal system, the mouth and lips take part in the cephalic phase of digestion. The sphincteric action of the orbicularis oris closes the oral stoma creating a seal. Oral competence prevents drooling while the tongue and cheeks manipulate intraoral solid and liquids. Contraction of perioral musculature positions the lips against the bony skeleton, thereby obliterating the gingivobuccal sulci for manipulation of the food bolus toward the teeth for chewing and oropharynx for swallowing. The same complex set of muscular actions enables newborns to suckle.
The lips participate in both verbal and nonverbal communication. Articulation, the physical production of speech sounds, is modified by lip movement. Lip position, shape, and motion are gestures used to express emotion. Indeed, a smile or a frown can be as effective in communication as the spoken word. Finally, kissing is a common means of social greeting as well as a form of intimate expression.
Topographically, the lips are distinct from surrounding structures. The upper lip extends cephalad to the nostril sills and alar base on each side and terminates laterally at the nasolabial creases (Figure 34.1). The upper lip is further divided into subunits by the philtral columns that extend from the nasal sills to the cutaneous–vermilion junction inferiorly. The philtral columns are created by contralateral orbicularis oris fibers that cross the midline to insert directly into the overlying dermis.1 The central depression between the philtral columns is termed the philtral groove or dimple. The Cupid’s bow is the area of the cutaneous–vermilion junction between the philtral columns, termed as such because its shape resembles the mythologic character’s weapon. The lower lip begins laterally at the continuation of the nasolabial creases and is bordered inferiorly by the labiomental crease. The upper and lower lips join at the commissure.
FIGURE 34.1. External lip anatomy. Philtral columns (A). Cupid’s bow (B). Commissure (C). White roll: most distinct centrally (D). Vermilion: widest in central lip (E). Tubercle (F). Philtral groove (G).
The lips’ cutaneous portions terminate at the vermilion–cutaneous junction termed the white roll or white skin roll. The color and elevation of the white roll is created by par marginalis fibers of the orbicularis oris.2 The white roll is most distinct in the lip center tapering gradually toward the commissures. The vermilion, which is composed of keratinized squamous epithelium, transitions distinctly at the red line into nonkeratinized squamous epithelium of oral mucosa. Similar to the white roll, the vermilion is widest in the central lip.
Muscles of the lip and perioral region are best understood by grouping them into functional categories. The maxillary region muscles that are responsible for the upper lip elevation include the zygomaticus major, zygomaticus minor, levator labii superioris alaeque nasi, levator labii superioris, and levator anguli oris (Figure 34.2A). The levator labii superioris, levator anguli oris, and zygomaticus minor contribute to the formation of the nasolabial crease. Retraction and depression of the lower lip are due to combined actions of muscles located around the central mandible, including the platysma, depressor anguli oris, and depressor labii. The mentalis muscles force the lower lip against the mandible, indirectly elevating it and creating a pout. Muscles of the intermaxillary region include the orbicularis oris, buccinator, and risorius. The orbicularis oris is composed of two components: the pars marginalis and pars peripheralis. The par marginalis lies anterior to the pars peripheralis and is mostly limited to the area directly deep to the vermilion. The pars peripheralis extends from deep to the pars marginalis to behind the cutaneous portion of the lip. The orbicularis is the most important lip muscle, providing oral competence through its sphincteric action in the coronal plane. The maxillary and mandibular perioral musculature adjust the sagittal and axial positions of the orbicularis oris. In the axial plane, the combined action of the orbicularis risorius, buccinator, and pharyngeal constrictors forms a muscular ring that presses the lips against the gingiva and teeth clearing intraoral sulci (Figure 34.2B). The modiolus refers to a complex interdigitation of the perioral muscles that retract the corners of the mouth.
The facial and perioral muscles are arranged into four layers based upon relative depth to one another. All of the muscles are innervated on their deep surface, with the exception of the deepest layer that includes the mentalis, levator anguli oris, and buccinator muscle.
Blood supply to the lips is based upon the network off the external carotid artery system. As the facial artery branches from the external carotid artery, it hooks around the mandible body immediately anterior to the masseter muscle. It courses deep to the risorius, zygomaticus major, and superficial lamina of the orbicularis oris muscle and lies superficial to the buccinator, the levator anguli oris, and deep lamina of the orbicularis oris muscle. The facial artery is located approximately 1.5 cm (range 9.2 to 19.8 mm) lateral to the oral commissure where it gives rise to the superior and inferior labial arteries.3 Since labial vessels reliably anastomose with their contralateral counterparts, a lip switch flap can be based at either side. The superior labial artery lies within 10 mm of the lip margin. This may or may not be within the actual red lip. The inferior labial artery is positioned 4 to 13 mm from the margin of the lower lip. The labial vessels lie either within or posterior to the orbicularis oris muscle, but never anterior to it. Within the lips, the facial vein is not a well-formed single anatomic structure, but more closely resembles a venous plexus. Lymphatic drainage proceeds via submental and submandibular nodal chains.
FIGURE 34.2. Lip musculature. Perioral muscles acting in the coronal plane (A). Perioral muscles acting in the axial plane (B).
Motor innervation to the lip musculature is provided by facial nerve (VII) branches. Zygomatic and buccal branches innervate lip elevators and retractors, whereas the marginal mandibular nerve innervates lip depressor muscles. Sensibility to the upper and lower lips is provided by the infraorbital (V2) and mental (V3) branches of the trigeminal nerve, respectively.
The major etiology of acquired lip deformities is cancer. Ninety-six percent of lip cancers occur on the lower lip presumably from prolonged sun exposure.4 Overall, squamous cell is the predominant tumor cell type (96%), followed thereafter by basal cell cancers, verrucous carcinomas, and adenocarcinomas. Ninety-seven percent of patients with lip cancer are male. Female patients are significantly more likely than men to have upper lip involvement (20% versus 4%). Uncommon indications for lip reconstruction include trauma, infectious diseases such as noma, vasculitis, vascular anomalies, and burn injury.
Historical review of lip reconstruction informs current methods of repair. Similar to other areas of plastic surgery, ideas are continually “re-invented” or modified. Crediting a single surgeon with a reconstructive technique can be incorrect since modern reconstruction has evolved after multiple iterations. Table 34.1 is a timeline of lip reconstruction, including a partial list of each author’s contribution.
General goals of reconstruction include maintaining a dynamic oral sphincter, a sufficiently sized stoma, and an acceptable cosmetic result. As defect size increases, an adequate reconstruction is progressively more difficult to achieve since additional muscle groups, sensory/motor nerves, and soft tissue are sacrificed. When feasible, the best functional and cosmetic outcomes can be achieved by adhering to the axiom of replacing “like with like.” If possible, a subunit approach to reconstruction leads to superior aesthetic results, so this should be followed particularly for the upper lip, where distinct anatomical structures are present.5 Finally, reconstruction of large defects can be associated with a negative impact on the quality of life with patients avoiding activities such as social interaction or public eating; therefore, potential sequelae should be discussed preoperatively. The plastic surgeon should keep all these aspects in mind when planning any lip reconstruction.
The vermilion should be carefully realigned on each side of any defect since small discrepancies are noticeable from a short distance. To avoid misalignment, regional anesthesia such as mental and infraorbital nerve blocks are preferable to the tissue distortion caused by direct local anesthetic infiltration. Alternatively, the white roll can be temporarily tattooed with methylene blue prior to anesthetic infiltration. During lip reapproximation, sutures should be placed either above or below the white roll, but not directly on it to avoid blurring this distinct anatomical landmark.
The smallest vermilion defects can be repaired either primarily or be allowed to heal by secondary intention. If possible, primary repairs should avoid crossing the white roll. When required, local flaps are harvested from the same lip if possible. The simplest method of repair is undermining of the immediately adjacent intraoral mucosa with defect closure by advancement. This technique is commonly indicated for total lip shaves when a “field defect” is present on the entire lower lip vermilion. The drawback of this approach is that the lip is pulled inward with flattening of its normal pouty appearance. To improve the bulk of vermilion reconstructions, a portion of orbicularis oris muscle can be included with the advancement flap. Wilson and Walker proposed the creation of a laterally based bipedicle mucosal flap harvested from the depth of the gingivobuccal sulcus (Figure 34.3A).6 Skin grafting or secondary intention healing of the donor site facilitates tension-free closure at the vermilion suture line with absent lip retraction. Full-thickness defects of the vermilion that include a majority of the underlying orbicularis but do not extend beyond the white roll can be reconstructed with lateral vermilion musculomucosal advancement flaps supplied by labial vessels on either side of the remaining lip (Figure 34.3B). An incision made exactly at the white roll takes advantage of inherent lip elasticity while keeping the scar hidden along this line. Alternatively, musculomucosal flaps composed of intraoral mucosa and orbicularis can be advanced from the sulcus in a V-Y fashion.
FIGURE 34.3. Vermilion reconstruction. Bipedicle flap released from gingivobuccal sulcus (A). Musculomucosal advancement flap (B). Unipedicle vermilion lip switch flap (C).
FIGURE 34.4. Partial-thickness defect involving the philtrum, Cupid’s bow, and vermilion. Advancement flap of right cutaneous lip with V-Y advancement for vermilion reconstruction. Skin graft reconstruction of Cupid’s bow (A). Inset (B). Final result (C).
When ipsilateral mucosa or vermilion is not available for reconstruction, regional donor sites must be sought. One solution is to create a unipedicle vermilion lip switch flap from the opposite lip which is divided after 10 to 14 days (Figure 34.3C). Flaps for reconstruction can also be created from the buccal mucosa. Paired 1 cm wide random musculomucosal flaps based at the angle of the mouth can be rotated 120° for the closure of lower lip vermilion defects. A more reliable intraoral musculomucosal flap is the facial artery musculomucosal flap (FAMM).7 This axial flap that includes the facial artery and buccinator muscle can be based either superiorly (retrograde) or inferiorly to reconstruct the vermilion and other intraoral defects. One drawback of all techniques that use nonkeratinized oral mucosa for vermilion reconstruction is the tendency for the tissue to desiccate.
As an alternative to intraoral cheek–based flaps for vermilion reconstruction, the tongue provides an alternate source of regional donor tissue. Tongue flaps require two stages, so they are significantly more cumbersome. These flaps should be based on either the lateral or ventral surface of the tongue mucosa since the dorsal tongue papillae has a sandpaper texture.
Superficial defects involving the cutaneous lip can be closed in a variety of ways, including primary closure, local flaps, or skin grafting. When closed primarily, circular defects should be closed in a vertical line carrying dog-ears superiorly and inferiorly along anatomical boundaries, such as the philtral columns, alar groove, nasolabial crease, labiomental groove, and white roll. Many partial-thickness defects are better managed by conversion into a full-thickness wedge excision if excess tissue develops intraorally or along the vermilion.
Local flaps are generally designed as either advancement or transposition flaps using cheek and/or adjacent lip tissue (Figure 34.4). Cheek tissue advancements frequently require removal of redundant tissue along the alar-facial groove referred to as perialar crescents (Figure 34.5).8 V-Y and nasolabial flaps from adjacent cheek tissues are other valuable alternatives. When using cheek tissue for lip reconstruction, patient gender is a special consideration. For example, in men, a superiorly based nasolabial flap is more appropriate for the upper lip since it replaces the hair-bearing tissue, although hair growth will be not be oriented properly. An inferior V-Y advancement from the cheek can also introduce hair-bearing tissue to the lip. In contrast, an inferiorly based nasolabial flap using tissue from higher on the cheek does not include hair in the reconstruction.
Skin grafting is not routinely employed for superficial lip defects since sufficient adjacent laxity usually exists to permit either local flap or primary closure. Exceptions may include small central philtral defects, where primary closure leads to distortion of the cupid’s bow (Figures 34.4 and 34.5). Full-thickness rather than partial-thickness grafts are preferred because of the superior cosmetic appearance.
Small Full-Thickness Defects
Due to the elastic nature of lip tissue primary closure is possible in many instances. Lower lip defects up to 40% can generally be reapproximated using layered closure. The upper lip’s distinct topographic landmarks, such as the philtrum and cupid’s bow, can only tolerate primary closure of defects up to 25% without significant distortion. All full-thickness lip repairs should be performed in three layers with careful apposition of the mucosa, orbicularis oris, and skin. To eliminate notching that tends to occur along the vermilion, wound edge eversion is compulsory. Furthermore, placement of a V-plasty or double-limb Z-plasty can prevent or correct linear scar contracture. Similar to partial-thickness closures, incisions for full-thickness defects should be placed at the junctions of anatomical boundaries. Full-thickness lower lip defects can be closed in a variety of ways with incisions concealed in the labiomental crease (Figure 34.6).
FIGURE 34.5. Partial-thickness defect involving Cupid’s bow, philtrum, cutaneous lip, and vermilion. Advancement flap of right cutaneous lip with excision of perialar crescent. Skin graft of Cupid’s bow, vermilion musculomucosal advancement (A). Inset (B). Final result (C).
FIGURE 34.6. Small full-thickness lower lip defects. Four patterns of lower lip excision.
In special circumstances, such as central upper lip defects involving the philtrum, closure with an Abbe flap (see later section) may be preferable even though primary closure can easily be achieved. A primary closure results in a single linear scar and flattens the contour of the upper lip, whereas the scars on either side of the Abbe flap replace the two philtral columns. This scenario is more important for women, whereas men can conceal a single upper lip scar within a moustache (Figure 34.7).
Large Full-Thickness Defects
Tissue for large lip defects can be obtained from one of two resources: the opposite lip or the adjacent cheek. Each donor site has benefits and drawbacks. Lip switches are composite flaps that replace “like with like,” including the orbicularis oris, mucosa, and vermilion. From a functional and aesthetic standpoint, these flaps are superior. Restoration of orbicularis continuity, although scarred, has the greatest likelihood of neurotization and achieving a competent stoma. Furthermore, lip switch flaps correct length discrepancies between the two lips. The utility of lip switch procedures is limited by the amount of available lip remaining following resection. At some point, insufficient residual lip remains for an adequate stoma. Microstomia has significant functional consequences, including an inability to use utensils, place certain food items in the mouth, perform oral care, and insert dentures. In contrast, reconstructions that recruit cheek tissue, while aesthetically inferior, are not routinely associated with microstomia. A requisite for using these flaps is sufficient cheek laxity to permit advancement; patients with regional scars or radiation fibrosis may not be candidates. The principal limitation of cheek advancement is that the normal trilaminar structure of the lip is not replaced with potentially inferior functional and cosmetic outcomes.
Although many of the flaps commonly used for lip reconstruction were originally described specifically for either upper or lower lip defects, with modifications in design and incision placement, they can be used for either lip.
Large central upper lip defects are best repaired with an Abbe flap harvesting tissue from the central segment of the lower lip based on either inferior labial artery (Figure 34.8).9 When the Abbe flap alone is inadequate to fill a central upper lip defect, lateral cheek tissue can be advanced with concomitant excision of perialar crescents.8 The Abbe flap can be created as wide as needed as long as primary closure of the lower lip is achievable. The flap is designed in the center of the lower lip, thereby preserving lateral innervation to the orbicularis oris. Basic reconstruction techniques can be used when harvesting large lower lip segments (Figure 34.6). Flap tissue harvested inferior and lateral to the labiomental sulcus is a source of additional tissue for nasal sill or columella reconstruction. To adequately perform an Abbe flap or other lip switch procedure, knowledge of the inferior labial artery position is important. In general, the artery is located at a level equivalent to the white roll on sagittal section. The artery’s position can also be evaluated at the cut margin of the non-pedicle side of the flap. The remaining connection to the lower lip should be as small as safely possible to permit adequate rotation to the upper lip. Case reports document flap survival despite inadvertent pedicle ligation with blood supply based on the mucosa only, although this is not recommended. As much surface area as possible of the flap should be inset into the upper lip defect to ensure adequate vascularization prior to pedicle division approximately 2 to 3 weeks postoperatively.
Application of the Abbe flap for central lower lip reconstructions is not as ideal. Although both the single- and double-reverse flaps have been described for medium-sized central lower lip defects, the upper lip is a suboptimal donor site because harvest of relatively small amounts can distort its unique anatomical landmarks. A better alternative for large central lower lip defects, or central upper lip defects not amenable to an Abbe flap with perialar crescents, is bilateral versions of the Karapandzic, modified Bernard, or nasolabial flaps. The Karapandzic flap is a musculocutaneous rotation advancement flap that uses remaining portions of the lip for reconstruction with preservation of its neurovascular supply (Figure 34.9).10 The flap is designed as a semicircle around the remaining portion of lip with a radius corresponding to the defect height. The first 1 cm of the incision is carried through all the lip layers, but beyond that the mucosa is preserved while only the skin and muscle are divided. The small mucosal incision ensures preservation of an adequate gingivobuccal sulcus. Spreading rather than division of regional cheek musculature preserves the underlying neurovascular supply with better long-term functional results. Similar to other rotation flaps, redundant skin along the outer circumference of the flap can be excised as a Burow’s triangle.
FIGURE 34.7. Full-thickness defect involving central upper lip. Bilateral upper lip advancement flaps with excision of perialar crescents (A). Flap elevation (B). Prior to inset (C). Final result (D).
FIGURE 34.8. Full-thickness defect involving central and left upper lip. Schematic of an Abbe flap (A). Central Abbe flap with bilateral upper lip advancement flaps and excision of perialar crescents (B). Inset (C). Final result (D).
An alternative to the Karapandzic flap is the modified Bernard operation. The original Bernard cheiloplasty described in 1853 for lower lip reconstruction has been modified many times, so it carries with it numerous names (Figure 34.10).11 The technique in principle creates a laterally based horizontal advancement flap by making incisions through the lip commissure with a second parallel incision at a level corresponding to the height of the missing lip. Incisions are made through skin and mucosa intraorally. Muscle is divided for 1 cm only along the leading edge of the flap. At the flap base, Burow’s triangles, equivalent in size to the amount of advancement, are excised to eliminate redundancy. The Burow’s excisions remove excess skin and subcutaneous fat only, but preserve the underlying muscle. A stair step of extra buccal mucosa harvested along the commissural incision of the flap is advanced for vermilion reconstruction. A final reconstructive alternative to consider for large central upper or lower lip defects is either partial- or full-thickness bilateral interdigitating nasolabial flaps.12 Proponents of this technique argue that no normal tissue is sacrificed, in contrast to the Bernard technique where “normal” tissue from the Burow’s triangles is discarded. Partial-thickness nasolabial flaps have a random blood supply when based on the subdermal plexus, whereas full-thickness “gate flaps” include the facial artery. When raised full thickness, these flaps denervate the upper lip with potential for further functional embarrassment.
FIGURE 34.9. Full-thickness defect involving lateral lower lip. Schematic of a bilateral Karapandzic flap (A). Schematic of a reverse bilateral Karapandzic flap (B). Unilateral Karapandzic flap with full-thickness lip advancement flap (C). Flap inset (D).
Large lateral and commissure defects of either lip can be repaired in a number of ways. Although originally described by Estlander as a medially based rotation-advancement flap from the upper to lower lip, a reverse Estlander can be performed by rotating a lower lip segment to a lateral upper lip or commissure defect (Figure 34.11).13 The technical principles of this operation are the same as an Abbe flap. The flap size should be one half the defect width, so correct proportions are maintained between the lips. Secondary commissuroplasty or commissurotomy may be required to correct the rounded appearance of the lip neocommissure.
The rotation-advancement fan flap described by Gillies is a modification of the Estlander flap with the exception of its shape.14 Whereas the Estlander flap is a “V” or pennant, the fan flap is a quadrilateral with an arc of rotation that resembles the opening of a fan. Variations of the fan flap were described by McGregor and Nakajima, who pivoted the cut vertical margin of the quadrilateral flap around the commissure rather than forward to meet the resection margin of the residual lip. The disadvantage of this method is the need for vermilion reconstruction; however, the commissure is not displaced and the stomal size is unchanged as with the Estlander or fan flaps. An alternative method for lateral defects that preserve the commissure is to perform an Abbe flap, also termed as Abbe-Estlander since it retains properties of both flaps. The advantage of this technique is the natural appearance of the preserved commissure and inconspicuous donor site scar when the flap is harvested from the central lower lip. Its shortcoming is the necessity to perform a second stage in all instances for flap division as well as the inconvenience of temporary microstomia. Finally, unilateral versions of the Karapandzic, Bernard, and nasolabial flaps can also be considered for large lateral lip defects (Figures 34.9C, D and 34.10). Of these options, the Karapandzic flap is preferred because of its superior functional and cosmetic results.
FIGURE 34.10. Full-thickness defect involving central and lateral lower lip. Schematic of a bilateral modified Bernard flap. Note the stair-step incision in the mucosa to include extra tissue for vermilion reconstruction (A). Right unilateral Bernard flap with left unilateral Karapandzic flap (B). Inset (C).
FIGURE 34.11. Full-thickness defect involving central and left upper lip. Schematic of an Estlander flap (above) and reverse Estlander (below) (A) (B). Reverse Estlander flap with cheek advancement flap and excision of perialar crescent (C).Inset (D). Final result (E).
FIGURE 34.12. Near total lower lip defect with involvement of adjacent chin soft tissue. Proposed resection (A). Defect (B). Folded radial forearm flap with palmaris tendon graft (C). Early postoperative result (D).
Total Lip Reconstruction
Adequate total lip reconstruction is difficult to achieve with regional tissues. For defects greater than 80%, the Karapandzic technique creates a significant microstomia, so either bilateral Bernard or nasolabial flap is the best reconstructive method if sufficient laxity permits. The use of cheek tissues for such large defects makes the lip tight with poor function and relative protrusion of the uninvolved lip. Functional sequelae are magnified particularly for lower lip defects since its contribution to oral competence is greater than the upper lip.
A final flap to consider from the reconstructive armamentarium for total lip reconstruction is the submental flap. Based on the submental branch of the facial artery, the flap can be transferred as an island to reach either lip. For benign processes, the flap can be prelaminated in advance with a skin graft or pre-expanded to increase its size. The main advantage of any regional tissue reconstruction over free tissue transfer is the superior cosmetic results.
Free tissue transfer for total lip reconstruction was first reported in 1974.15 It remains the best option for total lip defects not amenable to regional flaps or when a defect includes soft tissues extending beyond the lip (e.g., combined lower lip and chin defect). The thin and pliable radial forearm free flap is used most commonly and can be elevated either longitudinally or transversely on the forearm (Figure 34.12). The palmaris longus tendon, harvested as a free graft (longitudinal skin island) or composite graft (transverse skin island), is weaved into remaining portions of the orbicularis oris or modiolus. Simultaneously, vermilion reconstruction can be performed with bilateral FAMM flaps or in a delayed fashion with any of the aforementioned techniques (Figure 34.13). Cosmetic results for upper lip reconstruction in men can be improved through the use of hair transplantation (Chapter 52).
Depending upon the etiology and extent of the lip defect, partial face transplantation may be a valuable alternative to consider in some cases of total lip loss. Possible indications include soft tissue defects of both lips or composite defects of either the maxilla or mandible with adjacent entire lip. Although the field is in its infancy, composite tissue allotransplantation is promising with superior cosmetic and functional results in some instances (Chapter 6).
An algorithm for lip reconstruction is presented in Figure 34.14. Since each reconstructive scenario is unique and many flaps are suitable for a given defect, the algorithm provides a list of considerations rather than a single reconstructive method.
Although uncommon, traumatic amputation of the lip occurs most commonly from dog bites (Figure 34.15). If the segment is large enough, it should be carefully evaluated under microscopic magnification to identify and assess the quality of the labial artery for microsurgical transfer. The major obstacle to lip replantation is the poorly formed labial veins that are unsuitable for microsurgical anastomosis. Venous outflow can be generally achieved with leeches. Hospital stays are prolonged with the need for blood transfusions. When possible all efforts should be made at replantation since restoration with native tissue is superior both cosmetically and functionally to any reconstruction.
The long history of lip reconstruction provides a wide array of surgical techniques from which the surgeon can choose. The rich blood supply and elasticity of the lip and cheek allow for some of the most creative and unique reconstructive procedures in all of plastic surgery. Firsthand knowledge of lip history, anatomy, and function along with an understanding of basic reconstructive principles will yield the best outcomes.
FIGURE 34.13. Total lower lip and chin defect following arteriovenous malformation (AVM) excision. Preoperative (A). Template for folded radial forearm flap (B). Antegrade bilateral FAMM flaps for vermilion reconstruction (C). Four-year postoperative result (D).
FIGURE 34.14. A reconstructive algorithm for full-thickness defects.
FIGURE 34.15. Near total upper lip amputation. This 17-year-old male had the majority of his upper lip amputated by a dog (A). The part was replanted but swelling prevented immediate inset, and venous congestion necessitated leach therapy (B). After serial inset, the anatomic landmarks were restored, and at 6 months full function and sensation had returned (C, D) (photo courtesy of Dr. Helena Taylor).
1. Briedis J, Jackson IT. The anatomy of the philtrum: observations made on dissections in the normal lip. Br J Plast Surg. 1981;34:128-132.
2. Mulliken JB, Pensler JM, Kozakewich HP. The anatomy of Cupid’s bow in normal and cleft lip. Plast Reconstr Surg. 1993;92:395-403; discussion 404.
3. Schulte DL, Sherris DA, Kasperbauer JL. The anatomical basis of the Abbe flap. Laryngoscope. 2001;111:382-386.
4. Zitsch RP 3rd, Park CW, Renner GJ, et al. Outcome analysis for lip carcinoma. Otolaryngol Head Neck Surg. 1995;113:589-596.
5. Burget GC, Menick FJ. Aesthetic restoration of one-half the upper lip. Plast Reconstr Surg. 1986;78:583-593.
6. Wilson JS, Walker EP. Reconstruction of the lower lip. Head Neck Surg. 1981;4:29-44.
7. Pribaz JJ, Meara JG, Wright S, et al. Lip and vermilion reconstruction with the facial artery musculomucosal flap. Plast Reconstr Surg. 2000;105:864-872.
8. Webster JP. Crescentic peri-alar cheek excision for upper lip flap advancement with a short history of upper lip repair. Plast Reconstr Surg (1946). 1955;16:434-464.
9. Abbe R. A new plastic operation for the relief of deformity due to double harelip. Plast Reconstr Surg. 1968;42:481-483.
10. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg. 1974;27:93-97.
11. Webster RC, Coffey RJ, Kelleher RE. Total and partial reconstruction of the lower lip with innervated musclebearing flaps. Plast Reconstr Surg Transplant Bull. 1960;25:360-371.
12. Rudkin GH, Carlsen BT, Miller TA. Nasolabial flap reconstruction of large defects of the lower lip. Plast Reconstr Surg. 2003;111:810-817.
13. Sundell B. The classic reprint: translation of “Eine Methode aus der Eincn Lippe Substanzverluste der Anderen Zu Ersetzen”, by JA Estlander. Plast Reconstr Surg. 1968;42:7.
14. Gillies H. The Principles and Art of Plastic Surgery, Vol. 2, 1st ed. Boston, MA: Little, Brown and Company; 1957.
15. Harii K, Omori K, Omori S. Successful clinical transfer of ten free flaps by microvascular anastomoses. Plast Reconstr Surg. 1974;53:259-270.