Lip Reconstruction

Question 1

Describe what to look for when analyzing a defect of the lip.

Answer 1

Percent or fraction of lip involved.
Upper lip vs. lower lip.
Involvement of keep structures like vermilion, white roll, cutaneous lip.
Involvement of key anatomic structures such as Cupid’s bow, philtral column or philtra dimple.
Is the orbicularis or is involved?

Question 2

What history should be obtained during the work-up for a lip defect?

Answer 2

Sun exposure history, personal and family history of skin cancer, and genetic conditions such as Xeroderma pigmentosum, Gorlin’s syndrome, albinism, and vitiligo.

Genetic conditions can predispose individuals to skin lesions.

Question 3

What should be assessed during the physical examination of a lip defect?

Answer 3

Detailed examination of lips and oral cavity, characterize findings associated with skin lesion: size, color, shape, skin irregularity, and hyperkeratosis; lymph node examination for signs of metastatic disease.

Question 4

What diagnostic studies are recommended for a lip defect?

Answer 4

A biopsy should be performed at the time of evaluation if a lesion is present to establish a diagnosis. Full-thickness incisional versus excisional biopsies may be performed.

Avoid shave biopsies as they may lead to incomplete assessment, especially in melanoma.

Question 5

True or False: The size of the final defect can be anticipated before resection in skin cancer cases.

Answer 5

False.

Patients must understand that the final defect size cannot be predicted until after resection.

Question 6

What is the recommendation regarding Mohs surgery for lip defects?

Answer 6

Consider Mohs surgery referral if available, as it allows examination of ~100% of surgical margins, resulting in the highest cure rates.

This technique is particularly beneficial for skin cancers due to its precision.

Question 7

What are the goals of lip reconstruction after excision?

Answer 7

Restoration of function (oral competence, speech) and optimization of aesthetics.

Functionality and aesthetics are critical in reconstructive surgery of the lip.

Question 8

When should reconstruction be delayed after excision?

Answer 8

Reconstruction should be delayed until negative margins are confirmed on final pathology.

Question 9

What are some surgical pearls for lip reconstruction?

Answer 9

• Mark or tattoo landmarks prior to injecting local anesthetic
• Primary closure: Upper lip ≤ 1/4 defect, Lower lip ≤ 1/3 defect
• Larger defects may require Abbe flap or other reconstructive procedures

Question 10

Fill in the blank: For mucosal/vermilion defects, replace ‘like with like’ using _______.

Answer 10

mucosal advancement or vermilion advancement, FAMM flap, Abbe flap (vermilion lip switch, or tongue flap).

Question 11

What is the function of the facial artery musculomucosal (FAMM) flap? What is it used for?

Answer 11

Flap of intraoral mucosa (mucosa, submucosa, small amount of Gucci at or, and facial artery with venous plexus) useful for correction of long vermilion-only defects, based on the facial artery with superior or inferior pedicle.

Question 12

What is the purpose of the vermilion lip switch (Abbe flap)?

Answer 12

Utilized for larger defects, primarily of the upper lip, and requires a second stage for division of flaps 2-3 weeks later.

The Abbe flap is a common technique for achieving functional and aesthetic restoration.

Question 13

What is the source of the tongue flap used in lip reconstruction? What is its indication?

Answer 13

Anteriorly based, from the ventral surface of the tongue, and requires a second stage division.

The tongue flap is a versatile option for reconstructing larger defects of the mucosa/vermillion.

Question 14

What is the Abbe flap primarily used for? Describe it’s design and inset.

Answer 14

Reconstruction of upper lip full-thickness defects involving 1/3 to 1/2 the upper lip.

The Abbe flap is elevated from the central lower lip and is designed as 1/2 of the width of the defect. It is elevated to the labiomental fold. If the defect is more lateral on the upper lip, you continue elevation through the central chin pad. It is inset onto the columella, above the columellar base with extensions to the nasal sill.

Question 15

When is primary closure indicated for upper lip defects?

Answer 15

Full thickness defect ≤ 1/4 of lip (up to 33%)

Question 16

What is the preferred method for reconstructing a full aesthetic subunit of the lip?

Answer 16

Abbe flap

Question 17

What defect sizes can the Abbe flap correct?

Answer 17

Defects involving 1/3-1/2 of the lip (usually indicated for central lip)

Question 18

What is the timing for the second stage division of the Abbe flap?

Answer 18

2-3 weeks

Question 19

What is the Karapandzic flap primarily used for?

Answer 19

Lower lip defect involving 1/3-2/3 of lip, Utilized in the upper lip as well.

Question 20

What is a key advantage of the Karapandzic flap?

Answer 20

Restores oral competence and preserves neurovascular pedicle

Question 21

What is a potential complication associated with the Karapandzic flap?

Answer 21

Microstomia, especially in larger defects (if used for defect > 2/3’s of the lower lip)

Question 22

When is primary closure indicated for lower lip defects?

Answer 22

If defect ≤ 1/3 of lip

Question 23

What is the reverse Abbe flap used for?

Answer 23

Upper to lower lip switch

Question 24

What procedure is similar to the Schuchardt procedure? What is its indication?

Answer 24

Bernard and Webster procedures.

Used for 1/3 to 2/3 lip defects.

Question 25

What type of incisions are performed during the Schuchardt procedure?

Answer 25

Barrel-shaped incisions along labiomental crease. May be combined with bilateral lip switch to prevent microstomia.

Question 26

What flap is used for commissure defects?

Answer 26

Estlander flap

Question 27

What is the utility of the Estlander flap? Describe its design.

Answer 27

Useful for full-thickness defects 1/2-2/3 of the lip

Question 28

What is a method for total lip reconstruction?

Answer 28

Free radial forearm flap with palmaris longus sling for support. Suspension of folded RFFF over palmarus longus graft secured to maxilla to prevent flap ptosis that can >> loss of oral competence. A functional gracilis flap provides symmetric, dynamic, competent lower lip as well.

Question 29

What is a complication associated with facial reconstruction that requires re-excision?

Answer 29

Recurrent cancer

Question 30

What are the treatment options for wound dehiscence and partial flap necrosis?

Answer 30

Local wound care ## Footnote Local wound care is the primary treatment for these complications.

Question 31

What surgical technique may help prevent microstomia in facial reconstruction?

Answer 31

Postoperative Abbe flap ## Footnote A single or bilateral Abbe flap may be useful adjuncts to the primary flap procedure.

Question 32

Why is orbicularis reconstruction important in facial reconstruction?

Answer 32

Prevention of oral incompetence ## Footnote Proper reconstruction of the orbicularis oris is crucial to prevent oral incompetence.

Question 33

What is a critical error related to skin cancer management in facial reconstruction?

Answer 33

Failure to perform appropriate biopsy ## Footnote Appropriate biopsy is essential when there is concern for skin cancer.

Question 34

What is a critical error involving tissue resection in facial reconstruction?

Answer 34

Inadequate resection ## Footnote Inadequate resection can lead to complications in the reconstruction process.

Question 35

What should be ensured before performing reconstruction in facial surgery?

Answer 35

Negative margins ## Footnote Reconstruction should not occur prior to ensuring negative margins.

Question 36

What is a critical error related to orbicularis oris musculature in lip reconstruction?

Answer 36

Failure to repair orbicularis oris musculature ## Footnote Repairing the orbicularis oris musculature is essential in facial reconstruction.

Question 37

What three layers of tissue must be addressed in facial reconstruction?

Answer 37

Mucosa, muscle, and skin ## Footnote All three layers must be addressed, along with critical structures such as the philtrum, Cupid's bow, and white roll.

Question 38

___ advancement for partial thickness vermilion/mucosal defects. ____ advancement for small full-thickness defects.

Answer 38

Mucosal advancement for partial thickness defects. Vermillion advancement is a musculo-vermilion flap for small full thickness-defects.

Question 39

Describe the Karapandzic flap as if writing an operative note.

Answer 39

Indicated for up to 2/3 involvement of the lower lip. Perform circus oral incisions, mobilize the orbicularis oris while preserving innervation and vascular supply from the superior and inferior labial arteries

Question 40

How would you treat 75% loss of the central upper lip?

Answer 40

Treat with bilateral Karapandzic flap and central Abbe flap for philtra reconstruction. The Karapandzic flap retains innervation to the muscle unlike the Gilles flap.

Question 41

What are the mentalis muscles required for? Describe location.

Answer 41

Lower lip position and lip competence. They are large trapezoidal muscles that original from the mandible just below the attached gingiva and insert horizontally and inferiorly into the chin bad below the labiomental fold.

Question 42

What is the most important assessment when analyzing a lip defect? Why?

Answer 42

The amount of remaining vermilion. Contains orbicularis.

Question 43

How does lip vermilion differ from mucosa?

Answer 43

In its color and appearance.

Question 44

Why is the vermilion or white roll marked prior to infiltration of anesthetic solutions?

Answer 44

It is difficult to accurately identify the vermilion or the white roll after injection of local anesthetic solutions.

Question 45

What is desirable regarding the balance in length of the upper and lower lip?

Answer 45

Total lip tissue should be near equally shared by the two lips.

Question 46

Is functional reconstruction of the upper lip as critical as that of the lower lip?

Answer 46

No, it is not as critical.

Question 47

What can the lower lip tolerate for the majority of defects encountered?

Answer 47

Wedge excision.

Question 48

What is a distinct advantage of lip-switching procedures?

Answer 48

Simultaneously shortening the normal lip along with reconstructing the opposite lip defect.

Question 49

What advantage do the Abbe and reverse Abbe flaps have?

Answer 49

They do not move the commissure.