“Lip Reconstruction” Williams EF 3rd, Khanna, Manish, MD, Chris Hove, MD: In Papel, Nachlas, Sykes et al., editors: Facial Plastic and Reconstructive Surgery (5th ed.), New York, Thieme. (Accepted for publication 2005)
Lip reconstruction for large defects of the lower and upper lip continues to be a formidable challenge. The first written description of lip reconstruction was by Susruta in 1000BC, but an ancient Hindu description of facial, lip, and nasal reconstruction with a forehead flap is reported as early as 3000BC. Sabatini first described lip reconstruction using a cross-lip flap in 1837, but a subsequent modification of this technique by Abbe and Estlander resulted in their names being ascribed to this method of reconstruction. Bernard and Burow later described a method of lip reconstruction for total and subtotal defects using bilateral full-thickness advancement flaps to the cheeks that were brought to the midline to fashion a new lip. Full-thickness triangles were excised in the location of the nasal alar fold to alleviate puckering that resulted from tissue excess in that location. In the 1920’s, Gillies described a classic fan flap using a full-thickness pedicle that allows redistribution of the remaining lip during the reconstructive effort and emphasized the use of a similar or tissue like. This concept was further modified by Karapandzic in 1974, who made incisions through the skin and mucosa at a distance equal to the depth of the defect, but with primary emphasis on preservation of the underlying musculature and neurovascular structures. More contemporary refinements for reconstruction of large lip defects by Burget and Menick include the importance of the subunit principle as it applies to the upper lip for an optimal aesthetic result. Microvascular reconstruction using radial forearm free flap and temporal scalp free flap have been used for large and total defects of the lip, and their use may become more popular as more surgeons are trained in microvascular techniques and refinement procedures to maximize the functional and aesthetic outcomes.
Post-operative edema is an unavoidable aspect of lip reconstruction that should be discussed with the patient prior to the procedure. Based on the authors’ experience, the edema gradually resolves by between 12 and 18 months. The patient should be counseled on performing oral exercise as much as possible in the postoperative period. These exercises help to reestablish neuronal connections and lymphatic channels that can improve the functional result and help decrease edema, respectively.
Asymmetry of the oral commissure or microstomia can result from surgical defects of the lips and present an aesthetic and functional dilemma. Cross-lip flaps involving the commissure can result in blunting at the commissure. These problems can be addressed with a commissuroplasty, involving excision of a triangular piece of cutaneous skin at both commissures with mucosal advancement to the apex. Care must be taken to have precise alignment of the commissure at the appropriate level. This can be done as an office procedure under local anesthetic. Commissuroplasty is considered no sooner than 9 months after the lip reconstruction procedure.
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