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Lip & Cheek Reconstruction

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Lip & Cheek Reconstruction

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Lip and Cheek Reconstruction: 
Cheek Reconstruction: 
Local Anatomy: 
Blood Supply to the Cheek: End branches of the external carotid: facial and superficial temporal 
Cheek defects: 
Zones: Zone 1: suborbital, Zone 2 preauricular, Zone 3 buccomandibular

  •  Zone 1 Options: 
    • Primary closure of smaller lesions especially in older patients with lax skin folds 
    • Skin grafts: Full thickness from the preauricular, postaurituclar and supraclavicular regions (This is typically not first line) 
    • Local flaps: 
      • Rhomboid, VY, bilobed, Mustarde (medial cheek rotation), and cervicofacial flap (>4cm). 
        • The cervicofacial flap is most commonly used for larger defects given the good color match 
        • Mustarde: Medial cheek rotation
          • For superior cheek, inferior eyelid
          • like a Tenzel but extend incision to preauricular skin
    • Other Options:  tissue expansion, free flaps, temporalis flap
  • Zone 2 Options:  
    • Primary closure: skin laxity in this area often allows for primary closure  
    • Local flaps: can use a face lift incision to advance skin over the defect 
    • Regional flaps: 
      • Anteriorly Based Cervicofascial Flap supplied by the facial artery 
      • Cervicopectoral Flap:   these are for larger defects that also cover skin from the anterior chest and include blood supply from the anterior thoracic perforators off the IMA 
      • Submental Flap:  based on the submental branch of the facial artery
        • Anatomy of the Submental Artery: runs between horizontal ramus of mandible and submandibular gland, courses down and ends close to mandibular symphysis. 
        • Flap Design: Can take platysma only (must be careful to preserve cutaneous perforators), or can take combination of anterior digastric, mylohyoid, bilateral anterior digastric, and cutaneous paddle all the way up to the contralateral earlobe (may take contralateral submandibular gland)
    • Other options: tissue expansion, free flaps, temporalis flaps 
  • Zone 3: need to consider intraoral lining and soft tissue coverage 
    • Lining Options: 
      • Hemitongue basedon the axial lingual artery 
      • Buccal Fat Pad 
      • FAMM (facial artery myomucosal flap) 
      • Skin graft on the back of a flap
      • Two skin paddles from a free flap
    • Primary Closure: generally less successful given the lack of skin laxity in this region 
    • Local Flaps: ex. Rotation, advancent, transposition, rhomboid, VY, bilobed 
    • Regional Flaps: inferiorly based advancement flap or submental flap or pedicled pectoralis muscle or trapezius
    • Free Flaps: usually fasciocutaneous flaps – RFFF, ALT, parascapular, lateral arm 

Lip Reconstruction:

Anatomy

  • Lip aesthetic units: 
    • oral sphincter
    • commissures
    • philtrum
    • Cupids Bow 
    • Vermillion
  • Modiolus: attachment site lateral to commissure for multiple muscles
  • Sensory Innervation; 
    • Upper lip: infraorbital nerve (V2) 
    • Lower lip: mental nerve (V3) 
  • Blood Supply: 
    • Superior and inferiorly based labial arteries (branches of the facial artery) 

Reconstruction based on deficit: 

  • Vermillion Only: 
    • Small: VY advancement from intraoral tissue
    • Medium: Lip switch: taking from the other lip to supply the injured lip 
    • Larger: buccal mucosal advancement from the wet buccal mucosa to replace a deficient vermillion 
  • Full Thickness Lip Reconstruction (Upper Lip) 
    • Up to 1/3 of the lip is missing 
      • Generally can be closed primarily
      • If the vermillion is completely intact – can use a nasolabial flap to close upper lip defects (meaning the skin between the nose and the vermillion 
      • Central Defect: perialar crescentic advancement flap – this flap makes relaxing cuts around the ala and lateral nose in order to advance that skin medially 
    • 1/3 – 2/3: 
      • Central Defect with No Commissure Involvement: 
        • Abbe flap: You take from the lower lip as a pedicled flap and then divide the flap in 3 weeks
        • Karapandzic Flap: Single stage procedure creating rotational circumoral flaps that are based on the bilateral labial arteries. This can lead to microstomia if the defect is large. 
      • Commissure Involved: 
        • Estlander flap: This takes the tissue from the lower lip at the commissure, alters modiolus
    • > 2/3 of the lip is missing: 
      • Enough Cheek Tissue: 
        • Bernard Burrow: >2/3 (central for upper lip), must have adequate cheek tissue, oral sphincter incompetence, insensate; webster modification preserves innervation
      • Not enough cheek tissue: 
        • Total lip reconstruction: 
          • palmaris longus sling and RFFF (lateral antebrachial cutaneous nerve);
          • Functional gracilis and STSG to maintain movement of lip and superior aesthetic result
  • Full Thickness (Lower Lip) 
    • In general the same principles apply. 
      • Generally able to get primary closure on < 1/3 defects.
      • For > 1/3 use an Karapandzic or Abbe if the commissure is not involved and an Estlander flap if the commissure is involved 
      • For >2/3: use a Bernard Burrow if there is sufficient cheek tissue if not use a free flap 


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