Grabb’s Encyclopedia of Flaps Head and Neck

Tokyo: Anatomu Co., 1966;462-463, 551 (in Japanese).

Chapter 162
Subcutaneous Pedicle Flaps to The Lip
J. N. BARRON
M. N. SAAD
The use of subcutaneous pedicle flaps in lip reconstruction is limited, partly because of the multitude of excellent
standard flaps available and partly because of the difficulty in achieving a mobile lip unless functioning
orbicularis muscle is incorporated in the flap when repairing full-thickness defects (1). For these reasons,
subcutaneous pedicle flaps usually are limited only to skin defects (2, 3, 4). Platysma musculocutaneous flaps
from the neck are excellent for reconstructing the lower lip (see Chapter 174).
FLAP DESIGN AND DIMENSIONS
In men, it is important to repair lip defects with a hair-bearing flap, and whenever possible, bulky mushroomed
flaps should be avoided, especially when replacing a concave surface, such as the mentolabial groove. The
main sources of subcutaneous pedicle flaps for the repair of lip defects are the nasolabial fold, the chin, and the
lip itself.
Flaps from the Nasolabial Fold
The nasolabial fold provides an ample supply of tissue with a good color and texture match. It has a robust blood
supply based on the facial artery, and it leaves a linear scar at the donor site. In reconstruction of the upper lip,
subcutaneous pedicle flaps should be based inferiorly, and in suitable patients, bilateral flaps can be used to
resurface most of the upper lip. Figure 162.1 illustrates a defect of the upper lip repaired with an inferiorly based
nasolabial subcutaneous pedicle flap.
FIGURE 162.1 A: Upper lip defect. Planned repair with an inferiorly based nasolabial flap. B: Flap inset and
donor site sutured.
Flaps from the Chin
Lining defects of the lower lip can be repaired by flaps raised on the chin in hairless patients and based on the
subcutaneous tissue at the edge of the defect. The flap then is turned in and sutured to the mucosal defect. The
skin defect is repaired with a standard flap.
Flaps from the Lip

Small defects of the lip can be corrected by subcutaneous pedicle flaps from the lip itself. This is particularly well
illustrated in the correction of the “whistle tip” deformity seen in cases of bilateral cleft lips (Fig. 162.2). Two
horizontal V-Y flaps based on subcutaneous pedicles are advanced medially and sutured to each other to
provide the required fullness in the midline.
FIGURE 162.2 A: “Whistle tip” deformity in a repaired bilateral cleft lip. B: The median segment is
deepithelialized. The two flaps, based on anterior or posterior subcutaneous pedicles, are raised. C-F: The V-Y
flaps are sutured in position, providing the required fullness in the midline.
OPERATIVE TECHNIQUE
The general principles, design, and operative technique illustrating the use of subcutaneous pedicle flaps are
described in Chapter 44.
SUMMARY
Subcutaneous pedicle skin flaps are indicated for lip defects that involve skin or mucosal lining only. Muscle
loss should be replaced by other techniques.
References
1. Karapandÿzić M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93.
2. Barron JN, Emmett AJJ. The subcutaneous pedicle flaps. Br J Plast Surg 1965;18:51.
3. Spira M, Gerow FJ, Hardy SB. Subcutaneous pedicle flaps on the face. Br J Plast Surg 1974;27:258.
4. Chongchet V. Subcutaneous pedicle flaps for reconstruction of the lining of the lip and cheek. Br J Plast
Surg 1977;30:38.

Chapter 163
Advancement Musculocutaneous and Skin Flaps for Upper Lip
Repair
E. J. VAN DORPE
Tissue replacement in the central part of the upper lip, the area defined laterally by a vertical line from the alar
base to the free margin of the lip, is described. The flaps used are based on the principle of lip advancement by
perialar crescentic excision (1, 2, 3).
INDICATIONS
Even small skin lesions in the central upper lip region may be difficult to treat by simple elliptical excision
without disturbing the anatomic relationship between lip margin, alar base, and philtral ridge. Vertical ellipse
excision cannot be done if the lesion is adjacent to the alar base. If the lesion lies between the alar base
and the lip margin, an elliptical excision will produce vertical lengthening of the lip when it is sutured. The
lengthening is caused by the approximation of the curved edges, making a straight line that is longer than
the axis of the ellipse.
Repair of defects larger than half the central upper lip with this method using bilateral flaps is not
recommended because it results in a significant discrepancy in length between upper and lower lips. The
perialar flap can be used to cover any larger defect in the columella, the nostril floor, or both.
OPERATIVE TECHNIQUE
For smaller defects, lengthening of the lip may be avoided by using a small advancement flap with perialar
crescentic excision (Fig. 163.1). It may be considered an elliptical excision, with its upper part shifted laterally to
avoid the nostril.
FIGURE 163.1 A-C: Skin lesion of the upper lip adjacent to the nostril. V excision and perialar crescent. Closure
after undermining of the lateral flap.
FIGURE 163.2 The size of the perialar crescent is determined by the extent of the advancement to be achieved.

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When the defect is larger (up to half the central upper lip), with involvement of muscle, a vertical segment of the
lip is excised down to vermilion (Fig. 163.2). If possible, the mucosa is excised as an inverted V. Lateral lip
advancement is obtained by perialar crescentic excision. If the defect extends into the nostril floor and columella,
the perialar skin is preserved to reconstruct these areas (Fig. 163.3). It is raised as a caudally based flap, with its
width at the base equal to the width of the lip defect.
The alar base then is detached from the lip and cheek, the lateral segment of lip is moved medially to close the
defect, and suturing is done in three layers. Care should be taken to set in the alar base at the correct position,
which is determined by measuring up from the columella laterally and from the lip margin inferiorly. Often the ala
will have to be partly inset
across the base of the perialar flap. In this case, the area where ala must be inset is deepithelialized to preserve
the blood supply to the flap.
FIGURE 163.3 A: The extent of the excision. The perialar flap has been outlined and is divided into two parts,
one for the columella and one for the nostril floor. B: The flaps are in place, and the area where the ala has to be
inset is deepithelialized. C: The lateral edge of the secondary cheek defect is longer than the medial edge.
Closure is facilitated by Z-plasty. (Incision BC should be longer than AB.) D: The repair completed. (From Van
Dorpe, ref. 3, with permission.)

FIGURE 163.4 A: The tumor has been excised. Further excision of the lip margin and the flap are outlined. B:
The completed repair. The cheek defect has been closed with a double transposition flap. C,D: One week after
the repair. (From Van Dorpe, ref. 3, with permission.)
The lateral edge of the secondary cheek defect is often longer than the medial edge. Closure is facilitated by a
double transposition flap (Figs. 163.3C,D and 163.4).
SUMMARY
Defects of the upper lip can be closed with a good cosmetic result by using various modifications of lip
advancement and perialar crescentic excision.
References
1. Dieffenbach JF. Die Operatieve Chirurgie. Leipzig: Brockhaus, 1845;423.
2. Webster JP. Crescentic perialar cheek excision for upper lip flap advancement, with a short history of
upper lip repair. Plast Reconstr Surg 1955;16:434.
3. Van Dorpe EJ. Simultaneous repair of the upper lip and nostril floor after tumour excisions. Plast Reconstr
Surg 1977;60:381.

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Chapter 164
Submental Hair-Bearing Skin Flap to Upper Lip
H. SCHAUPP
EDITORIAL COMMENT
The finesse of this procedure is that it produces a hair-bearing upper lip that has normal-looking hair in the
proper direction, as opposed to an island temporal hair-bearing scalp flap that more closely resembles a
Groucho Marx moustache. This procedure could be applied to female patients in a similar manner if a
hairless resurfacing of the upper lip is required, but it should be limited to severe cases.
Donor sites for hair-bearing skin flaps used in the reconstruction of the upper lip are the scalp (bitemporal flaps),
the cheeks (advancement flaps), and the cervical and submental regions (unilateral or bilateral pedicle flaps) (1).
The submental flap is preferable for defects of the upper lip and adjacent cheeks in which at least part of the
labial mucosa is preserved.
INDICATIONS
In reconstructing the upper lip, the aims are (a) to provide the upper lip with sufficient skin and
subcutaneous tissue to cover defects after incision or elevation of scarred and retracted lip tissue; (b) to
replace hairless, ugly scars with hair-bearing skin in males; and (c) to lengthen the columella if necessary.
In patients with a cleft lip/nose deformity, the submental hair-bearing skin flap can correct the nasal
malformation and improve respiratory function as well as allow active movement of the upper lip. Other
indications are large scars and deformities after injuries of the lip and adjoining cheek and defects after
tumor resection.
The skin of the submental region is quite similar to that of the lip. As a substitute, it is aesthetically well
accepted, even in women. In men, the new moustache is an additional excellent camouflage. Most of our
male patients, unable to hide the deformity preoperatively, proudly presented with a moustache
postoperatively.
An important advantage of the flap is the hidden donor site, which normally contains a surplus of skin, and a
fine scar that lies within relaxed skin tension lines. In most cases, the linear submental scar is scarcely
noticeable. The shape of the untubed flap preserves skin and, in addition, makes a skin graft unnecessary
(2).
OPERATIVE TECHNIQUE
Between mastoid and submental regions on both sides, 2-cm-wide handle-like flaps containing skin,
subcutaneous tissue, and fat are excised and elevated (Fig. 164.1B). The resulting wounds under the flaps are
closed after mobilizing the adjacent skin, and the untubed strips are covered with nonadhering dressing.

FIGURE 164.1 A: A 36-year-old patient after multiple corrective operations for bilateral cleft lip and palate
deformity in childhood. B: Elevation of the handle-like pedicles. C: Flap inset on the upper lip. D: Postoperative
view. The columella was lengthened by using the hairless skin on the upper lip.
The midline “pillar” (which should be wider than the upper lip to cope with shrinkage) is incised, delayed, and
finely transected about the tenth day in two to three sessions until the flap can be swung up to the upper lip to
cover the defect. Five days later, depending on the viability of the medial part of the flap, the pedicles can be
transected, first on one side and, 1 to 2 days later, on the other side.
CLINICAL RESULTS
Nasal respiration was improved in every case of bilateral cleft lip in which the tip of the nose was previously
dropped and the nostrils were in a horizontal position. In patients in whom the mobility of the upper lip was
restricted by scars, induration, or narrowing, the reconstructed lip showed an almost free mobility. In men,
the aesthetic results were quite good. In women, without the camouflage possibilities of a moustache, the
results were satisfactory, but I suggest that the procedure be limited to severe cases.
Further disadvantages arise from the necessity of at least four operative procedures and the consequent
length of time necessary until the pedicles can be removed (at least 16 days) because the flap has no
anatomically defined vessels. Keeping the surgical wound open may be unpleasant for the patient
compared with the use of a tubed flap, but this disadvantage is outweighed by the avoidance of split-
thickness skin grafts.
SUMMARY
A submental hair-bearing skin flap can be used in several stages to cover a scarred upper lip. The
columella can be lengthened at the same time.

References
1. Denecke HJ, Meyer R. Plastische Operationen an Kopf and Hals, Vol. 1: Nasenplastik. Berlin: Springer-
Verlag, 1964.
2. Schaupp H. Spatkorrektur der Oberlippen-Columella-Region bei operierten beidseitigen Lippen-Kiefer-
Gaumenspalten unter Verwendung des Submentallapens. Laryngol Rhinol Otol (Stuttg.) 1977;56:244.

Chapter 165
Hair-Bearing Skin Flaps
J. S. P. WILSON
M. D. BROUGH
Hair-bearing skin flaps of the scalp can be used for reconstruction of hair-bearing areas of the scalp itself and
also of sideburns and the moustache and beard areas in men. Bald areas of the scalp may be used to
reconstruct non-hair-bearing areas of the face or oral cavity. Immediate skin cover to large defects of the cranium
may be provided by large, narrow-based flaps or single or multiple, broad-based flaps.
Scalp flaps used to reconstruct defects of the scalp may be axial pattern or random pattern, but those used in
reconstructing other areas are almost invariably axial-pattern flaps and most commonly are based on the
posterior branch of the superficial temporal artery and its associated veins. Much of this chapter is devoted to
flaps based on this vessel, as they are the most versatile and most useful flaps of the hair-bearing scalp.
RECONSTRUCTION OF HAIR-BEARING AREAS OF THE FACE (1, 2, 3, 4, 5)
Hair-Bearing Margin of the Forehead
Defects of this margin, other than the receding hairline of male pattern baldness, are not common but, when
present, cause a significant deformity. They usually can be reconstructed with transposition flaps based on the
posterior branch of the superficial temporal artery. A secondary defect may leave an obvious bald patch at the
back of the scalp. If the flap is large and the galea is cross-hatched with multiple incisions, it will expand and a
secondary defect may be avoided. Figure 165.1 shows how three flaps were expanded in a girl aged 8 years to
reconstruct the anterior hairline, which had been destroyed by a burn injury in infancy.
FIGURE 165.1 A: Anterior hairline defect following burn injury in infancy. B: Plan of flap movement. C,D: Early
postoperative view of anterior hairline reconstruction.
Eyebrows
Eyebrows help frame the forehead and divide the upper third from the middle third of the face. When thick, as
commonly found in men, they can be reconstructed readily on narrow- pedicled flaps based on the posterior
branch of the superficial temporal artery. The reconstruction of a hairy eyebrow, because it is the narrowest area
of hair-bearing skin, provides an excellent model to explore the potential of the narrow-pedicled hair-bearing

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flaps; however, it is not always possible to give adequate cover to the vascular pedicle in the grafted forehead of
the burned patient.
A narrow-pedicled, hair-bearing flap may be used as an alternative. As long as the pedicle includes the posterior
superficial temporal vessels, the hair-bearing flap can be angled to improve the direction of the hair. Bilateral
hair-bearing flaps were used in a patient with burn scarring of the forehead (Fig. 165.2).
It may well be, however, that one of the posterior superficial temporal vessels has been divided or used
previously for the construction of a forehead. It is then necessary to raise a flap with an even longer pedicle to
allow bilateral reconstruction of the eyebrow. Such a case is illustrated in Figure 165.3A. The contralateral
eyebrow could be shaped primarily, however. The ipsilateral eyebrow was too large and
had to be revised subsequently (Fig. 165.3B). Still, this exercise does indicate the potential of narrow-pedicled
flaps.
FIGURE 165.2 A: Narrow-pedicle flap being raised to reconstruct the right eyebrow. B-D: Composite picture of
bilateral reconstruction of eyebrows as narrow-pedicle flaps.

FIGURE 165.3 A: Extended narrow-pedicle flap for the bilateral reconstruction of the eyebrows. B-D: Composite
photograph showing bilateral reconstruction of the eyebrows with a single pedicle.
FIGURE 165.4 A-C: Composite photograph showing reconstruction of frontal temporal hairline and sideburns by
a superiorly based bipolar flap.
Frontal Temporal Hairlines and Sideburn
Two cosmetic units can be reconstructed by a superiorly based transposition flap of postauricular scalp. The
position of the normal hairline and sideburn is delineated (Fig. 165.4A), and the scar tissue is excised. A bipolar
flap is raised (Fig. 165.4B). The anterior flap completes the frontal hairline. The large posterior flap provides hair-
bearing skin to create the lateral temporal hairline and sideburn (Fig. 165.4C).

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FIGURE 165.5 A: Diagram illustrating reconstruction of preauricular defect following radical resection of the
parotid by transposed flap. B: Postoperative result.
Sideburns
Sideburns, particularly in men, are important in framing the face. They may be reconstructed by a flap based on
the posterior branch of the superficial temporal artery, but this flap needs to be rotated through almost 180
degrees at its base. Sometimes the pathology causing loss of the sideburn or its treatment also has caused loss
of the posterior branch of the superficial temporal artery. This may occur, for example, following radical parotid
surgery. If this has occurred, a transverse local transposition flap from the scalp based anteriorly, as illustrated in
Figure 165.5, may be used for reconstruction.

FIGURE 165.6 A: Diagram of flap based on the posterior branch of the superficial temporal artery for moustache
reconstruction. B: Diagram of flap after being raised. C: A narrow-based scalp flap raised for reconstruction of
moustache. D: Upper lip defect created by excising extensive scar tissue from trauma. E: Moustache
reconstruction. F: Final result.
Moustache
Large areas of full-thickness skin losses in the upper lips of men are readily reconstructed with a scalp flap
based on the posterior branch of the superficial temporal artery. Many different shapes of moustache can be
fashioned (6), but the standard reconstruction is shown in Fig. 165.6. The reconstruction should be symmetrical,
so the defect may have to be enlarged to the size of the cosmetic unit. The scars introduced by the flap are well
concealed by the hair of the flap. The reconstruction of a philtrum by introduction of an Abbé flap from the lower
lip will improve the appearance.
Full-thickness reconstruction of the upper lip can be achieved using a bipolar flap with a hair-bearing flap based
on the posterior branch of the superficial temporal artery providing skin cover; a hairless forehead flap based on
the anterior branch of the superficial temporal artery provides buccal cavity lining. When this reconstruction is
executed, it is usually necessary to add a tongue flap to reconstruct the vermilion border. This not only prevents
hairs turning into the oral cavity, causing irritation, but also improves the contour of the lip.
Beard
Reconstruction of areas of skin loss in the bearded patient should be repaired with hair-bearing skin. This is well
illustrated in a patient with severe acne keloid (Fig. 165.7A). Free skin grafts had been unsatisfactory. The
creation of a hemi-beard restored the cosmetic appearance with no recurrence of the keloid (Fig. 165.7B-D).

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A total beard area may be required, and it is important to note the position of the crown on the scalp and to take
scalp
tissue in front of this for the reconstruction whenever possible. Transfer of the scalp from the crown is safe, but it
can produce a bizarre appearance owing to the centrifugal direction of hair growth at this point.
FIGURE 165.7 A: Massive acne keloid of right bearded area. B: Raising of narrow-pedicle scalp flap. C: Scalp
flap inset. D: Final result showing reconstruction of the beard and absence of keloid.
The lower lip, following full-thickness loss, can be reconstructed like the upper lip. Again, a tongue flap should be
introduced to provide a vermilion border. It is also possible to reconstruct both the moustache and beard areas
with one flap (Fig. 165.8). When this is done, a central incision is made in the flap, taking care to avoid dividing
any major vessels, to provide an oral stoma. A tongue flap is introduced to provide a vermilion border to the
lower lip and to the upper lip, if necessary. Local transposition flaps may have to be introduced into the
commissures to increase mobility between the lips.
RECONSTRUCTION OF NON-HAIR-BEARING AREAS OF THE FACE AND ORAL
CAVITY
Areas of baldness in men can be used to reconstruct non-hair-bearing areas of the face and lining of the oral
cavity. A large central area of baldness on the vertex can be used for extensive intraoral reconstruction. Smaller
areas of bald scalp may

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be found in a receding anterior hairline, and these also can be used for reconstructing non-hair-bearing areas
with benefit.
FIGURE 165.8 A: Excision of multiple squamous carcinomas of the upper lip, nose, and lower lip in a patient
with xeroderma pigmentosa. B: A single flap raised for reconstruction of the upper and lower lip and
simultaneous forehead flap for reconstruction of the nose. C: Flaps inset. Central flap incised to create the
mouth and tongue flap introduced. D: Postoperative result.
RECONSTRUCTION OF HAIR-BEARING AREAS OF SCALP
Many small defects of the scalp can be reconstructed by expanding local flaps. This is achieved by reflecting the
flaps back to their base at the edge of the scalp and dividing the galea with multiple incisions, allowing
advancement or expansion of the flap into the defect (7). Flaps may be raised on either side of the defect to
achieve closure. Each flap should be broad based, but it can be narrow if one of the named vessels lies within its
base.

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Larger scalp defects are reconstructed with transposition flaps. The ideal donor site is in the occipital region,
where the resultant defect is repaired with a split-thickness skin graft. This is subsequently covered by hair
growing down from the vertex above. Flaps from this region can be based anteriorly on the supraorbital vessels
or posteriorly on the occipital vessels. Greater versatility is achieved when the flaps are based on the
contralateral posterior branch of the superficial temporal artery.
FIGURE 165.9 A: Defect following craniofacial resection of tumor of the orbit and middle cranial fossa. B: Entire
remaining scalp raised on a broad pedicle flap. C: Flap transposed and sutured into position to cover the defect.
D: Two-flap repair to reconstruct the right upper half of face and to cover the craniotomy.
REPAIR OF DEFECTS OF THE FACE AND SKULL
Occasionally, scalp flaps based on the posterior branch of the superficial temporal artery can be used to provide
immediate cover to large defects of the face and skull and may be useful in extensive trauma or following failure
of other flaps. They are perhaps more often applicable following extensive craniofacial resections (Fig. 165.9A).
A large posteriorly based combined scalp and forehead flap (Fig. 165.9B) can be used to line the orbital cavity,
adjacent areas, and the craniotomy suture line of the osteoperiosteal flap (7) (Fig. 165.9C). When the wounds
have healed, the hair-bearing part may be excised or partly returned, leaving the galea to be covered with split-
thickness skin grafts or other flaps (6).
A single broad, posteriorly based flap may be used to cover the defect following radical resection of the temporal
bone (7).
ANATOMY
The scalp consists of soft tissue lying external to the calvaria. It is bounded by the eyebrows overlying the

supraorbital ridges and laterally and posteriorly by the margins of the hair-bearing skin. Some hair-bearing skin
usually extends onto the nape of the neck below the superior nuchal line of the occipital bone. The scalp
contains a large non-hair-bearing area, the forehead. The anatomy of the latter is described in Chapter 106. The
scalp has five tissue layers: skin, subcutaneous tissue, the galea aponeurotica and its muscle bellies of frontalis
and occipitalis, a layer of loose areolar tissue, and pericranium. The principal blood vessels lie in the
subcutaneous layer of the galea.
The blood supply of the scalp is rich and is derived from the terminal branches of both the internal and external
carotid arteries. There is a rich network of vessels throughout the scalp, fed by six principal arteries (Fig.
165.10). The supraorbital and supratrochlear arteries are derived from the internal carotid artery and emerge
from the roof of the orbit to pass vertically upward, supplying the forehead and anterior part of the hair-bearing
area of the scalp. The superficial temporal artery (see Fig. 165.10) is a terminal branch of the external carotid
artery. It emerges from the parotid gland to pass over the zygomatic process of the temporal bone, against which
it can be palpated 1 cm in front of the tragus. It passes vertically upward for approximately 4 cm before dividing
into anterior and posterior branches. The anterior branch follows a convoluted path forward to supply the non-
hair-bearing skin of the forehead. The posterior branch passes vertically upward in a straighter course toward
the vertex of the scalp. Variations of the normal distribution have been reported (8).
The posterior auricular artery is a small branch of the external carotid artery given off above the digastric muscle.
It passes under the parotid gland toward a groove between the cartilage of the auricle and the mastoid process,
where it divides to supply branches to the area of scalp behind the pinna.
FIGURE 165.10 Radiograph of cadaveric scalp after injection of Micropaque showing the vascular anastomoses.
STA, superficial temporal artery; ANT, anterior branch.
The occipital artery is another branch of the external carotid artery. It is given off below the origin of the posterior
auricular artery. It arises from the posterior aspect of the external carotid artery and passes along the deep
surface of the posterior belly of the digastric muscle. It ascends toward the mastoid process, where it divides into
several branches supplying the surrounding muscles. The terminal branch supplies the posterior aspect of the
scalp and the occipitalis muscle.
Within the scalp, the venous drainage is similar to the arterial supply, although it differs beyond its limits. The
lymphatic drainage follows the venous drainage, but there are no lymph nodes on the scalp.
Although the anatomy of the scalp has been known and well documented for centuries, it was recognized only
recently that the blood flow pattern within the scalp does not necessarily follow the basic anatomic vascular
arrangements. Because of the rich network of vessels, changes can occur in the flow pattern without any
significant change in the viability of tissue that these vessels supply.
Investigations on cadaver scalps and on clinical cases (1, 2) revealed that an area of hair-bearing skin could be
safely carried on a long narrow pedicle containing the posterior branch of the superficial temporal artery, and as

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long as the vessel was contained in the pedicle of the flap, anastomoses with adjacent angiotomes or vascular
territories were adequate to maintain viability of the flap. Clinical cases of scalp replantation have demonstrated
that the entire scalp can survive on one set of vessels (9).
The posterior branch of the superficial temporal artery is the longest vessel in the scalp, and it supplies directly
the largest territory of the scalp. This, together with its position, makes it the most versatile vessel for transferring
scalp flaps outside the region of the scalp. It can be used to transfer small delineated areas of the scalp or,
indeed, the entire scalp by forming a two- or three-angiotome system similar to the multiangiotome system in the
forehead (3).
FLAP DESIGN AND DIMENSIONS
Scalp Flaps Based on the Posterior Branch of the Superficial Temporal Artery
Investigation of the vascular anatomy of the scalp and clinical practice have confirmed that it is possible to raise
a narrow-pedicled hair-bearing flap of sufficient length to reconstruct any defect on the face. The flap with the
best blood supply extends transversely across the vault of the scalp from ear to ear, including the ipsilateral and
contralateral posterior branches of the superficial temporal vessels. The flap may be 30 cm long and only a few
centimeters wide, provided these vessels are included in the flap. Figures 165.11A and B illustrates a combined
forehead and scalp flap. Fig. 165.11C illustrates the level to which it can be taken on the contralateral side. The
total hair-bearing area of the scalp can be transposed on a narrow pedicle if it contains the posterior branches of
the superficial temporal vessels. We have not had to raise such a flap, but we had one patient in whom two
thirds of the hair-bearing area of the scalp was raised and successfully transposed (Fig. 165.12). The entire
scalp, including the forehead, could be raised if based on the superficial temporal vessels at a point just anterior
to the tragus of the ear. This would provide a flap
of adequate length and size to cover any defect on the face or upper neck, but a clinical situation requiring this
procedure must be rare.
FIGURE 165.11 Varying applications of hair-bearing scalp flaps. They show the potential diversity in design that
is provided by the superficial temporal artery, its posterior branches, and anastomoses. A: Thirty-centimeter
scalp flap based on a narrow pedicle containing the superficial temporal artery. B: Combined scalp and forehead
flap. C: Inset of narrow-based scalp flap to two thirds of the lower face.
Most scalp flaps used in clinical practice vary in size between the long, narrow pedicle flap and the total hair-
bearing area of the scalp. Provided the posterior branch of the superficial temporal artery remains patent
entering the base and within the pedicle, the flap will remain safe and can be cut to produce any reasonable

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shape required. Fig. 165.6 illustrates the use of a flap to reconstruct an upper lip defect with a moustache.
FIGURE 165.12 Large scalp flap based on a narrow pedicle.
At operation, the defect to be reconstructed should be enlarged to the shape of an appropriate cosmetic unit. It is
preferable that beards and moustaches be made symmetrical where possible. A template of the appropriate
defect is made. The template is swung onto the vertex of the scalp, with a pivot point based 1 cm above the
zygomatic arch of the temporal bone, over a point where the superficial temporal artery can be palpated. If a
longer pedicle is required to avoid tension, it can be extended to a pivot point just anterior to the tragus of the
ear. The template is placed on the scalp in front of the crown in order that hair growth will be in the correct
direction, particularly for reconstructing the moustache and beard areas of the face. The flap is marked out with a
2-cm pedicle down to the zygomatic arch.
Other Scalp Flaps
Scalp flaps based on the other named vessels of the scalp can be used to transfer large areas of hair-bearing
scalp. Very long flaps across the scalp can be raised, but their base should be 12 cm wide to ensure inclusion of
the named vessels, as these are smaller than the posterior branches of the superficial temporal vessels and are
less easily identified preoperatively or perioperatively until the flap is almost fully raised.
Combined scalp and forehead flaps are used to provide immediate cover following craniofacial resections (10).
OPERATIVE TECHNIQUE
Careful preoperative preparation of the scalp is essential when using scalp flaps. The superficial temporal artery
and its branches are palpated, and their course in the scalp is marked. The Doppler probe is not normally
necessary for tracing the vessels. The hair in the area to be used should be cut short enough to identify any
previously unrecognized scars. With dense hair, the scalp should be shaved, but with
sparse hair, this step may not be necessary; preservation of hairs 0.5 cm long allows identification of direction of
hair growth. It is always desirable to shave the planned margins of the flap completely. After the hair has been
cut, the whole scalp should be shampooed and thoroughly washed to remove all cut hairs.
The flap is raised from the contralateral side first. It is raised in the plane beneath the galea aponeurotica. Care
must be taken to avoid raising the pericranium, which must be preserved for subsequent application of a split-
thickness skin graft.
As the flap is raised across the midline, the posterior branch of the superficial temporal artery and its

accompanying veins come into view on the undersurface. The pedicle then is fashioned to include these vessels
in the center of the pedicle as it is raised down to the zygomatic arch (Fig. 165.6). The anterior branch of the
superficial temporal artery is divided as this is done. The pedicle then can be turned safely at its base to allow
the flap to be inset into the defect.
In most cases, 90% of the flap can be inset, which allows safe division of the flap at 2 weeks. Occasionally, it
may be desirable to leave the flap longer before dividing the pedicle. There is no necessity to cover the posterior
aspect of the pedicle with grafts; indeed, to do so would make return of the pedicle more difficult. Normally, the
posterior aspect of the pedicle can be covered with paraffin gauze. The donor defect of the scalp usually is
covered with a split-thickness skin graft. If the defect is small, it may be closed primarily, and this can be made
easier by reflecting back the local scalp flaps and incising the galea before advancing them into the defect (1).
If the posterior branches of the superficial temporal vessels are not available, it may be possible to use the
contralateral posterior branches of the superficial temporal vessels. If these vessels are not available, a broad-
based 12-cm flap may be required; however, a broad-pedicled flap is less mobile and therefore should be 1½
times longer than the appropriate pedicled flap. The flap is raised in the same manner.
Modifications in Technique
Split Flap
Where two adjacent hair-bearing areas require reconstruction, the flap may be axially split into two parts. This is
well illustrated in Figure 165.13A, in a patient with an unsatisfactory repair of a gunshot wound of the lower third
of the face. The pedicle skin of the previous repair was used to provide adequate lining, and the resultant defect
in the upper lip and chin was repaired by providing hair-bearing flaps shaped as a beard and moustache carried
on a single pedicle containing the posterior superficial temporal artery (Fig. 165.13).
Multiple Flaps
Bilateral scalp flaps can be synchronously combined with a modified Converse forehead flap to create an
eyebrow and moustache and to reconstruct the nose. Additional hair-bearing skin can be gained by using the
hair-bearing pedicle of the moustache flap following a delay procedure at 14 days to fill in the defect in the
bearded area of the chin (Fig. 165.8).
Two-Flap Repair
Very large craniofacial defects require the introduction of two flaps (Fig. 165.9). Immediate skin cover to the face
and left lateral skull is provided by a combined forehead and scalp flap based on the posterior superficial
temporal vessels. This supplies support to the frontal lobe of the brain. A broad-based contralateral flap is
transposed forward to overlie the part of the craniotomy suture line not covered by the first flap. The hair-bearing
scalp in the forehead region subsequently may be excised, and a nonhairy split-thickness skin graft is applied to
the forehead.
CLINICAL RESULTS
We have used long, vascularly based flaps in more than 180 patients. Most were used in reconstructions of
defects in the moustache and beard area, and in these patients, the cosmetic results have been excellent,
primarily because the hair growth conceals the quality of the underlying skin and camouflages surrounding
scars.
Owing to their vascularity, these flaps are not only easy to raise but relatively free of complications. We
have had only six patients in whom there has been a small area of flap necrosis. The area of loss was
small, and the defect was reconstructed by further advancement of the scalp flap. We have not encountered

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a case of total loss.
In only two patients was any significant infection detected. There was no problem with hematoma formation
in any flap, undoubtedly owing to the fact that there is no overt bleeding from the galea. The only significant
bleeding from the flap is from the edges. This is controlled, of course, as the flap is inset.
On several occasions we noted some hair loss from the flap, but it was temporary and there was
subsequently normal growth of hair in the flap. In one patient, the pericranium was inadvertently raised from
the skull, and the defect had to be covered with a local transposition flap.
Asymmetry of reconstructed hair-bearing cosmetic units can be corrected by electrolysis or the
subcutaneous excision of hair follicles. Major irregularities of hair growth in comparison with the normal side
can be adjusted by the excision of the hair-bearing skin and its replacement by a full-thickness skin graft or
local flap.
The donor area of the flap has not proved to be a significant problem, as many elderly patients readily
accept a small grafted area on the scalp. When small flaps are used, the donor defect sometimes can be
closed primarily, although this is often difficult in elderly patients. Expansion flaps can be used to assist this
primary closure, particularly in the younger patient. Transposition flaps can be used to cover obvious bald
areas at the expense of less obvious areas. Alternatively, serial excision of the bald area successfully
repairs the bald area. Large defects are most readily concealed by a toupee or wig. Wigs have been
acceptable to a few female patients on whom we have used this flap. There is always an area of loss of
sensation of the scalp following the use of these flaps, but only one of our patients has complained of this.
SUMMARY
Various modifications of hair-bearing scalp flaps can be used to reconstruct multiple defects about the face.

FIGURE 165.13 A: Unsatisfactory repair of gunshot wound to upper and lower lip. B: Pedicle skin used to
create lining of pseudo-exposed vermilion border. Pattern made of defects. C: Pattern of the two flaps on a
narrow-based pedicle. D: Flaps raised. E: Flaps inset. F: Postoperative results.
References
1. Wilson JSP, Galvao MSL, Brough MD. The application of hair-bearing flaps in head and neck surgery.
Head Neck Surg 1980;2:386.
2. Wilson JSP, Galvao MSL. Some observations on facial reconstruction by the use of hair-bearing flaps. In:
Proceedings of the VIIth International Congress of Plastic and Reconstructive Surgery, Rio de Janeiro, May
1979. São Paulo: Sociedade Brasileira de Cirurgia Plastica, 1980.
3. Wilson JSP. Major flaps in the reconstruction of defects of the head and neck. In: Chambers RG, ed.
Cancer of head and neck: proceedings of an international symposium. Amsterdam: Excerpta Medica,

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1975;256-279.
4. Brent B. Reconstruction of ear, eyebrow, and sideburn in the burned patient. Plast Reconstr Surg
1975;55:312.
5. Wilson JSP. 478 Major flaps in head and neck reconstruction: some observations on scalp, narrow pedicle
forehead and deltopectoral flaps. In: Transactions of the Sixth International Congress of Plastic and
Reconstructive Surgery. Paris: Masson, 1975.
6. Edgerton MT, Snyder GB. A combined intracranial-extracranial approach and the use of the two-stage
split-flap technique for reconstruction with craniofacial malignancies. Am J Surg 1965;110:595.
7. Westbury G, Wilson JSP, Richardson A. Combined craniofacial resection for malignant disease. Am J
Surg 1975;130:463.
8. Stock AL, Collins HP, and Davidson TM. Anatomy of the superficial temporal artery. Head Neck Surg
1980;2:466.
9. Miller GDH, Anstee EJ, Snell JA. Successful replantation of an avulsed scalp by microvascular
anastomosis. Plast Reconstr Surg 1976;59:133.
10. Wilson JSP, Westbury G. Combined craniofacial resection for tumours involving the orbital walls. Br J
Plast Surg 1973;26:44.

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Chapter 166
Stepladder Skin-Muscle-Mucosal Flap for Lower Lip
Reconstruction
A. D. PELLY
E.-P. TAN
It is generally accepted that the orbicularis oris should be reconstructed following major resections of the lower
lip. Many methods involving full-thickness flaps from the upper lip are likely to produce further functional
disruptions of the circumoral sphincter. Dissatisfaction with these methods of repair led surgeons to develop
alternative techniques (1, 2, 3).
INDICATIONS
We present a technique of lower lip repair that allows adequate excision of the primary lesion, respects the
functional integrity of the upper lip, and permits reconstruction of the circumoral sphincter in the same
operation (4). This technique has been used without complication in reconstruction of defects of half the
lower lip extending to the commissure (Figs. 166.1 and 166.2). The technique has been extended to restore
the oral sphincter following damage to the ramus mandibularis of the facial nerve.
OPERATIVE TECHNIQUE
The extent of a full-thickness excision of the lip is outlined along with a stepladder incision over the right side of
the lower lip (Fig. 166.1A). The lesion is excised, and the right lower lip is advanced by the stepladder technique
(Fig. 166.1B). A prophylactic vermilionectomy is carried out on the remainder of the right lower lip.
A mucosal flap then is fashioned in the left lower buccal sulcus. This incision extends backward to the molar
region, and with the help of a generous back cut in the cheek mucosa, the mucosal flap then can be rotated and
advanced to meet the mucosa over the right side of the lower lip. A flap of skin only is designed over the left
cheek (Fig. 166.1B). This is advanced medially and rotated superiorly to provide skin cover. No muscle is
included in this flap.
The cheek mucosal flap then is sutured to the lip excisional defect to provide complete mucosal lining. The
stepladder incision is advanced and sutured. The covering skin flap is raised and advanced into position (Fig.
166.1C). The skin is sutured,
and the only residual raw area is over the free border of the lower lip close to the commissure, where the
mucosal lining flap and the external skin flap are apposed (Fig. 166.1D).

FIGURE 166.1 A: Extent of the excision and the stepladder flap outlined. B: Flap (B) (including all of cross-
hatched area) consists of skin only. A prophylactic vermilionectomy is carried out over the remainder of the lower
lip. (Continued)
FIGURE 166.1 Continued. C: Mucosal flap (A) from the buccal aspect of the left lower lip is sutured into place.
D: Flap A is sutured into place, and flap B (Fig. 166.1B) is advanced to fill the defect. E: A musculomucosal flap
from the left upper buccal sulcus is designed. F: The musculomucosal flap is used to complete the repair. (From
Pelly, Tan, ref. 4, with permission.)

FIGURE 166.2 A: An elderly man presented with a malignant lesion that required surgical excision of the left half
of the lower lip. The lesion was excised and repaired as described. B: Result 6 weeks postoperatively. C,D:
Three months later, electromyography showed normal electrical activity in the transposed muscle flap. The
appearance and function of the mouth, both at rest and in action, were satisfactory. (From Pelly, Tan, ref. 4, with
permission.)
A mucomuscular flap then is fashioned on the buccal aspect of the left upper lip. It is based at the modiolus, is 3
cm long and 1 cm wide, and contains the full thickness of the middle third of the orbicularis muscle. The flap is in
the general horizontal line of the circumoral sphincter (Fig. 166.1E).
The flap is transposed and sutured into the defect at the free border of the left lower lip. The muscular
component is sutured to the orbicularis of the right side of the lip to restore the continuity of the circumoral
sphincter. The mucosal component completes the lip border (Fig. 166.1F).
SUMMARY
The stepladder skin-muscle-mucosal flap combination can be used to provide a functional lower lip
reconstruction without unnecessarily violating the upper lip.
References
1. Fries I. Advantages of a basic concept in lip reconstruction after tumour resection. J Maxillofac Surg
1973;1:73.
2. Johanson B, Aspelund E, Breine U, Holmstom H. Surgical treatment of nontraumatic lower lip lesions with
special reference to the step technique. Scand J Plast Reconstr Surg 1974;8:232.
3. Puckett CL, Neale HW, Pickrell KL. Dynamic correction of unilateral paralysis of the lower lip. Plast

Reconstr Surg 1975;55:397.
4. Pelly AD, Tan E-P. Lower lip reconstruction. Br J Plast Surg 1981;34:83.

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Chapter 167
“Bandoneon” Technique: Mucomyocutaneous Stretched Flaps in
Lip Reconstruction
I. J. PELED
Y. ULLMANN
EDITORIAL COMMENT
The innovative nomenclature of this flap is appropriate in that the musical instrument called a bandoneon is
like an accordion that stretches and contracts as required. The authors have used this principle in
stretching the tissue for lip reconstruction.
Up to two thirds of the lip can be repaired by using a mucomyocutaneous flap in the remaining lip, which is
stretched as a “bandoneon,” following a zigzag release incision (Fig. 167.1). Results are quite satisfactory, with
no alteration of the commissure, no significant decrease of mouth opening, and well-located scars.
INDICATIONS
Tumors of the lip are quite frequent, especially squamous cell carcinomas. The best treatment is adequate
surgical excision, with immediate repair of the defect. Depending on the remaining defect after tumor
excision, the choice can be as simple as direct suture, or more sophisticated techniques may be required.
The flap described here is suitable for the repair of rather large defects in partial reconstruction of the lip
using one or two mucomyocutaneous flaps of the remaining lip in a single-stage procedure. Following wide
excision of the tumor and frozen sections of the borders, the remaining defect, from one third to two thirds of
the lip, is reconstructed by the bandoneon technique.
Other reports have described use of this procedure for the vermilion only (1, 2) or for lip reconstruction
without incising the mucosa (3). Some techniques leave unacceptable scarring and may alter the angle of
the mouth (4, 5).
ANATOMY
This is an arterial flap supplied by the inferior coronary (orbicularis) artery.

FIGURE 167.1 Lower-lip defect following excision of squamous cell carcinoma. A: Zigzag drawn at labiomental
horizontal junction delimits the flap. B: Following incision and complete release of the flap from buccal mucosa.
C: The “bandoneon” stretched flap is advanced to bridge the gap. D: Early postoperative result showing scar
and satisfactory cosmetic result.
FLAP DESIGN AND DIMENSIONS
The commissure is not sacrificed, and the scar is strategically placed in the labiomental junction or nasolabial
groove. Continuity of the remaining orbicularis oris muscle is preserved, and by suturing the cut edges the
sphincter mechanism can be reconstructed.
OPERATIVE TECHNIQUE
With the patient under local or general anesthesia, the tumor is excised with reasonable margins, and adequacy
is established by intraoperative frozen sections. For defects in the lower lip, the horizontal line of the excision at
the junction of the lip with the mental area is laterally prolonged in a zigzag or running double W up to or passing
the level of the contralateral corner of the mouth (Fig. 167.1A). This is a full-thickness incision including skin,
muscle, and mucosa of the lip.
The remaining lip is raised as a flap and completely freed from the soft-tissue mandibular attachment (Fig.
167.1B). The flap is stretched toward the lateral border of the lip defect (Fig. 167.1C) and sutured in three planes
(i.e., mucosa, muscle, and skin) without tension. The running double W facilitates horizontal advancement, and
the small triangles are further positioned and indented. The broken scar line makes it less visible, and there is
less scar contracture (Fig. 167.1D).
In medial defects of the lower lip, the same principles can be followed. Two lateral lip flaps in the remaining
tissue, adjacent to the angle of the mouth, can be horizontally advanced to bridge the gap. This allows
reconstruction of a defect of two thirds of the lower lip. The same procedure can be performed in defects of the
upper lip. In these cases, the running W horizontal incision is placed at the nasolabial groove, resulting in an
inconspicuous scar.

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CLINICAL RESULTS
Using well-vascularized mucomyocutaneous flaps, all cases healed primarily without any complication.
Minimal scarring and good placement of scars, as well as the unaltered angle of the mouth, are significant
contributors to a good aesthetic and functional result. The strategic location of the scars is in the natural
labiomental junction or nasolabial groove, and dogears are avoided. Continuity of the remaining orbicularis
oris muscle is preserved. By suturing the cut edges, the sphincter mechanism can be reconstructed.
SUMMARY
This simple procedure offers reconstruction of a defect of up to two thirds of the lip, with no alteration of the
angle of the mouth, with well-located scars, and with good aesthetic and functional results in suitable cases.
References
1. Goldstein MH. A tissue-expanding vermilion myocutaneous flap for lip repair. Plast Reconstr Surg
1984;73:786.
2. Mutaf M, Sensoz O, Tuncay E. The split-lip advancement technique (SLAT) for the treatment of congenital
sinuses of the lower lip. Plast Reconstr Surg 1993;92:615.
3. Galli JJ. Reconstrucion del labio inferior. Rev Cir Plast Argent 1985;8:3.
4. Webster RC, Coffey RJ, Kelleher RE. Total and partial reconstruction of the lower lip with innervated
muscle bearing flaps. Plast Reconstr Surg 1960;25:360.
5. Karapandžić M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93.

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Chapter 168
Nasolabial (Gate) Skin-Muscle-Mucosal Flap to Lower Lip
R. FUJIMORI
EDITORIAL COMMENT
This procedure certainly accomplishes what it sets out to do; however, the editors are concerned with the
innervation to the upper lip unless care is taken not to damage the muscle while making the nasolabial
incisions.
There are only a few reports in the literature on total lower lip reconstruction using innervated muscle-bearing
flaps (1, 2). However, when planning a complete reconstruction of the lower lip, the following points should be
considered: First, the flaps used should be local flaps, including innervated muscle. Second, all the suture lines
should be in natural facial creases or follow the function lines of the various facial aesthetic units. Finally, the
flaps should be large enough to replace tissue loss.
INDICATIONS
Some previous techniques (3, 4, 5), although producing excellent functional and aesthetic results, created a
tight lower lip with obvious protrusion of the upper lip. Other procedures also produced a large dog-ear on
either side of the mentolabial groove, requiring that large amounts of skin be discarded postoperatively for
correction.
The gate flap (6), which uses a flap from each nasolabial fold, is an improvement over previous procedures.
The main advantages of this design are (a) the flap can be made 3 cm larger than nasolabial rotation flaps,
(b) rotation of the flap is possible without the formation of a dog-ear, (c) the flap contains innervated muscle,
and (d) the procedure can be carried out in one stage.
OPERATIVE TECHNIQUE
The whole of the affected lower lip is excised as a rectangle (Fig. 168.1A, BB' DD'). The inferior margin of
resection ( DD') follows the mentolabial groove. Whenever possible, a 3- to 4-mm-wide strip of labial mucous
membrane is left attached near the labioalveolar sulcus. The lateral margin of resection ( BD and B' D') is usually
placed 0.5 to 1.0 cm laterally to perpendiculars dropped from the labial commissures ( OO′), but it may extend 2
cm laterally in older patients with wrinkled faces. The width of the nasolabial skin-muscle-mucosal flaps ( BC =
DE, B' C′ = D' E') is usually 3 cm, and the suture lines of the flap donor sites ( AED, A' E' D') should follow the
natural nasolabial fold. The dotted lines ( AlB, AmC, A' l' B' , A' m' C′) represent incisions made through the
mucous membrane, which should be about 1 cm wider than the flap itself, so excess mucous membrane can be
available for reconstruction of the new red lip.
When making flap incisions CED and C'E'D' below the line CC' that connects both labial commissures, only skin
and subcutaneous tissue should be cut, keeping the muscle, and mucous membrane intact in the flap pedicle.
Further undermining of the flap pedicle skin is required to allow flap rotation. Flaps prepared in this fashion
contain innervated

muscles: orbicularis oris, caninus, zygomaticus major or minor, risorius, triangularis, and buccinator.
FIGURE 168.1 Gate flap. A: Distance OB = O'B' = 0.5 to 1.0 cm in normal patients, but it can be extended to 2
cm in the case of older patients with wrinkled faces. Distance BC = B'C' = 3 cm. Skin incision along AB and AC
should be made through-and-through into the mouth. Skin incision along CE and ED should be made only
through subcutaneous tissue. Incision in the mucous membrane is performed along the dotted lines (AlB, AmC,
A'l'B', A'm'C') that run laterally to the skin incision lines (AB, AC). Dotted area is undermined subcutaneously. B:
Suture lines run along the nasolabial fold and mentolabial groove centrally. (From Fujimori, ref. 6, with
permission.)
As soon as the flaps have been mobilized, incisions should be closed in the four layers of mucous membrane,
muscle layer, subcutaneous tissue, and skin. The excess mucous membrane above the upper border of the
transposed flap is used to replace vermilion. This new red lip will be thinner than the normal lip. Because of
cicatricial contraction, the newly reconstructed lower lip tends to become puffy and rounded. This distortion can
be effectively corrected by keeping continuous pressure on the lower lip by the sponge fixation method for 3
months postoperatively.
FIGURE 168.2 A: The carcinoma was excised and skin incisions for the flap were made in the nasolabial folds.

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B: The flaps raised. C,D: Flaps rotated and sutured. (From Fujimori, ref. 6, with permission.)
A final procedure involving Z-plasties or scar revision is often required 3 months postoperatively, after the tissues
have become supple (Figs. 168.2 and 168.3).
FIGURE 168.3 A: Squamous cell carcinoma of the lower lip. B: Gate flap rotated. C,D: Six months
postoperatively.
CLINICAL RESULTS
Because these flaps contain innervated muscle, the newly reconstructed lower lip has good motor function.
These flaps have a good blood supply and can be moved into the excisional defect in one stage without any
delay procedure.
SUMMARY
The gate skin-muscle-mucosal flap can be used to provide a functional reconstruction of the entire lower lip.
References
1. Webster RC, Coffey RJ, Kellecher RE. Total and partial reconstruction of the lower lip with innervated
muscle-bearing flaps. Plast Reconstr Surg 1960;25:360.
2. Karapandžić M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93.

3. Wang MKH, Converse JM, Macomber WB, Wood-Smith D. Deformities of the Lips and Cheeks. In:
Converse JM, ed. Reconstructive plastic surgery. Philadelphia: WB Saunders, 1967;851.
4. Lentrodt J, Luhr HG. Reconstruction of the lower lip after tumor resection combined with radical neck
dissection. Plast Reconstr Surg 1971;48:579.
5. Bretteville-Jensen G. Reconstruction of the lower lip after central excisions. Br J Plast Surg 1973;26:247.
6. Fujimori R. “Gate flap” for the total reconstruction of the lower lip. Br J Plast Surg 1980;33:340.

Chapter 169
Steeple Skin-Muscle-Mucosal Flap for Lower Lip Reconstruction
M. F. STRANC
G. A. ROBERTSON
The repair of extensive lower lip defects has challenged the ingenuity of reconstructive surgeons for many years
(1, 2, 3, 4, 5, 6, 7). The methods that have evolved can be broadly classified into three categories: those using
lip tissues, those that rely on head and neck tissues, and those in which reconstructive material is brought in
from a distance.
INDICATIONS
Satisfactory reconstruction of the lower lip must provide a lip curtain of adequate dimensions with sufficient
muscular activity and sensory appreciation to allow normal speaking, drinking, and eating. It also must
provide adequate access to all parts of the oral cavity and present an acceptable appearance.
Only locally available tissues are likely to meet these criteria. The problems become particularly acute when
more than half the lip is missing. The steeple flap was designed to help this group of patients (8).
FLAP DESIGN AND DIMENSIONS
Following marking of the extent of the incision, the defect is converted into a rectangle, with the short side
indicating the height of the lip resection and the long border marking the length of the excised lip. The island flap
is marked out by extending the lower line of excision laterally for a distance equal to the height of the resected
lip. Vertical sides of the island equal to the length of the resected lip are marked. A skin triangle is marked at the
top to allow straight-line wound closure (Fig. 169.1A). The facial artery and its labial branches are located and
marked. A Doppler device is of considerable assistance at this stage.
OPERATIVE TECHNIQUE
The lesion is excised as planned. The skin and subcutaneous tissues are incised around the flap. The incision is
deepened to full thickness superiorly, inferiorly, and medially. The facial artery is identified on the superomedial
aspect of the flap and tied. Tension on the tied vessel helps precise and safe location of the artery on the lateral
side (Fig. 169.1B). Once the vessel is located, incisions above and below it are deepened to full thickness to
within 5 mm of the vessel. Mucosa deep to the artery is divided, allowing transposition of the cheek tissues into
their new site.
The planning of mucosal incisions for reconstruction of the vermilion relates directly to the site of entry of the
facial artery into the flap. When the artery enters the flap low, cheek tissues are “tumbled” into the lip defect, with
mucosa along the lateral border cut to excess to provide material for vermilion reconstruction (Fig. 169.1C).
When the artery enters the flap high, the cheek tissues are slid into the lip defect; mucosa along the medial
border of the island is used for vermilion reconstruction (Figs. 169.1D and 169.2).
CLINICAL RESULTS
This method was used in ten patients. In two patients, total lip reconstruction with bilateral steeple flaps was
undertaken. A satisfactory lip curtain was produced in all instances. It is interesting that significant

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microstomia was avoided in all patients. The average intercommissural distance for the group was 4.9 cm.
The lowest recorded distance was 3.8 cm in a patient who had a total lower lip reconstruction. The recovery
of cutaneous sensation varied, depending on the interval between surgery and assessment. All patients
showed evidence of motor activity, both clinically (Fig. 169.3) and electromyographically. The length of
follow-up varied from 6 to 27 months. Occasional dribbling of fluids, caused by an incomplete motor and
sensory recovery, was noted in three patients.
The appearance of the reconstructed lip pleased all patients but one. From our point of view, the
appearance of the lips was satisfactory, but an unpleasant fullness of lip was noticeable during lip closure,
almost certainly the result of slow resolution of edema, scar contraction, and an incorrect orientation of the
underlying muscle fibers.
There were no instances of flap loss. In one patient, excessive swelling postoperatively necessitated the
removal of mucocutaneous sutures. No tissue loss occurred, but healing was delayed.
A patient with total lower lip reconstruction using bilateral steeple flaps, an 80-year-old man, suffered minor
dehiscence of the suture line between the two flaps (Fig. 169.4). Spontaneous healing occurred without
significant scarring.
SUMMARY
The steeple skin-muscle-mucosal flap has been designed for functional lower lip reconstruction. Bilateral
flaps can be used to reconstruct the entire lower lip.
FIGURE 169.1 A: Plan of surgery. B: Maneuver for safe identification of the facial artery. C: Island flap
“tumbled” into position. D: Island flap slid into position. (From Stranc, Robertson, ref. 8, with permission.)

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FIGURE 169.2 A: Planning of surgery following positive biopsy for squamous cell carcinoma in a 50-year-
old man. B: Island flap fully mobilized. (Continued)
FIGURE 169.2 Continued. C: Formation of new lip. D: Appearance 18 months after reconstruction.
FIGURE 169.3 A 55-year-old man showing clinical evidence of motor function of reconstructed lip 27
months after surgery.

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FIGURE 169.4 An 80-year-old man with squamous cell carcinoma. A: Bilateral steeple flaps for total lower
lip reconstruction. B: Final result. (From Stranc, Robertson, ref. 8, with permission.)
References
1. Owens N. Simplified method of rotating skin and mucous membrane flaps for complete reconstruction of
the lower lip. Surgery 1994;15:19.
2. May H. The modified Dieffenbach operation for closure of large defects of the lower lip and chin. Plast
Reconstr Surg 1946;1:194.
3. Gillies H, Millard DR, eds. The principles and art of plastic surgery, Vol. 2. Boston: Little, Brown,
1957;507.
4. Freeman BS. Myoplastic modification of the Bernard cheiloplasty. Plast Reconstr Surg 1958;21:453.
5. O'Brien BM. A muscle-skin pedicle for total reconstruction of the lower lip. Plast Reconstr Surg
1970;45:395.
6. Olivari N. One-stage reconstruction of the whole lower lip. Br J Plast Surg 1973;26:66.
7. Karapandžić M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93.
8. Stranc MF, Robertson GA. Steeple flap reconstruction of the lower lip. Ann Plast Surg 1983;10:4.

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Chapter 170
Upper Lip Angular Skin-Muscle-Mucosal Flap to Lower Lip
C. R. BALCH
A cross-lip flap from the upper lip provides the best repair for many defects of the lower lip (1). The angular
musculocutaneous flap minimizes the resulting deformity in the donor (upper) lip that is frequently associated
with other flap designs (2, 3).
INDICATIONS
The elasticity of the lips and the design of the angular flap allow this flap to be used for reconstruction of
large wedge, rectangular, or trapezoidal defects of the lower lip. After creation of the flap, its shape may be
modified to fit the defect. The scar of the upper lip is partly concealed in the nasolabial fold (see Fig. 170.2).
FIGURE 170.1 A: Design of the angular cross-lip flap. B: Rotation of the flap and closure of the donor site.
(From Balch, ref. 1, with permission.)
FLAP DESIGN AND DIMENSIONS
An angular flap is designed on the upper lip (Fig. 170.1A). Line a is in the nasolabial fold. Line c is perpendicular
to the vermilion border and is placed as far laterally as possible without sacrificing the commissure. The position
of line d is determined by the width of the lower lip defect. The width of the flap should be approximately half the
width of the lower lip defect. Line b then is placed so an angle is created at the intersection of lines b and d. The
combined length of lines a and c needs only to approximate the combined length of lines b and d.

FIGURE 170.2 A: Cancer of the lower lip. B: Defect of the lower lip with the design of the angular flap. Note that
the commissure is preserved. C,D: Four months postoperatively. E: The final result. (From Balch, ref. 1, with
permission.)
OPERATIVE TECHNIQUE
The lower lip lesion is excised, and the ipsilateral commissure is preserved, if possible. The angular flap
designed on the upper lip may be based medially (Fig. 170.2) or laterally on the coronary vessels. A standard
three-layer closure of both the donor and recipient sites is done. Ten to 14 days later, the pedicle is divided and
inset.
CLINICAL RESULTS
The triangular relationship of the ipsilateral pillar of the philtrum, the nasolabial fold, and the line through the
commissure and peak of the cupid's bow is maintained (Figs. 170.1B and 170.2). An S- or C-shaped
deformity of the nasolabial fold is avoided, and the commissure is preserved. The final scar is within the
lines of expression, and notching of the border of the lips is avoided.
SUMMARY
The upper lip angular musculocutaneous flap provides not only a functional reconstruction of the lower lip,
but also an excellent cosmetic result.
References
1. Balch CR. Modification of cross lip flap. Plast Reconstr Surg 1978;61:457.
2. Kazanjian VH. Supporting flaps used in reconstruction of the lower lip. In: Kazanjian VH, Converse JM,
eds. The surgical treatment of facial injuries. Baltimore: Williams & Wilkins, 1949.

3. Estlander JA. Classic reprint. Eine Methode aus der einen Lippe Substanzverluste der Anderen zu
Erstetzen (A method of reconstructing loss of substance in one lip from the other lip. Translated from the
German by B. Sundell). Arch Klin Chir 1872;14:622. (Plast Reconstr Surg 1968; 42:360.)

Chapter 171
Functional Lower Lip and Oral Sphincter Reconstruction With
Innervated Depressor Anguli Oris Flaps
G. R. TOBIN
EDITORIAL COMMENT
The objective of the procedure, which is to restore the oral sphincter with innervated muscle, is correct. In
practice, the technique is cumbersome, because in most cases simple reapproximation of the remnants of
the orbicularis muscle may suffice. Further experience with this flap, particularly applicable to postcancer
patients, demonstrates that the flap can be extended down along the so-called jowls below the horizontal
ramus of the mandible. This is most helpful in reconstructing the upper portion of the lower lip, providing
sufficient height with good sphincter restoration.
The innervated depressor anguli oris (DAO) musculocutaneous-mucosal flap is a compound flap that provides
functional lower lip and oral sphincter reconstruction with all the necessary components: skin cover, mucosal
lining, vermilion, oral sphincter, and sensation.
INDICATIONS
Depressor anguli oris flaps reconstruct sensate lips and functional oral sphincters of normal dimensions in
one operation without invading or denervating the upper lip. All previously described methods of lower lip
reconstruction suffer from one or more of the following disadvantages:
1. Partial sacrifice or denervation of the upper lip and its orbicularis oris sphincter
2. Transection of the orbicularis oris sphincter lateral to the oral commissure
3. Obliteration of the oral commissure
4. Microstomia
Lip-switch flaps (1, 2) sacrifice upper lip and transect its orbicularis oris sphincter, denervate the orbicularis
oris medial to the donor site, fail to restore oral circumference, and produce denervated reconstructions
(although partial reinnervation subsequently occurs (3)). Inferiorly based nasolabial flaps (4) denervate the
upper lip and produce partially or totally denervated reconstructions. They also destroy functional
orbicularis oris around the commissure. Inferior pedicle cheek transposition flaps (5) transect the orbicularis
oris at the commissure and fail to reconstruct the lower lip sphincter or provide sensation. Lateral
advancement cheek flaps (6, 7, 8, 9) denervate the upper lip, transect the orbicularis oris muscle at the
commissure, and fail to reconstruct the lower lip sphincter. The myoplastic modification of the Bernard
method (10) overcomes some of these disadvantages by preserving upper lip innervation and by avoiding
transection of orbicularis oris at the commissure when short advancements are done for small defects.
Microstomia and obliteration of the oral commissure occur with Estlander, “fan” (11, 12), and Karapandžić
(13) flaps; however, the Karapandžić method is the only technique that reconstructs the oral sphincter and
preserves motor and sensory innervation to the extent of depressor anguli oris reconstructions.
One depressor anguli oris flap reconstructs over half of a lower lip (Figs. 171.1 and 171.2), and bilateral
depressor anguli oris flaps reconstruct an entire lower lip of normal length (Fig. 171.3). The principal

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advantages of this technique are (a) reconstructed lips with normal sensation and functional oral sphincters,
(b) avoidance of microstomia in reconstruction of large defects, (c) preservation of upper lip structure and
function, and (d) provision of all lip elements by one flap in one operation. The principle of innervated facial
musculocutaneous flap lip reconstruction can be extended to innervated depressor labii inferioris and facial
platysma flaps, which also restore sensation and sphincter function in specific anatomic circumstances.
Depressor anguli oris flaps are my first choice for lateral defects involving between one third and two thirds
of the lower lip. Based on the preceding discussion, my total approach to lower lip reconstruction is as
follows:
1. Defects involving less than a third of the lip are closed directly with V or W excisional preparation.
2. Lateral defects involving between one third and two thirds of the lip are reconstructed with an innervated
depressor anguli oris flap.
3. Central lower lip defects involving between one third and two thirds of the lip are closed with either the
Karapandžić (13) or myoplastic techniques (10).
4. Total lower lip loss is reconstructed with bilateral depressor anguli oris flaps.
FIGURE 171.1 Depressor anguli oris flap anatomy and transfer technique. A: Flap outline and
components shown. These include skin, depressor anguli oris muscle (DAO), inferior labial artery (ILA),
mental nerve (V), marginal mandibular nerve (VII), and mucosa. B: Flap transposition into lip defect
reorients the muscle to restore the oral sphincter. C: Mucosal advancement restores vermilion (V). Donor
defect (D) is closed directly.
5. Innervated depressor labii inferioris flaps are used for central lower lip defects with preserved vermilion
and mucosa (Figs. 171.4 and 171.5).
6. Innervated facial platysma flaps are used for defects that destroy the depressor anguli oris
musculocutaneous unit along with the lower lip (Fig. 171.5).
ANATOMY
The depressor anguli oris, or triangularis, is the muscle of facial expression that joins the oral commissure to the
lower mandibular border in the line of the nasolabial fold. It functions to depress the oral commissure in facial
expression. The depressor anguli oris lies lateral to the depressor labii inferioris and medial to platysmal
extensions crossing the mandible into the lower cheeks. The vascular pedicle of the flap is the lower labial
branch of the facial vessels, which enter the flap base at the oral commissure (see Fig. 171.1A).

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FIGURE 171.2 Transfer technique illustrated in reconstruction of half the lower lip resected for squamous cell
carcinoma. A: Flap outlined and nerve positions marked (V, VII) after tumor resection and contralateral
vermilionectomy. B: Flap transposition. The motor nerve (VII) and sensory nerve (V) to the flap have been
dissected. The same incision is used for submental and supraomohyoid lymphadenectomy. S, skin; DAO,
muscle; M, mucosa. C: The result is a lower lip and oral sphincter of normal dimensions. D: Normal lip sensation
and oral sphincter function result.
Flap sensory innervation is the trigeminal nerve mental branch, which also supplies the vermilion and lip that this
flap replaces. Depressor anguli oris motor innervation is the facial nerve mandibular branch, which also supplies
the orbicularis oris sphincter that this flap reconstitutes. These two nerves are dissected and preserved in the
creation of the flap (see Figs. 171.1 and 171.2).
FIGURE 171.3 Total lower lip reconstruction with bilateral innervated depressor anguli oris flaps demonstrated in
a cadaver. A: Lower lip totally resected and bilateral depressor anguli oris flaps (DAO) with squared distal ends
incised. B: Flap transposition and mucosal advancement (M) restore total lip and sphincter of normal length. C:
Mucosal components (M) restore labial sulcus and vermilion.
FLAP DESIGN AND DIMENSIONS

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To restore lips with normal dimensions, flap dimensions are matched to the defect size. The depressor anguli
oris muscle is approximately 4 cm long and 2 cm wide. These dimensions allow reconstruction of up to two thirds
of a lower lip. The skin component can be safely extended longer than 4 cm by inclusion of submental skin, but
the distal flap then has no motor component for sphincter reconstruction. The length of the mucosal component
is limited by the depth of the labial-gingival sulcus to approximately 3 cm. Reconstruction of longer mucosal
defects requires enlarging the mucosal component with a lateral extension from the labial-gingival sulcus or
advancing mucosa from the margins of the recipient defect.
The flap is marked on the skin overlying the depressor anguli oris muscle, which is located preoperatively by
palpation during scowling. The flap is superiorly based at the level of the oral commissure, and its axis is the
nasolabial fold extended distally to the jaw line (see Figs. 171.1A and 171.2A). The medial border originates at
the oral commissure.
Bilateral innervated depressor anguli oris flaps reconstruct a total lower lip and are designed with squared distal
ends. Muscle, mucosa, and skin are joined in the midline. The flaps are each made one half of the lower lip
length, approximately 2.5 cm long each (see Fig. 171.3).
FIGURE 171.4 Innervated depressor labii inferioris flap reconstruction of lower lip, sphincter, and mental
prominence. Lip vermilion and mucosa were preserved. A: Flap outlined and muscle position marked (DLI). B:
Flap elevated. S, skin; DLI, muscle; V, mental nerve; VII, mandibular nerve. C: A functional oral sphincter and a
sensate lip and chin are the result.
OPERATIVE TECHNIQUE
After the skin is incised, the motor and sensory nerves are dissected. First, the facial nerve mandibular branch is
approached by a horizontal incision in the shadow area beneath the body of the mandible (see Fig. 171.2B).
This incision also can serve to approach a submental and cervical lymphadenectomy, if indicated. The motor
nerve is located by careful dissection of the plane deep to the platysma. If the nerve is difficult to locate,
techniques exploiting the anatomic relationship of the nerve to the cervical vessels are useful (1, 2). Once the
nerve trunk is identified, it is dissected distally to the flap.
Next, the mental nerve is approached by incising the tip of the flap through the muscle to enter the submuscular
space above the periosteum. This loose areolar plane is easily dissected to locate the mental foramen. Lateral
branches of the mental nerve are then dissected to the flap (see Fig. 171.2B). Once the nerves are dissected,
the remaining deep tissues and mucosal components of the flap are incised. The depressor anguli oris
musculocutaneous unit without mucosa is used if mucosa is preserved in the recipient defect.
Flap transposition into the lip defect reorients the muscle to restore the oral sphincter and reroutes the motor and
sensory nerves (see Fig. 171.1B).

FIGURE 171.5 Depressor labii inferioris (L), depressor anguli oris (I), and fascial platysma (P) innervated
musculocutaneous flaps are marked directly over the respective muscles.
Vermilion is provided by advancement of flap mucosa (which is made approximately 1 cm wider than the skin and
muscle medially) over the medial flap border in similar fashion to a vermilionectomy procedure (see Fig. 171.1C).
Mucosal, muscle, and skin layers are closed individually, and the donor defect is closed directly.
If clinical circumstances dictate use of an innervated depressor labii inferioris or fascial platysma flap, the
sequence of dissection is the same, except that medial branches of the mental nerve supply sensation to the
innervated depressor labii inferioris flap and the sensory supply of the innervated fascial platysma flap is division
II of the fascial nerve, not the mental nerve.
CLINICAL RESULTS
The depressor anguli oris flap is highly reliable. Complete flap survival and restoration of lip structure and
function have followed all uses to date.
A small but definable functional donor defect is seen in the early postoperative period. In a balanced smile,
the ipsilateral oral commissure rises more than the contralateral one, and in scowling, the ipsilateral oral
commissure depresses less than the contralateral one. In repose and in a full smile, this defect is not
evident. With training before a mirror, this minor defect can be eliminated. The skin donor-defect scar is
inconspicuous because it falls in the extended nasolabial fold between the cheek and chin aesthetic units.
SUMMARY
Innervated depressor anguli oris musculocutaneous-mucosal flaps reconstruct total or subtotal sensate
lower lips and functional oral sphincters with normal dimensions and function as a consequence of
preserved innervation.
References
1. Kazanjian VH, Roopenian A. The treatment of lip deformities resulting from electric burns. Am J Surg
1954;88:884.
2. Estlander JA. Eine Methode aus der einen Lippe Substanzverluste der Anderen zu Erstetzen (A method of
reconstructing loss of substance in one lip from the other lip. Translated from the German by B. Sundell).
Arch Klin Chir 1872;14:622. Plast Reconstr Surg 1968;42:360.

3. Smith JW. The anatomic and physiologic acclimatization of tissue transplanted by the lip-switch technique.
Plast Reconstr Surg 1960;26:40.
4. Fujimori R. “Gate flap” for the total reconstruction of the lower lip. Br J Plast Surg 1980;33:340.
5. Diffenbach JF. Chirurgische Erfahrungen, besonders ueber die Wiederherstellung Zerstoerter Theile des
menchlichen Koerpers nach neuen Methoden. Berlin: Enslin, 1829-1834.
6. Bernard C. Cancer de la lèvre inférieure. restauration à l'aide de lambeaux quadrilataires-latereaus. In:
Guérison. Vol. 5. Liege: Scapel, 1852-1853; 162-164.
7. Fries R. The merits of Bernard's operation as a universal procedure for lower lip reconstruction after
resection of carcinoma. Chir Plast 1971;1:45.
8. Webster RC, Coffey RJ, Kelleher RE. Total and partial reconstruction of the lower lip with innervated
muscle-bearing flaps. Plast Reconstr Surg 1960; 25:360.
9. Meyer R, Farlot ASA. New concepts in lower lip reconstruction. Head Neck Surg 1982;4:240.
10. Freeman BS. Myoplastic modification of the Bernard cheiloplasty. Plast Reconstr Surg 1958;21:453.
11. Gillies HD. Plastic surgery of the face. London: Henry Frowde, Oxford University Press, 1920.
12. Gillies HD, Millard DR Jr., eds. Principles and art of plastic surgery. Boston: Little, Brown, 1957.
13. Karapandžić M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93.

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Chapter 172
Orbicularis Oris Muscle Flaps
C. L. PUCKETT
K. L. PICKRELL
J. F. REINISCH
Mobilization of the orbicularis oris muscle flap has been useful in reconstruction for paralysis or discontinuity of
the orbicularis muscle.
INDICATIONS
The two clinical circumstances in which we have used this technique most successfully have been (a)
dense paralysis of
the lip associated with injury to the marginal mandibular branch of the facial nerve (1), and (b) sphincteric
discontinuity of the orbicularis oris muscle in the bilateral cleft lip patient (2).
ANATOMY
The orbicularis oris muscle is a sphincter that has no clearly defined origin and insertion; however, its lateral
attachments at the modiolus can be considered the origin, with the insertion being into its contralateral half in the
center of the upper and lower lips. The muscle is flattened, somewhat ribbon-like, with a thickness of
approximately 0.5 cm, and it varies from 1 to 2 cm in width. It is innervated in quadrants (although there is
significant overlap) by the zygomatic branches of the facial nerve for the upper half and the marginal mandibular
branch of the facial nerve for the lower half (3). There is variable input by the buccal branch. Three or more
filaments of these nerves may enter the muscle quadrant. Blood supply is from the facial artery by means of the
labial branches.
FLAP DESIGN AND DIMENSIONS
Because of a rich blood supply, the muscle can be used as a flap based either medially or laterally. When based
laterally, flap innervation can be maintained, but if based medially, the flap is effectively denervated.
Unilateral Lower Lip Paralysis
Following marginal mandibular branch injury in which nerve repair is not feasible, a medially based flap of the
atrophic orbicularis oris muscle can be combined with a wedge resection of the lip to improve the appearance of
the defect. This is particularly helpful when the paralysis is dense and associated with atrophy of the orbicularis
oris muscle and droop of the lateral lower lip. A V-shaped wedge of lower lip is marked, with the width of the V
matching the amount of orbicularis atrophy (Fig. 172.1A). The lateral limb of the V is 1 or 2 mm medial to the
commissure of the lip.