Grabb’s Encyclopedia of Flaps Head and Neck

FIGURE 172.2 A: A patient with dense marginal mandibular branch paralysis. Note atrophy in the right lateral lip
segment and ptosis of the vermilion. B: Two years after wedge resection and orbicularis oris muscle flap. (From
Puckett et al., ref. 1, with permission.)
Infiltration with epinephrine aids in identifying the muscle. The muscle flap is dissected circumferentially, leaving
some of the scar of the previous lip repair attached to the muscle medially. This serves as a handle and as
reinforced tissue for suture placement. Dissection is carried laterally almost to a point above the commissure.
Intermittent traction on the muscle may reveal skin dimpling, indicating that additional release is necessary.
When the two muscle flaps can be approximated in the midline without dimpling the skin, the dissection has been
adequate. A tunnel is developed in the prolabial segment. Usually, some tissue resection is necessary to accept
the bulk of the muscle and simultaneously create a philtral dimple. The muscle repair is an imbricating one using
horizontal mattress sutures of nonabsorbable material. We have found that a tiny suction drain is helpful in
decreasing postoperative swelling.
CLINICAL RESULTS
Unilateral Lower Lip Paralysis
The procedure used in unilateral lower lip paralysis has proven helpful in minimizing the deformity resulting
from unilateral marginal mandibular branch injury (Fig. 172.2). We emphasize that its most precise indication
is dense paralysis associated with some degree of orbicularis oris atrophy and lip ptosis. Although repair of
the injured nerve is the foremost consideration when feasible, a number of occasions exist in which this is
either not appropriate or not possible. Because this operation does not provide depressor reanimation, it
may be of little value in patients in whom the only defect is absence of depressor function.
Bilateral Cleft Lip
This procedure also has been useful in eliminating or minimizing one of the many aspects of the bilateral
cleft lip deformity. Disruption has been evident in only one patient in 20, and a distinct improvement in the
double-bump deformity has been observed in approximately 90% of patients. The procedure often
exaggerates the lateral vermilion pout, which is corrected easily by a horizontal wedge resection of the
vermilion, but we have been reluctant to do this at the same time as the initial procedure for fear that we
would misjudge the amount needed.
SUMMARY
Orbicularis oris muscle flaps can be used for either the upper or lower lip to restore a more natural

functional appearance. This has been especially useful both in patients with unilateral lower lip paralysis
and in patients with bilateral cleft lip deformities.
References
1. Puckett CL, Neale HW, Pickrell, KL. Dynamic correction of unilateral paralysis of the lower lip. Plast
Reconstr Surg 1975;55:397.
2. Puckett CL, Reinisch JF, Werner RS. Late correction of orbicularis discontinuity in bilateral cleft lip
deformity. Cleft Palate J 1980;17:34.
3. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based on the
dissection of 100 facial halves. Plast Reconstr Surg 1962;29:266.

Chapter 173
Paired Deltopectoral Skin Flap to The Lip
M. SOUSSALINE
EDITORIAL COMMENT
It appears that this reconstruction could be accomplished with one deltopectoral flap if the surgeon desired.
This denervated lower lip reconstruction will tend to sag because of its own weight and the continuous pull
of gravity.
One or two deltopectoral flaps can be used for reconstruction of the lower lip, chin, and floor of the mouth after
cancer resection (1, 2, 3, 4, 5, 6, 7, 8).
ANATOMY
The main blood supply of the deltopectoral flap is provided by the second and third intercostal arteries (see
Chapter 127).
FIGURE 173.1 A-E: The technique for repair of a total defect of the lower lip and chin with two folded
deltopectoral flaps: the “Pharoah” technique. (From Soussaline and Kauer, ref. 8, with permission.)
FLAP DESIGN AND DIMENSIONS
The superior edge of the flap is 2 cm below the clavicle, and it parallels the inferior edge, which starts between
the third and fourth sternocostal joints and runs to the acromial bump (Fig. 173.1A). The size of the flap depends
on the specific patient, but it generally averages 25 cm long and 12 cm wide. The pivot point is around the
emergence of the second intercostal vessel, and the arc of rotation is 70 to 90 degrees.

FIGURE 173.2 A: Huge resection with segmental mandibulectomy. Before division of the pedicle: the “Pharaoh”
aspect. B,C: Result 3 weeks after pedicle division; good functional result.
It is possible to raise two symmetrical flaps for reconstruction; however, when the defect does not extend to the
labial commissure, one flap is usually enough, depending on flap design. In the case of a single flap, I lengthen
the flap for 3 to 4 cm and place its superior edge above the clavicle for about a third of the flap length (Fig.
173.1B). Paired deltopectoral flaps raised together provide tissue 24 cm in width and 13 cm in height. One
enlarged flap can be designed to allow a portion of tissue 15 cm wide and 13 cm high.
OPERATIVE TECHNIQUE
Dissection proceeds from lateral to medial, leaving the fascia on the muscle, and is stopped 3 to 4 cm before the
edge of the sternum. The pedicles are usually not visualized.
When two flaps are used, they are sutured together for the last 12 cm. The flaps are first sutured to the middle of
the lower edge of the defect. Then suturing is done between the lateral edge of the resection and the
commissure, proceeding along the defect in the floor of the mouth.
The patient's head is put in flexion to reduce the distance between the flap pedicle and the chin. When suturing
is finished, the flaps are folded in on themselves and maintained by two gauze pledgets, one placed along the
floor of the mouth in the natural fold between lip and chin (Fig. 173.1E). These pledgets give shape to the lower
lip, and they must be moderately tightened. At the end of the procedure, the portion of the flap between the face
and the pedicle is tubed without tension. If a single enlarged deltopectoral flap is used, the technique is quite
similar.
Two sutures are placed between the commissure and the chest wall. I call these “alarm sutures,” and they retain
good patient position for 3 to 4 days postoperatively.
The second stage is performed 3 weeks later. The flap is divided under the chin, the remaining portion is placed
in the pectoral area, and the deltoid area is grafted, if necessary. Division must be done 3 to 4 cm under the
inferior edge of the defect to bring in some excess tissue under pressure from bottom to top, giving the best
shape to the reconstructed lower lip (Fig. 173.2). Between the two stages, a nasoesophageal feeding tube is
used, and the mouth is washed carefully several times a day.
CLINICAL RESULTS
In my experience, the standard deltopectoral flap can be used for all kinds of reconstruction of the head and
neck. The rate of flap necrosis in the distal third was 12% in 125 patients. Used for lower lip reconstruction,
in six patients with two deltopectoral flaps, I had no necrosis; in eight patients with one enlarged flap, I had

one necrosis. In all patients, I delayed the flap. In two patients, I had partial dehiscence without necrosis,
necessitating another operation with the patient under general anesthesia within the first 15 days.
After the second stage, functional results for eating were good in 13 patients and for drinking in 11 patients.
Feeding was allowed after about 24 days. In three patients, a procedure to prevent saliva leak was
performed 3 months later. Cosmetic results were acceptable in nine patients after the second stage. Six
patients asked for a further operation to improve the cosmetic result. This permitted five very good results
after 1 year using two further stages.
Postreconstruction follow-up of malignancy (all patients with T4 tumors) was good, with eight patients alive
at 3 years.
SUMMARY
Use of the deltopectoral flap provides large surfaces of soft tissue that can be molded and adapted for
reconstruction in this complex area. The technique allows good functional results, and results are
cosmetically acceptable even in huge lower lip tumors.
References
1. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin
flap. Plant Reconstr Surg 1965;36:173.
2. Bakamjian VY, Culf NK, Bales HW. Versatility of the deltopectoral flap in reconstruction following head and
neck cancer surgery. In: Transactions of the Fourth International Congress for Plastic and Reconstructive
Surgery, Vol. 1. Amsterdam: Excerpta Medica, 1969;808.
3. McGregor IA, Jackson U. The extended role of the deltopectoral flap. Br J Plast Surg 1970;23:173.
4. Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructive
surgery of the head and neck. Br J Plast Surg 1971;24:174.
5. Kauer C. Reparation des vastes pertes de substance labio-jugales à l'aide du lambeau delto-pectoral.
Paris: Thesis from the Faculté Neckêr-Enfants Malades, 1976.
6. Soussaline M, Grellet M. Technique, indications et résultats de l'utilisation du lambeau delto-pectoral clans
les pertes de substance cervicofaciale. In: Transactions of the Sixth International Congress for Plastic and
Reconstructive Surgery. Paris: Masson, 1976.
7. Soussaline M, Kauer C, Grellet M. Reconstruction de la région labiojugale à l'aide du lambeau delto-
pectoral. Ann Chir Plast 1977;22:57.
8. Soussaline M, Kauer C. Reconstruction of the lower lip after radical resection for cancer. Plast Reconstr
Surg 1977;60:172.

Chapter 174
Platysma Musculocutaneous Flap to The Lower Lip
J. N. BARRON
M. N. SAAD
EDITORIAL COMMENT
The anatomic description and blood supply for the standard platysmal flap apply here. The illustrative case
provided by Drs. Barron and Saad shows an innovative way of using the platysmal flap.
For anatomy, flap design, and operative technique see Chapter 124.
CLINICAL RESULTS
If the nerve supply to the platysma is preserved, the tone of the transplanted muscle is sufficient to prevent
the development of a labial ectropion. Careful fixation to the cheek musculature at each lateral margin of the
defect is, of course, necessary.
If neck skin is used to reconstruct the vermilion, a subtle color change takes place so that a natural, smooth
pink appearance can be expected.

FIGURE 174.1 A: Extensive squamous cell carcinoma of the lower lip. B: Lesion widely excised. C:
Bipedicled platysma musculocutaneous flap from the lower neck used for placement of lower lip lining and
vermilion. D: Skin defect repaired with bipedicled neck flap. Neck donor site is grafted. E: Postoperative
result.

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Chapter 175
Fan Flaps
W. R. MULLIN
D. R. MILLARD JR.
These flaps were given the name “fan flaps” because of their resemblance to the rotational opening of an
oriental folding fan.
INDICATIONS
The fan flap procedure is used today to correct larger full-thickness defects of both upper and lower lips.
Attributes of the fan flap are as follows. Two basic principles (1) are observed using this flap: (a) losses
should be replaced with similar types of tissue, and (b) tissue from an area of relative excess to supply an
area of need should be used. Few conventional axial flaps allow such freedom of movement of such large
amounts of tissue based on such a small pedicle. Also, most donor-area scars may be located close to the
natural junction lines of facial units.
The fan flap has found its best use for reconstruction of large central full-thickness defects of both upper
and lower lips. In such defects, the use of bilateral symmetrical flaps rotated medially usually affords the
most satisfactory final result.
FLAP DESIGN AND DIMENSIONS
Owing to the marked elasticity of the lips, evaluation of defects must be determined in the absence of induration
and edema. The exact amount of lip loss usually can be judged quite accurately, especially in primary surgical
losses resulting from resections for carcinoma if there has not been a large inflammatory response to the tumor.
Defects secondary to burns or infection should be allowed to heal to stability and softness before planning
reconstruction.
It is most important to recognize that the amount of tissue required to reconstruct an attractive lip is always less
than the size of the original defect. It must be stressed that the edges of the defects actually must be grasped
and approximated to the desired location so that the true defect to be reconstructed can be visualized and
measured. One may see exact percentages quoted, stating X percent of a lip defect can be closed primarily;
however, this is a general rule and only a rough guide. More important are the actual examination and the final
relationship
of the lip to the opposite lip once the defect is closed. For example, one may be able to close an upper lip tightly
without the use of a flap; however, the lower lip may have an unsightly protruding appearance relative to the
upper lip.

FIGURE 175.1 A-D: Unilateral fan flap for the upper lip.
The units of the lips always must be honored. In large central upper lip defects, a midline shield-shaped Abbé
flap from the lower lip to reconstruct a philtrum may be in order (2, 3); however, this should be done as a
secondary procedure so as not to compromise any blood supply traversing the circumoral labial vessel.
Large full-thickness defects of the lateral lip may be repaired using the unilateral fan flap. One also should
consider the use of an off-center Abbé flap (4) or an Estlander flap (5), which may be a less elaborate solution to
the problem.
Once the true defect that requires reconstruction has been determined, considering laxity and opposite lip
relationship, one may proceed to the outline of the flap. A dot is placed at the desired location of the new mouth
corner. The length of the defect to be filled is transferred along the adjacent vermilion, and from the point
marked, a line is dropped perpendicular from the white roll. The length of this line establishes the bulk and size
of the flap, and usually it is at least 1 to 1.5 cm long.
An angle of approximately 60 degrees is turned toward the nasolabial fold. Once the nasolabial fold area is
transected, the line follows this area to a point that will provide adequate height and bulk to the flap. In general,
approximately no more than one half the upper lip (Fig. 175.1) and two thirds of the lower lip (Fig. 175.3) should
be attempted using a unilateral fan flap (1).
OPERATIVE TECHNIQUE
The rules of oncologic surgery must be honored if one is dealing with carcinoma as the primary lesion; that is,
one must have every assurance that the patient is free of his or her original tumor, and one must not include
precancerous tissue in the flap.
Defects of the Upper Lip
Cutting the flap is accomplished nicely using a no. 11 blade pushed through the lip beginning at the dot so that
the back of the blade protects the vascular pedicle. The only other landmarks that should be noted are the
surface area of the internal lining and, in larger flaps, the exit of Stensen's duct. As the fan flap is rotated into
position, the trailing 60-degree triangular segment of tissue finds its own new location, and the most appropriate
cut is made so that this point may be inset, thus forming a Z-plasty. Once this tissue is positioned satisfactorily, a

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three-layer closure is accomplished, closing mucous membrane, muscle, and then skin. Of course, natural
landmarks are carefully approximated, namely, the white roll and vermilion border (Figs. 175.1 and 175.2).
Defects of the Lower Lip
Basic steps of design are the same as for the upper lip. Because the lower lip is responsible for oral competence
and prevention of drooling, the amount of tissue to be brought in must not be underestimated. Careful attention
to closure of the vertical axis to maintain height is paramount to prevent notching in this area and thus
incompetence and drooling. A Z-plasty of the labial sulcus mucous membrane closure is often useful (Figs. 175.3
and 175.4).
FIGURE 175.2 A,B: Diagrams of bilateral fan flaps for upper lip defect.
FIGURE 175.3 A-C: Unilateral fan flap for the lower lip.
FIGURE 175.4 A,B: Diagrams of bilateral fan flaps for lower lip defects.

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FIGURE 175.5 A-E: Commissuroplasty done as a secondary procedure.
Secondary Procedures
The microstomia and rounded lip corners resulting from the use of fan flaps must now be corrected as a
secondary procedure. Time should be allowed for the flaps and scars to soften, and this usually takes a
minimum of 2 to 3 months. During this time, the patient who has dentures may have difficulty, and this
problem must be taken into consideration.
The commissuroplasty is performed as follows (Fig. 175.5). The new apex of the commissure is located by
noting the normal location on the opposite side, or if this is absent, a perpendicular line is dropped from an
area below the pupil of the eye. This gives an approximate lateral extent of where a normal commissure
should lie. A triangle of skin is excised, leaving the vermilion rim intact. A point is located along the lower
aspect of the vermilion that would reach the new commissure point when lifted and outfolded into that area.
Next, the vermilion is lifted with a few fibers of orbicularis oris muscle. Once this component is freed, full
division through the orbicularis is accomplished; in some cases, thinning is required. The vermilion flap then
is rolled laterally into the new position. The raw surface along the lateral aspect of the lower lip must be
covered using a flap of mucous membrane dissected from within and rolled out onto this area. The mucous
membrane substitution for vermilion may be satisfactory; however, in some cases, it is markedly redder than
normal vermilion. Also, in some cases, an entropion of this area is caused by contracture of the flap. If this is
a problem, one may consider a full-thickness graft of true vermilion from an area that can afford to donate to
this area.
Modifications in Operative Technique
A modification of the traditional fan flap is described by other authors (6, 7) in which a rectangular segment of
tissue is rotated into position and the raw surface must be covered by advancing mucosa or an inferior surface
tongue flap. Because the location of the commissure is unchanged, the secondary revision and microstomia are
avoided; however, donor-area scars do not seem to follow the natural lines of facial units as well as those of
traditional fan flaps, and the area of vermilion to be covered with the advanced mucosa or tongue flap is larger.
CLINICAL RESULTS
Criticism that may be directed toward the use of fan flaps is as follows: Two stages are required to correct
the relative microstomia and to reconstruct a new commissure following rotation of a fan flap. Motor nerves
innervating the orbicularis oris muscle are divided.
Addressing this problem, Karapandžić (8) (see Chapter 176) describes a similar flap based on mucosal

lining. He carefully describes microdissecting the neural filaments in this area to prevent division. In certain
circumstances, leaving these nerves intact may hinder the mobility of this flap compared with a completely
dissected fan flap.
Branches of the facial motor units divided medial to the lateral canthus of the eye regenerate, or new
attachments are formed so that reanimation is possible (1, 6, 9). Such may be the case when fan flaps are
used, for after some time has been allowed for the area to soften and settle, voluntary circumferential
contracture in the rotated flap may be observed. This may represent real muscle contracture as a result of
ingrowth of new motor nerves, new anastomotic connections, or simply transmitted vectors from the
animation of the opposite lip. Neurologic return in transplanted flaps (6) has shown that pain returns first,
followed by tactile sensation, temperature sensation, and sympathetic function, in that order, with total
return at 2 years.
SUMMARY
The fan flap is a versatile and satisfactory flap to use in the reconstruction of certain large full-thickness
defects of the lips.
References
1. Gillies HD, Millard DR, Jr., eds. Principles and art of plastic surgery. Boston: Little, Brown, 1957.
2. Grabb W, Smith JW, eds. Plastic surgery, 3d ed. Boston: Little, Brown, 1979.
3. Millard DR Jr. Composite lip flaps and grafts in secondary cleft deformities. Br J Plast Surg 1974;17:40.
4. Abbé RA. A new plastic operation for the relief of deformity due to double harelip (Classic Reprint). Plast
Reconstr Surg 1968;42:481.
5. Estlander JA. A method of reconstructing loss of substance in one lip from the other lip (Classic Reprint).
Plast Reconstr Surg 1968;42:360.
6. Smith JW. The anatomical and physiologic acclimatization of tissue transplanted by the lip-switch
technique. Plast Reconstr Surg 1960;26:40.
7. Stranc MF. Steeple flap reconstruction of the lower lip. Ann Plast Surg 1980; 10:4.
8. Karapandžić M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93.
9. McGregor IA. Reconstruction of the lower lip. Br J Plast Surg 1983;36:40.

Chapter 176
Innervated Musculocutaneous Lip and Cheek Flaps
M. KARAPANDŽIć
EDITORIAL COMMENT
This is a classic description of one of the most important procedures currently used to reconstruct defects of
the upper and lower lips. This is so particularly because of the attention paid to functional restoration of the
oral sphincter.
The aim of reconstruction of lip defects by innervated musculocutaneous lip and cheek flaps is to form new lips
that are anatomically and functionally able to satisfy the everyday needs of feeding, phonation, emotional
expression, and communication. The reconstructed lip should be able to match the normal one, with parallel
appearance, color, texture, hairiness, shape, thickness, elasticity, and dynamics of movement.
The reconstructive method of innervated musculocutaneous arterial flaps is based on the principle of replacing
lost tissue with labial or cheek tissue that most closely resembles that of the lips. The flaps should contain skin,
muscle, and mucous membrane with discrete blood and nerve supplies. This makes possible immediate mobility
and normal sensibility with preservation of vegetative functions in a newly formed vermilion-bordered lip (1, 2, 3).
INDICATIONS
The procedure is applied in all patients in whom lip defects cannot be sutured directly without functional
consequences. It is most frequently applied in defects caused by radical excision of malignant tumors and
traumatic avulsion.
ANATOMY
Flaps are formed from all the anatomic elements of the lip and part of the cheek tissue. Essential elements of the
flap are lip muscles covered with skin.
Lip muscles can be classified as either constrictors or dilators. The muscles are arranged in three layers:
peripheral, medial, and deep. According to their position and function, these muscles may act as synergists or
antagonists in the coordination of lip movement.
The orbicularis oris muscle is the most significant muscle. It is included in the structure of innervated
musculocutaneous arterial flaps, together with the buccinator, both forming an orbicularis-buccinator complex
that makes a newly formed lip equal in functional quality to the normal lip.
The orbicularis oris muscle is composed of several layers of muscle fibers that surround the lip orifice and stretch
in various directions (Fig. 176.1). Its muscular structure may be divided into two concentric rings according to the
origin of the fibers. The peripheral ring consists of muscle fibers that are radially located and inserted into upper
and lower lips. The central ring consists of its own semicircular fibers that stretch obliquely through the thickness
of the lip, running from the deep skin surface of one commissure toward the mucous membrane of the opposite
commissure. The function of the centrally positioned orbicularis oris muscle is primarily sphincteric; the other lip
muscles serve a supporting and dilatating function.

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The facial artery with its branches, the inferior and superior labial arteries, supplies the innervated
musculocutaneous flaps (Fig. 176.2). Adequate blood circulation in these flaps is extremely important, especially
in elderly and previously irradiated patients. The anterior facial vein with its branches, the upper and lower labial
veins, provides venous drainage. Lymphatic drainage is to the regional submental and submandibular glands.
The sensory innervation of the flaps originates from the second and third branches of the trigeminal nerve. Parts
of the flap from the upper lip are innervated by the infraorbital nerve, and those formed from the remaining lower
lip are innervated by branches of the mental nerve. The commissure area derives sensory innervation from the
buccinator nerve.
The motor nerves that are preserved with the flap originate from the buccal and mandibular rami of the facial
nerve. The superficial buccal branches pass under the skin and over the superficial facial muscles, which they
innervate. Deep fibers supply the zygomatic and quadratus muscles of the upper lip; the deep buccal branches
innervate the buccinator and orbicularis oris muscles. The ramus marginalis passes forward under the platysma
and the triangularis, supplying innervation to the lower lip muscles and the chin (see Figs. 176.1 and 176.2).
FIGURE 176.1 Anatomy of the lip muscles in layers and their participation in forming the peripheral ring of the
orbicularis oris muscle. Position of the facial artery and its branches in relation to the muscles is shown. The
branches of the facial nerve enter the orbicularis oris and the other lip muscles.
FLAP DESIGN AND DIMENSIONS
The dimensions of innervated musculocutaneous arterial lip and cheek flaps depend on the size, position, and
cause of the defect. Flaps can be located in the lower and upper lips in the area of lip angles or in both lips
simultaneously. Defects are most frequently partial and rarely involve the whole lip. The most frequent defects
are those of the lower lip, and they usually are located between the medial line and the commissure, rarely
involving the central part.
Dimensions of defects that are suitable for lip reconstruction with this kind of flap are generally from 3 to 9 cm
long. Flap width and length vary, depending on the pathologic process that caused the defect. Flaps are formed
on both sides of the defect, and their width is equal to the height of the defect. The most suitable width of flaps is
from 18 to 25 mm, and the flap should, in principle, have the dimensions of the orbicularis oris muscle.
Planning the flap begins with measurement of the lengths of the lower and upper lips and rima oris. The part of
the lip to be excised is marked and measured. The defect is planned as a quadrilateral because this form is most
convenient for the sliding and rotation of musculocutaneous flaps. From the edge of the planned defect, the
width and length flap dimensions are marked on both sides and should follow the course of the orbicularis oris
muscle and the natural lines of the face so that scars will not be noticeable.

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FIGURE 176.2 The separated orbicularis oris muscle with preserved motor and sensory nerves and the facial
artery with its branches form the innervated musculocutaneous arterial lip and cheek flaps.
The planned flaps should be long enough and wide enough that the newly formed lip may be constructed with an
adequate rima oris for normal feeding, intelligible speech, and easy approach to the oral cavity for further
therapeutic procedures. Adequate flap width allows encircling of the lip and prevents dribbling.
OPERATIVE TECHNIQUE
Defects of the Lower Lip
Full-thickness defects of the lower lip are reconstructed by the formation of two flaps from the remaining healthy
lip tissue and tissue from the opposite lip, with the addition, in large defects, of some cheek tissue.
The operative procedure in forming innervated musculocutaneous arterial lip and cheek flaps is a continuous
process in which nerve elements and blood vessels are sought simultaneously with selective cutting of some
muscle fibers and separation of the orbicularis oris muscle into a special functional unit. From the edge of the
defect, the incision advances at an equal distance from the mucocutaneous vermilion line, curving in the
direction of the orbicularis oris muscle toward the lip commissure, which it curves around.
Then the incision continues at an equal distance over the nasolabial sulcus to the upper lip, to the area of the
vertical
projection of the nasal wing. The flap is of equal width along its full length. The incision continues deep to the lip
muscles toward the region of the commissure to the site where the surrounding muscles intermingle with the
orbicularis oris muscle. To this point, the muscle fibers are gradually cut so that the incision reaches only the
mucous membrane in the initial part of the flap. Then, with the preparation of surrounding supporting muscle,
some muscle bundles are selectively cut and the orbicularis oris muscle is separated. In the region of the lip
commissure, muscle fibers are cut only in the superficial layer, while the deeper fibers of the orbicularis and
buccinator muscles are preserved. It is especially important to preserve the medial part of the buccinator muscle
because these decussated fibers are contained in the composition of lower and upper lip muscles (see Fig.
176.2).
If the defect is not large, a smaller part of the triangularis muscle fibers (which continue toward the upper lip) and
part of the caninus muscle fibers (which continue to the lower lip) can be preserved in the region of the
commisure. Preservation of the triangularis and caninus muscle fibers is necessary so that the mobility of the
musculocutaneous flap will not be damaged. In large defects, the orbicularis oris muscle is separated completely
from the surrounding muscles; thus, the mobility of the flaps is increased. In all cases, buccinator muscle fibers
are saved to maintain functional harmony of the facial muscles with the orbicularis oris muscle. In the upper lip
region, only the superficial muscle layer is cut to separate the orbicularis oris muscle and to improve the mobility

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of the musculocutaneous flaps.
In flap preparation that selectively cuts muscle fibers to separate the orbicularis oris muscle, full attention must
be given to preserving the motor and sensory nerves and the facial artery and all its branches. The whole
surgical procedure is directed mainly toward finding and preserving the nerve elements and the vascular
network. It is usually necessary to use magnifying loupes during preparation of the nerve elements.
While preparing flaps from the remaining lower lip and cutting the superficial muscle fibers at the initial part of the
flap, it is necessary to find the fibers of the mental nerve. Usually, one big branch is found, but sometimes there
are two. Then the triangularis muscle is cut, preserving the branches of the marginal mandibular nerve that go
toward the orbicularis oris muscle. In the region of the commissure, the buccal branches that lie immediately by
the facial artery are prepared and preserved. Advancing in the direction of the upper lip, the other motor fibers
that innervate the orbicularis oris muscle are gradually revealed. It is usually possible to preserve several buccal
branches. Nerve fibers enter the flaps radially; during the preparation and cutting of the muscle fibers, this fact
must be kept in mind (Fig. 176.3D and E).
In the region of the commissure, when cutting the superficial muscles, the facial artery that lies under the
triangularis muscle must be preserved. At this site, lower and upper labial arteries can be found. When the facial
artery is discovered, it should be carefully prepared in the direction of its central flow so that when the flaps are
moved, blood flow will not be strangulated and reduced. Careful attention must be given at the start of cutting
muscles in the initial preparation of the flaps because of the variable position of the lower labial artery.
Mucous membrane is cut only enough to ensure sliding of the flaps and to set medial sutures. The rest of the
mucous membrane is preserved.
FIGURE 176.3 A: Squamous cell carcinoma of the lower lip. B: Planning tumor excision and flaps. C: Defect
prepared for reconstruction. D: The buccal branches and the facial artery are prepared and preserved in the
formed flap (highlighted by background material). E: The separated and raised flaps with the neurovascular
elements. (Continued)

FIGURE 176.3 Continued. F: The patient 10 days after formation of the new sphincter can keep water under
pressure in the mouth. G: Ten days postoperatively, coordinate action of the orbicularis oris and other lip
muscles is present. H: Eight months postoperatively, the sphincteric action of the newly formed lip is shown in
whistling. I: In the same period, the sphincteric action of the newly formed lip is equal to that of the normal lip. J:
The normal aperture of the newly formed lip covered with vermilion. K: Final result with symmetrical lip angles
and normal appearance of newly formed lip.
The innervated arterial lip and cheek flaps are now completely mobile and can be raised from the base and
brought into the defect by sliding and rotation. First, the flaps are sutured together in the middle, beginning with
mucous membrane through the muscles to the skin. In this way, the sphincteric lip ring is formed, completely
surrounded by vermilion. To gain a symmetrical lip aperture, flap position is centered, and the medial suture line
of the two flaps usually lies in the middle of the previous defect. Mucous membrane and muscle layers then are
sutured slowly and carefully to preserve flap innervation and to maintain arterial supply and venous drainage.
The muscle suture must be exact, especially in the region of convergence of the dilatator muscles in the lip
commissure, set symmetrically on the flaps, so that these muscles may retract equally and give a symmetrical lip
aperture.
Formation of the new commissure after reconstruction of the reduced lip sphincter is carried out by suturing the
cut muscle fibers of the zygomaticus, risorius, and triangularis muscles into their new position. These retract the
new commissure by their tonus. In the same way, the volume of the secondary defect is reduced by the sutures,
and correct redistribution of the flaps into the defect is undertaken. If there is a marked disproportion between the
outer circumference of the flaps and the secondary defect, a triangular excision of skin is performed downward in
the direction of the nasolabial furrow or upward in the region of the upper lip. Lip construction is finished by
suturing muscles, subcutaneous tissue, and skin.
Defects of the Whole Lower Lip
Defects of the whole lower lip are most generally from 6 to 9 cm long and include all structural muscles.
Reconstruction of such large defects should be planned carefully. If the lower lip defect stretches toward both the

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commissures, innervated musculocutaneous arterial lip and cheek flaps can be formed from the remaining tissue
of the commissure and the upper lip according to the principles mentioned earlier (Fig. 176.4B). This sort of lip
reconstruction reduces the circumference of the lip sphincter somewhat and can be accompanied by varying
degrees of microstomia. To avoid microstomia, which sometimes entails secondary reconstruction, and to
manage defects that include both lip commissures and portions of the upper lip, reconstruction can be performed
using a larger part of the cheek tissue.
Innervated musculocutaneous arterial lip and cheek flaps for the reconstruction of the largest lower lip defects
begin
with an incision parallel to the mucocutaneous line, over the upper lip, toward the nasolabial sulcus. Then, at the
same distance, alongside the defect of the commissure curving downward over the cheek tissue, the incision
continues toward the projection of the mental foramen. A curved incision is made from the lower edge of the lip
defect, parallel to the previous one, and adequate flap width is maintained. The width of the flaps in the region of
the upper lip and cheek is equal to the height of the lower lip defect.
FIGURE 176.4 A: Squamous cell carcinoma involving the whole lower lip. B: Defect of the whole lower lip over
the region of both commissures. Lip and cheek flaps are designed. C: Innervated musculocutaneous lip and
cheek flaps transposed into lip defect. D: Newly formed lip is completely mobile, showing the coordinating action
of the orbicularis oris muscle. E: Result 5 years later, with expressed sphincteric action. F: Five years
postoperatively, the normal appearance of the reconstructed lip with all functions preserved. (From Karapandžić,
ref. 1, with permission.)
In the mental region, the flap is completed by a horizontal incision. The length of the flap from the edge of the
defect (exactly from the commissure to the mental region) should be half the length of the lower lip defect. The
second half of the length of the lower lip defect is replaced by a flap from the opposite side (Fig. 176.4C). The
full thickness of the cheek tissue is cut at the beginning of the flap that lies below the lower edge of the lip defect.
The other part of the flaps in the region of the commissure and toward the upper lip is prepared according to the
principles discussed earlier. Motor nerve fibers are preserved in both the region of the commissure and in the
upper lip as well as in other parts of the flaps if possible. The facial artery is preserved during flap preparation.

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The mobilized flaps are raised from the donor region and transposed into the defect without any tension. After
the flaps are brought into the defect, sutures are placed in the medial surfaces of the flaps, and continuity of the
new lip is formed. The mucous membranes of the flaps cover the fresh surface, and so the new lip vermilion is
formed. A tongue flap can be used for reconstruction of the vermilion.
Secondary defects in the region of the cheek and mental area are sutured in accordance with anatomic layers,
attending to nerve fibers and the facial artery. Flaps are positioned in primary and secondary defects following
anatomic layers and paying attention to the depth of the labial sulcus and the height of the newly formed lip. After
suturing, the reconstruction is completed, and the newly formed lip has almost the same length and width as the
patient's previous lip. This can be ensured by measuring the dimensions of the defect and rima oris
preoperatively and the newly formed lip and rima oris postoperatively. The results of reconstruction by such flaps
are absolutely satisfactory, because microstomia does not occur and the functional abilities of the newly formed
lip are completely adequate.
Defects of the Upper Lip
Innervated musculocutaneous arterial lip and cheek flaps for the reconstruction of upper lip defects are formed
from the remaining parts of the resected upper lip and healthy lower lip in dimensions that correspond in width
and length to the size of the defect. The same principles that are valid for reconstructing lower lip defects are
used (Fig. 176.5).
FIGURE 176.5 A: Recurrent irradiated squamous cell carcinoma of the upper lip. B: Operative plan. C:
Prepared flaps for reconstruction, with neurovascular elements preserved. D: Postoperative result. Newly formed
lip in action of whistling. E: Final result with normal appearance of reconstructed upper lip.
Defects of Both Upper and Lower Lips
The simultaneous presence of upper and lower lip defects of larger size considerably reduces the quantity of
labial tissue. The process of simultaneous reconstruction of such defects becomes more complicated. Often the
cause of such simultaneous defects on both lips is malignant tumors whose treatment requires radical excisions

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of the attacked lip parts in the same operative procedure. Defects of both lips also occur after voluminous lip and
facial traumas that are accompanied by the avulsion of soft tissues. Reconstruction of full-thickness upper and
lower lip defects of large dimensions during the same operative procedure would be impossible without
innervated musculocutaneous arterial lip and cheek flaps.
Surgery is planned to remove the tumors of both lips by radical excision. Then, by a curved incision from the
base of the lower lip defect at an equal distance, following the orbicularis oris muscle and the necessary width of
the flap, the incision is continued over the cheek toward the base of the upper lip defect. A curved incision on the
opposite side, symmetrical to the previous one, follows the orbicularis oris muscle to join the base of the upper
and lower lip defects (Fig. 176.6).
In the region of the lip commissure, the muscle fibers of the superficial layer are gradually cut, and the buccal
branches of the facial nerve and facial artery with its branches are immediately found. The preparation continues
with selective cutting of the muscle fibers that are intermingled with the orbicularis oris muscle. Separation of the
orbicularis oris muscle in the direction of the bases of the upper and lower lip defects is performed. The
buccinator muscle is preserved.
The beginnings of the musculocutaneous lip and cheek flaps are separated from the surrounding muscles right
up to the mucous membrane, which is cut only as far from the defects as will make possible the movement of
flaps toward each other. The mobilized flaps are raised from their bases and moved simultaneously to the middle
of the upper and lower lip defects, and then they are sutured along the medial surfaces in accordance with the
anatomic layers.
In this way, the oral sphincter is formed by two semicircular innervated musculocutaneous arterial flaps from the
remaining parts of the upper and lower lips and part of the cheek. The bases of these flaps are in the region of
both lip angles. After formation of the circular ringlike flap, a symmetrical lip aperture is achieved by redistributing
and centralizing the flaps. The flaps are redistributed to the primary and secondary defects by suturing according
to the anatomic layers.
Although the defects are large, simultaneous reconstruction of the upper and lower lips by innervated
musculocutaneous arterial lip and cheek flaps, surrounded by intact vermilion, is possible. Microstomia is not
marked, although it could be expected in view of the dimensions of both lip defects.
Defects in the Region of the Lip Commissure
Innervated musculocutaneous arterial flaps of the upper and lower lips are used. Flap preparation is carried out
according to the usual principles. For this location, the flaps are not
begun at angles of 90 degrees. Rather, the angles are about 60 degrees on the outer flap circumference, while
the angle toward the vermilion border of the flaps is about 120 degrees. This form makes the creation of an
adequate lip commissure, which is not always easily achieved, quite possible. The problem is in the exact
positioning and symmetry of the commissure with the normal side. Satisfactory shape and symmetry can be
obtained by reducing the secondary defect and correctly redistributing the flaps according to the primary defect.

FIGURE 176.6 A: Simultaneous presence of lower and upper lip carcinoma and planned flaps. B: Excised larger
parts of lower and upper lips. Design of flaps for simultaneous reconstruction of both lip defects. C: Innervated
musculocutaneous arterial lip and cheek flaps prepared, with neurovascular elements preserved. D: Sphincteric
action after reconstruction of both lips is shown. E: Final result with normal appearance of both reconstructed
lips with adequate rima oris. F: Patient can eject water out of mouth in a thin jet, owing to reconstructed lip
sphincter. (From Karapandžić, ref. 1, with permission.)
CLINICAL RESULTS
The value of innervated musculocutaneous arterial lip and cheek flaps was tested in 522 patients from 1966
to 1982. Tests included those for arterial and venous blood circulation and lymphatic drainage, both
intraoperatively and postoperatively. Sensibility to pain, touch, temperature, modalities of superficial
sensibility, and vegetative function also were tested. Special attention was paid to motor functions.
Electromyographic results on functional values were checked by clinical methods, studying muscle
movement in carrying out basic and complicated lip functions. The results of these tests showed that the
reconstructed lip preserved motility, sensibility to all qualities, vegetative functions, and complete circulatory
networks (see Figs. 176.3, 176.4, 176.5, 176.6).
The newly formed lip was mobile so that it not only achieved contact with the opposite lip in action but
participated in all dynamic movements. It retained liquid in the mouth even under the highest pressure (Fig.
176.3F). Motility and sensibility in the newly formed lip prevented the uncontrolled dribbling of liquid and
saliva, and no patient had drooling. The restored labial sphincter that contained innervated muscles made
normal feeding and intelligible speech possible as well as whistling, blowing, smiling, kissing, sucking,
pursing, and other everyday lip movements (see Figs. 176.3, 176.4, 176.5, 176.6).
Besides functional ability, characteristics of the newly formed lip were symmetry and the absence of
changes in flap volume due either to atrophy or to the presence of edema. The smooth contour of the newly
formed lip that was covered with vermilion was flexible and enabled the lip to open sufficiently to fulfill its
functions. The adequate height of the newly formed lip had the corresponding depth of the labial sulcus.

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The position of the lip corners suited facial proportions; the position of the lip did not differ from the opposite
one in protrusion. By its position and similarity of tissue to the normal lip and the mobility accompanied by
changes in
the size of the rima oris, the reconstructed lip gave the impression of a normal one. Therefore, the aesthetic
results of this procedure were completely satisfactory (see Figs. 176.3, 176.4, 176.5, 176.6).
The limited quantity of labial and cheek tissues for the formation of innervated musculocutaneous arterial lip
and cheek flaps in large lip defects is a shortcoming of this procedure for surgical reconstruction in the lip
area. Microstomia, which may occur as a result of applying these flaps, may be avoided by using larger
areas of cheek tissue as well as by wider mobilization and correct redistribution of the flaps on the primary
and secondary defects. Another drawback might be the appearance of a noticeable scar, in the medial line
of the flaps, but a Z-plasty may be used to ameliorate this problem.
SUMMARY
Innervated musculocutaneous arterial lip and cheek flaps can be used for all local applications, depending
on the defects presented. The number, size, and position of the defects lend themselves to varying specific
techniques for flap design and deployment. These flaps also may be applied in combination with other flaps
for larger defects in the immediate lip area.
References
1. Karapandžić M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 1974;27:93.
2. Jabaley ME, Orcutt TW, Clement RL. Applications of the Karapandžić principle of lip reconstruction
following excision of lip cancer. Am J Surg 1976;132:529.
3. Jabaley ME, Clement RL, Orcutt TW. Musculocutaneous flaps in lip reconstruction: applications of the
Karapandžić principle. Plast Reconstr Surg 1977;59:680.

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Chapter 177
Tongue Mucosal and Musculomucosal Flap for Lip Reconstruction
J. GUERREROSANTOS
EDITORIAL COMMENT
The use of tissue from the undersurface of the tongue is preferable for lip reconstruction because the
dorsum of the tongue has a papillary appearance that does not change significantly with time. In addition,
tongue flaps used for lip reconstruction need constant moisture because of their tendency to dry and scale.
The tongue provides a valuable and versatile mucosal and musculomucosal unit for reconstruction of the
vermilion border and lining of the inner aspect of the lip (1, 2, 3, 4).
INDICATIONS
The tongue musculomucosal flap can be used in reconstruction of both the upper and lower lips. For
carrying out surgical repairs, one can use one or two tongue flaps that can be combined, when necessary,
with skin flaps. Most frequent indications for this procedure are defects subsequent to removal of benign or
malignant tumors, defects after trauma, and secondary deformities because of clefting.
ANATOMY
The principles of tongue mucosal and musculomucosal flaps are based on the fact that the blood supply to the
mucous
membranes is derived from the perforating vessels of underlying muscle (5, 6). The tongue is a mobile mass of
striated muscle covered by mucous membrane. It may be divided into a fixed part, which is the root, and a mobile
part, which is formed by the body and apex. The body is divided into two halves by a median raphe that is seen
externally as the median sulcus (Fig. 177.1).
FIGURE 177.1 Anatomy and blood supply of the tongue. Abundant communicating arterial branches and arcades

in lingual apex.
The areas of the tongue covered by the mucous membrane are the apex or tip, the dorsum, the right and left
margins, and the inferior surface. The root of the tongue is irrigated by the lingual artery and vein, which have
transverse branches; from this part, transverse flaps can be taken. The mobile part of the tongue is irrigated by
the ranine arteries and veins. The ranine arteries course next to the deep muscular mass and, forward of this
point, have 10 to 12 collaterals.
The terminal branches anastomose in the lingual apex, forming the ranine arch. The median raphe separates
both sides perfectly in the lingual body without any vascular anastomosis; this was recently confirmed in
arteriographic studies. Longitudinal flaps can be obtained on the lingual body; it is not advisable to design flaps
that cross the median raphe. Longitudinal as well as transverse and bipedicle flaps can be created on the apex
because of the rich vascularity (see Fig. 177.1).
FLAP DESIGN AND DIMENSIONS
Three basic factors must be considered in designing a successful tongue flap. First, the exact location, width,
and length of the flap depend on the location and size of the defect at the recipient site in the lip. Second, the
outlines of the flap should be made following the direction of the blood supply in the root, body, and apex. Third,
tension and distortion are the main enemies of successful tongue flap repair; good arterial and venous blood
supply and gentle handling of the tissue are the only allies. A flap site that avoids tension from the mobility of the
tongue should be selected (Fig. 177.2).
Although tongue musculomucosal flaps can be obtained equally well from the dorsum, lateral margins, or inferior
surface, it is recommended that flaps for labial reconstruction be taken from the margins or the undersurface
because the mucosa of these areas is smooth and resembles vermilion. It is not wrinkled and does not have
papillae like the mucous membrane of the lingual dorsum.
FIGURE 177.2 Direct tongue musculomucosal flap in reconstruction of the lower lip. A: The defect and the
tongue musculomucosal flap outline are shown. B: Tongue musculomucosal flap has been elevated. C: Tongue
musculomucosal flap sutured in single layer. After 3 weeks, the flap is ready for division.

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OPERATIVE TECHNIQUE
Reconstruction of the Lower Lip
Direct Tongue Musculomucosal Flap
When total vermilion reconstruction is planned, a single flap is taken from the tip and margin and applied to the
lower lip as a single unit. This flap can be used when a lip shave is done in cases of leukoplakia or multiple small
epitheliomas. The flap is designed with a single pedicle, including the right amount of muscle for aesthetic
reconstruction (Figs. 177.2 and 177.3). After careful hemostasis, the flap is sutured in a single layer, with a small
raw area left in the pedicle. After 3 weeks, the flap is ready to be divided along a line 1.5 cm behind the posterior
margin of the defect. In some cases, a surgical revision is made some months later to correct a residual bulge.
Occasionally, the flap has a dark red color because of vascular congestion, and this coloration may last for some
months; it later fades.
FIGURE 177.3 Patient with squamous cell carcinoma on the right side and cheilitis of the lower lip vermilion.
Note the vertical scar on the left side of the lip from a previous squamous cell carcinoma removed 1 year before.
A: Excision of the vermilion and part of the lower lip is outlined. B: Lower lip has been sutured and tongue
musculomucosal flap from the apex used to repair vermilion wound. C: Patient 8 months postoperatively.
Direct Marginal Tongue Musculomucosal Flap
The edge of the tongue is a good flap site for lip reconstruction. This flap is useful for primary or secondary
reconstruction of half the vermilion border as well as for reconstruction of the labial commissure (Fig. 177.4). I
have used this flap for primary repair in patients who have hemangiomas invading the vermilion border (7), the
muscular portion, and mucosa of the lower lip (Fig. 177.5) and for secondary repair in patients with vermilion
border deficits after burns and other trauma. The buccal commissure can be successfully reconstructed after
trauma or electrical burn (8, 9).

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FIGURE 177.4 Direct marginal tongue musculomucosal flap. A: Lower lip defect. B: Tongue flap obtained from
marginal edge of the tongue; loss of lip substance is exposed. C: Tongue flap is sutured in a single layer. D:
Three weeks later, the pedicle is sectioned.
Total Reconstruction of the Lower Lip
By using a combined technique using skin flaps and tongue musculomucosal flaps, it is possible to totally
reconstruct the lower lip (10).
Reconstruction of the Upper Lip
Direct Tongue Flap (11, 12)
The tip of the tongue and anterior margins are good donor sites for direct flaps in upper lip reconstruction. The
thickness
of the vermilion, which may be very thin after trauma, tumor removal, or cleft lip repair, can be increased. When
the integument of remaining vermilion is altered by scar tissue or pigmentation, it can be aesthetically improved if
the flap is obtained from the margins or inferior aspect of the tongue. The surgical procedure is simple and
consists of making a correctly sized flap and suturing it onto the raw surface of the lip, leaving it in that position
for 3 weeks (Fig. 177.6) and then sectioning the pedicle. When sectioning the pedicle, the surgeon should be
careful to create a rounded vermilion border that is aesthetically acceptable (Fig. 177.7).

FIGURE 177.5 A: A 52-year-old patient with angioma involving the entire half of the lower lip vermilion. B:
Postoperative view 1½ years later. (From Guerrerosantos et al., ref. 7, with permission.)
Buried Denuded Tubular Tongue Flap
This flap provides filling for a labial defect in which the vermilion border has an epithelial covering without scars
or color abnormalities. After primary reconstruction of the upper lip in some patients with cleft lip, some sequelae
may be observed: notching, extremely narrow vermilion border, unilateral lack of tissue, and a short, tense
vermilion border. The filling provided by this flap makes the fissures disappear and the narrow vermilion fill out,
and it corrects asymmetries caused by a lack of tissue.
FIGURE 177.6 Reconstruction of the upper lip using direct tongue musculomucosal flap. A: Tongue flap has
been transferred into and sutured to the lower border of the defect. B: At a later stage, the pedicle of the flap is
severed. Dotted area shows new vermilion. C: Operation is completed.
The mucosa is removed, and the tip of the flap is introduced into a pocket made in the lip through an incision in
the posterior surface of the lip (Figs. 177.8 and 177.9). The flap that is introduced is left in position for a period of
3 weeks, after which the pedicles are sectioned. The quantity of mucosa that is denuded depends on the size of
the defect and the volume required. The minimum amount to be denuded and introduced into the pocket should
be 1.5 cm. The tubular tongue-tip flap heals well because of its excellent blood circulation.
CLINICAL RESULTS
In a series of 198 tongue musculomucosal flaps used in lip repair at the Jalisco Reconstructive Plastic
Surgery

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Institute, only two patients had problems with healing. Severe infection in these patients resulted in
complete flap separation.
FIGURE 177.7 A: A 22-year-old patient with a cutaneous scar and asymmetry resulting from a deficiency of
vermilion on the left. B: Result 2 years after revision and direct tongue flap to the lip. (From Guerrerosantos
et al., ref. 11, with permission.)
FIGURE 177.8 Buried denuded tubular musculomucosal tongue flap. A: The tubular flap is outlined on the
tongue tip, and the mucosa of the upper surface is removed. B: A pocket is formed in the upper lip. C: The
tongue flap is inserted into the pocket, and 3 weeks later, the pedicle is sectioned.

FIGURE 177.9 A,B: A 21-year-old woman with cleft lip sequelae shown before and after reconstruction with
a buried denuded tubular tongue flap. The discrete contours of the entire vermilion border are an advantage
of this procedure.
When the flap is obtained from the lingual dorsum, the mucosa is roughened by lingual papillae and looks
different from the integument of the vermilion border. In long-term observations in a series of 36 patients, I
noted that only two patients had rough mucosa in the flap after more than 2 years. In 20 to 90 days in most
patients, the rough papillary appearance of the lingual mucosa gradually changes into the smooth
appearance of the vermilion border after passing through a period of hyperkeratinization. I have not seen
any lingual dysfunction after tissue donation for lip repair.
SUMMARY
The tongue can be used to reconstruct the upper and lower lip vermilion as either a mucosal or a
musculomucosal flap. This flap can be used in conjunction with other flaps to reconstruct the entire lip, or it
can be used alone to build bulk in an otherwise acceptable lip.
References
1. Bakamjian V. Use of tongue flap in lower lip reconstruction. Br J Plast Surg 1964;17:76.
2. Guerrerosantos J, Vasquez-Pallares R, Vera-Strathmann A, et al. Tongue flap in reconstruction of the lip.
In: Transactions of the Third International Congress of Plastic Surgeons. Amsterdam: Excerpta Medica,
1964;1055.
3. Grosserez M, Stricker M. La langue, materiaux de choix dans la réparation des pertes de substance
labiale. In: Transactions of the Third International Congress of Plastic Surgeons. Amsterdam: Excerpta
Medica, 1964;551.
4. McGregor IA. Tongue flap surgery. Br J Plast Surg 1966;19:253.
5. Cadenat H, Combelles R, Fabie M. Lambeaux de langue: Vascularisation, morphologie et utilization. Ann
Chin Plast Esthet 1973;18:223.

6. Bracka A. The blood supply of dorsal tongue flaps. Br J Plast Surg 1981;34:379.
7. Guerrerosantos J, Casteneda A, Barba A. Surgery for labial angioma. Arch Surg 1967;94:728.
8. Zarem HA, Greer DM Jr. Tongue flap for reconstruction of lips in electrical burns. Plast Reconstr Surg
1974;53:310
9. Ortiz-Monasterio F, Factor R. Early definitive treatment of electric burns of the mouth. Plast Reconstr Surg
1980;65:169.
10. Fujino I. Reconstruction of an extensive defect of the lower lip with Bernard's muscle-bearing flap and a
tongue flap after radical surgery of a lower lip tumor. Jpn J Plast Reconstr Surg 1969;12:24.
11. Guerrerosantos J. Use of a tongue flap in secondary correction of cleft lips. Plast Reconstr Surg
1969;44:368.
12. Jackson IT. Use of a tongue flap to resurface lip defects and close palatal fistulas in children. Plast
Reconstr Surg 1972;49:537.

Chapter 178
Bilateral Lateral Vermilion Border Transposition Flaps
K. MATSUO
EDITORIAL COMMENT
This is a good way to correct the whistle deformity and to provide for a symmetric lip with equal thickness
throughout. It is especially suitable when V-Y advancement is not possible because of a shortage of midline
tissue.
Bilateral lateral vermilion border transposition flaps can be used to correct the “whistling lip” deformity after cleft-
lip repair. The procedure is a modification of a V-Y advancement of lateral vermilion flaps transposed 90 degrees
(1, 2).
INDICATIONS
When patients with the whistle deformity have relatively ample lateral vermilion, these flaps can be used to
reconstruct the absent median tubercle. The flaps can easily reconstruct a natural-appearing peaked and
everted tubercle, decrease upper-lip tension, and deepen the labiogingival sulcus. They reduce the need
for additional surgery, as in the creation of a cross-lip Abbé flap. The flaps can be used to repair a
symmetric whistle deformity after bilateral cleft-lip repair and also to repair an asymmetric whistle deformity
after unilateral cleft-lip repair.
FLAP DESIGN AND DIMENSIONS
The lateral vermilion flaps are marked inside the vermilion-mucosal junction (Fig. 178.1). These flaps tend to be
wider than planned because the central-lip deficiency usually requires more tissue than expected. Lambdoidal
markings in the midposterior prolabium should be located so as to decrease horizontal lip tension and to deepen
the labiogingival sulcus after flap transposition. When used to correct an asymmetrical deformity, the width of the
flaps and the location of the markings should be considered even more carefully.
OPERATIVE TECHNIQUE
The flaps, which involve mucosa, submucosa, and orbicularis oris muscle, are elevated laterally to medially.
They are based on the prolabium and should be raised without leaving a cicatricial connection between the flaps
and the surrounding tissue to avoid distortion. The flaps are transposed into a lamboidal incision in the
midposterior prolabium. The donor sites in the lateral lip are closed primarily. A dog-ear at the end of the closure
between the lateral vermilion flaps is necessary to construct a natural-appearing peaked tubercle; when the
result is too peaked, careful trimming should be done (see Figs. 178.1 and 178.2D-G).
CLINICAL RESULTS
When used for patients with the whistle deformity, these flaps have produced satisfactory results from both
static and dynamic viewpoints. Although the lateral lip donates a compound flap to the tubercle, its
thickness appears undiminished. Some patients require secondary reduction of the reconstructed tubercle

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because the width of the flaps was larger than necessary (Fig. 178.2A-C, H-J).
FIGURE 178.1 A, B: Bilateral compound flaps and lambdoidal incision markings are drawn inside the
vermilion-mucosal junction. C: Compound flaps are transposed into the midposterior area of the prolabium.
D,E: Flaps are sutured into position and donor sites are closed primarily.
FIGURE 178.2 Bilateral cleft lip. A-C: Preoperative views. D-G: Operative steps as shown in Figure 178.1

H-J: Postoperative views.
SUMMARY
Bilateral lateral vermilion border transposition flaps to correct the whistle deformity can be effectively used
to reconstruct a natural-appearing peaked and everted tubercle, decrease upper-lip tension, and deepen
the labiogingival sulcus.
References
1. Matsuo K, Fujiwara T, Hayashi R, et al. Bilateral lateral vermilion border transposition flaps to correct the
“whistling lip” deformity. Plast Reconstr Surg 1993;91:930.
2. Kapetansky KI. Double pendulum flaps for whistling deformities in bilateral cleft lips. Plast Reconstr Surg
1971;47:321.

Chapter 179
Bilateral Vermilion Flaps for Lower Lip Repair
H. OHTSUKA
EDITORIAL COMMENT
Useful techniques rely on the dispensability of the vermilion portion of the lip. If the advancement is
considerable, it will create a skin dog-ear inferiorly, which the author resects in the form of a triangle.
Bilateral vermilion flaps, a modification of a single arterialized vermilion flap used for small defects (1), can be
used for median or central and rather lateral, larger defects of the lower lip (2).
INDICATIONS
These flaps are indicated for vermilion defects spanning two fifths to three fifths of the lower lip. Smaller
defects also can be repaired, with better postoperative symmetrical balance than can be achieved by the
unilateral flap (3). Advantages over other standard techniques include simplicity and safety, the requirement
for little or no sacrifice of healthy tissue, and the promotion of rapid wound healing because the flaps are
very well vascularized (2).
Bilateral vermilion flaps have been used for squamous cell carcinomas, malignant melanoma, and blue
nevus. Where vermilion-only defects were present, the flaps were raised as myocutaneous tissue-
expanding vermilion flaps, according to Goldstein (1). Where the defects extended to the white lip, a
subcutaneous V-Y advancement flap of the lower lip was added to the bilateral vermilion flaps.
ANATOMY
The inferior labial artery runs close to the mucous membrane. There may be asymmetries or variations of lower-
lip vermilion vascularization, including the equal distribution of the bilateral inferior labial arteries, the
predominance of the artery on one side, the presence of the artery on only one side, or the artery presenting as
the terminal branch of the sublabial artery (4, 5). In any case, an abundant vascular network is constantly
recognized in the vermilion.
FLAP DESIGN AND DIMENSIONS
The mucocutaneous junction of the vermilion with lip skin is outlined with a marking pen preoperatively. Each
vermilion flap extension to the commissure depends on the location and size of the defect.
OPERATIVE TECHNIQUE
At tumor resection, the labial artery is recognized as an important landmark on each side. Cutting through the
mucocutaneous junction of the vermilion will expose the orbicularis oris muscle. A wider mucosal incision is
recommended near the labial commissure (3). After mucosal incision, the entire thickness of the vermilion is
excised, including the labial artery. If the vermilion defects extend to the white lip, a subcutaneous V-Y
advancement flap of the lower lip is added (Fig. 179.1). A long and narrow horizontal lip defect (perhaps within
1.5 cm downward from the vermilion border) may be effectively repaired by a combination of unilateral or bilateral
vermilion flaps and a V-Y advancement flap without sacrificing any additional healthy tissue (Figs. 179.2 and

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179.3).
CLINICAL RESULTS
The procedure was used in eight patients with both vermilion-only defects and defects extending into the
white lip; follow-ups ranged from 4 months to 6 years. In all patients, cosmetically and functionally
satisfactory results were obtained. Complete sensory recovery was observed about 6 months
postoperatively. Electromyographic evaluations in two patients revealed that the motility of the orbicularis
oris muscle was almost normal within 11 and 12 months, respectively.
SUMMARY
Bilateral vermilion flaps are of value in the repair of larger vermilion defects because of their inherent
elasticity and the use of a common anatomic unit. Long and narrow horizontal lip defects may be effectively
treated by a combination of vermilion flap(s) and a V-Y advancement flap of the lower lip.
FIGURE 179.1 Diagram of operative procedure for median and lateral vermilion-only defects using bilateral
vermilion flaps (dotted line shows the mucosal incision).
FIGURE 179.2 Diagram of operative procedure for median and lateral vermilion defects extending to the
white lip using bilateral vermilion flaps and a subcutaneous V-Y advancement flap.

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FIGURE 179.3 A 71-year-old man with squamous cell carcinoma of the lower lip. A: Preoperative findings:
depiction of incision line and vermilion border. B: Resected tumor and horizontal defect of the lower lip. C:
First stage of wound closure. D: Eleven months postoperatively.
References
1. Goldstein MH. A tissue-expanding vermilion myocutaneous flap for lip repair. Plast Reconstr Surg
1984;73:768.
2. Ohtsuka H, Nakaoka H. Bilateral vermilion flaps for lower lip repair. Plast Reconstr Surg 1990;85:453.
3. 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.
4. Hu H, Song R, Sun G. One-stage inferior labial flap and its pertinent anatomic study. Plast Reconstr Surg
1993;91:618.
5. Midy D, Mauruc B, Vergnes P, et al. A contribution to the study of the facial artery, its branches and
anastomoses: Application to the anatomic vascular bases of facial flaps. Surg Radiol Anat 1986;8:99.

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Chapter 180
Commissure Reconstruction: Overview
H. G. THOMSON
EDITORIAL COMMENT
Because this chapter provides a comprehensive review of the various techniques described for commissure
reconstruction, the names of authors have been included. In most other chapters, we have tried to avoid
lengthy lists of historical details. These have instead been referred to the list of references.
Bakamjian (1) in 1964 stated that molding the lip commissure with functional fidelity is an almost impossible task.
The aim of surgical reconstruction is to give symmetry to the commissure in repose and to permit full opening
without webbing. The former goal is much easier to attain than the latter. The subtle flow line of the red lip to its
termination at the angle of the commissure and its ability to move up, down, and laterally, as well as vertical
mucosal stretching, were well described by Stricker in 1981 (2). The Z distribution of the skin and the accordion
effect of the mucosa were emphasized. To achieve this is the goal of reconstructive surgery, but the most
common shortfall is the apparent fullness in the commissure owing to a lack of contouring.
INDICATIONS
Defects of the commissure apex are rare; most problems are pericommissural in nature and involve the
apex. The most common indication is trauma, especially electrical oral burns.
ANATOMY
To apply the tenets of reconstruction properly, we must first appreciate the topographic location of the
commissure on the face. Broadbent and Matthews (3) described the normal location of the oral commissure. With
the normal in mind, various landmarks can be chosen and methods for locating the apex of the proposed
commissure can be applied (Fig. 180.1). There should be a special awareness of the tapering effect of the
commissure, and this begins at a vertical line through the medial canthus.
FLAP DESIGN AND DIMENSIONS
Tongue Flaps
Bakamjian (1) described several types of tongue flap designs, in particular a ventrolateral, anterior-based flap,
which he included in commissure reconstruction as part of partial or total red lip reconstruction after cancer
ablation. Guerrerosantos et al. (4) in 1963 were really the first authors to describe the use of a tongue flap that
could give not only mucosal functional and aesthetic advantages but also a degree of much needed bulk in the
area. They also described the microscopic papillary appearance of
tongue mucosa, which, after 20 to 90 days, takes on a smooth red lip appearance. They usually used the tongue
tip.

FIGURE 180.1 Wright's facial landmarks for commissure location.
FIGURE 180.2 Converse type of tongue flap for commissure reconstruction.
McGregor (5) also described a tongue flap. Jackson (6) reported the use of tongue flaps in oral electrical burns
and the need for awareness of the fact that the tongue flap can be separated by young patients' sharp teeth. To
prevent this, he fabricated a prophylactic bite block. He reported an anterior-based sublingual flap that required
lanolin three times a day for a few months to prevent desiccation. Jackson makes a point that the tongue papillae
do not always disappear, and therefore, his sublabial flap, which is smooth and less red, provides better
cosmetic coverage.
In 1974 Zarem and Greer (7) described a sublabial or ventral flap that is anteriorly based and applied to only one
surface of the commissure; the other surface is closed with simple mucosal advancement. They did this in an
attempt to reduce ultimate bulk excess. They emphasized the shortfall of the color match provided by the vivid
pink of the tongue mucosa. They prefer this reconstruction to be initiated 3 weeks after injury and have found
that the pedicle can be separated at 2 weeks. A similar technique was reported by Converse in 1977 (8) (Fig.
180.2). In 1980 Ortiz-Monasterio and Factor (9) described an anterior-based, split, lateral sublabial tongue flap
for commissure reconstruction that provides significant tissue to the commissure area and, indeed, may create
difficult problems with debulking (Fig. 180.3).
Cheek Flaps
Reconstructions of the lips with cheek flaps are legend. Those related to the commissure only are somewhat
limited in number and relate to primary tumor resection and reconstruction. Tumors of the commissure constitute
fewer than 6% of those involving the lip area. Zisser (10) in 1975 reported a technique for cheek advancement
and mucosal flap reconstruction of the commissure. The deepithelialized flaps are rotated up into the defect to
give both bulk and alignment (Fig. 180.4). Brusati (11) in 1976 described a similar technique for commissure
reconstruction (Fig. 180.5) that is also based on a Burow's triangle principle. Attempts are made to keep the
major scar lines in the axis of the smile crease. This flap is more suitable for horizontal defects compared with the
Zisser flap, which is more applicable to vertical problems.

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FIGURE 180.3 Ortiz-Monasterio and Factor split pedicle tongue flap.
FIGURE 180.4 Zisser method of advancement commissure reconstruction for vertical defects.
Red Lip Flaps
In 1931 Joseph (12) described a “back-flip” mucosal flap with direct closure of the donor site in the buccal
gingival sulcus area. Kazanjian and Roopenian (13) in 1954 described simple advancement flaps of existing red
lip for defects less than 1 to 1.5 cm long (Fig. 180.6). Gillies and Millard (14) in 1957 reported a partial leading
edge “back-flip” flap. These flaps can function adequately if the donor site is not deficient and additional bulk is
not necessary (Fig. 180.7).
Buccal Mucosal Advancement Flaps
In 1959 Converse (15) described his technique for elongation of the oral fissure and restoration of the angle of
the mouth. This consisted of a triangular scar excision with advancement of three mucosal flaps (Fig. 180.8).
Pons in 1968 (16) described an additional attempt to establish continuity of the orbicularis oris by repositioning
the muscle and fibrous tissue remnants. In 1971 Wustrack (17) emphasized his method of dermomuscle stocks to
ensure competence of the oral commissure. This concept was further elaborated by Villoria (18) in 1972, who
used two muscle and fibrous tissue flaps, coupled with Converse's principle (Fig. 180.9). Argamaso et al.
(19) in 1974 reemphasized the translocation of orbicularis oris remnants.

FIGURE 180.5 Brusati technique for more horizontal commissure defect.
FIGURE 180.6 Kazanjian and Roopenian advancement flaps.
FIGURE 180.7 Gillies and Millard back-flip flap.

FIGURE 180.8 Converse mucosal advancement flaps.
FIGURE 180.9 Villoria muscle-fibrous tissue flaps with Converse commissure reconstruction.
FIGURE 180.10 Gillies and Millard single flap with additional mucosal advancement.
A slightly different mucosal rotation advancement using a portion of the reepithelialized commissure as a flap for
the upper lip and a rotation advancement of the endoral mucosa for the lower lip (Fig. 180.10) was described by
Gillies and Millard in 1957 (14). Muhlbauer in 1970 (20) used an “out of series” double Z-plasty, interposing red

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and white lip flaps, with possible secondary color match problems (20) (Fig. 180.11).
Buccal Mucosal Rotation Flaps
Kazanjian and Roopenian in 1954 (13) described a laterally based double mucosal pedicle to reconstruct the
commissure (Fig. 180.12). This is the basis of my methods of reconstruction (21, 22). The biggest hurdle created
by this technique is the inappropriate color match and a pouting commissure due to an overabundance of
mucosa and poor tailoring of the flap. I have outlined the difficulties of this type of reconstruction in previous
publications (21, 22, 23, 24).
The most critical aspect of the operation is to establish the location of the commissure apex with some degree of
accuracy. This is done by using basic landmarks (medial canthus, philtrum, normal commissure, alar base, and
so forth). The measurements are achieved by using suture material rather than a ruler or compass (Fig. 180.13A
and B).
A single-pedicle flap similar to that described by Limberg is simple to design and will provide good opening, but
excess mucosal bulk in the commissure is common (Fig. 180.13C-E). A more satisfactory technique is to use two
marginally based rotation flaps that meet in the commissure apex, with primary closure of the donor site (Fig.
180.14). If two isolated Limberg-like flaps are used, with the apex of the commissure as the juncture point, good
tailoring and aesthetics also can be achieved (Fig. 180.15).
FIGURE 180.11 Muhlbauer double white and red Z-plasties.
CLINICAL RESULTS
There is no “best” technique for commissure reconstruction with a simple or composite flap. It is impossible
to reconstruct a commissure that has a normal, unoperated appearance, particularly when additional white
lip scarring is present. Various interpositional and tunnel flaps can be
used to eliminate this latter problem, but there is a risk of additional secondary scarring being created in
attempts to eliminate the original. In view of these difficulties, it is important to program the patient for
additional revisionary surgery after a delay of 1 year.

FIGURE 180.12 Kazanjian and Roopenian double mucosal pedicle.
FIGURE 180.13 A: Suture material from midpoint of cupid's bow to commissure on normal side. B: In
position on affected side, intercept of arc from midpoint of upper and lower lips locates commissure. C:
Stippled area in white lip is to be superficially excised and closed with Z-plasty; diamond area is to be

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totally excised and replaced with mucosa. D: Limberg type of flap outlined. E: Flap in place and Z ready to
be cut.
SUMMARY
This chapter outlines the many various methods designed to reconstruct the lip commissure.
FIGURE 180.14 A: Diamond area to be excised. B: Two marginally based sickle flaps outlined; dotted area
to be removed. C: Flaps in position with juncture point in commissure apex.
FIGURE 180.15 A: Left oral commissure stenosed. B: Two rotation-advancement flaps outlined; oblong
area to be excised. C: Flaps in place. D: Late result outlined by stippled area.

References
1. Bakamjian V. Use of tongue flaps in lower lip reconstruction. Br J Plast Surg 1964;17:76.
2. Stricker M. La commissure buccale. Ann Chir Plast 1981;26:131.
3. Broadbent TR, Matthews NL. Artistic relationships in surface anatomy of the face: Application to
reconstructive surgery. Plast Reconstr Surg 1957;20:1.
4. Guerrerosantos J, Vasquez-Pallaves R, Vera-Strathman A, et al. The tongue flap in reconstruction of the
lip. In: Transactions of the Third International Congress of Plastic Surgery. Amsterdam: Excerpta Medica,
1963.
5. McGregor IA. The tongue flap in lip surgery. Br J Plast Surg 1966;19:253.
6. Jackson IT. Use of tongue flaps to resurface lip defects and close palatal fistulas in children. Plast
Reconstr Surg 1972;49:537.
7. Zarem HA, Greer DM. Tongue flap for reconstruction of the lips after electrical burns. Plast Reconstr Surg
1974;53:310.
8. Converse JM, ed. Reconstructive plastic surgery. Philadelphia: WB Saunders, 1977.
9. Ortiz-Monasterio F, Factor R. Definitive treatment of electric burns of the mouth. Plast Reconstr Surg
1980;65:169.
10. Zisser G. A contribution to the primary reconstruction of the upper lip and labial commissure following
tumor excision. J Maxillofac Surg 1975;3:211.
11. Brusati R. Reconstruction of the labial commissure by a sliding U-shaped cheek flap. J Maxillofac Surg
1979;7:11.
12. Joseph J. Nasenplastik and sonstige Gesichtsplastik nebst einen Anhang über Mammaplastik and
einige weitere Operationen aus dean Gebiete der ausseren korperplastik. Leipzig: Kabitsch, 1931.
13. Kazanjian VH, Roopenian A. The treatment of lip deformities resulting from electric burns. Am J Surg
1954;88:884.
14. Gillies HD, Millard DR, eds.: Principles and art of plastic surgery. Boston: Little, Brown, 1957.
15. Converse JM. Surgical treatment of facial injuries. Baltimore: Williams & Wilkins, 1959;795.
16. Pons J. À propos du temps musculaire clans les commissurotomies labiales. Ann Chir Plast 1968;13:4.

17. Wustrack KO. Reconstruction of incompetent oral commissures with dermal muscle flaps from the lips.
Plast Reconstr Surg 1971;62:118.
18. Vittoria JM. A new method of elongation of the corner of the mouth. Plast Reconstr Surg 1972;49:52.
19. Argamaso RV, Strauch B, Lewin ML, et al. Lip-commissuroplasty after electrical burns. Chir Plast
1975;3:27.
20. Muhlbauer WD. Elongation of mouth in postburn microstomia by a double Z-plasty. Plast Reconstr Surg
1970;45:400.
21. Thomson HG, Juckes AW, Farmer AW. Electric burns to the mouth in children. Plast Reconstr Surg
1965;35:466.
22. Thomson HG. Electric burns to the mouth. In: Feller I, and Grabb WC eds. Reconstruction and
rehabilitation of the burned patient, Ann Arbor, Mich.: National Institute for Burn Medicine, 1979. Chap.
62;216.
23. Al-Qattan M, Gillett D, Thomson HG. Long-term objective lip assessment following electrical burns to the
oral commissure in infancy and childhood. Can J Plast Surg 1996;4:2.
24. Al-Qattan MM, Gillett D, Thomson HG. Electrical burns to the oral commissure: does splinting obviate the
need for commissuroplasty? Burns 1996;22:555.

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Chapter 181
Commissure Reconstruction
R. V. ARGAMASO
EDITORIAL COMMENT
The technique demonstrated here is a functional restoration of the commissure, which should be kept in
mind for relatively large defects, particularly following cancer resection. On the other hand, for children who
occasionally suffer from electrical burns of the commissure, the simple technique of an angle prosthesis to
stretch the area and to soften the scar tissue should also be considered.
The lips form an aesthetic unit of the face and are multifunctional. When an electrical burn occurs at the
commissure of the mouth (an injury more likely to be acquired by inquisitive infants and young children), some
functional impairment and structural asymmetry may result. Deep burns disrupting the orbicularis oris muscle are
a challenge to adequate reconstruction (1).
INDICATIONS
The vermilion tapers and disappears at the corners of the mouth. A full-thickness destruction of tissue at the
commissure invariably includes muscle fibers. As a consequence, the normally closed interval between the
lips at the corner when the mouth is at rest is transformed into a gap. During the acute
stage of the injury, this corner of the mouth becomes incompetent and allows continuous drooling of saliva,
which is both untidy and unsightly.
An acute injury is treated conservatively to allow healing with the least sacrifice of viable tissue. As a result
of scar deposition and contracture, the oral circumference is reduced. The resulting postburn microstomia is
disfiguring and, in severe cases, causes feeding difficulties.
ANATOMY
The orbicularis oris muscle, unlike the orbicularis oculi, is formed by complex strata of muscle fibers surrounding
the mouth. These fibers originate from other muscles of the face and therefore come from several directions.
At the commissure, the buccinator sends upper and lower fibers to the upper and lower lips, respectively. Its
middle fibers decussate with those of the levator anguli oris to pass to the lower lip and with those of the
depressor anguli oris to pass to the upper lip. The zygomaticus inserts obliquely into the angle of the mouth and
blends with the levator and depressor anguli oris. The risorius runs horizontally and inserts into the constituted
orbicularis muscle and the skin at the corner of the mouth. These muscles are innervated by the buccal branches
of the seventh nerve.

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FIGURE 181.1 Stages in reconstruction of the commissure (see text).
FLAP DESIGN AND DIMENSIONS
When there has been only minor tissue loss, skin and mucosal flaps may be shifted to the area involved. With
significant damage to the orbicularis muscle, however, a restoration of muscle continuity within the area of the
vermilion is an important aspect of the procedure described (Fig. 181.1).
OPERATIVE TECHNIQUE
Once the scar has been excised, the original area of the defect is recreated. Assessment of the orbicularis
remnant is undertaken by a careful skin dissection. The stumps of the destroyed segment are identified, and the
ends are cut squarely. The intact component fibers of the muscle are mobilized gently toward these stumps.
Continuity of the orbicularis ring at the vermilion then is reestablished by an end-to-side suture of the
discontinuous stumps to the continuous, contiguous muscle fibers. The new position of the translocated muscle
segments now will form the substance or framework of the new commissure.
The skin defect toward the upper lip is repaired by approximating the skin margins, marked a and b in Figure
181.1, in a lateral to medial direction. A straight-line closure is directed vertically to the lip or slightly obliquely.
The skin sutures stop
at the vermilion, the final suture catching some fibers directly underneath, to maintain the transposed muscle in
the medial position.
The apex of the new commissure then is determined by plotting the distance between the corner of the lip and
the peak of the cupid's bow on the uninvolved side and then transposing this measurement from the
corresponding peak of the cupid's bow to that point on the involved side. A slight overcorrection is advisable
because healing generally involves some shortening of this distance.
The skin now is incised in line with the vermilion ridge of the upper lip to the point indicated as the apex of the
reconstructed commissure. A triangular flap (c) is thus created. This is transposed for coverage of the skin defect
of the lower lip.
Finally, buccal mucosal flaps are fashioned and tailored into the corner of the mouth to line the new vermilion.
Dogears that develop are trimmed accordingly (Figs. 181.2 and 181.3).

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FIGURE 181.2 A: A severe electrical burn to the left commissure in an infant was allowed to heal spontaneously.
A marked reduction of the oral opening made spoon-feeding rather difficult. An appreciable defect resembling the
acute deformity was recreated following scar excision; a portion of the orbicularis muscle was missing. B:
Continuity of the orbicularis muscle ring at the vermilion was reestablished by the method described. C:
Immediate postoperative result. D: Late result. As a consequence of severe muscle deficiency, restoration of
fullness of the vermilion was only partially achieved.
CLINICAL RESULTS
The suture lines are usually subjected to some degree of tension. Inflammation is common, but it is easily
controlled with local hygiene and topical antibiotics. The functional results generally are gratifying, but the
prominence of postoperative scars almost always requires their future revision. Readvancement of healthy
mucosal flaps to replace scarred areas also contributes to the patient's acceptance of the final outcome of
repair.
SUMMARY
A method of reestablishing continuity of the orbicularis oris muscle at the commissure, commonly disrupted
by an electrical burn, is described. A successful reconstruction helps to restore lip competency at the angle
of the mouth and also improves the contour and symmetry of the vermilion.