Local Flaps in Facial Reconstruction

446
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
E
F
G
H
E, One week after transfer of flap to nose. F, Three weeks after transfer, pedicle divided and flap inset.
G, Subcutaneous tissue pedicle amputated and cheek wound closed. H, Flap trimmed of excess skin and inset.
FIGURE 18-28, cont’d  ■

18  RECONSTRUCTION OF THE NOSE
447
FIGURE 18-29  ■  A-D, Same patient shown in Figure 18-28. Preoperative and 3-month postoperative views. No revision surgery
performed.
A
B
C
D
remove excessive subcutaneous fat not trimmed at the
time of flap transfer. The residual skin of the alar unit is
excised if it is present. However, a 1-mm fringe of skin
at the junction of the ala and the alar-facial sulcus is
preserved (see Fig. 18-28). The flap is precisely trimmed
to fit the skin defect and sutured in place with simple
interrupted 5-0 fast-absorbing plain gut sutures. When
the alar base is absent, the flap is tailored to replace the
missing base and is integrated with the nasal sill. When
the sill requires reconstruction, the flap is trimmed so
that it has a tapered end that may serve as the sill. The
end is turned medially and sutured to the upper lip.
A necessary third surgical stage in 75% of cases is
subsequent flap contouring and the creation of an alar
groove. It is performed 3 months after flap inset. A tem­
plate of the contralateral normal alar unit is made,
reversed, placed over the reconstructed ala, and traced
carefully with a marking pen. The superior border of the
tracing represents the appropriate location for the alar
groove. If the superior border of the flap is no more than
1 cm superior to the border of the tracing, the scar
marking the juncture of the flap and native nasal skin is
used as the access incision for contouring the flap. If a
larger portion of the sidewall was resurfaced, a 3-cm inci­
sion is made along the superior border of the tracing. The
flap is undermined, leaving a few millimeters of subcuta­
neous fat attached to the dermis. For men, the flap is
elevated in a more superficial plane immediately below

448
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
B
C
D
E
F
FIGURE 18-30  ■  A, A 3 × 3-cm skin defect of ala and alar-facial sulcus. Interpolated subcutaneous tissue pedicled island flap designed
for repair of alar component of defect. Broken line indicates pedicle of island flap; unbroken line marks melolabial crease; horizontal
lines mark anticipated standing cutaneous deformity resulting from transfer of flap. Arrow indicates direction of cheek advancement
flap. B, Auricular cartilage framework graft in place. C, Cheek advancement flap dissected to repair cheek component of defect. Flap
reflected laterally for exposure to dissect subcutaneous tissue pedicle of island flap. D, Island flap based on subcutaneous tissue
pedicle transferred to ala. E, Cheek advancement flap and island flap in place. F, Postoperative view at 1 month. Subcutaneous
tissue pedicle of interpolated flap obliterates alar-facial sulcus.

18  RECONSTRUCTION OF THE NOSE
449
G
H
I
J
K
G, Contouring procedure performed to create alar-facial sulcus. H, Two months after contouring procedure.
Fullness in area of reconstruction necessitated second contouring procedure. I, Patient marked for second contouring procedure 6
months after first contouring procedure. J, Alar groove constructed and cheek scar revised. K, Cotton bolster dressing used to
maintain constructed alar groove.
FIGURE 18-30, cont’d  ■

450
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
Excision continues deeply until the cartilage graft used
in the first surgical stage is exposed. A trough of cartilage
centered under the planned alar groove is excised from
the graft with a scalpel. The trough typically measures
4- to 5-mm wide and extends along the entire projected
length of the groove. See Chapter 27 for a detailed
discussion of flap contouring and refinement. Care is
taken not to deepen the cartilage trough excessively as
this may cause a depressed narrow furrow to form in
place of the shallow valley of the alar groove typically
observed in most noses. Some of the cartilage shavings
may be replaced if it is overcorrected. Proper contour is
determined by replacing the skin of the flap and com­
pressing it gently. Continued excision of soft tissue and
cartilage is performed until the constructed groove is
the dermis to expose all of the hair follicles transferred
from the cheek. This may require undermining of the
entire flap caudally to the level of the nostril margin. The
exposed follicles are cauterized individually under mag­
nification with a fine-tipped monopolar electrocautery.
The power setting of the cautery device is set sufficiently
low to prevent damage of the adjacent dermis. To ensure
flap survival in patients who use tobacco, it may be
prudent to depilate the flap in two stages: the superior
part of the flap at the time of flap contouring and restora­
tion of the alar groove and the inferior part 2 to 3 months
later.
Flap contouring and construction of an alar groove are
accomplished by removal of scar tissue and the majority
of the remaining subcutaneous fat beneath the flap.
FIGURE 18-31  ■  Same patient shown in Figure 18-30. A-D, Preoperative views and postoperative result at 1 year, 3 months. Two
contouring procedures and cheek scar revision performed.
A
B
C
D

18  RECONSTRUCTION OF THE NOSE
451
A
Cutaneous pedicle
Defect “squared off”
Auricular cartilage rim graft
B
C
D
Pedicle divided here
E
topographically identical to its counterpart. A dental
cotton roll is cut longitudinally and used as a bolster. It
is secured in place along the length of the constructed
groove by passing interrupted 4-0 polypropylene sutures
full thickness through the nose in such a manner as to
straddle the groove. The roll offers an effective method
of obliterating potential dead space, enhancing hemosta­
sis, and maintaining the constructed groove. The bolster
is removed on the fifth postoperative day along with the
cutaneous sutures. Alternatively, full-thickness horizontal
mattress transnasal bolster sutures of 4-0 plain gut are
placed to eliminate dead space between the flap and deep
tissues. These must be tied loosely to prevent skin necro­
sis as the flap swells postoperatively. The third stage of
contouring the cartilaginous framework and subcutane­
ous tissues completes the reconstruction of the ala. It has
the effect of improving the patency of the reconstructed
nasal airway by removing excessive bulk in the area of the
internal nasal valve.15,16
The peninsular flap is the other form of the melolabial
interpolated flap used to reconstruct the ala. It depends
on the dermal and subdermal vascular plexuses of the
cutaneous pedicle to provide vascularity to the distal flap.
The cutaneous pedicle must be of sufficient width and
thickness to ensure this vascularity. In designing a penin­
sular flap, the orientation of the template remains the
same as in designing an island flap (Fig. 18-32). The
width of the cutaneous pedicle is approximately the width
FIGURE 18-32  ■  A, A 2 × 1.4-cm cutaneous defect of lateral tip and alar groove. Cutaneous pedicled interpolated melolabial flap
designed for repair. B, Defect enlarged to create square corners. Auricular cartilage rim graft in place for support of nostril. C, In
situ flap incised. D, Flap transferred to nose. E, Three weeks after initial transfer, flap is inset.
Continued

452
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
H
I
F
G
F-K, Preoperative and 3-year postoperative views. No revision surgery performed.
FIGURE 18-32, cont’d  ■
of the template, although it may be narrower than the
template when a wide (more than 2 cm) flap design is
required. The peninsular flap is elevated in a subcutane­
ous plane, maintaining 3 mm of fat on the undersurface
of the cutaneous pedicle. This is in contrast to the island
flap, based on a subcutaneous tissue pedicle that may be
as much as 1.5 cm thick. Thus, the plane of dissection for
the peninsular flap is considerably more superficial. Like
the island flap, the peninsular flap pivots 90° toward the
midline and is sutured to the nose in a fashion similar to
that described for the island flap. Care is taken not to
kink the pedicle on transfer of the flap. Like the island
flap, the distal half of the flap may be thinned as necessary
to replicate the thickness of the recipient site. The proxi­
mal portion of the flap bridging between cheek and nose
is not thinned to ensure an ample vascular supply. The
cheek wound is closed by a method identical to that for
the island flap.
Similar to the island flap, the peninsular flap remains
attached to the cheek for 3 weeks to enable the

18  RECONSTRUCTION OF THE NOSE
453
usually corresponds to the vertical tangent of the medial
border of the eyebrow.17 The artery exits the orbit by
piercing the orbital septum and passing under the orbi­
cularis oculi and over the corrugator supercilii muscle.
At the level of the eyebrow, the artery passes through
orbicularis and frontalis muscles and continues in a verti­
cal direction upward in a subcutaneous tissue plane.
Because of this, the portion of the flap extending from
the level of the eyebrow to the hairline can be trimmed
of its frontalis muscle and much of the subcutaneous fat
without harming the blood supply to the overlying skin.
The axial nature of the flap, based on a single supra­
trochlear artery, enables the pedicle to be as narrow as
1.2 cm.17 The narrow pedicle minimizes the standing
cutaneous deformity that develops as the flap pivots. An
exact template of the defect is used to design the para­
median forehead flap, which is centered over the vertical
axis of the supratrochlear artery. The length of the flap
is determined by measurement. If an adequate length
necessitates extending the flap into the hair-bearing
scalp, the author prefers turning the flap obliquely along
the hairline to prevent transfer of hair-bearing skin to
the nose. However, this design may not be prudent if the
flap must be more than 3 cm in width. Oblique forehead
flaps wider than 3 cm remove excessive skin from the
lateral portion of the forehead, sometimes causing
unsightly scars or upward distortion of the central
portion of the eyebrow. Thus, flaps wider than 3 cm
should be extended into the hair-bearing scalp rather
than designed in an oblique fashion.
The paramedian forehead flap is elevated in a subfas­
cial plane just superficial to the periosteum of the frontal
bone. To avoid injury to the arterial pedicle, blunt dissec­
tion is used near the eyebrow to separate the corrugator
establishment of collateral vascularity. The pedicle is
divided at a second stage (see Fig. 18-32E), and the proxi­
mal portion of the pedicle is inset in the cheek by opening
the superior portion of the donor site scar for 1 to 2 cm.
The wound edges are spread widely, creating a space to
accommodate the proximal pedicle. The skin adjacent to
the opened wound is undermined for 2 cm. This allows
the cheek skin to contract, assisting in enlarging the
wound. The pedicle stump is then trimmed to precisely
fit the wound and inset in the melolabial fold, creating a
V-shaped wound closure. Returning most of the skin of
the proximal pedicle to the cheek helps maintain the
natural fullness observed in the superior portion of the
melolabial fold.
The greatest advantage of using the melolabial flap in
the form of an interpolated rather than a transposition
flap is the preservation of the aesthetically important alar-
facial sulcus. The technique also minimizes flattening of
the superior melolabial fold because the majority of skin
removed from the cheek is from the middle and inferior
portions of the fold.
Paramedian Forehead Flap
Paramedian forehead flaps are the preferred local flap
for resurfacing most large nasal defects. The reader is
referred to Chapter 13 for an in-depth discussion of the
paramedian forehead flap, which is the sole topic of the
chapter. The flap is usually dissected under local anes­
thesia. The base of the pedicle is placed in the glabellar
region centered over the supratrochlear artery on the
same side as the majority of the nasal defect (Fig. 18-33).
The origin of the supratrochlear artery is consistently
found to be 1.7 to 2.2 cm lateral to the midline and
J
K
FIGURE 18-32, cont’d

454
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
Cheek advancement flap
Auricular cartilage framework graft
B
C
D
E
F
G
FIGURE 18-33  ■  A, A 1.9 × 1.4-cm skin and soft tissue defect of ala and medial cheek. Cheek flap advanced to alar-facial sulcus.
Auricular cartilage graft provides framework for alar construction. B, C, Paramedian forehead flap provides external cover for defect.
D-I, Preoperative views and postoperative result at 1 year, 9 months. Three contouring procedures and forehead scar revision per­
formed. Right temple and nasal tip defects repaired with full-thickness skin grafts.

18  RECONSTRUCTION OF THE NOSE
455
thinned to the level of the dermis to duplicate the thin
skin that is normally found in this area. Deep-layer
closure is not necessary because the wound should not be
under any closure tension. The base of the pedicle is
returned to the donor site in such a way as to restore the
normal anatomic and spatial relationship of the two eye­
brows. Care is taken to maintain the muscle component
of the pedicle returned to the forehead so that a depres­
sion between the eyebrows does not occur. Any excess
pedicle extending above the level of the eyebrows is dis­
carded rather than returned to the forehead. Unlike with
the interpolated melolabial flap used to reconstruct the
ala, a third-stage contouring of the paramedian forehead
flap is usually not necessary except when the flap is used
to reconstruct the ala and nasal sidewall concomitantly.
In this instance, a contouring procedure is usually neces­
sary to restore the alar groove. On occasion, forehead
flaps used to reconstruct the other aesthetic units of the
nose may require refinement, such as Z-plasties of the
scar surrounding the flap or additional thinning of
the flap in patients with thin native nasal skin adjacent to
the flap.
SKIN GRAFTS
Full-Thickness Skin Grafts
A full-thickness skin graft consists of epidermis and full-
thickness dermis. It resists contraction, has texture and
pigmentation similar to those of normal skin, and requires
a well-vascularized, uncontaminated recipient site for
survival. The graft survives initially by diffusion of nutri­
tion from fluid in the recipient site, a process called
plasma imbibition. Vascular inosculation occurs during
muscle from the flap and to facilitate mobility. Incisions
may be extended below the eyebrow if necessary to
increase the length of the flap. Adequate flap mobiliza­
tion usually requires complete sectioning of the corruga­
tor supercilii muscle to achieve free movement. Before
the flap is sutured in place, the flap is sculpted and con­
toured to fit the depth of the defect perfectly by removal
of all or some of the muscle and subcutaneous tissue from
the distal portion. When necessary, all but 1 mm of fat
beneath the dermis may be removed. In instances in
which the nasal skin is quite thin, it is sometimes even
necessary to resect a portion of the dermis along the
border of the flap so that the thickness of the skin of the
flap matches the adjacent nasal skin. This is performed
only along the border, not more centrally. Only the distal
three-fourths of the surface area of the flap required for
reconstruction is thinned; the proximal one-fourth is left
thick and is debulked at the time of pedicle detachment
3 weeks later. Prudence in thinning the flap is advised in
patients who smoke. Donor site closure is accomplished
by undermining the forehead skin in the subfascial plane
from the anterior border of one temporalis muscle to the
other. Any portion of the donor site that cannot be closed
primarily should be left to heal by secondary intention,
keeping the open wound moist at all times. Healing
usually results in an acceptable scar, but complete healing
may take 6 weeks.
Three weeks after the initial flap transfer, the pedicle
is divided under local anesthesia. The nasal skin sur­
rounding the defect superiorly is undermined for a dis­
tance of approximately 1 cm. The portion of the flap not
thinned at the time of transfer is now thinned and the
flap is trimmed to precisely fit the recipient site. In the
case of reconstruction of skin-only nasal defects that
extend to the rhinion, the flap must be aggressively
H
I
FIGURE 18-33, cont’d

456
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 18-34  ■  A, A 3 × 2.5-cm skin defect of nasal tip and dorsum repaired with full-thickness skin graft from supraclavicular fossa.
B, Postoperative result at 1 year. Graft dermabraded. Skin grafts may be used to repair superficial skin defects anywhere on nose
in individuals with thin nasal skin. Such individuals tend to be fair-skinned women.
A
B
the first 24 to 48 hours. After 48 to 72 hours, capillaries
in the recipient site begin to grow into the graft to provide
new circulation. By 3 to 5 days, a new blood supply has
been established. Initially, a full-thickness skin graft
appears blanched; during 3 to 7 days, a pink color devel­
ops, signaling neovascularization. After 4 to 6 weeks, the
pink color begins to fade, but the graft often remains
lighter than the surrounding skin, especially in dark-
skinned individuals.
Compared with split-thickness grafts, full-thickness
grafts have the advantages of better color and texture
match with nasal skin, fewer contour irregularities, no
need for special equipment to harvest the graft, and easier
donor site wound care. The disadvantages include
reduced survival rate for larger grafts and longer healing
time.18
The ideal nasal defect to repair with a full-thickness
skin graft is smaller than an aesthetic unit. Ideally, the
defect should be superficial, with loss of skin but not
underlying muscle. The vascularity of shallow wounds is
greater than that of defects extending through the muscle
to the underlying cartilage or bone. The ideal defect is
separated from the free margin of the nostril by at least
5-mm and is located in thin-skinned areas of the nose.
These areas include the cephalic sidewalls, dorsum, and
infratip lobule. Shallow wounds in these areas are typi­
cally completely filled by a full-thickness skin graft,
leaving no step-down contour deformity.
The areas of the nose covered with thicker skin include
the tip, alae, and caudal aspect of the sidewalls and dorsum
(see Fig. 18-2). Although the nasal skin is thin in the area
of the rhinion, it becomes thicker as it transitions toward
the nasion. Full-thickness skin grafts used to repair
defects of the nose in regions of thicker nasal skin tend
to heal with a contour depression and noticeable textural
discrepancies between graft and adjacent nasal skin. This
is because the nasal skin in these areas tends to have a
more sebaceous nature than the graft.
There is wide variation of nasal skin thickness among
individuals, and the overall thickness of the nasal skin is
an important preoperative consideration. For similar
nasal defects, a skin graft may provide a perfect match in
terms of thickness for one person and a poor match for
another. There are individuals who have thin nasal skin
covering the entire nose. These individuals are often fair-
skinned women (Fig. 18-34). Except for patients with

18  RECONSTRUCTION OF THE NOSE
457
perfect. Six weeks after grafting, the area may be lightly
dermabraded to blend the graft with the nasal skin
(Fig. 18-36).
RECONSTRUCTION OF THE NASAL
AESTHETIC UNITS
Defects of the nose may be classified according to loca­
tion, depth, and size. Skin-only defects may be replaced
with full-thickness skin grafts, local flaps (if the defect is
small), or skin transferred from the cheek or forehead.
Defects involving loss of skeletal structure require replace­
ment of skeletal support with like tissue. Full-thickness
defects of the nose require replacement of the missing
lining with flaps harvested from the interior of the nose
whenever possible. These defects always require replace­
ment of the missing skeletal framework and thus should
extremely thick skin, full-thickness skin grafts may be
used in cases of very superficial cutaneous defects any­
where on the nose without the consequence of significant
contour or textural discrepancies between graft and nasal
skin (Fig. 18-35). The only exception is in the area of the
nostril margin, where scar contraction after skin grafting
is likely to distort the border of the nostril.
In general, cutaneous flaps from the nose, forehead,
or cheek are the preferred method of resurfacing for
deeper cutaneous defects of the nose. However, the
infratip lobule is one site where a full-thickness skin graft
is preferred to a cutaneous flap. Provided the defect does
not involve the margin of the nostril and there is no loss
of the intermediate crura, cutaneous defects of the infratip
lobule are best covered with a full-thickness skin graft
harvested from the preauricular or postauricular skin.
The match in thickness and color between the skin from
these sources and the skin of the infratip lobule is nearly
FIGURE 18-35  ■  A, A 2.5 × 2.5-cm superficial skin defect of nasal tip. B, Full-thickness skin graft harvested from supraclavicular fossa
used to repair defect. C, Bolster dressing in place over skin graft. D, Postoperative view at 9 months. Graft dermabraded. Superficial
nature of defect and thin nasal skin provided reasonable likelihood of acceptable aesthetic results with skin graft.
A
B
C
D

458
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 18-36  ■  A, A 0.5 × 0.6-cm skin defect of infratip lobule repaired with full-thickness skin graft. B, Postoperative view at 1 year.
Graft dermabraded. Full-thickness skin grafts are preferred method for repair of skin-only defects of columella, nasal facets, and
infratip lobule.
A
B

18  RECONSTRUCTION OF THE NOSE
459
be resurfaced with an interpolated paramedian forehead
or melolabial flap.
Reconstruction of Columella
and Nasal Facets
The columella and nasal facets are the most difficult
aesthetic units of the nose to reconstruct. Skin-only
defects are best repaired with full-thickness skin grafts
(see Fig. 18-36). Small defects of skin and cartilage
limited to 1.5 cm in greatest dimension may occasionally
be repaired with composite grafts from the auricle in
nonsmokers (see Chapter 15 for detailed discussion of
composite grafts). The grafts are chilled with ice com­
presses for 3 days after transfer, and systemic steroids are
administered for 1 week. It is preferable to allow the
initial defect to heal by secondary intention and then to
perform the composite graft after preparation of a fresh
recipient site by removal of all scar and neoepithelializa­
tion. The graft is oversized by 2-mm to accommodate
wound contraction.
Depending on extent of the tissue loss, larger defects
of the columella are best repaired with unilateral or bilat­
eral superiorly based interpolated melolabial flaps. Septal
cartilage grafts are used for the framework. The initial
flap transfer will produce a thick columella that will
require secondary thinning. Defects that extend into the
infratip lobule from the columella require structural
support with cartilage grafts and a paramedian forehead
flap for cover. By extending the incision for the forehead
flap into or below the eyebrow, the flap may reach the
upper lip without excessive wound closure tension.
Full-thickness defects of the columella and tip are best
reconstructed with a pivotal septal composite chondro­
mucosal flap (see Fig. 18-9). Mucosa of the flap is peeled
downward bilaterally to provide internal lining. Auricular
cartilage grafts are attached to the composite flap to
provide structural support laterally. A paramedian fore­
head flap is best for exterior covering.
Reconstruction of Nasal Tip
Small, skin-only superficial defects of the nasal tip may
be repaired with a bilobe nasal flap as described earlier
or a full-thickness skin graft. Sizeable defects of the nasal
tip may be repaired with a full-thickness skin graft with
expectations of an aesthetically pleasing result if the
defect is shallow and the adjacent tip skin is thin (see Fig.
18-35). However, a paramedian forehead flap will usually
give a more natural result because the entire aesthetic
unit can be covered by the flap, placing scars in borders
of aesthetic units. Cartilage grafts are used routinely
along the margin of the nostril when the defect extends
from the tip into the nasal facet. This is in addition to
any missing lower lateral cartilage, which is replaced as
well.
Bilateral full-thickness defects of the tip and columella
are repaired with a pivotal septal composite chondromu­
cosal flap (see Fig. 18-9). However, unilateral full-
thickness defects can be nicely reconstructed with an
ipsilateral intranasal hinge mucoperichondrial flap for
internal lining. If the defect is large, a contralateral dorsal
septal mucoperichondrial hinge flap is used to provide
lining for the more cephalic portion of the defect (Fig.
18-37). Septal and auricular cartilage grafts are used for
the framework. A paramedian forehead flap provides the
external cover for the construction of the tip. The ipsi­
lateral lining flap spans the nasal passage on the affected
side. Concomitant with inset of the forehead flap 3 weeks
after transfer, the hinge mucoperichondrial flap is released
from the septum, restoring patency of the nasal airway.
Full-thickness defects of the nasal tip that involve the
nostril margin may also be reconstructed by a single
paramedian forehead flap folded on itself to provide con­
comitant internal lining and external cover. This tech­
nique is reserved for patients with thin skin (Fig. 18-38)
and in cases in which use of a septal mucoperichondrial
flap is not possible or would not be prudent. This
approach requires a multiple-stage reconstruction. Stage
one is the initial transfer of the flap to the recipient site.
In the second stage, the lining component of the flap is
inset by making an incision through the paramedian fore­
head flap along the planned nostril margin. The lining
flap is thinned of subcutaneous fat and early scar forma­
tion. An auricular cartilage graft is positioned along the
planned nostril margin, spanning the entire width of the
defect. The paramedian forehead flap remaining attached
to the forehead is unfurled and used to resurface the
external defect, covering the cartilage graft. The third
surgical stage involves insetting of the forehead flap, cov­
ering the tip defect. The surgical stages are performed at
3-week intervals. It is sometimes necessary to perform a
fourth surgical stage, which is to contour the covering
flap to maximize the aesthetic result. This is more
common in patients with thicker skin.
Reconstruction of Ala
Skin defects of the ala may be reconstructed by a number
of surgical approaches. One approach in patients with
limited partial-thickness alar defects who wish to avoid
an interpolated cheek or forehead flap is the combination
of a subcutaneous tissue hinge cheek flap and full-
thickness skin graft. A hinge flap consisting of subcutane­
ous tissue and harvested from the cheek is used to fill the
depths of the nasal defect and is covered with a full-
thickness skin graft.19 The flap may also nourish an alar
rim cartilage graft when required. This approach is useful
only for defects of the ala or sidewall that are not full
thickness and are immediately adjacent to or involve the
medial cheek or alar-facial sulcus. The technique has the
advantage of a one-stage procedure that does not violate
the melolabial fold (Fig. 18-39). It avoids the need for an
interpolated cheek or forehead flap, and it restores a
natural contour to the repair, often achieving comparable
aesthetic results. When the nasal defect extends into the
cheek, the cheek component is repaired by advancement
of cheek skin to the level of the alar-facial sulcus (cheek-
nose junction). This places scars in the aesthetic border
and restores the sulcus between these structures. The
subcutaneous tissue hinge cheek flap is discussed in
Chapter 15.
Superficial defects of the ala or nostril margin may
sometimes be repaired with a full-thickness skin graft.

460
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
B
C
Ipsilateral hinge flap
Contralateral
hinge flap
Septal cartilage graft
Auricular cartilage
framework graft
Island flap
D
FIGURE 18-37  ■  A, B, Full-thickness defect of nasal hemi-tip, ala, and caudal sidewall. Defect extends into medial cheek. C, Ipsilateral
septal mucoperichondrial hinge flap reflected inferiorly and contralateral dorsal septal mucoperichondrial hinge flap reflected supe­
riorly from depths of nasal passage. Flaps provided internal lining to hemi-tip, ala, and sidewall defect. V-Y subcutaneous tissue
pedicled island advancement flap designed to repair cheek component of defect. D, Septal cartilage graft used to replace missing
upper lateral cartilage. Auricular cartilage graft used for framework of ala and hemi-tip.

18  RECONSTRUCTION OF THE NOSE
461
E
F
G
H
E, Island flap advanced. Interpolated paramedian forehead flap designed to cover nasal component of defect.
Remaining skin of sidewall aesthetic unit marked for excision. F, Flaps in place. Caudal border of forehead flap sutured to caudal
border of ipsilateral mucoperichondrial hinge flap. G, H, Postoperative views at 9 months. Contouring procedure performed to create
alar groove.
FIGURE 18-37, cont’d  ■

462
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
Covering segment
not thinned
This skin becomes
nostril margin
This skin becomes
nostril margin
External covering
Folded over for lining
Lining segment thinned
FTSG
B
C
D
E
F
Rim incision
Lining flap thinned
Auricular cartilage rim graft
Auricular cartilage rim graft
Covering flap detached from lining flap
G
H
I
J
K
FIGURE 18-38  ■  A, A 2.4 × 1.5-cm full-thickness defect of nasal tip. Caudal border of alar cartilage visible in depth of wound. B, Single
paramedian forehead flap designed to resurface internal lining and external cutaneous defects. C, D, Dissected flap. Lining compo­
nent of flap thinned before folding flap on itself. E, Forehead flap transferred to nose. Pedicle covered with full-thickness skin graft.
F, Distal portion of flap provides lining to defect. G, Three weeks after initial flap transfer to nose, lining portion of flap inset by
making incision along reconstructed nostril margin. H, Lining flap thinned of early scar deposition. I, J, Auricular cartilage rim graft
sutured to lining flap. K-M, Distal portion of remaining forehead flap unfurled, thinned of scar and subcutaneous fat, used to cover
cartilage graft and external cutaneous defect. N, O, Three weeks after second surgical stage, covering flap is inset. P-U, Preoperative
and 2-month postoperative views after contouring procedure (fourth surgical stage).

18  RECONSTRUCTION OF THE NOSE
463
Incision to inset flap
L
M
N
O
FIGURE 18-38, cont’d
This approach is most effective in patients with thin nasal
skin. To reduce the risk of nostril retraction resulting
from contraction of the skin graft, a narrow (5-mm)
auricular cartilage graft is used to span the width of the
defect at the margin of the nostril (Fig. 18-40). Soft tissue
tunnels on either side of the defect are created at the
inferior border of the nostril to accommodate the medial
and lateral ends of the graft. The graft is sutured to the
skin of the nasal vestibule with one or two horizontal
mattress 5-0 absorbable sutures. A skin graft is then used
to cover the skin defect and directly covers the exposed
cartilage graft. The graft is secured in place with a gauze
bolster dressing for 5 days.
Deeper defects confined to the ala with or without
limited extension into the nasal tip or sidewall are best
resurfaced with a superiorly based interpolated melola­
bial flap. This flap is discussed in a previous section of
this chapter. When using this flap, I routinely resurface
the entire ala regardless of the size of the alar defect.4
The melolabial flap based on a subcutaneous tissue
pedicle is preferred because this design minimizes the
amount of skin that is disturbed in the superior melola­
bial fold. Preserving the superior fold is paramount in
maintaining symmetry of the cheeks after reconstruction
of the ala with a cheek flap (Fig. 18-41). Cartilage grafts
are used in the majority of alar defects. This is because
most lesions involving resection of alar skin also require
removal of the underlying firm fibrofatty subdermal
tissue that provides the ala form and structural support.
This must be replaced by cartilage to prevent upward
migration of the ala and notching of the margin of the
nostril.
Deep alar defects in younger patients without a
developed melolabial fold or visible crease are often
repaired with a paramedian forehead flap as the cover­
ing flap. Flap donor site scars tend to be less apparent
on the forehead compared with the medial cheek in
these patients (see Fig. 18-33). In addition, men with
dark, thick facial hair may be better served with the
forehead rather than the cheek as the donor site for
covering flaps to repair alar defects (see Fig. 18-39). Use
of the forehead flap usually avoids the problems of
transferring hair-bearing skin to the ala.
Internal lining for full-thickness alar defects is pro­
vided by bipedicle vestibular skin flaps or ipsilateral hinge
septal mucoperichondrial flaps (Fig. 18-42). As discussed
in an earlier portion of this chapter, an additional contra­
lateral hinge mucoperichondrial flap may be necessary if
the vertical height of the defect is such that an ipsilateral
hinged mucoperichondrial flap will not provide sufficient
tissue to replace the entire missing lining. Defects of the
ala that extend into the cheek or upper lip require flaps
to repair these aesthetic regions that are independent
from the flap used for construction of the ala.20 If the alar
defect is full thickness, it is prudent to reconstruct the
portion of the defect involving the upper lip as a first
surgical stage and to delay the reconstruction of the ala.
Alar reconstruction is performed once healing of the
lip is complete and all scars have contracted to the
maximum degree. This approach creates an upper lip that
provides a stable foundation on which to build a new ala
(Fig. 18-43).
Reconstruction of Nasal Dorsum
The nasal dorsum is perhaps the least complex portion
of the nose to reconstruct. Superficial skin defects may
be repaired with full-thickness skin grafts with expectant
Continued

464
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
P
Q
R
S
FIGURE 18-38, cont’d

18  RECONSTRUCTION OF THE NOSE
465
not provide sufficient tissue, bilateral paramedian fore­
head flaps are recommended. One flap provides internal
lining and the other provides external coverage. A
cranial or rib bone graft is placed between the flaps for
structural support.
Reconstruction of Nasal Sidewall
Reconstruction of the sidewall of the nose is relatively
uncomplicated. Small skin-only defects of the caudal
sidewall may be repaired with a bilobe flap harvested
from the remaining nasal sidewall skin. Full-thickness
skin grafts harvested from the preauricular area of the
cheek or supraclavicular fossa also provide a reasonable
option for covering defects located in the cephalic portion
of the sidewall because of the thin skin in this location.
Larger surface defects are best covered with a paramedian
forehead flap (Fig. 18-44). When structural support is
absent from the cephalic third of the nasal sidewall, it is
replaced with a calvarial bone graft; the caudal two-thirds
of the sidewall skeleton is best replaced with septal or
costal cartilage grafts. Full-thickness sidewall defects may
be lined with contralateral hinged septal mucoperichon­
drial flaps based on the nasal dorsum and delivered
through a superiorly located nasal septal fenestra. For
more caudal sidewall defects, a unilateral mucoperichon­
drial hinge flap based on the caudal septum may provide
sufficient lining (Fig. 18-45). However, this approach
requires subsequent detachment of the flap’s pedicle. It is
usually necessary to use both the contralateral dorsally
based flap and the ipsilateral caudally based septal muco­
perichondrial hinge flap to provide lining for full-
thickness defects that involve the ala and extend the
entire length of the nasal sidewall.
acceptable results. Forehead skin in the form of an inter­
polated paramedian flap is usually preferred for resurfac­
ing of deeper skin and soft tissue defects of the caudal
dorsum. However, bilobe flaps or full-thickness skin
grafts may also be used. Likewise, skin defects of the
cephalic dorsum may be repaired with glabellar flaps
such as the dorsal nasal flap or full-thickness skin grafts.
However, paramedian forehead flaps are usually pre­
ferred for reconstruction of more extensive dorsal
defects, especially if they extend into other aesthetic units
of the nose.
Small defects of the dorsal framework may be replaced
with septal cartilage grafts. More extensive defects of the
nasal skeleton extending from the frontal bone to the
nasal tip are best replaced with calvarial bone or rib grafts
secured to the frontal bone or remaining nasal processes
of the maxillae with plate and screw fixation. To prevent
medialization of the nasal sidewall after wound healing,
structural defects that extend into the sidewall require
replacement concurrent with replacement of the dorsal
framework. Septal bone or additional cranial bone grafts
plated to the dorsal graft work well for this purpose.
Internal lining for full-thickness dorsal nasal defects
can usually be provided by mucoperichondrial flaps
reflected laterally from the exposed dorsal septum as
long as there is sufficient height to the remaining
septum.20 Unilateral or bilateral hinge septal mucoperi­
chondrial flaps based on the caudal septum and includ­
ing the septal branch of the labial artery may sometimes
be used for lining when there is not considerable loss of
dorsal septal height. A pivotal septal composite chon­
dromucosal flap, as discussed earlier in this chapter,
should be used to provide lining and structural support
for the dorsum in extensive bilateral full-thickness dorsal
nasal defects. In instances in which this approach will
T
U
FIGURE 18-38, cont’d
Text continued on p. 476

466
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 18-39  ■  A, A 1.5 × 1.5-cm skin defect of ala extending to alar-facial sulcus. Auricular cartilage graft held by forceps in anticipa­
tion of placing it along caudal border of alar defect. B, Subcutaneous tissue hinge flap harvested from medial cheek reflected medi­
ally over cartilage graft. Flap fills depths of defect. C, Borders of hinge flap tucked beneath edges of defect and held in place with
mattress sutures. D, Full-thickness skin graft (FTSG) placed over hinge flap for external covering. E, Bolster dressing in place to
secure skin graft. F, Postoperative view at 5 months. Graft dermabraded.
A
Auricular cartilage
rim graft
Hinge flap
FTSG
B
C
D
E
F

18  RECONSTRUCTION OF THE NOSE
467
FIGURE 18-40  ■  A, A 1 × 0.8-cm cutaneous defect of ala. B, Auricular cartilage rim graft inserted along nostril margin, spanning defect.
C, D, Full-thickness skin graft (FTSG) secured by bolster dressing. E, Postoperative view at 4 months. No revision surgery
performed.
A
Auricular cartilage
rim graft
FTSG
B
C
D
E

468
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
B
C
D
FIGURE 18-41  ■  A, A 1.5 × 1.5-cm deep skin and soft tissue defect of ala. B, Auricular cartilage graft sculpted for framework. Interpo­
lated melolabial subcutaneous tissue pedicled island flap designed for repair of defect. C, In situ incised flap. Cartilage graft in place.
Remaining skin of alar aesthetic unit excised. D, Flap transferred on subcutaneous tissue pedicle.

18  RECONSTRUCTION OF THE NOSE
469
E
F
G
E, F, Flap in place. Donor site closed. G, Postoperative view at 7 months. Contouring procedure performed.
FIGURE 18-41, cont’d  ■

470
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
A
Septal mucoperichondrial flap
Lip advancement flap
Septal hinge flap
Cheek advancement flap
B
Auricular cartilage
framework graft
C
Paramedian forehead flap
Septal mucoperichondrial flap
D
E
FIGURE 18-42  ■  A, Full-thickness defect of ala and caudal sidewall. Ipsilateral septal mucoperichondrial hinge flap reflected inferiorly
for repair of lining defect. B, Lip and cheek advancement flaps created to repair lip and cheek components of defect. C, Lip and
cheek advancement flaps in place. Auricular cartilage framework graft provides structural support. D, Interpolated paramedian
forehead flap transferred to cover cartilage graft and nasal cutaneous defect. E, Preoperative view demonstrating full-thickness
nature of defect.

18  RECONSTRUCTION OF THE NOSE
471
F
G
H
I
F-M, Preoperative and 11-month postoperative views. Contouring procedure performed 4 months after inset
of lining and forehead flaps. (From Baker SR: Intranasal flaps. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New York,
Springer, 2011.)
FIGURE 18-42, cont’d  ■
Continued

472
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
J
K
L
M
FIGURE 18-42, cont’d

18  RECONSTRUCTION OF THE NOSE
473
A
B
Septal mucoperichondrial flap
Hinge flap
Hinge flap reflected downward
C
D
E
FIGURE 18-43  ■  A, A 3 × 2.6-cm skin and soft tissue defect of medial cheek and 2 × 2-cm full-thickness defect of ala. V-Y subcutaneous
tissue pedicled advancement flap designed to repair cheek defect. B, Island flap in place. Stent secures full-thickness skin graft
placed along borders of alar defect. C, Postoperative view 3 months after first-stage reconstruction. Missing ala is evident. D, Ipsi­
lateral septal mucoperichondrial flap reflected from nasal passage to provide lining to alar defect. Hinge flap of healed skin graft
also used to assist mucosal flap in providing lining to ala. E, Hinged skin flap reflected downward and sutured to mucosal flap held
by forceps.
Continued

474
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
H
I
Septal mucoperichondrial flap
Auricular cartilage framework graft
J
F
G
F, Auricular cartilage framework graft sutured to skin and mucosal lining flaps. G, Paramedian forehead flap
provides external cover for alar reconstruction. H-J, Postoperative result at 1 year. Contouring procedure and Z-plasty lip scar revi­
sion performed.
FIGURE 18-43, cont’d  ■

18  RECONSTRUCTION OF THE NOSE
475
A
B
C
D
FIGURE 18-44  ■  A-F, Preoperative and 1-year postoperative views after paramedian forehead flap to reconstruct 4 × 3.5-cm skin and
soft tissue defect of nasal dorsum, sidewall, and ala. Contouring procedure (third surgical stage) performed 5 months after forehead
flap inset. Forehead and nasal scar revisions also performed.
Continued

476
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
E
F
FIGURE 18-44, cont’d
FLAP REFINEMENT
Nasal reconstruction begins with the transfer of tissue of
volume and surface area similar to those of the missing
tissues. Depending on the nature of the defect and the
type of flap used, some amount of sculpting of the sub­
cutaneous tissues of the covering flap is usually necessary.
With increasing experience and skill of the surgeon, a
greater level of refinement may be achieved in the initial
stages of nasal reconstruction. However, for complex
nasal repairs, it is often necessary to perform additional
staged procedures aimed at improving the final aesthetic
outcome.
There are three stages at which thinning and contour­
ing of covering flaps may be performed. Sculpting of the
restored nasal framework and overlying flaps and grafts
begins at the time of initial repair. Paramedian forehead
flaps may be thinned of accompanying muscle and fat
when they are initially dissected without compromising
survival. This initial contouring will at times be sufficient
and eliminate the need for additional procedures.
However, there are limits to the extent of thinning and
debulking that may be performed at the time of flap
transfer. This is especially true of interpolated melolabial
flaps. Excessive contouring of melolabial flaps may com­
promise the vascularity of the flap, leading to necrosis.
This is particularly true for smokers or individuals who
have peripheral vascular disease, as in cases of diabetes or
after irradiation. When an interpolated flap is used as a
covering flap, the distal portion is contoured at the initial
transfer. Three weeks later, when the flap is inset, the
more proximal portion of the flap is sculpted so that flap
thickness matches the adjacent nasal skin. The 3-week
interval between flap transfer and pedicle division and
flap inset enables the surgeon to safely thin the proximal
portion of the flap. By this time, the distal portion of the
flap has developed adequate collateral circulation to
support the proximal portion. Interpolated paramedian
forehead and melolabial flaps are thinned in this staged
manner. When necessary, a third contouring of the flap
is performed. This is delayed for 2 or 3 months after flap
inset. By then, the flap has acquired an adequate blood
supply from its periphery and underlying soft tissues and
is capable of withstanding more aggressive removal of
subcutaneous fat. This procedure is performed if the cov­
ering flap appears thickened and does not accurately
reflect the topography of the underlying nasal frame­
work. In these circumstances, the flap is elevated in the
superficial subcutaneous tissue plane to expose deeper
scar and subcutaneous fat. The underside of the flap is
thinned of fat with fine scissors, and the deeper scar and
subcutaneous fat are completely removed to expose the
nasal framework.
A contouring procedure to create an alar groove is a
necessary third surgical stage in 75% of cases of alar
reconstruction. This is performed 3 months after inset of
an interpolated melolabial or forehead flap used for
resurfacing of the ala. The procedure is necessary
whenever the defect extends cephalic to the alar groove
(Fig. 18-46).
SUMMARY
Reconstruction of the nose has in the last decade pro­
gressed to a new level of finesse that allows the surgeon
to restore nearly normal form and function to all but the
most extensive defects of the nose. These advances are

18  RECONSTRUCTION OF THE NOSE
477
A
B
C
D
FIGURE 18-45  ■  A, A 3 × 4-cm full-thickness defect of ala, caudal sidewall, and dorsum. B, Ipsilateral septal mucoperichondrial hinge
flap dissected for internal lining. C, Septal flap sutured to margins of mucosal defect to seal nasal passage from external exposure.
D, Septal cartilage graft (superior) replaces missing upper lateral cartilage. Auricular cartilage graft (inferior) provides framework
of ala.
Continued

478
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
E
F
G
E, Interpolated paramedian forehead flap transferred for external covering. F, G, Postoperative views at
2.5 years. Contouring procedure performed.
FIGURE 18-45, cont’d  ■

18  RECONSTRUCTION OF THE NOSE
479
FIGURE 18-46  ■  A-C, Template of contralateral ala used to mark location of planned alar groove. D, Previously transferred interpolated
melolabial flap dissected in subdermal plane and reflected inferiorly. E, Soft tissue resting on surface of nose represents tissue
removed to contour flap. F, Trough in previously grafted cartilage creates contour of alar groove. G, Flap repositioned. Bolster
sutures straddle reconstructed alar groove. H, Cotton bolster secured with sutures along constructed alar groove. (From Baker SR:
Interpolated melolabial flaps: reconstruction of alar and columellar units. In Baker SR, editor: Principles of nasal reconstruction, ed 2, New
York, Springer, 2011.)
C
D
A
Soft tissue and cartilage
excised along this line
Planned alar groove
B
G
H
E
Soft tissue removed
Cartilage removed
Alar groove constructed
Remaining framework graft
Bolster sutures
F

480
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
6. Simons RL. Adjunctive measures in rhinoplasty. Otolaryngol Clin
North Am 1975;8:17.
7. Crumley RL, Lancer R. Quantitative analysis of nasal tip projec­
tion. Laryngoscope 1988;2:202.
8. Baker SR. Nasal lining flaps in contemporary reconstructive rhino­
plasty. Facial Plast Surg 1998;14:1.
9. Baker SR. Reconstruction of facial defects. In: Cummings CW,
Fredrickson JM, Harker LA, et al, editors. Otolaryngology—head
and neck surgery. 3rd ed. Philadelphia: Mosby; 1998. p 527.
10. Murakami CS, Kriet D, Ierokomos AP. Nasal reconstruction using
the inferior turbinate mucosal flap. Arch Facial Plast Surg 1999;1:97.
11. Burnham HH. An anatomical investigation of blood vessels of the
lateral nasal wall and their relationship to turbinates and sinuses.
Laryngol Otol 1935;50:569.
12. Padgham N, Vaughan-Jones R. Cadaver studies of the anatomy of
arterial supply to the inferior turbinates. J R Soc Med 1991;84:728.
13. Rohrich RJ, Muzaffar AR, Adams WP Jr, et al. The aesthetic unit
dorsal nasal flap: rationale for avoiding a glabellar incision. Plast
Reconstr Surg 1999;104:1289.
14. Herbert DC. A subcutaneous pedicled cheek flap for reconstruc­
tion of alar defects. Br J Plast Surg 1978;31:79.
15. Robinson JK, Burget GC. Nasal valve malfunction resulting from
resection of a cancer. Arch Otolaryngol Head Neck Surg 1990;116:
1419.
16. Constantian MB. The incompetent external nasal valve: patho­
physiology and treatment in primary and secondary rhinoplasty.
Plast Reconstr Surg 1994;93:919.
17. Baker SR, Alford EL. Mid-forehead flaps. Oper Tech Otolaryngol
Head Neck Surg 1993;4:24.
18. Glogau RG, Haas AF. Skin grafts. In: Baker SR, Swanson NA,
editors. Local flaps in facial reconstruction. St. Louis: Mosby; 1995.
p. 247.
19. Johnson TM, Baker SR, Brown MD, et al. Utility of the subcutane­
ous hinge flap in nasal reconstruction. Dermatol Surg 1994;30:459.
20. Baker SR, editor. Principles of nasal reconstruction. 2nd ed. New
York: Springer; 2011.
based on the contemporary concepts of respecting the
borders of aesthetic units of the nose and replacing
missing tissue with like tissue. The nose is reconstructed
separately from any extension of a nasal defect into the
cheek and lip, which in turn are repaired by tissue within
their respective aesthetic regions. Internal lining is
replaced with nasal mucoperichondrial flaps, which
because of their nature provide adequate vascularity to
nourish and to sustain the cartilage and bone grafts used
for nasal skeletal replacement. Missing bone and cartilage
are replaced with similar tissue that is carefully crafted to
replicate the exact size, configuration, and contour of the
missing nasal skeleton. The majority of surface defects
are covered with cheek or forehead skin transferred by
interpolation to prevent disturbance of the aesthetic
boundaries between the nose and other regions of the
face. This surgical approach provides natural building
material precisely fitted to restore nasal deficits to a con­
dition as nearly normal as possible.
REFERENCES
1. Burget GC, Menick FJ. Nasal support and lining: the marriage of
beauty and blood supply. Plast Reconstr Surg 1989;84:189.
2. Menick FJ. Reconstruction of the nose, local flaps in facial recon­
struction. In: Baker SR, Swanson NA, editors. Local flaps in facial
reconstruction. St. Louis: Mosby; 1995. p. 305–37.
3. Burget GC, Menick FJ. Aesthetic reconstruction of the nose.
St. Louis: Mosby; 1993.
4. Baker SR, Johnston TM, Nelson BR. The importance of maintain­
ing the alar-facial sulcus in nasal reconstruction. Arch Otolaryngol
Head Neck Surg 1995;121:617.
5. Baker SR. Contemporary aspects of nasal reconstruction. In: Myers
E, Krause CJ, editors. Advances in otolaryngology—head and neck
surgery, vol. 12. St. Louis: Mosby; 1998. p. 235–61.

481
C H A P T E R 1 9 
RECONSTRUCTION OF THE LIPS
Gregory J. Renner
INTRODUCTION
The upper and lower lips compose a distinct anatomic
unit that is the principal feature of the lower face. The
lips have a major importance to facial appearance and
function. Reconstruction of the lip can present a chal­
lenge to the reconstructive surgeon who seeks excellence
in restoration of the aesthetics and functioning of this
unique structure. Descriptions of lip reconstruction date
to at least BC 1000 in the Eastern Sanskrit writings of
Susruta.1,2 Early reports of lip reconstruction in the
Western literature date to at least the first century (Fig.
19-1). Description of the classic V-shaped excision of the
lip and primary repair has been credited to a writing by
Louis in 1768, although this method of treating lip neo­
plasms was certainly performed many centuries before
that.1 A large variety of methods for reconstructing the
lips were developed and reported in the medical literature
of the 19th century, from which most of the procedures
performed today have some derivation.
ANATOMIC CONSIDERATIONS
Lip tissue is a composite of skin, muscle, and mucosa
(Fig. 19-2). The most distinguishing feature of the lip is
the vermilion, which is modified mucosa that covers the
free margin of the lips and is adapted for external expo­
sure. There are relatively few glands beneath the vermil­
ion, in contrast to the multitude of minor salivary glands
found immediately deep to labial and buccal mucosa. The
well-defined line where the anterior limit of the vermil­
ion adjoins the adjacent lip skin is referred to as the
mucocutaneous or anterior vermilion line. It represents
an important landmark in lip reconstruction. The poste­
rior vermilion line is defined as the innermost line of
contact between the upper and lower lips when the mouth
is closed. Labial vermilion is characteristically red among
those of light skin color and dark among those with dark
skin color. Fullness of the rounded vermilion, particularly
in women, is considered a mark of beauty in many
cultures.
The body of the lips is made up principally of the
orbicularis oris muscle. Orbicularis muscle fibers of the
upper and lower lip interconnect or decussate as they
meet at the oral commissures. This arrangement allows
the muscle to function as a sphincter that regulates
opening and closing of the lips. The muscles of facial
expression that influence the lips are distributed in a
radiant fashion about the orbicularis muscle in bilaterally
paired sets. The facial expressive muscles are attached at
specific locations along the outer margin of the orbicu­
laris muscle. Selective contractions of the muscles serve
to create the varied shapes that can be demonstrated by
the lips. Because there is no internal skeleton, lip tissue
is elastic and can be stretched to a remarkable degree,
offering a trait that can be useful in reconstructive surgery.
Upper and lower labial arteries are the principal vas­
cular supply to the lips. Both arteries are derived from
the facial artery on either side of the face. The labial
arteries course horizontally across the lip in the submu­
cosal plane, immediately posterior to the orbicularis
muscle at approximately the same level as the anterior
vermilion line. Whereas the labial artery of the lower lip
tends to remain in the same horizontal plane as it crosses
the lip, that of the upper lip may rise slightly as it passes
medially toward the center of the lip. Some labial arteries
may have a tortuous course through the muscle. The
course of the labial artery can be detected with gentle
palpation and is typically easy to map out with use of a
Doppler device. In studies of arterial anatomy of the
lower face, a variable pattern of vessels anastomosing
across the lower lip and chin was found, with one or more
vertically oriented labiomental branches descending to
the chin region. A horizontally oriented mental branch
was noted in many cases.3,4 Multiple anastomoses between
the vertical and horizontal branches were observed when
both were present.3 In the central region of the upper lip,
the superior labial artery gives rise to multiple septal and
alar branches.3 The exact pattern for venous drainage is
less well defined and has commonly been considered to
be largely by venae comitantes. Superior and inferior
labial veins have been described. Both veins typically
drain into the ipsilateral facial vein and are less distinct
than the arteries and difficult to identify. In a cadaver
study, Park et al3 identified a deep venous system of the
upper lip that was considered to be independent of the
arterial system. An understanding of the vascular supply
of the lips is important in the planning of many recon­
structive lip flaps.
The limit of the superior border of the upper lip cen­
trally is the nasal base. The limit of the inferior border
of the lower lip centrally is the mental crease, which
separates the lip from the chin. The lateral borders of the
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482
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
orbicularis muscle fibers. The philtrum is an embryologi­
cally derived structure with two parallel raised ridges that
has no functional significance but has aesthetic impor­
tance to the central region of the upper lip. Incisions of
either lip create less unsightly scars when they are made
parallel to the long axis of the philtrum or to the labial
relaxed skin tension lines.
The lips exhibit multiple motor functions, which
include various facial expressions, oral retention of food
and liquids, articulation of speech, and the acts of whis­
tling and kissing. The lips also have important sensory
functions of touch, pain, and temperature perception,
which enable the monitoring of materials that enter the
mouth and provide some pleasures. The most ideal lip
reconstructions are those that best preserve or restore
these different functions. Restoration of the orbicularis
muscle sphincter is highly desirable, particularly of the
lower lip. As a general rule, it is best if reconstruction of
FIGURE 19-1  ■  Method of reconstruction of lower lip described by Celsus in first century AD. Releasing cheek incisions used to achieve
closure of lip defect after resection of neoplasm.
FIGURE 19-2  ■  Cross section of lip showing (from right to left)
skin, muscle, mucosa.
FIGURE 19-3  ■  Aesthetic borders of lips marked by melolabial
and labiomandibular creases on either side and mental crease
inferiorly. Rhytids of lips parallel relaxed skin tension lines,
which display radiant pattern about oral stoma.
upper and lower lips are marked by the melolabial and
labiomandibular creases that separate the lips from the
cheeks. These peripheral defining lines may not be so
obvious in young children, but they are more pronounced
with age and are recognized natural lines of the face. The
melolabial and mental creases mark the sites where
muscles of facial expression attach to the orbicularis
muscle, providing the muscle with an indirect connection
to the facial skeleton. These crease lines are strongly
favored sites for making incisions required for excision of
lip tumors and for the outline of many reconstructive
flaps.
The relaxed skin tension lines for the lips course in a
radiant fashion about the oral stoma in a manner analo­
gous to the spokes of a wheel and reflect the wrinkle lines
of older patients (Fig. 19-3). These lines are vertical in
the central region of the lips and are progressively more
oblique or slanted in lateral regions of the lips. The ori­
entation of the lines is perpendicular to the underlying

19  RECONSTRUCTION OF THE LIPS
483
necessary, dissection may extend the entire vertical height
of the lip to the apex of the gingivolabial sulcus. The flap
is advanced forward over the free margin of the lip to the
desired point, which is usually the anterior vermilion line.
Because the vermilion is actually a modified mucosal
surface, reconstruction with labial mucosa offers a close
substitute. In most cases, a slight prominence of the soft
tissue at the mucocutaneous junction is considered to be
a favorable feature of lip contour. However, it is difficult
to restore this fullness in areas reconstructed by mucosal
advancement flaps. This may be related to contraction of
the mucosal flap as the wound heals. There is less flap
retraction when dissection of the flap requires limited
undermining of the mucosa of the lip.
Reconstruction of the vermilion with a mucosal
advancement flap may produce a pleasing aesthetic res­
toration of either lip. However, several difficulties may
be encountered with this technique. An early difficulty is
restoration of accurate positioning of the anterior vermil­
ion line when there is an adjacent skin defect at the lip
margin. In such instances, wound contraction inherent to
wound maturation may influence the position of the ver­
milion line. If distortion or displacement of the anterior
vermilion line occurs, repositioning of the reconstructed
line may be possible with revision surgery. Another
the lip is accomplished from within the lip complex,
except when that would result in excessive microstomia.
In most cases, reconstruction of slightly more than half
of either lip can be accomplished by use of tissue from
within the respective aesthetic region of the lips. When
additional tissue is required, most reconstructions involve
the use of local flaps harvested from the adjacent regions
of the cheek or chin. With current designs, any flap har­
vested from outside the lip complex to repair full-
thickness lip defects fails to restore a complete functional
orbicularis muscle sphincter. To a limited degree, tight­
ness in a reconstructed lip may help compensate for defi­
ciency of the muscle sphincter.
VERMILION RECONSTRUCTION
Mucosal Advancement Flaps
The most favored method of restoration of the vermilion
is anterior advancement of the mucosa that lines the
inner surface of the lip (Fig. 19-4). A mucosal flap is
created by undermining beneath the labial mucosa in a
plane that is deep to the minor salivary glands and super­
ficial to the posterior surface of the orbicularis oris. If
FIGURE 19-4  ■  A, A 4 × 1-cm defect of lower lip vermilion and skin. B, Labial mucosal advancement flap dissected deep to minor sali­
vary glands and immediately superficial to orbicularis muscle. C, Flap advanced. Margin of skin defect not dissected. Skin margin
left to migrate cephalically by scar contraction. D, Anterior vermilion line in acceptable position. Continued scar maturation will
reduce scar thickness.
A
B
C
D

484
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
the employment of mucosal advancement flaps, there are
individuals in whom sensory return is inadequate. Influ­
enced by Karapandzic’s concept of lip flap design, this
author performs dissections with a selective spreading
technique in an attempt to preserve the small neural and
vascular structures that are encountered as the mucosal
advancement flap is dissected (see Fig. 19-4B).1,5,6 These
neurovascular structures are then gently stretched forward
with advancement of the mucosal flap.
Mucosal V-Y Island Advancement Flaps
In some cases, small volume deficiencies of the vermilion
may be restored with V-Y advancement flaps of labial or
buccal mucosa (Fig. 19-6). The advancement flap is
created by a V-shaped incision with the apex of the inci­
sion positioned toward the gingivolabial sulcus. Mucosal
V-Y advancement flaps may also be created as island flaps
to repair small adjacent vermilion defects. Incisions are
made to the level of the orbicularis oris, creating an island
flap that is pedicled on the underlying deep tissue. The
triangle-shaped island is advanced into the adjacent
recipient site, maintaining sufficient deep tissue attach­
ments to ensure its viability. The donor site is closed
primarily by direct approximation of the adjacent wound
margins, resulting in a Y configuration to the wound
closure. Closure of the donor site assists with securing
the position of the advancement flap. Most V-Y island
advancement flaps of the lip are designed to advance in
a vertical or near-vertical orientation. There are some
cases in which horizontal tissue movement is employed,
with use of either a single island flap or bilateral opposing
island flaps. Mucosal V-Y island advancement flaps are
best suited for repair of small defects of the vermilion.
Mucosal Cross-Lip Flaps
A vermilion defect may in some cases be restored with
an interpolated cross-lip transfer of labial mucosa or
difficulty encountered with mucosal advancement flaps is
that the flaps tend to display a slightly deeper red color
than that of the natural vermilion, especially in those with
more “weathered” lips. In some cases, the darker red
color can impart a slightly feminine appearance to the
reconstructed vermilion, particularly when the flap covers
a large surface area (Fig. 19-5).
Because greater scar contraction occurs when mucosal
advancement flaps cover a large surface area, eventual
wound contraction may cause the body of the lip to
assume a more rounded appearance. As the vermilion line
is pulled posteriorly by wound contraction, adjacent
whisker hairs may begin to turn up slightly and become
a source of irritation to the opposing lip when the mouth
is closed. This may require repositioning of the anterior
vermilion line of the reconstructed lip.
Whereas a majority of patients regain some degree of
touch, pain, and temperature sensation to the recon­
structed vermilion within a matter of several months after
FIGURE 19-5  ■  Mucosal advancement flap used to reconstruct
inferior vermilion. Color is darker red than natural vermilion.
FIGURE 19-6  ■  A, V-Y mucosal advancement flap used to repair small deficiency of vermilion. B, Wound closure assumes Y-shaped
configuration.
A
B

19  RECONSTRUCTION OF THE LIPS
485
Tongue Flaps
Portions of the mucosal surface of the anterior tongue
may be transferred to the lip to repair a vermilion defect.
A mucosal flap in the form of an interpolated tongue flap
is constructed for this purpose (Fig. 19-10).8,9 Mucosa
transferred to the lip from the dorsal surface of the tongue
will maintain the many fine filiform papillae that are
characteristic of the glossal surface. Use of a tongue flap
to restore the vermilion will likely create a red vermilion
that can be surprisingly satisfactory. A glossal flap is
usually harvested from the ventral surface of the tongue
for lower lip repair and from the dorsal surface of the
tongue for repair of the upper lip. It is also possible to
design a flap from the lateral margin of the tongue. In
nearly all cases, the pedicle is created at or near the free
margin of the tongue. The leading edge of the flap is
sutured to the anterior border of the vermilion defect in
the best possible manner, anticipating that there will be
considerable pulling with tongue movements. Attach­
ment of the flap to the posterior border of the defect is
accomplished at a second stage after division of the pedicle
and flap inset. The second stage is usually performed 3
weeks after initial flap transfer. The tongue donor site
wound may be closed partially or allowed to granulate
while the pedicle of the flap remains attached to the
recipient lip. Tongue flaps are awkward and difficult for
vermilion along with some underlying soft tissue (Fig.
19-7). Cross-lip transfer may be accomplished with a
single-pedicle flap for small defects or a bipedicle flap
(“bucket handle”) for wider defects that extend horizon­
tally across the lip (Fig. 19-8). A cross-lip mucosal flap is
typically designed as a linear band of mucosa, harvested
from the region immediately posterior to the posterior
vermilion line of the donor lip. The width of the band is
determined by the width of the vermilion defect and by
what will allow donor site wound closure. The mucosal
flap is most often elevated in the plane immediately
superficial to the orbicularis muscle, although some
muscle may be included in the flap when it is necessary
to fill a soft tissue defect of the recipient lip. The labial
artery may be incorporated into larger flaps, providing an
axial circulation and ensuring a greater likelihood of flap
viability. Once it is dissected, the flap is transferred across
the oral aperture to the vermilion defect and sutured in
place (Fig. 19-9). The donor site is closed primarily. Divi­
sion of the pedicle and flap inset are performed 3 weeks
later as a second-stage procedure.
An alternative design of a cross-lip mucosal flap that
does not require an axial pattern vascular supply is a
broad flap pedicled on the free margin of the donor lip
that can be separated after 16 days.7 Use of this flap causes
greater restriction of mouth opening while the pedicle is
in place.
FIGURE 19-7  ■  A, B, Interpolated cross-lip vermilion flap used to reconstruct vermilion defect of upper lip. Donor site repaired by
advancing labial mucosa. C, Division of pedicle and flap inset.
A
B
C

FIGURE 19-8  ■  A, Large defect of lower lip vermilion. Broken lines indicate incisions to create interpolated bipedicle labial mucosal
flap. B, Flap transferred to lower lip. Donor site repaired by labial mucosal advancement. C, Pedicles divided and flap inset.
A
B
C
FIGURE 19-9  ■  A, Loss of vermilion of right lateral aesthetic unit
of upper lip. B, Unipedicle interpolated cross-lip vermilion flap
transferred from lower lip to upper lip. Pedicle must be ade­
quate to accommodate repeated motion of lip during first
stage. C, After vermilion cross-lip flap inset to restore vermil­
ion and full-thickness skin graft to replace missing skin of lip.
A
B
C

19  RECONSTRUCTION OF THE LIPS
487
flap includes the vermilion portion of the orbicularis
muscle. Flap dissection may require a lengthy incision to
allow adequate stretch. A meticulous wound closure is
necessary to minimize visible scars in this aesthetically
sensitive region.
CUTANEOUS RECONSTRUCTION
The principles of cutaneous lip flap designs are similar to
those applicable to other cutaneous surfaces. In recon­
struction of the lip, it is preferable to confine tissue
the patient. For this reason, tongue flaps are not consid­
ered a first choice for vermilion reconstruction.
Vermilion Advancement Flaps
A full-thickness loss of vermilion and immediate underly­
ing muscle may be a difficult defect to reconstruct. If the
defect involves less than one-third of the width of the lip
vermilion, it is possible to repair the defect by creating
an advancement flap of the remaining vermilion (Fig.
19-11).2,10 A full-thickness incision is made along the
anterior vermilion line inferior to the labial artery. The
FIGURE 19-10  ■  A, Defect of lower lip vermilion and outline of superiorly based tongue flap. B, Inferior margin of tongue donor site
anchored to inner margin of lip defect. C, Tongue flap transferred to vermilion defect. D, Three weeks later, pedicle divided and flap
inset, completing reconstruction of vermilion.
A
B
C
D

488
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
facial aesthetic regions can provide maximum aesthetic
results.
Fusiform Repair
The preferred method for dealing with most cutaneous
tumors of the lip remains fusiform excision and primary
wound repair. When possible, the fusiform excision is
movement within the aesthetic region of the lips unless
this causes excessive distortion of adjacent structures,
such as the melolabial crease. Limitations are imposed on
transfer of tissue within the lip complex because of the
oral aperture and nasal base. In some cases of reconstruc­
tion of the cutaneous lip, it is necessary to include skin
from the adjacent cheek or chin. Designing local flaps
compatible with relaxed skin tension lines and borders of
FIGURE 19-11  ■  A, Full-thickness vermilion defect. Full-thickness vermilion advancement flap incised. Bilateral opposing vermilion
advancement flaps may also be used. B, Vermilion flap advanced and wound repaired. C, Full-thickness defect of vermilion and
adjacent lip. Full-thickness transposition flap and vermilion advancement flap incised. D, Flaps transferred to recipient sites. E, Two
flaps in place and wounds repaired.
B
A
C
D
E

19  RECONSTRUCTION OF THE LIPS
489
growth is minimal. In men, the skin of the more superior
portion of the upper lip tends to be non–hair bearing and
is not a good source for construction of a cutaneous
flap to repair the inferior region of the upper lip. When
labial transposition flaps are used, closure of the donor
site may distort the melolabial crease. In men, the flap
may also disrupt the natural pattern of hair growth of the
upper lip.
Chin and Submandibular Transposition Flaps
Cutaneous transposition flaps may be transferred to the
lips from the chin, submandibular area, or medial cheek.
Flaps of the chin may be designed as a single or bilobe
flap and may recruit skin from the submental region (Fig.
19-13). The chin is a distinct facial aesthetic region and
a highly visible facial feature. Careful planning is impor­
tant in designing a flap in this region, anticipating exactly
what changes will occur in the appearance of the chin
after flap transfer. Secondary procedures may be required
to restore normal contours, particularly in the region of
the mental crease.
Labial Rotation and Advancement Flaps
Labial cutaneous rotation and advancement flaps are used
to repair skin defects of either lip. Flaps are designed to
move skin medially from the area immediately lateral to
the defect. Transfer of such flaps often involves moving
skin around the oral commissure in a manner that employs
variable degrees of rotation and advancement. The nature
of the tissue movement is dependent on the exact loca­
tion, size, and shape of the defect. Defects located later­
ally require flaps that are transferred to the recipient site
with greater pivotal movement (Fig. 19-14). Defects
located medially require flaps that are transferred primar­
ily by advancement. For laterally located upper lip skin
defects, rotation flaps are designed so that the lateral
border of the flap is in or parallel to the melolabial crease.
Flaps may extend inferiorly below the level of the oral
commissure on the involved side (Fig. 19-15). Because
the distance between the melolabial crease and vermilion
diminishes near the oral commissure, the peripheral
border of the flap is extended lateral to the crease into
the cheek as necessary to achieve adequate flap width.
Careful flap design is required to ensure that the width
of the flap provides adequate vertical height to the recon­
structed lip.
Dissection of labial rotation and advancement flaps is
in the subcutaneous tissue plane superficial to the level
of the orbicularis and facial muscles. For rotation flaps, a
longer wound border is expected in the cheek lateral to
the flap. This disparity in wound length can usually be
accommodated by equally dividing the skin redundancy
during wound closure. If necessary, a small equalizing
Burow triangle of skin is excised from the cheek opposite
the most inferior portion of the flap or in the alar-facial
sulcus.11
Cutaneous lip rotation flaps are most frequently
employed to repair defects involving the more lateral
portion of lip skin (see Fig. 19-14). In contrast, advance­
ment flaps are most commonly used to repair centrally
oriented with its long axis parallel to relaxed skin tension
lines of that region of the lip. From an aesthetic view­
point, it is preferable that fusiform excisions be confined
within the boundaries of the lip, avoiding extension
beyond the melolabial or mental crease lines. An M-plasty
at the end of the excision line may be useful in avoiding
the need to extend an incision beyond the aesthetic
borders of the lips or into the vermilion (Fig. 19-12).
This will require closure of two small and slightly diverg­
ing incision lines near the involved end. M-plasty may
also reduce tissue redundancies, particularly near the free
margin of the lip.
Intralabial and Perilabial Flaps
Intralabial Transposition Flaps
There are few situations in which a transposition flap
designed within the aesthetic region of the lip is a pre­
ferred method of repairing cutaneous defects of either
lip. In some cases, a small cutaneous defect of the inferior
or superior portion of the upper lip may be repaired with
transposition of skin from the lateral region of the lip. If
the flap requires only limited pivotal movement, the
resulting distortion of perioral rhytids and pattern of hair
FIGURE 19-12  ■  A, Planned fusiform excision of skin cancer.
M-plasties designed to minimize length of excision and to avoid
encroachment on vermilion. Orientation of excision parallel to
relaxed skin tension lines of lip. B, Wound repaired after
excision.
A
B

490
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-13  ■  A, A 4 × 2-cm deep defect of inferior portion of
lower lip. Transposition flap from chin designed for wound
repair. B, Flap transferred. C, Postoperative result at 2 years.
Revision surgery is necessary to restore natural contour of lip
and mental crease.
A
B
C
FIGURE 19-14  ■  A, Full-thickness upper lip defect. Mucosal
defect closed primarily. Majority of orbicularis muscle sphinc­
ter remained intact. Large rotation flap designed for repair.
Broken line indicates additional small advancement flap from
central region of lip used to lessen wound closure tension.
Small curved arrows indicate excision of standing cutaneous
deformity of upper lip and an equalizing Burow triangle of
cheek skin. B, Wound repaired. Note elevation of right oral
commissure resulting from transfer of lateral lip flap. C, One
month postoperatively. Commissure in favorable position
because of pull of facial musculature. Melolabial crease on
surgical side is more lateral in position compared with its
counterpart. Appearance of lip is relatively natural.
A
B
C

19  RECONSTRUCTION OF THE LIPS
491
FIGURE 19-15  ■  A, A 3 × 3-cm cutaneous defect of upper lip.
Curved broken line indicates incision to create rotation
advancement flap used to reconstruct defect. Triangle in alar-
facial sulcus indicates excision of an equalizing Burow triangle
of skin. B, Flap in place. C, One year postoperatively. No revi­
sion surgery performed. Care is taken with this surgical
approach to minimize distortion of philtrum and nasal base.
A
B
C
located cutaneous defects. As the flap is advanced medi­
ally, its base often overlaps the oral commissure. This
redundancy of skin at the commissure may require exci­
sion. In more extreme cases, the oral commissure may be
pulled superiorly or inferiorly with medial advancement
of the flap. This may be self-correcting as the natural
pulling of the lip musculature causes a corrective adjust­
ment over time (see Figs. 19-14 and 19-15).
For unilateral cutaneous lip defects, the surface area
requirements of a laterally based labial rotation or
advancement flap designed for repair of the defect may
be reduced by use of a concurrent opposing medially
based flap constructed of skin from the opposite side of
the defect. For upper lip defects, the opposing flap is
designed with incisions extending from the defect beneath
the base of the nose and along the anterior vermilion line
to a desired point. For lower lip defects, incisions for the
medial opposing flap are usually placed along the anterior
vermilion line and in the mental crease. Movement of the
opposing medially based flap is considerably less than
that of the laterally based flap as there is less skin redun­
dancy of the central lip. For upper lip defects, it is easy
to distort the philtrum and nasal base when bilateral flaps
are used. Extending the incision across the superior
margin of the philtrum causes it to widen somewhat,
whereas use of a shorter incision tends to cause the phil­
trum to be displaced laterally.
Melolabial Flaps
Transposition of skin from the medial cheek or melola­
bial fold may be used to restore a cutaneous defect of
either lip. The typical melolabial flap has a linear and
triangular design with an outline that tapers to a distal
point. The medial border of the flap is designed in the
melolabial crease. The lateral border is marked so that
the flap is sufficiently wide to meet the requirements of
the lip defect. The flap is designed slightly wider than the
height of the lip defect in anticipation of wound contrac­
tion. This is particularly important when reconstruction
involves a large defect or the defect encroaches on the
free margin of the lip. Wound contraction may result in
a deficient height of the reconstructed lip. For this reason,
flaps used to repair defects near the lip margin must be
of sufficient width to prevent the need for stretching of
the flap in the vertical plane.
Melolabial cutaneous transposition flaps may be
designed with a pedicle that is either superiorly or infe­
riorly based. A flap with a superiorly based pedicle is
commonly used to reconstruct defects of the central
upper lip. A flap with an inferiorly based pedicle is often
used to reconstruct defects involving more lateral por­
tions of the upper or lower lip. Use of melolabial flaps to
repair the lips incurs some degree of flattening of the
melolabial folds. Flaps with a superiorly based pedicle

492
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-16  ■  A, A 2 × 2-cm skin defect of upper lip. B, C, Defect converted to full thickness, sparing most of the exposed muscle,
and wound closed primarily. D, E, Preoperative and 1-year postoperative views. No revision surgery performed. (Courtesy of Shan
R. Baker, MD.)
A
B
C
D
E
produce the greatest degree of distortion of the melola­
bial fold as they extend across the most defined and
visible portion of the fold. A second surgical stage involv­
ing revision of the pedicle to align scars parallel to the
melolabial crease is frequently indicated in cases in which
a melolabial transposition flap is used to reconstruct the
upper lip.
There is considerable tendency for linear transposi­
tion flaps to become slightly raised, causing a trap-door
deformity as scar tissue matures beneath the flap and
along its margins. Trap-door deformities may be mini­
mized by wide undermining around the margins of the
wound and by approximation of deep tissue layers, creat­
ing eversion of all skin edges. In some cases, it may be
helpful to place one or more “tacking” sutures on the
ventral surface of the flap before approximation of wound
edges. This reduces the space available for collection of
blood between the flap and recipient site. A collection of
blood beneath a flap is a common cause of trap-door
deformity.
Distortion of the melolabial fold and crease, alteration
in the orientation of facial hair growth pattern, and ten­
dency toward development of trap-door deformity are
reasons that melolabial cutaneous transposition flaps are
not frequently used to repair skin defects of the lips.
Cutaneous defects in the central portion of the lip are
often best reconstructed with bilateral advancement flaps.
Larger (≥2 cm) central defects usually are converted to
full-thickness defects and closed primarily (Fig. 19-16).
Similar to centrally located defects, small laterally located
cutaneous defects of the lip can be closed with bilateral
advancement flaps, often in the form of an A-T plasty
(Fig. 19-17). Larger (≥2 cm) laterally located cutaneous
defects of the upper lip are effectively reconstructed with
V-Y subcutaneous tissue pedicled melolabial advance­
ment island flaps (see Chapter 12) (Fig. 19-18). The flap
is freed from its orbicularis muscle attachments near the
commissure and is based solely on the abundant subcu­
taneous fat located just lateral to the commissure. This is
only when the flap is sufficiently large to necessitate the
incorporation of skin of the melolabial fold into the flap.
For sizable (2-3 cm) lip skin defects adjacent to the
inferior border of the ala, it may be beneficial to excise
the small peninsula of skin between the ala and melolabial
fold in the process of enlarging the defect so that the
defect extends to an aesthetic boundary.8 The peninsula
is then reconstructed by appropriately designing the
island flap so that the superior portion of the flap replaces
the peninsula (Figs. 19-18 and 19-19). This technique
provides the best camouflage because the superior border
of the flap is positioned within the aesthetic boundaries
of the alar-facial sulcus and melolabial crease. When this
peninsula is not replaced, the flap must cross the base of
the peninsula and may mar an otherwise excellent result.
The major advantage of subcutaneous tissue pedicled
melolabial advancement flaps used to repair sizable cuta­
neous defects of the upper lip is that there is no need to
resect standing cutaneous deformities because these do
not develop with this flap. For this reason, they are par­
ticularly advantageous compared with transposition and
cutaneous pedicled advancement flaps, which often have
sizable deformities that must be resected and discarded.
There is no wasted skin with the island flap. Another
important advantage of the island flap is that there is
considerably less dead space beneath the flap as well as
beneath skin surrounding the donor defect compared
with use of cutaneous pedicled flaps. Less dead space
means less space available for collection of blood and

FIGURE 19-17  ■  A-C, A 1 × 1.5-cm skin and vermilion defect. Bilateral advancement flaps (A-T plasty) designed to repair cutaneous
component of defect. Mucosa advanced to reconstruct vermilion (arrow). D, Postoperative result at 10 months. No revision surgery
performed. (Courtesy of Shan R. Baker, MD.)
A
Mucosal advancement
Mucosal advancement
Orbicularis m.
B
C
D
FIGURE 19-18  ■  A, A 2 × 2.1-cm skin and vermilion defect of lip. V-Y subcutaneous tissue pedicled lip advancement island flap designed
for repair. Flap designed to recruit medial cheek skin. Non-stippled area represents subcutaneous vascular pedicle on which flap is
based. Peninsula of skin in alar-facial sulcus replaced with flap to maximize scar camouflage. B, In situ flap incised.
C, D, Flap advanced to recipient site. E-G, Preoperative and 5-month postoperative views. No revision surgery performed. (Courtesy
of Shan R. Baker, MD.)
A
Remove skin peninsula
V-Y island flap
B
C
D
E
F
G

494
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-19  ■  A, A 3.8 × 2.8-cm defect of skin, vermilion, and muscle of lip. B, Excision of remaining skin of lateral aesthetic unit
planned. Template of contralateral aesthetic lip unit used to design V-Y subcutaneous tissue pedicled melolabial rotation advance­
ment island flap. C, Flap width enlarged 1 cm to accommodate scar contracture and subsequent diminution of vertical height of
reconstructed lip. D-F, Flap transferred to recipient site. Labial mucosa advanced outward to reconstruct vermilion. G, H, Eight
months after reconstruction and 2 months after contouring of flap and Z-plasty scar revision. (Courtesy of Shan R. Baker, MD.)
A
Template of contralateral
aesthetic lip unit
Flap enlarged here to
accommodate contraction
B
C
D
E
Mucosal advancement flap
F
G
H