Local Flaps in Facial Reconstruction

496
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
with sutures that are adjacent to or include the deep
portion of the reticular dermis. The epithelium of the
skin is closed in a manner that ensures a slight eversion
of the skin edges. Attention to detail throughout wound
closure will achieve an optimal scar that is narrow and
flush with adjacent lip tissue.
The anterior vermilion line is the principal landmark
of the lip. To ensure symmetry, its precise location on
opposing edges of the wound should be identified early
in the course of lip repair. Once it is identified, the line
is marked in some way as a reference to help guide the
rest of the lip repair. To serve this purpose, a 6-0 silk
suture may be inserted at the anterior vermilion line and
initially left untied. Of equal aesthetic importance is sat­
isfactory approximation of the posterior vermilion line,
which for the purpose of repair is the visible posterior
limit of the vermilion.
It is important to minimize irregularity or disparity in
vertical height and contour of the vermilion between the
two margins of a lip defect. The vermilion of the lateral
portion of the lip is normally narrower than the central
portion. As the two borders of the lip defect are approxi­
mated, accommodation for the disparity of the width of
the vermilion is accomplished by forward advancement
of vermilion of the lateral lip segment and simultaneous
slight posterior advancement of vermilion of the medial
border of the wound.
The portion of the orbicularis muscle that lies imme­
diately beneath the vermilion and superior to the hori­
zontal plane of the anterior vermilion line is known as
the vermilion muscle and is the principal tissue that pro­
duces the fullness and rounded appearance of the free
margin of the lip. Failure to achieve accurate muscle
approximation of this region will significantly increase
the likelihood of development of a notched or retracted
vermilion with wound maturation. This portion of the
orbicularis muscle is approximated with two or three
sutures placed immediately beneath the vermilion,
between the anterior and posterior vermilion lines.
During excision of a lip neoplasm and primary wound
closure, the V-shaped excision is designed in such a way
that it extends the complete height of the lip from the
vermilion to the mental crease in the case of the lower
lip and to the base of the nose or melolabial crease in the
case of the upper lip. This is usually necessary to create
an acute angle for ease of wound closure. In some cases,
maintaining the V-shaped design within these borders
can compromise the adequacy of resection margins,
thereby necessitating modification of the design. A
slightly greater amount of tissue can be resected around
a lip tumor by modifying the shape of the excision so that
it has the configuration of a shield or is U-shaped. In
more lateral portions of the lip, a shape that is more
skewed, like that of a “hound’s tooth,” will allow the final
scar to parallel the more angulated relaxed skin tension
lines natural to this region. Wound closure is performed
in a manner similar to that of the V-shaped excision,
except that it must accommodate the disparity of lengths
between the two wound margins.
A W-shaped excision is another way of achieving
greater resection of lip tissue without extending the apex
of the excision beyond the mental or melolabial crease
FIGURE 19-22  ■  A, Lip marked for W-shaped full-thickness exci­
sion of lip malignant neoplasm. Tip of central angle of W posi­
tioned at mental crease. Broken lines indicate alternative plan
for repair with bilateral advancement flaps. B, Primary wound
closure of full-thickness W-shaped lip excision. Untied suture
placed at anterior vermilion line as reference for aligning lip
repair.
A
B
(Fig. 19-22). The apexes of the three points of the W
usually remain within the confines of the lip aesthetic
region. When the points must extend beyond the aes­
thetic region of the lip, consideration is given to placing
the apex of the central point of the W at the mental or
melolabial crease, depending on the location of the exci­
sion. This design provides a natural break between the
single vertical scar line of the lip and the diverging distal
scar lines required for closure of the more peripheral
wound (see Fig. 19-22). In some situations, designing the
two angles of the W with dissimilar sizes can achieve a
more natural appearing scar, particularly for excision of
tumors of the lateral lip. W-shaped excisions of lateral
portions of the lip are best accomplished by designing a
smaller angle of the W medially and a larger angle later­
ally (Fig. 19-23).
Bilateral Lip Advancement Flaps
Reconstruction of rectangular full-thickness defects of
either lip may be achieved with bilateral advancements of
the remaining lip segments (Figs. 19-24 and 19-25).
Bilateral advancement flaps of the lower lip are created
with release of the remaining lip segments by incisions

19  RECONSTRUCTION OF THE LIPS
497
FIGURE 19-23  ■  A, Atrophy of lower lip from radiotherapy in childhood for hemangioma of lip. Persistent hemangioma is present.
Lip marked for W-shaped excision. W has angles of different sizes for scar to parallel relaxed skin tension lines of lateral lip.
B, Postoperative result at 6 months. Slight asymmetry of lower lip present.
A
B
FIGURE 19-24  ■  A, Full-thickness rectangular excision of central lower lip. Bilateral opposing advancement flaps designed for repair.
Flaps created by single opposing incisions marked in mental crease. B, Flaps apposed and wound closure in progress. Such wounds
can frequently be repaired with limited releasing incisions along mental crease.
A
B
A
B
FIGURE 19-25  ■  A, Bilateral labial flaps created by full-thickness incisions along mental crease after full-thickness excision of central
lip. The author prefers to dissect deeper layers by Karapandzic type of dissection to preserve as much lip sensory function as pos­
sible.5,6 B, Postoperative result at 5 years. Patient exhibited excellent lip function.

498
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
disruption of sensory nerve fibers to the upper lip. For
centrally located upper lip defects, advancement flaps do
not provide restoration of the philtrum. A vague sem­
blance of the philtrum is provided by the central verti­
cally oriented scar. Lack of an actual philtrum tends to
be less obvious in older patients.
Bilateral advancement flaps are best suited for restora­
tion of full-thickness defects of the central region of the
upper or lower lip because of the equal pull on the tissues
of the lateral lip. Bilateral advancement flaps are less ideal
for repair of defects of lateral portions of the lips. For the
upper central lip, it is best to minimize lateral tissue
movement because it often causes distortion of the phil­
trum. Reconstruction of full-thickness defects of the lip
will cause them to be tighter and less compliant than the
opposite, unviolated lip. This tends to be more obvious
when the lips are closed. Tightness of the reconstructed
lip tends to lessen over time because of gradual accom­
modative tissue stretching.
Circumoral Full-Thickness Rotation
Advancement Flaps
Full-thickness composite lip flaps can be transferred
around the oral commissure as either single or bilateral
opposing flaps. This method of reconstruction, first
described in 1857 by von Bruns, is intended to restore a
complete and functional muscle sphincter (Fig. 19-29).1,15
Flap movement employs both rotation and advancement
as the flap is transferred around the oral commissure to
close the defect. This method of reconstruction is more
commonly employed for reconstruction of full-thickness
defects of the lower lip but may be reversed for upper lip
repair as well. Flaps are designed to optimize preserva­
tion and function of the remaining orbicularis muscle.
Karapandzic Flaps
A significant modification of the full-thickness circum­
oral composite rotation advancement lip flap was
described by Karapandzic in 1974. This modification
preserves most of the neural and vascular structures
entering the flap (Fig. 19-30).1,5,6 The technique typically
involves the creation of bilateral opposing flaps that may
along the mental crease. Incisions are curved gently
downward at each end of the crease to follow the superior
margin of the aesthetic border of the chin. Incisions may
be full thickness or partial thickness as required by the
situation. Although it is not necessary, dissection through
the subcutaneous tissue and muscle layer of the flaps may
be performed in the fashion described by Karapandzic,
which attempts to preserve neural and vascular structures
to offer optimal preservation of sensory function and
tissue vascularity (see later section on Karapandzic
flaps).1,5,6 Because of the elasticity of mucosa, the mucosal
portion of full-thickness incisions is not carried as far
laterally as that of the skin and muscle. Approximation of
the two flaps is accomplished in a fashion similar to that
described for full-thickness primary lip repair. For full-
thickness defects of the lower lip repaired with bilateral
advancement flaps, accommodation is made for tissue
redundancy along the superior margin of the chin as the
lip flaps are advanced. This is accomplished by perform­
ing bilateral excisions of equalizing Burow triangles of
skin from the chin side of the incision.1,11,12
A variation for designing bilateral advancement flaps
to repair full-thickness defects of the lower lip advocated
by Isaksson and Johanson uses a stair-step design (Fig.
19-26).13,14 The lip tumor is removed by a rectangular
excision. To create the advancement flaps, a series of
bilateral square or rectangular incisions are made that
connect in a downward diagonal fashion following the
aesthetic border of the chin. At the termination of the
incisions, bilateral small triangles of skin are excised. As
the lip segments are advanced for wound closure, the
series of rectangles and terminal triangles are closed, cre­
ating a stair-step wound closure line that is intended to
minimize the effects of scar contracture. Although this is
a functional and novel method of repair, it creates a scar
that is not as natural to the lower face as one placed
directly in the mental crease.
Bilateral advancement flaps may also be used for
reconstruction of full-thickness defects of the upper lip.
To facilitate medial advancement of lip tissue, excision of
crescent-shaped segments of skin from the cheek in the
region immediately lateral to the nasal alae is usually
required (Figs. 19-27 and 19-28). The perialar crescent
excisions are of skin only, with care taken to minimize
FIGURE 19-26  ■  A, Rectangular excision of central lower lip. Bilateral full-thickness opposing stair-step advancement flaps used for
reconstruction. B, Wound closure has stair-step configuration.
A
B

19  RECONSTRUCTION OF THE LIPS
499
but is similar for reconstruction of upper lip defects
(Fig. 19-32). Bilateral flaps are designed so that their
width remains nearly uniform, with a tolerance for varia­
tion that is only gradual when attempts are made to
accommodate the natural facial features at the periphery
of the flaps.
Full-thickness circumoral flaps in the form of Kara­
pandzic flaps are most ideal for reconstruction of large
centrally located full-thickness defects of the lower lip
and, to a lesser degree, the upper lip. Flaps may be
adapted to repair full-thickness defects of more lateral
regions of the lower lip, but there is greater limitation to
their use for reconstruction of defects of the lateral upper
lip. Whereas full-thickness lip flaps can readily be
advanced past the midline of the lower lip, this maneuver
is not generally favored in the upper lip, where it will
cause distortion of the philtrum.
A helpful feature in restoration of central full-thickness
defects of either lip is to design bilateral flaps of similar
size (mirror image), which ensures symmetry. In recon­
struction of the lateral portion of the lower lip, bilateral
flaps are commonly designed of different lengths, with a
preference to create longer flaps from the contralateral
lower lip (Fig. 19-33). This approach may avoid distor­
tion of the central region of the upper lip.
be of different lengths, depending on the circumstances.
Unique to the Karapandzic technique is making incisions
for the flaps that are not full thickness. Incisions are made
through the skin of the flaps and separate incisions
through the mucosa on the deep surface of the flaps. Dis­
section of the flaps is performed with an attempt to iden­
tify and to preserve as many neural and vascular structures
as possible. Separation of the subcutaneous tissue and
muscle of the flaps from the adjacent facial tissues is
performed bluntly with scissors to gently spread the
tissue apart to avoid cutting through any neural or vas­
cular structures unless necessary (see Fig. 19-30B). Neural
and vascular structures are dissected sufficiently to allow
them to be stretched and carried along with the transfer
of the flaps without the need to cut the structures. This
approach maximizes vascular supply and preserves
optimal motor and sensory function to the reconstructed
lip, minimizing the need for reinnervation.
An incision to create a Karapandzic flap is made paral­
lel to the free margin of the lips, creating a flap with a
uniform width throughout. To optimize aesthetic results
in reconstruction of the lower lip, an incision is made
along the course of the mental crease as far as possible
and then carried around the oral commissure and into
the melolabial crease (Fig. 19-31). Flap design is modified
FIGURE 19-27  ■  A, Full-thickness tissue loss of central upper lip. Advancement of remaining lip segments is planned. Anticipated
bilateral standing cutaneous deformities resulting from advancement of lip segments marked for excision in alar-facial sulci. Exci­
sion of deformities facilitates advancement of flaps. B, Deformities excised, with care taken to preserve larger neural and vascular
structures. C, Flaps advanced and wound repaired. D, Postoperative result at 6 months. In this case, lack of philtrum does not cause
marked deformity.
A
B
C
D

500
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-28  ■  A, Full-thickness defect of central lip and columella. Bilateral opposing advancement lip flaps marked for repair.
Anticipated standing cutaneous deformities resulting from advancement marked in alar-facial sulci. B, Lip flaps apposed in midline.
Crescent-shaped deformities preserved and transferred with flap to assist with repair of anterior floor of nose. C, Flaps sutured in
place. Some exposed surfaces within nasal passage left to heal by secondary intention. D, Postoperative result at 2 years. No revi­
sion surgery performed.
A
B
C
D
FIGURE 19-29  ■  Reconstruction of lip with full-thickness circumoral rotation advancement flaps, as originally described by von Bruns
in 1857. (From von Bruns V: Chirurgischer Atlas: Bildliche Darstellung der chirurgischen Krankheiten und der zu ihrer Heilung erforderlichen
Instrumente, Bandagen, und Operationen, II Abt, Kau- und Geschmaks-Organ, Tubingen,1857/1860, Laupp.)

19  RECONSTRUCTION OF THE LIPS
501
FIGURE 19-30  ■  A, Full-thickness defect of lower lip. Bilateral Karapandzic flaps incised. B, Demonstration of vessels preserved with
Karapandzic technique of dissection. Compared with central lip, identification of peripheral margin of orbicularis muscle in vicinity
of commissures is more difficult. Release of facial muscle attachments to orbicularis muscle may be performed lateral to actual
peripheral margin of orbicularis muscle near commissures to ensure consistency of thickness of muscle layer of flaps. C, Flaps
approximated. D, For proper lip height, flaps are designed with uniform width throughout length of flaps. For this reason, it is
necessary to design flaps lateral to melolabial crease near commissure. E, Postoperative result at 6 months. F, Postoperative result
at 1 year. Reconstructed lip has tightened from scar contraction. Such long-term changes are common.
A
B
C
D
E
F

502
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-31  ■  A, Lip cancer marked for excision. Reconstruction planned with bilateral Karapandzic flaps. Outline of flaps is marked
in mental crease as far laterally as possible and then transitions into melolabial creases. B, Cancer excised and flaps apposed.
A
B
FIGURE 19-32  ■  A, Bilateral Karapandzic flaps marked for reconstruction of central upper lip deficiency. B, Flaps apposed. C, Patient
experienced difficulty in passing oversize denture through oral stoma required to obturate palatal defect after reconstruction. Mouth
expanded during interval of several weeks with graduated lip-stretching device. Soft tissue deficiency in superior region of upper
lip subsequently reconstructed with melolabial transposition flap.
A
B
C

19  RECONSTRUCTION OF THE LIPS
503
FIGURE 19-33  ■  A, Malignant neoplasm of left lower lip. B, Same patient shown in A with full-thickness defect of half of lower lip
after excision of cancer. Defect involves commissure. Bilateral Karapandzic flaps of unequal length designed for reconstruction.
C, D, Flaps of unequal length have been dissected. Lower lip flap provides majority of tissue for restoration of defect. Anterior
vermilion line approximated first. E, Lip anastomosis performed before reattachment of surrounding facial musculature in anatomi­
cally correct orientation. F, Postoperative result at 6 months. Small oral stoma acceptable. Accommodation for dentures is an
important consideration in selection of this method of repair.
A
B
C
D
E
F
For repair of centrally located lower lip defects, bilat­
eral flaps are created by making incisions from the defect
that extend laterally and superiorly around the oral com­
missure into the melolabial creases. The incisions typi­
cally end at the level of the nasal alae. This provides
composite flaps that offer symmetry with respect to the
nasal base and the reconstructed oral stoma. Once the
flaps have been dissected, it is best to first secure together
the two opposing borders and then to adjust the remain­
ing wound closure to the surrounding facial tissues (see
Fig. 19-33E). Care is taken to reattach the various muscles
of facial expression to the orbicularis muscle in anatomi­
cally appropriate orientation and location, although to a
large extent this occurs naturally as the wound margins
heal. Failure to perform a meticulous layered wound
closure can result in a scar that has a “clown-like” appear­
ance as it encircles the lips. Some degree of distortion of
the oral commissure is inevitable, causing the commis­
sures to be more rounded. In the majority of cases, the
position of the commissure is unchanged but the shape

504
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-34  ■  A, Full-thickness defect occupying two-thirds of lower lip. Arrows indicate advancement of cheek and chin tissue.
Broken lines mark incisions for bilateral Karapandzic flaps of unequal lengths. B, Wound repaired. C, Postoperative result at 1 year.
A
B
C
is blunted and pulled slightly in the direction of flap
transfer. Bilateral commissure distortion tends to be less
apparent than unilateral distortion.
In some patients, the Karapandzic technique may be
used to repair a defect as large as two-thirds of the width
of either lip (Fig. 19-34). However, there is variability
among patients as to how well lip tissue will stretch
without excessive distortion of the commissures or cre­
ation of limiting microstomia. Lip tissue of older patients
is more redundant and tolerant to stretching. A smaller
mouth opening may not be acceptable for patients who
wear dentures and must be able to pass dentures in and
out of the mouth with relative ease. However, the oral
aperture can be made larger over time with persistent
stretching of the lips by either repeated manual manipu­
lation or insertion of an adjustable lip-stretching mouth
appliance.
Transoral Cross-Lip Flaps
Abbe (Sabattini) Flap
Sabattini appears to have been the first to describe cross-
lip transfer of full-thickness lip tissue in 1838.1,16 By the
turn of the 19th century, several modifications of design
of cross-lip flaps had been reported.1,17-19 Flap design
described by Sabattini and later by Abbe in 1898 involved
transfer of a triangular full-thickness segment of lip tissue
from the lower lip to a full-thickness upper lip defect.
The flap was designed slightly smaller in width compared
with the defect (Fig. 19-35).16,19 More often, there is need
to transfer a flap from the upper lip to reconstruct a
defect of the lower lip, where cancer occurs with greater
frequency. The labial artery is preserved on one side to
serve as the pedicle of the interpolated flap (Fig. 19-36).
Venous drainage of the flap is provided by small veins
that approximately parallel the course of the artery. The
flap is pivoted nearly 180° on its pedicle as it is inserted
into the opposing lip defect and sutured into place. The
flap donor site is closed primarily. In approximately 3
weeks, the pedicle is divided and the flap inset. While the
pedicle is in place, patients may take an oral diet best
limited to liquids and soft foods that require minimal
biting and chewing.
After study of the complex vascular distribution of the
lower lip and chin, Kriet et al4 described the design and
use of an extended cross-lip flap that included a portion
of tissue from the chin to repair a large defect of
the upper lip and adjacent cheek (Fig. 19-37). More stan­
dard cross-lip flaps may be designed with variations of
V, W, rectangular, or other configurations, depending on
the particular requirements of a given reconstructive

19  RECONSTRUCTION OF THE LIPS
505
FIGURE 19-35  ■  Illustration of cross-lip flap reconstruction as reported by Abbe. (From Abbe R: A new plastic operation for the relief of
deformity due to double harelip. Med Rec 53:477, 1898.)
A
B
C
FIGURE 19-36  ■  A, Incised Abbe flap pedicled medially on upper lip. B, Cross-lip flap at end of first stage. Donor site closure not
illustrated. C, Pedicle divided and flap inset at second stage.
Continued

506
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
E
F
C
D
E
A
Abbe flap extends to
inferior chin border
Excise skin
Preserve vermilion
Cheek advancement
Extended Abbe flap
B
D
D, E, Cross-lip flap used to repair right lower lip defect. Vermilion of flap advanced to match width of vermilion
at recipient site. F, Division of pedicle and flap inset.
FIGURE 19-36, cont’d  ■
FIGURE 19-37  ■  A, B, Large full-thickness defect of lip and ala with extension to medial cheek. Extended Abbe flap designed for repair
of lip defect. Cheek advancement flap designed for repair of cheek component of defect. C, Flaps in place. Extended Abbe flap used
to line anterior floor of nose. Vermilion of left upper lip preserved. D, E, Abbe flap inset. Ala reconstructed with mucoperichondrial
flap hinged on caudal septum, auricular cartilage framework graft, and interpolated paramedian forehead flap.

19  RECONSTRUCTION OF THE LIPS
507
F
G
H
I
F-I, Preoperative and 1-year postoperative views. Upper and lower lip scars revised 6 months after inset of
paramedian forehead flap. (Courtesy of Shan R. Baker, MD.)
FIGURE 19-37, cont’d  ■
situation (Fig. 19-38).20-22 Similar to the orientation of
V-shaped and W-shaped full-thickness lip excisions that
are closed primarily, cross-lip flaps are designed so that
their axes parallel relaxed skin tension lines. The size of
cross-lip flaps may vary from one that is the size of a given
defect to one that fills only a small portion of the defect.
In this circumstance, a greater concomitant advancement
of lip segments on either side of the defect is required.
Likewise, when there is a major tissue loss, a cross-lip flap
can in some cases be combined with unilateral or bilateral
horizontally oriented advancement flaps to collectively
achieve lip reconstruction. On occasion, a second flap in
addition to the cross-lip flap is employed. In most cases,
the height of the cross-lip flap is designed to match that
of the recipient site. The size of the two lips remains
proportionally similar if the width of the flap is designed
to be half the width of the defect. For upper lip defects
of an entire aesthetic unit, such as the philtrum or lateral
aesthetic unit, consideration is given to transfer of a flap
from the lower lip that is the same size as the defect so
that the flap will restore the complete aesthetic unit of
the lip.22

508
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-38  ■  A, Full-thickness W-shaped excision of lower lip. Cross-lip flap designed for reconstruction. Perialar skin included in
flap design will lengthen flap, transfer larger skin surface area to recipient site, and facilitate donor site closure. B, Medial pedicled
flap transferred to recipient site. C, Flap in place. Donor site closed. D, Several months after pedicle division and flap inset. Flap
displays trap-door deformity.
A
B
C
D

19  RECONSTRUCTION OF THE LIPS
509
Cross-lip flaps may be pedicled medially or laterally,
except when the defect involves the more lateral portion
of the lip. For extreme laterally located defects, the flap
is based medially. In all other circumstances, a decision
pertaining to the location of the pedicle is influenced by
which side will allow an easier flap transfer and inset with
respect to the oral commissure. The labial artery courses
between the labial mucosa and orbicularis oris muscle,
just deep to the posterior vermilion line. It has a tendency
to lie slightly higher in the central region of the upper
lip, making a lateral pedicle slightly safer to use when the
flap is harvested from the upper lip.
The cross-lip flap pedicle necessarily includes the
labial artery and a small cuff of surrounding tissue at the
free margin of the lip. A tradeoff is made between having
sufficient soft tissue in the pedicle to ensure adequate
venous drainage and having a more bulky pedicle that
causes greater difficulty in accurately approximating the
flap donor site on the pedicled side (Fig. 19-39). The
labial artery lies posterior to the orbicularis muscle, so
the skin incision used to create the flap may extend a
limited distance through the anterior portion of the ver­
milion if necessary for optimal transfer of the flap to the
recipient lip.
FIGURE 19-39  ■  A, Abbe flap designed for repair of defect. B, Flap incised. C, Flap turned upward based on narrow pedicle consisting
of vermilion muscle. D, Preoperative view. Full-thickness defect of central lip after resection of lip cancer. E, One week after flap
transfer. F, Six months after flap inset. No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E
F
An attempt to transfer full-thickness lip tissue to the
opposite lip as a free composite graft without a vascular
pedicle is risky as the chance for success with any sizable
graft is poor, and it offers the potential loss of additional
lip tissue. If a composite lip graft is used, it should be very
small and adequately secured in position. Repeated move­
ment within the lip complex will serve to hinder survival
of the graft. When the consequences of further tissue loss
are considered, it is reasonable to use a cross-lip flap that
has a temporary pedicle and optimizes the chance for
successful tissue transfer.
Cross-lip flap reconstruction involves transfer of full-
thickness lip tissue, so there is restoration of the orbicu­
laris oris sphincter (Fig. 19-40). The first signs of motor
reinnervation begin to appear a few months after flap
transfer and are demonstrated by irregular, single, low-
amplitude motor unit potentials. Studies by Smith23
and Thompson and Pollard24 show that single and poly­
phasic motor unit potentials are detected with voluntary
effort, develop greater amplitude, and appear increas­
ingly normal during the first year after transfer of cross-
lip flaps (Figs. 19-41 and 19-42). The quality of muscle
movement that returns to cross-lip flap tissue is variable.
Many patients eventually display adequate motor

510
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
Cross-lip flaps sustain at least temporary loss of sensa­
tion as they are dissected and transferred. A partial return
of sensory function is typically first observed several
months after flap transfer. Sensory function returns in the
order of pain, touch, and temperature (cold, then hot).
In studies of denervated cross-lip flaps by Smith,23 return
of pain sensation could be detected 2 months after flap
transfer, followed by tactile sensation at 3 months, cold
at 6 months, and warmth at 9 months. Smith determined
that by 1 year after flap transfer, pain, touch, and sweating
of the flap are nearly normal, whereas temperature detec­
tion tends to remain slightly impaired.23 This author has
observed that some patients may notice a slight dysesthe­
sia or hypersensitivity of the flap to stimuli such as cold
during the first year or two after reconstruction. However,
this phenomenon appears to dissipate over time.
There is a strong tendency for cross-lip flaps to appear
thickened, even after many years, resulting in a trap-door
deformity (Fig. 19-43). The flap may appear thin and well
matched to the adjacent lip tissue when it is stretched in
activities such as smiling but then appears excessively
thick when relaxed. Unfortunately, the scar that sur­
rounds a cross-lip flap cannot completely match the elas­
ticity of natural lip tissue and is the likely cause of the
thickened appearance of the flap. The scar is full thick­
ness and completely encircles the flap except along the
free margin of the lip. Lymphatic drainage from cross-lip
FIGURE 19-41  ■  A, Lips in repose 1 year after cross-lip flap recon­
struction of lower lip. B, Pursing of lips activates contraction of
muscle within flap tissue.
A
B
FIGURE 19-42  ■  A, Patient undergoing electromyographic analy­
sis 5 years after cross-lip flap reconstruction of lower lip.
B, Electromyography recording comparing motor activity in
region of lip that was not operated on (top) with activity found
within cross-lip flap (bottom).
A
B
FIGURE 19-40  ■  Cross-lip flap with wide pedicle. Labial artery
is located immediately deep to posterior vermilion line, so inci­
sion to create flap may extend through anterior portion of
vermilion.
function within the flap tissue; others demonstrate some
degree of persistent motor weakness. This may result in
some deficiency of oral continence, particularly with
liquids. Problems with oral continence appear to be more
likely in patients of advanced age and in patients who are
edentulous.

19  RECONSTRUCTION OF THE LIPS
511
flaps is restricted because of the scar. An additional factor
that may contribute to trap-door deformity of the flap
may be related to wound closure techniques. If all tissue
layers and particularly the muscle layer are not carefully
approximated, there is a greater tendency for scar con­
traction, resulting in a depressed scar about the borders
of the flap that enhances trap-door deformity.
Overall, the greatest disadvantages of lip reconstruc­
tion with cross-lip flaps relate to the prolonged phase of
denervation, the temporary inconvenience inherent in
dealing with a transoral pedicle, and the technical diffi­
culties in achieving an optimal contour match between
the flap and the adjacent lip. The greatest benefit of using
this flap is that composite lip tissue is transferred to the
opposing lip without violation of the commissures.
Estlander Flap
In 1872, Estlander was first to describe a cross-lip flap
repair that involved transfer of a full-thickness lip flap
with a pedicle that was incorporated into the recon­
structed ipsilateral oral commissure (Fig. 19-44).1,25
Similar to other cross-lip flaps, the Estlander flap is typi­
cally designed to harvest tissue from the opposing lip to
help restore approximately half or more of a given lip
defect. The flap is transposed around the oral commis­
sure on a small vascular pedicle containing the labial
artery. The Estlander cross-lip flap is performed as a
one-stage reconstruction (Fig. 19-45). The Estlander
cross-lip flap is suited for repair only of a defect involv­
ing the lateral portion of either lip. Baker26,27 has sug­
gested a modification of the design of superiorly based
Estlander flaps that places the donor site scar within the
melolabial crease (Fig. 19-46). The greatest disadvantage
FIGURE 19-43  ■  A, Same patient shown in Figure 19-38D 1 year
after cross-lip flap reconstruction of lower lip. Scar lines are
ideal, and there is minimal trap-door deformity. B, Same patient
5 years later. Recipient lip has “aged.” Scars are more apparent,
and flap displays greater trap-door deformity.
A
B
FIGURE 19-44  ■  A, B, Original illustrations. (From Estlander JA: Eine Methode aus der einen Lippe Substanzverluste der anderen zu ersetzen.
Arch Klin Chir 14:622, 1872.)
A
B

512
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-45  ■  A, Estlander cross-lip flap attached to donor lip by pedicle. B, Flap secured in recipient site.
A
B
FIGURE 19-46  ■  A, Estlander cross-lip flap with rounded apex for donor site scar to lie in melolabial crease. B, Vermilion of flap
advanced anteriorly to match width of recipient lip vermilion.
A
B

19  RECONSTRUCTION OF THE LIPS
513
C
D
E
A
Full thickness
incision
Extended Estlander
flap
B
FIGURE 19-47  ■  A, Traumatic partial avulsion of upper lip and cheek soft tissue. B, C, Wound repaired. Lateral portion of right upper
lip necrosed, resulting in scarring and destruction of commissure. D-G, Loss of lateral lip segment reconstructed with Estlander flap.
H-K, Six months after Estlander flap, commissureplasty performed. L, M, Six months after commissureplasty, Z-plasties and addi­
tional refinement of commissure performed. N, O, Six months after Z-plasties. (Courtesy of Shan R. Baker, MD.)
of this flap is that it creates fullness or blunting of the
involved oral commissure. Whereas this deformity may
not be readily seen when the lips are closed, it is often
obvious when the mouth is held open and the two com­
missures are seen simultaneously (Fig. 19-47). Several
techniques are described for a second-stage revision of
the distorted oral commissure; however, none appears to
completely restore a natural appearance (see section on
commissureplasty).
Double Lip Flap Repair
Several authors have described cross-lip transfer with two
flaps to repair a large defect of the opposing lip. In 1848,
Stein first described the simultaneous use of small bilat­
eral laterally based cross-lip flaps harvested from the phil­
trum and used to reconstruct a large defect of the central
lower lip.17 Although it is clearly more complicated to
work with two flaps and their pedicles, this design main­
tained symmetry within the donor lip. Kazanjian later
modified Stein’s design to preserve the central philtrum
by harvesting flaps from either side of the philtrum.28 In
most situations, preference is given to use of a single flap
to limit the number of scars and anastomotic connections
of lip segments. Martin29 in 1932 and Murray30 in 1972
reported on the use of large bilateral Estlander flaps to
reconstruct full-thickness defects of the entire lower lip.
Despite the consequent reduction in size of the oral
stoma, both authors reported that lip symmetry and func­
tion were satisfactory and acceptable, considering the
magnitude of such reconstruction.
In 1876, Buck described a two-flap reconstruction
involving one cross-lip flap and one transposition flap to
reconstruct a full-thickness defect of the central region
of the lower lip (Fig. 19-48).18 The transposition flap
moved the remaining lip segment medially on the ipsi­
lateral side of the lip defect. A releasing incision extended
inferiorly from the oral commissure to create the full-
thickness transposition flap so that the flap could be
sutured to the opposite border of the lip defect. The
donor defect created by the transposition flap was
repaired with an Estlander cross-lip flap. This and other
two-flap methods are more complicated and result in
three scar lines in the reconstructed lip; they also result
in greater denervation of the reconstructed lip compared
with use of single cross-lip flap techniques. Consequently,
Continued

514
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
H
I
J
F
Full thickness incision
Skin only excision
Vermilion advanced to here
G
M
N
O
K
Excise redundant
skin
Advance mucosa
here
Z-plasties to improve
depressed scar
Z-plasty to move
alar base medially
L
FIGURE 19-47, cont’d

19  RECONSTRUCTION OF THE LIPS
515
FIGURE 19-48  ■  A, B, Two-flap technique, as described by Buck.
A
B
two-flap techniques are not generally favored methods
of lip reconstruction.
Gilles Fan Flap
Gilles described a method of lip reconstruction that
employs lip tissue movement in a manner similar to that
accomplished by the two-flap method described by Buck
but with a single flap (Fig. 19-49A, B).31 The flap is a
composite flap created by full-thickness lip incisions and
is designed to transfer the remaining lip segment from one
side of a defect together with lip tissue from the lateral
portion of the opposing lip. The flap is designed to have
a narrow pedicle that incorporates the ipsilateral oral com­
missure. The flap is pivoted about the commissure toward
the defect. Movement of the flap around the oral commis­
sure has often been compared with that observed with
opening of an old-fashioned collapsible hand-held fan.
Thus, this method of reconstructing the lip has commonly
been referred to as a fan flap. The feature that most dis­
tinguishes this method of repair from the circumoral
rotation advancement flaps of von Bruns and Karapandzic
is the near-vertical full-thickness incision made in the
opposing lip. This incision is similar to the medial incision
of an Estlander flap. Transfer of the flap causes blunting
of the commissure, similar to that created with use of an
Estlander flap. Gilles flaps may be used bilaterally when
necessary to restore large full-thickness lip defects of the
central lower lip (Fig. 19-50A). The primary limitation of
this approach is the resulting microstomia.
McGregor has described a modification of the Gilles
flap that has a similar shape but involves transfer of tissue
to a defect of the upper lip from the melolabial region
(see Fig. 19-49C, D).22,32 Like the Gilles flap, the
McGregor flap is a composite flap created by full-
thickness lip incisions. This modified design adds addi­
tional tissue about the mouth but fails to restore a
complete lip muscle sphincter and does not restore a
natural vermilion. Similar to the Gilles flap, the McGregor
flap can be used bilaterally to reconstruct large full-
thickness lip defects of the central upper lip (see Fig.
19-50B). Depending on the design of the flap, mucosa
from the posterior surface of the flap may be available for
advancement over the exposed border of the flap to
restore the vermilion. Surgeons have used a Z-plasty
along the lateral margin of the flap to assist in making
the circumoral transfer (see Fig. 19-50B).
Expanded use of the Karapandzic flap has now largely
replaced the use of the Gilles and McGregor flaps.
However, the McGregor flap offers a reasonable alterna­
tive for repair of lateral upper lip defects when there is
insufficient remaining tissue to repair the lip without
recruitment of cheek skin (Fig. 19-51). When this flap is
used, it is necessary to anticipate the degree of flap con­
traction that is likely to occur, particularly if the flap
requires a skin graft on the deep surface for lining and
for reconstruction of the vermilion.
Commissureplasty
A problem inherent to all cross-lip flaps with a pedicle
that becomes the oral commissure is blunting and distor­
tion of the involved commissure. A later-stage commis­
sureplasty is often necessary. The simplest method of
commissureplasty involves making a horizontal full-
thickness incision at the level of the blunted commissure
that extends laterally to a point corresponding in position
to that of the contralateral normal commissure (Fig.
19-52).33 Labial mucosa is then advanced forward on each
side of the incision to restore a vermilion surface. In some
cases, it may be helpful to remove a small triangle of skin
and subcutaneous tissue from the area of the commis­
sureplasty for a more natural result. This is performed
cautiously to avoid oral incontinence.
An alternative method of commissureplasty makes use
of small flaps of vermilion and orbicularis muscle (Fig.
19-53). A triangle of skin and subcutaneous tissue is
excised immediately lateral to the blunted commissure.

FIGURE 19-50  ■  A, Gilles flaps may be used bilaterally to reconstruct large full-thickness central defects of lower lip. B, McGregor
flaps may be used bilaterally to reconstruct large full-thickness central defects of upper lip.
A
B
FIGURE 19-49  ■  A, B, Gilles fan flap for reconstruction of lower lip. C, D, McGregor modification of Gilles flap for reconstruction of
upper lip. Both designs were described with full-thickness lip incisions.
A
B
C
D

19  RECONSTRUCTION OF THE LIPS
517
FIGURE 19-51  ■  A, Large defect of upper lip. Bilateral McGregor flaps designed to recruit tissue from cheek for reconstruction. Broken
lines indicate incisions for flaps. Skin grafts applied to deep surface and free margin of flaps. B, Flaps in place. C, Postoperative
result at 6 months. Vertical height deficiency of reconstructed lip is apparent.
A
B
C
FIGURE 19-52  ■  Commissureplasty. A, Small triangle of skin may or may not be excised lateral to distorted commissure. B, Horizontal
incision made through blunted commissure. C, Mucosa advanced superiorly, inferiorly, and laterally to restore vermilion of lips and
commissure.
A
B
C

518
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-53  ■  Commissureplasty. A, Triangle of skin marked for excision to point of new commissure. Vermilion of blunted com­
missure marked to create flap pedicled on upper lip. B, Skin excised. Broken line indicates planned incision through muscle of
blunted commissure to extend commissure laterally and to create inferiorly based mucosal flap. C, Vermilion flap transposed
to reconstruct vermilion of superior aspect of commissure. Mucosal flap advanced to reconstruct inferior vermilion of commissure.
D, Flaps sutured in place.
A
C
D
B
The apex of the triangle extends to the point of the new
commissure. A small vermilion flap is created from one
lip and left pedicled on the opposite lip. A horizontal
incision is made through the muscle tissue to the point
of the new commissure. The vermilion flap is advanced
to this point. A small flap is created from the mucosa of
the lip serving as the donor for the vermilion flap. The
mucosal flap is advanced over the free border to restore
the vermilion of the donor lip.
Bilateral Cheek Advancement Flaps
Full-thickness lip defects of up to half of the width of
either lip can usually be restored satisfactorily with bilat­
eral lip advancement flaps. For larger defects, it is usually
best to consider some other method of lip repair that will
add more tissue to the reconstructed lip. The elasticity
of lip tissue will vary among patients, as does tolerance
for microstomia. In some situations, repeated manual
stretching or use of a prosthetic lip-stretching appliance
may help reduce problems with microstomia. In other
cases, it will be necessary to recruit tissue from the adja­
cent cheek during reconstruction to prevent microsto­
mia. Bernard in 1852 and von Burow in 1853 and 1855
advanced the concept of using tissue from the cheeks to
restore major defects or complete loss of the upper or
lower lips.1,11,34 Tissue is advanced horizontally from the
medial aspect of one or, more commonly, both cheeks in
the form of bilateral opposing cheek advancement flaps.
This method of lip repair has been referred to as a
Bernard cheiloplasty. Standing cutaneous deformities
form on either side of the base of each advancement flap
and are referred to as Burow triangles.11,34 A major feature
of Bernard cheiloplasty is the resection of Burow trian­
gles of skin resulting from the advancement of the cheek
flaps. Excision of the triangles facilitates tissue advance­
ment. Reconstruction of the upper lip with bilateral
opposing cheek advancement flaps requires excision of
four triangles of cheek skin (Fig. 19-54). Bilateral trian­
gles of skin and subcutaneous tissue are removed from
the vicinity of the alar-facial sulci superior to the flaps.
Additional triangles of skin are removed from the cheek

19  RECONSTRUCTION OF THE LIPS
519
FIGURE 19-54  ■  A, B, Bernard–von Burow opposing cheek advancement flaps for reconstruction of entire upper lip by four triangular
skin excisions to facilitate advancement of cheek flaps.
A
B
inferior to the flaps and lateral to the oral commissures.
When the Bernard cheiloplasty is used to reconstruct
full-thickness defects of the lower lip, reconstruction
requires excision of three triangles of skin (Fig. 19-55).
Triangles are removed bilaterally superior to the oral
commissures. A larger triangle of skin is excised in the
midline extending inferiorly from the lip defect into the
chin as necessary.
Modifications of the Bernard–von Burow flaps have
subsequently been described by several authors.35-37 In
1960, Webster proposed a modified design for lower lip
reconstruction that employs a more linear horizontal
advancement of cheek tissue compared with the Bernard–
von Burow techniques. This modification positions scars
in natural facial skin creases and avoids violation of the
aesthetic region of the chin (Fig. 19-56).1,35 The Webster
design also minimizes the tendency for vertical deficiency
in the midline of the reconstructed lower lip (Fig. 19-57).
These techniques were originally described with use
of full-thickness cheek incisions and do not restore the
FIGURE 19-55  ■  A, B, Bernard–von Burow opposing cheek advancement flaps for reconstruction of entire lower lip by three triangular
skin excisions to facilitate advancement of cheek flaps.
A
B

520
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-56  ■  A, B, Webster modification of Bernard–von Burow opposing cheek advancement flaps for reconstruction of entire
lower lip by four triangular skin excisions to facilitate advancement of cheek flaps. This method preserves aesthetic region of chin.
A
B
A
B
C
D
FIGURE 19-57  ■  A, Recurrent cancer of lower lip. Width of lower lip reduced from previous wedge excision. Tumor marked for
W-shaped excision. Bilateral opposing cheek advancement flaps marked by use of Webster modification without planned excision
of triangles of skin from lower cheeks. B, Alternative configuration of lip excision designed so that aesthetic region of chin is not
violated. C, W-shaped excision performed instead of rectangular excision in attempt to preserve sensory fibers of inferior mental
nerves. D, One week postoperatively. Full-thickness horizontal incisions were made only through orbicularis muscle. Beyond this
point, incisions were only through skin and subcutaneous tissues. Incisions through mucosa were made independent of skin inci­
sions and at slightly superior level so that mucosal flaps could be dissected and advanced over exposed free margins of lateral
segments of reconstructed lip.

19  RECONSTRUCTION OF THE LIPS
521
E
F
G
H
E, F, Postoperative views at 2 months with mouth closed and open. Patient is able to insert upper denture.
Tightness of reconstructed lip compensates for lack of motor function of repaired lip. G, Patient cannot smile at this point without
opening lips slightly. H, When simulating kissing or whistling, lips do not remain apposed.
FIGURE 19-57, cont’d  ■
orbicularis muscle sphincter. It is of greater benefit to the
patient if flaps can be transferred with minimal violation
of the facial musculature by limiting the extent of full-
thickness incisions. There is also benefit to the patient if
flaps are dissected with minimal violation of the sensory
innervation of the flap tissue. Limiting the extent of inci­
sions to create flaps helps preserve sensory innervation to
the region. Therefore, a preferred approach for perform­
ing the Bernard and Webster cheiloplasties is to make
incisions only through the skin and subcutaneous tissue
layer. Labial and buccal mucosa incisions are made sepa­
rate from skin incisions. The mucosal incisions do not
usually require extension as far laterally as the skin inci­
sions. Mucosal incisions are typically made at the same
level as the skin incisions but may be offset at a slightly
superior or inferior level, depending on which lip is
reconstructed. The offset provides more mucosa that can
be advanced with the flap. This additional mucosa is used
to create mucosal flaps that are draped across the free
margins of the flaps to restore the vermilion of the lateral
portions of the reconstructed lip. What remains of orbi­
cularis muscle is freed up sufficiently to allow flap
advancement. Violation of the facial mimetic muscula­
ture is minimized by blunt spreading of tissue to enable
adequate stretching without separation of the muscle
attachments of the cheek flaps. Freeman37 has described
a dissection along the orbicularis muscle of the opposite
lip in an attempt to advance more of this muscle along
with the cheek advancement flaps with the intent of
improving lip function. However, this is technically dif­
ficult to accomplish.
Reconstruction of full-thickness defects of the lip with
opposing cheek advancement flaps is technically difficult
and oral functioning is fair at best (see Fig. 19-57). The
lack of a functional muscle sphincter is offset in part by
the tightness that is inherent to the reconstructed lip by
this surgical approach. Whereas basic mouth opening
and closing may be acceptable, more specialized lip func­
tions, such as whistling and kissing, tend to be signifi­
cantly impaired (see Fig. 19-57G, H).
Melolabial Transposition Flaps
Similar to cutaneous melolabial transposition flaps used
to reconstruct cutaneous defects of the lip (see section on
melolabial flaps for cutaneous repair), a thicker compos­
ite melolabial transposition flap consisting of skin and
subcutaneous tissue may be used to repair full-thickness
lip defects. In such instances, it is necessary to line the
deep surface of the flap. This is most commonly achieved

522
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
provides a portal for drainage of fluid collecting beneath
the flap. This maneuver also serves to begin the process
of vermilion restoration necessary for the free margin of
the reconstructed lip.
The use of skin-lined melolabial transposition flaps to
reconstruct full-thickness lip defects will result in a thin
adynamic lip segment. Designing the flap with a greater
width than the vertical height of the lip defect is advisable
so that the reconstructed lip will maintain adequate verti­
cal height after wound contraction and scar maturation
(Fig. 19-59). Although the flap should not be subjected
to excessive wound closure tension, some tightness of the
reconstructed lip can help offset the problems associated
with an adynamic lip segment. Bilateral melolabial trans­
position flaps may be used to reconstruct large full-
thickness lip defects or complete absence of the lip; one
flap is used for the external lip surface, and the other is
turned inward to provide lining for the reconstructed lip.
However, this technique requires flaps with extended
lengths, and it is technically difficult to inset the flaps
while working around the pedicle of the lining flap.
Island Flaps
Several island flaps have been described for use in recon­
struction of full-thickness lip defects. McHugh38 has
described a horizontally oriented island flap consisting
of tissue from the cheek that is transferred to the lower
lip by a V-Y advancement. Fugimori39 and Stranc and
with a skin graft (Fig. 19-58). A split-thickness skin graft
can be used for this purpose with perhaps an improved
survival of the graft compared with use of a full-thickness
skin graft. However, full-thickness skin grafts cause less
wound contraction. There is considerable tendency for
contraction of the melolabial flap and the lining skin
graft. For this reason, both graft and flap are designed
wider than the vertical height of the lip defect. The skin
graft is draped over the free margin of the flap for resto­
ration of the vermilion. A mucosal free graft may sub­
sequently be used to replace the skin graft of the
reconstructed vermilion. This is performed as a second­
ary procedure once the skin graft has completely healed.
Melolabial flaps have a random vascular supply. Thus,
they are at greater risk of necrosis when they are long
relative to flap width. A greater risk of necrosis is also
observed in patients who use tobacco products or have
been irradiated. When there is concern for the viability
of a melolabial transposition flap, employment of an
initial delay may be appropriate, especially if the flap is
lengthy (see Fig. 19-58). Whenever flap delay is used,
consideration is given to placement of a lining skin graft
on the deep surface of the flap at the time of delay. The
flap is then transferred to the lip as a composite flap. This
approach avoids the difficulty of securing a skin graft to
the deep surface of the flap after it has been positioned
in the lip recipient site. Less inflammation occurs if the
grafted skin is made to extend to at least one of the skin
margins along the border of the delayed flap. This
A
B
FIGURE 19-58  ■  A, First-stage reconstruction of upper lip by delayed melolabial transposition flap lined with skin graft. Previous
attempts to reconstruct upper lip had failed. Patient also smoked tobacco, so delayed flap was constructed as bipedicle flap.
B, Remnants of chest flap previously used by another surgeon present in right cheek and upper lip.

19  RECONSTRUCTION OF THE LIPS
523
C
D
E
F
C, At second stage, inferior pedicle divided and flap prepared for transfer. Healed skin graft observed on deep
surface of flap. The author has since observed less inflammation when edges of skin graft are sutured to borders of flap at time of
delay. D, Flap transferred to upper lip. Donor cheek wound opened to facilitate cheek repair. E, Large standing cutaneous deformity
at base of flap required excision in third surgical stage. F, Several months after third surgical procedure consisting of excision of
standing cutaneous deformity and contouring of flap.
FIGURE 19-58, cont’d  ■

524
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
temporal artery that travels from the preauricular region
superiorly beneath the skin in the plane of the temporo­
parietal fascia to the midline of the scalp. In many patients,
the course of the artery can be detected with gentle palpa­
tion and can be mapped out very well with use of a
Doppler device. The flap is created by making vertical
incisions angled posteriorly on both sides parallel to the
course of the posterior branch of the superficial temporal
artery (Fig. 19-60). The flap is pedicled on tissue in the
immediate preauricular region at the level of the zygoma.
Care is taken to avoid injury to the temporal artery and
accompanying venous drainage, particularly in the region
of the pedicle.
In anticipation of wound contraction, it is best to
design the flap with a width that exceeds the vertical
height of the recipient lip defect. The distal end of the
flap is tapered near the center of the scalp. The flap is
designed with sufficient length to reach the recipient site
without excessive wound closure tension. The long flap
is possible because it is designed as an axial flap based on
the temporal artery. It is better to construct a flap with
extra length than to risk injury to the pedicle by extend­
ing the inferior dissection below the level of the zygoma.
The scalp donor site is closed primarily in some cases but
not in all. Closure depends on the width of the flap and
the laxity of adjacent scalp. Closure of the donor site with
excessive tension may result in loss of hair in the region.
If scalp wound closure tension is excessive, a portion of
the wound may be left open to heal by secondary inten­
tion or repaired with a skin graft. The resulting scar or
skin graft can subsequently be excised and the wound
closed by scalp advancement. The proximal portion of
the flap not used to reconstruct the lip may be returned
to the scalp when the flap is inset.
When full-thickness lip defects are reconstructed with
an interpolated temporoparietal scalp flap, the deep
surface of the flap is usually covered with either a full-
thickness or split-thickness skin graft to provide an intra­
oral surface lining. Whereas a split-thickness skin graft is
relatively easy to harvest and can have a long length to
cover a sizable portion of the flap’s undersurface, a full-
thickness skin graft offers a more durable tissue surface
and is relatively less prone to contraction. It can be
Robertson40 have described a design for an island flap that
employs the transfer of vertically oriented tissue to the lip
from the melolabial region. The flap is pedicled on a sub­
cutaneous tissue pedicle and is pivoted 90° and set hori­
zontally into the lower lip. Bilateral island flaps may be
used to repair larger lip defects. The island flap is created
by making an incision completely around the designed
flap. The flap remains pedicled on the subcutaneous tissue
immediately beneath the flap. A mucosal advancement
flap is draped over the free margin of the newly recon­
structed lip to provide a vermilion replacement.
Horizontally oriented V-Y island advancement flaps
championed by McHugh require incisions through skin
and subcutaneous tissue externally and mucosa internally
while maintaining the facial muscle attachments to the
flap.38 The flap described by Fugimori39 and Stranc and
Robertson40 is also based on the facial musculature and
requires a 90° pivot, so a greater dissection within the
muscle layer is required to enable flap transfer compared
with the McHugh flap. Island flaps have less of a problem
with bulkiness of the pedicle than flaps with a cutaneous
pedicle do. The pedicle of island flaps must have an
adequate random vascular supply or be designed with an
axial vascular system based on branches of the facial
artery. Concerns with use of island flaps for major lip
reconstruction include difficulty with flap mobilization,
impairment of facial nerve function, difficulty with ori­
entation of the flap, appearance of scar lines, and viability
of the flap. At present, island flaps are not considered a
first choice for full-thickness lip reconstruction.
Temporoparietal Scalp Flaps
Interpolated temporoparietal scalp flaps used for lip
reconstruction are technically regional flaps. In some
situations, the temporoparietal flap may prove to be
useful for reconstruction of large full-thickness defects of
the upper or lower lip. Description of the flap is included
in this chapter because it can offer a reasonably simple
functional flap for restoration of a variety of large
lip defects without disruption of the opposing lip and
adjacent perioral structures. The temporoparietal scalp
flap is based on the posterior branch of the superficial
FIGURE 19-59  ■  A, Ten years after reconstruction of right lower lip with melolabial transposition flap. B, Although flap is adynamic,
patient has oral continence.
A
B

19  RECONSTRUCTION OF THE LIPS
525
challenging to securely attach a skin graft to the deep
surface of the temporoparietal scalp flap as the flap is
being transferred to the mouth because a bolster dressing
to secure the skin graft is awkward and may risk impair­
ment of vascularity to the flap. When possible, it may be
preferable to stage the procedure by delaying the flap and
placing a skin graft on the ventral surface of the flap (Fig.
19-61). Use of a delayed stage can help “train” the flap
tissue to adapt to an alteration in its vascular supply while
simultaneously allowing a skin graft to heal to the deep
surface of the flap. The second stage is then performed,
transferring the composite flap to the recipient lip site.
During the delay stage, the distal end of the flap may
remain attached to the scalp in the form of a bipedicle
flap until the time of actual flap transfer.
When a temporoparietal flap is used in a staged pro­
cedure, the edges of the skin graft are sutured to both
borders of the flap. The graft should be sufficiently large
to eliminate the need to stretch the skin graft as it is
sutured in place. Approximating the edges of the skin
graft to one or both borders of the flap minimizes accu­
mulation of serum and other debris beneath the flap
during healing. Suturing of the graft to the posterior flap
border provides the restoration of a vermilion. The skin
graft is designed longer than necessary to offer greater
flexibility when the flap is transferred to the mouth. In
addition, a long skin graft lining the temporoparietal
scalp flap will serve to lessen contracture of the flap width
FIGURE 19-60  ■  A, Temporoparietal scalp flap marked. Course of posterior branch of superficial temporal artery marked in center of
flap. Course of anterior branch of artery indicated at base of flap. B, Same patient as in A with flap transferred to upper lip.
A
B
during the phase that it remains pedicled. The skin graft
also lessens the tendency for maceration of the cheek skin
due to contact between the cheek and the undersurface
of the flap pedicle. The skin graft is removed from the
portion of the pedicle returned to the scalp when the flap
is inset.
The temporoparietal scalp flap can be designed for
reconstruction of an entire upper or lower lip. It can be
designed as a bipedicle flap that is connected across the
top of the scalp and transferred to the lip as an interpo­
lated flap in a bucket-handle fashion. Such a flap design
is more safely accomplished by use of a delayed stage as
circulation across the top of the scalp is random. It is
possible to reconstruct an entire lip with use of a single-
pedicled temporoparietal flap (Fig. 19-62). In such cases,
use of a delayed stage is preferred to ensure the vascular­
ity of the distal end of the flap. Insetting of a single-
pedicle flap is much easier than that of a bipedicle flap.
A single-pedicle flap also causes less distortion of the
scalp. It is also appreciably easier for the patient to deal
with a flap pedicled on only one side of the face. The
amount of surface contact between the flap and the lip
recipient site influences how long the flap remains pedi­
cled to the scalp. In most cases, a period of at least 3
weeks is used between the initial transfer of the flap to
the mouth and flap inset, but this interval can be varied.
On occasion, division of the pedicle may be performed
in stages to reduce the risk of flap necrosis.

526
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 19-61  ■  A, Skin graft placed on deep surface of temporoparietal scalp flap at time of flap delay. B, Incisions closed after
placement of skin graft.
A
B
FIGURE 19-62  ■  A, Full-thickness defect of entire lower lip. B, C, First-stage reconstruction of same patient as in A with single-pedicle
interpolated temporoparietal scalp flap lined with full-thickness skin graft.
C
A
B
Scalp skin has a different character than lip skin (Fig.
19-63). Because the temporoparietal scalp flap is hair
bearing, it is more suited to reconstruction of the lip in
men. Hair growth on the flap can simulate a moustache
or beard and aid in camouflage of the reconstruction (Fig.
19-64). It is important to appreciate that reconstruction
with a temporoparietal scalp flap does not restore motor
function to the lip but will serve as a static mouth cover.
Adynamic reconstruction is better suited to restoration
of the upper lip than of the lower lip.
Other Flap Reconstructions
A number of additional flaps from regional or distant sites
may be used to reconstruct full-thickness defects of the
lip. These flaps are beyond the purpose of this chapter
and are mentioned only briefly for completeness.41-44
Regional and distant flaps are usually selected for lip
reconstruction when there is need for total restoration
of either lip. Historically, the most common regional
flap used for this purpose consisted of transposition of

19  RECONSTRUCTION OF THE LIPS
527
FIGURE 19-63  ■  A, After first-stage interpolated temporoparietal scalp flap to reconstruct upper lip. B, Postoperative view 6 months
after division of pedicle and inset of flap. Considerable discrepancy of skin color, texture, and pattern of hair growth exists between
flap and native lip skin. Patient considered overall lip function satisfactory and did not wish vermilion reconstruction with mucosal
graft. Prosthetic nose in place. C, Large lower lip defect. Previous melolabial transposition flap repair failed. D, Same patient as in
C several months after two-stage reconstruction with interpolated temporoparietal scalp flap.
A
B
C
D
FIGURE 19-64  ■  A, After transfer of interpolated temporoparietal scalp flap to reconstruct upper lip. Note: Local anesthetic containing
epinephrine has been infiltrated into the pedicle, causing blanching; distal end of flap continues to demonstrate normal skin color,
indicating no impairment of vascularity. B, Same patient as in A after inset of flap. Hair growth on flap simulates moustache and
aids in scar camouflage.
A
B

528
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
forehead skin pedicled laterally on the anterior branch
of the superficial temporal artery. This flap remains an
option for reconstruction of the entire lip; however, it is
currently less favored as it requires multiple stages and
tends to cause a “skull-like” appearance of the donor
forehead, which is covered with a split-thickness skin
graft.41,43 The deltopectoral chest flap offers a large quan­
tity of tissue that can be used for reconstruction of major
defects of one or both lips.42,43 Whereas the pedicle is
based on multiple intercostal perforating arteries from
the anterior chest wall, the useable distal portion of the
flap has a random circulatory supply, and thus the flap
requires delay to ensure its viability. Redundant pedicle
tissue of the flap may be folded and used for lip lining.
This approach provides improved results compared with
use of a skin graft to line the flap.
In addition to the deltopectoral chest flap, other flaps
constructed from the platysma and sternocleidomastoid
muscles have been used to reconstruct large full-thickness
lip defects. These muscle flaps are difficult to dissect and
are uncertain in their result. The current trend for total
lip reconstruction is immediate single-stage reconstruc­
tion with a microsurgical flap. The radial forearm flap is
the preferred flap because it offers a relatively thin and
pliable skin flap and limited donor site morbidity in most
patients.44 Although regional, distant, and microsurgical
flaps can transfer large surface areas of skin and soft tissue
to the region of the lip, such flaps provide limited or no
dynamic motion of the reconstructed lip and show con­
siderable tendency to sag, particularly when they are used
to reconstruct the lower lip.
SUMMARY
The reconstructive surgeon has a number of surgical
options when reconstructing the lip. Many of the options
have been discussed in this chapter. A detailed analysis of
the lip defect is mandatory before the preferred method
of reconstruction is selected. There are many individual-
specific factors to consider, and the method of repair
selected for one patient may be different from that selected
for another with a defect of similar size and location. It is
best to keep the repair simple when possible and to confine
reconstructive flaps to the lip aesthetic region, unless
doing so will result in excessive microstomia. The surgeon
must consider the consequences of disruption and the
benefit of preservation of the motor and sensory nerves
of the lips and the adjacent cheek in selecting a method
of reconstruction. In addition, great importance is given
to maintenance and restoration of facial features.
For cutaneous defects of the lip, reconstruction is
usually performed with some form of cutaneous transfer
that will produce the least adverse scarring or distortion
of adjacent facial structures. In some cases, it may be
acceptable to resect deeper tissue from within the wound
and to close the defect primarily. A majority of full-
thickness lip defects can also be closed primarily. When
additional tissue is required for repair of the lip, single or
bilateral opposing advancement flaps are usually possible,
particularly if the defect involves the central region of
either lip.
When full-thickness lip defects approach half or more
of the width of either lip, a decision as to which method
of reconstruction to use becomes more difficult. In these
instances, the most important decision is whether to
recruit tissue for repair from the opposing lip or to use
additional tissue from an area beyond the aesthetic region
of the lips to maintain an adequate oral stoma. If the
decision is made to use tissue from the opposing lip, the
method of lip repair is typically a cross-lip flap or a Kara­
pandzic flap. Experience is helpful in envisioning what
the comparative outcome is likely to be with either
choice, recognizing that long-term results are not always
as pleasing as those observed in the initial postoperative
months.
Whereas restoration of the orbicularis muscle sphinc­
ter is always desirable during lip reconstruction, many
patients do manage to function reasonably well with an
adynamic lip segment, particularly when it is located in
the upper lip. Use of a melolabial or temporoparietal
scalp flap is the author’s preferred method of reconstruct­
ing the lip if the lip cannot be repaired with tissue con­
fined to the aesthetic region of the lips. These flaps can
restore tissue to the defect without disruption of the
opposing lip and adjacent midface structures. In some
cases, adaptation of the McGregor or modified Gilles
flap may be satisfactory in restoring the lip. It is the
author’s opinion that all of the various flap designs that
advance a significant amount of tissue medially from the
cheeks tend to produce a crudely functional and margin­
ally aesthetic end result. These repairs are nearly always
reserved for patients who have a major defect or total
loss of the lip. The use of distant or microsurgical flaps
is the next preferred method of reconstruction of patients
with major tissue loss of the lip and adjacent facial areas.
These flaps serve to fill the defect but provide limited
functional and aesthetic restoration of the perioral region.
Microsurgical partial face transplantation may hold
promise for patients suffering total loss of both upper
and lower lips.
REFERENCES
1. Mazzola RF, Lupo G. Evolving concepts in lip reconstruction. Clin
Plast Surg 1984;11:583.
2. Zide BM. Deformities of the lips and cheeks. In: McCarthy JG,
editor. Plastic surgery, vol. 3. Philadelphia: WB Saunders;
1990.
3. Park C, Lineaweaver WC, Buncke HJ. New perioral arterial flaps:
anatomic study and clinical application. Plast Reconstr Surg
1994;94:268.
4. Kriet JD, Cupp CL, Sherris DA, Murakami CS. The extended
Abbe flap. Laryngoscope 1995;105:988.
5. Karapandzic M. Reconstruction of lip defects by local arterial flaps.
Br J Plast Surg 1974;27:93.
6. Jabaley ME, Clement RL, Orcutt TW. Myocutaneous flaps in lip
reconstruction: application of the Karapandzic principle. Plast
Reconstr Surg 1977;59:680.
7. Reid DA. A mucosal cross-lip flap. Br J Plast Surg 1956;9:106.
8. McGregor IA. The tongue flap in lip surgery. Br J Plast Surg
1966;19:253.
9. Bakamjian V. Use of tongue flaps in lower lip reconstruction. Br J
Plast Surg 1964;17:76.
10. Goldstein MH. A tissue-expanding vermilion myocutaneous flap
for lip repair. Plast Reconstr Surg 1984;73:768.
11. von Burow CA. Beschreibung einer neuen Transplantations-
methode (Method der seitlichen Dreiecke) zum Wiederersatz ver­
lorengegangener Teile des Gesichts. Berlin: Nauck; 1855.

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12. Szlazak J. The application of a Burow triangular flap in reconstruc­
tion of the lower lip. Br J Plast Surg 1958–1959;11:128.
13. Isaksson I, Johanson B. Partial reconstruction of the lower lip.
Panminerva Med 1967;9:420.
14. Johanson B, Aspelund E, Breine U, Holmstrom H. Surgical treat­
ment of non-traumatic lower lip lesions with special reference to
the step technique. Scand J Plast Reconstr Surg 1974;8:232.
15. von Bruns V. Chirurgischer Atlas: Bildliche Darstellung der chirur­
gischen Krankheiten und der zu ihrer Heilung erforderlichen
Instrumente, Bandagen und Operationen, II Abt, Kau- und
Geschmaks-Organ. Tubingen: Luupp; 1857/1860.
16. Sabattini P. Cenno storico dell’origine e progressi della rinoplastica
e cheiloplastica. Bologna: Belle Arti; 1838.
17. Stein SAW. Laebedannelse udført paa en ny methode. Hospitals-
Meddelelser 1848;1:212.
18. Buck G. Contributions to reparative surgery: showing its applica­
tion to the treatment of deformities, produced by destructive
disease or injury; congenital defects from arrest or excess of devel­
opment; and cicatricial contractions from burns. New York: D
Appleton; 1876.
19. Abbe RA. A new plastic operation for the relief of deformity due
to double hairlip. Med Rec 1898;53:477.
20. Franchebois P. Improved surgical treatment of cancer of the lower
lip. Int Surg 1975;60:204.
21. Templer J, Renner G, Davis WE, Thomas JR. A modification of
the Abbe-Estlander flap for defects of the lower lip. Laryngoscope
1981;91:153.
22. McCarn KE, Park SS. Lip reconstruction. Facial Plast Surg Clin
North Am 2005;13:301.
23. Smith JW. The anatomical and physiologic acclimatization of tissue
transplanted by the lip switch technique. Plast Reconstr Surg
1960;26:40.
24. Thompson N, Pollard AC. Motor function in Abbe flaps: a histo­
chemical study of motor reinnervation in transplanted muscle
tissue of the lips in man. Br J Plast Surg 1961;14:66.
25. Estlander JA. Eine Methode aus der einen Lippe Substanzverluste
der anderen zu ersetzen [reprinted in English translation in Plast
Reconstr Surg 42:361, 1968]. Arch Klin Chir 1872;14:622.
26. Baker SR, Swanson NA. Local flaps in facial reconstruction.
St. Louis: Mosby; 1995.
27. Baker SR, Krause CJ. Cancer of the lip. In: Suen JY, Myers EN,
editors. Cancer of the head and neck. New York: Churchill Living­
stone; 1981.
28. Kazanjian VH, Roopenian A. The treatment of lip deformities
resulting from electric burns. Am J Surg 1954;88:884.
29. Martin HE. Cheiloplasty for advanced carcinoma of the lip. Surg
Gynecol Obstet 1932;54:914.
30. Murray JF. Total reconstruction of a lower lip with bilateral Est­
lander flaps: case report. Plast Reconstr Surg 1972;49:658.
31. Gilles H, Millard R. The principles and art of plastic surgery.
London: Butterworth; 1957.
32. McGregor IA. Reconstruction of the lower lip. Br J Plast Surg
1983;36:40.
33. Anderson R, Kurtay M. Reconstruction of the corner of the mouth.
Plast Reconstr Surg 1971;47:463.
34. Bernard C. Cancer de la lèvre inférieure: restauration á l’aide de
deux lambeaux latéraux quadrilatères: guérison. Bull Mem Soc Chir
Paris 1853;3:357.
35. Webster RC, Coffey RJ, Kelleher RE. Total and partial reconstruc­
tion of the lower lip with innervated muscle-bearing flaps. Plast
Reconstr Surg 1960;25:360.
36. Webster JP. Crescentic peri-alar cheek excision for upper lip flap
advancement with a short history of upper lip repair. Plast Reconstr
Surg 1955;16:434.
37. Freeman BS. Myoplastic modification of the Bernard cheiloplasty.
Plast Reconstr Surg 1958;21:453.
38. McHugh M. Reconstruction of the lower lip using a neurovascular
island flap. Br J Plast Surg 1977;30:316.
39. Fujimori R. “Gate flap” for the total reconstruction of the lower
lip. Br J Plast Surg 1980;33:340.
40. Stranc MF, Robertson GA. Steeple flap reconstruction of the lower
lip. Ann Plast Surg 1983;10:4.
41. McGregor IA. Reconstruction following excision of intraoral and
mandibular tumors. In: Converse JM, editor. Reconstructive plastic
surgery, vol. 5. Philadelphia: WB Saunders; 1977.
42. Bakamjian V, Culf NK, Bales HW. Versatility of the deltopectoral
flap in reconstructions following head and neck cancer surgery. In:
Sanvenero-Rosselli G, Boggio-Robutti G, editors. Transaction of
the 4th International Congress of Plastic Surgery, Rome. Amster­
dam: Excerpta Medica; 1969.
43. Renner G. Lip reconstruction. In: Day TA, Girod DA, editors.
Oral cavity reconstruction. New York: Taylor & Francis; 2006.
44. Sadove RC, Luce EA, McGrath PC. Reconstruction of the lower
lip and chin with the composite radial forearm–palmaris longus free
flap. Plast Reconstr Surg 1991;88:209.

530
C H A P T E R 2 0 
RECONSTRUCTION OF THE CHEEK
Amit D. Bhrany  •  Dewayne T. Bradley  •  Craig S. Murakami
INTRODUCTION
Achieving aesthetic surgical outcomes after reconstruc­
tion of cutaneous cheek defects requires knowledge of
cheek anatomy and facial aesthetic regions. The size and
location of the defect and the structures adjacent to the
defect are assessed to determine where tissue can be
recruited for construction of skin flaps without adversely
affecting the nose, lips, and eyelids by secondary tissue
movement. Analysis of each cheek defect is essential, and
fundamental concepts of cutaneous flap biomechanics
should be addressed (see Chapter 3) to facilitate tension-
free wound closures with optimally positioned scars.
The cheek is the largest aesthetic region of the face
and has a broad, slightly convex contour. The aesthetic
region of the cheek may be divided into the zygomatic,
medial, lateral, and buccal units as a conceptual frame­
work for determining reconstructive options. This con­
ceptualization is based on the anatomic characteristics of
inherent skin elasticity and mobility and the presence of
adjacent mobile facial structures. The following discus­
sion of reconstruction of cutaneous defects of the cheek
is organized by aesthetic units of the cheek and by size
of the defect. Each section highlights the facial structures
that can be distorted by secondary tissue movement in
the process of reconstructing a defect and details tissue
amenable for recruitment to construct local flaps.
FUNDAMENTAL CONCEPTS
Anatomy and Aesthetic Units
The cheek is the largest facial aesthetic region and is
juxtaposed to the orbital, nasal, and lip aesthetic regions.
The aesthetic region of the cheek has the following
boundaries: inferior bony orbital rim, nasofacial (cheek-
nose junction) sulcus, line from the lateral canthus to the
root of the helix, preauricular crease, melolabial crease,
labiomandibular crease, and inferior border of the man­
dible (Fig. 20-1). The cheek can be conceptually divided
into areas based on the difference of underlying bone,
soft tissue, skin quality, and skin laxity. On the basis of
these anatomic differences, there are four aesthetic units:
medial, lateral, zygomatic, and buccal. The skin of the
medial and buccal units is thicker and more mobile than
the skin of the other units of the cheek. The skin of the
lateral unit is moderately fixed to the underlying fascia,
and the skin of the zygomatic area is quite fixed, in part
by the cutaneous retaining ligaments in the region. This
unit also has the least skin laxity.1
Several important ligaments collectively referred to as
cheek retaining ligaments support the soft tissues of the
cheek. Retaining ligaments in the area of the zygoma
(known as McGregor’s patch)1 serve as strong bone
anchors for supporting the skin overlying the zygoma.
More inferiorly and anteriorly, a dense attachment to the
skin known as the mandibular retaining ligament is
present at the cheek where it joins the lower lip. This
ligament accounts for the formation of the labioman­
dibular crease. Fibrous attachments of the superficial
musculoaponeurotic system (SMAS) to the cheek skin at
the junction of cheek and upper lip create the melolabial
crease. The labiomandibular and melolabial creases
provide important landmarks for concealing incisions
and represent aesthetic boundary lines between the cheek
and the upper and lower lips. The contour of the cheek
is due to the convexity of the maxilla and the malar fat
pad. The fat pad is well known to plastic surgeons for its
relationship to aging of the midface. In addition to retain­
ing ligaments, the cheek is supported by the muscles of
facial expression. Most notable is the zygomaticus major
positioned deep to the malar fat pad and invested by the
SMAS.1
Lymphatic drainage of the cheek is primarily to
the submental, submandibular, and preauricular lymph
nodes. Additional drainage occurs to the second echelon
of lymph nodes in the superior jugular chain.2 The vas­
cular supply to the cheek skin is derived from three major
sources, which perfuse the dermal and subdermal plex­
uses.1 The superficial temporal artery provides a minor
supply through the transverse facial branch. The infraor­
bital artery provides collateral supply to the midcheek
with anastomotic connections to the facial artery. The
facial artery and its continuation as the angular artery
provide the majority of blood to the skin of the cheek.
The venous drainage is based on vessels that follow the
named arterial supply.
The facial nerve provides motor innervation to the
muscles of facial expression that form a base on which
the subcutaneous tissue and skin of the cheek rest. The
majority of sensory innervation of the cheek is provided
by branches of the second division of the trigeminal nerve
through the infraorbital nerve. The third division of the
 Videos available online

20  RECONSTRUCTION OF THE CHEEK
531
outline the borders of the cheek and adjacent facial aes­
thetic regions and to determine where the final scars will
lie after reconstruction.
When possible, scars should be positioned at the
border of aesthetic units to provide the best camouflage.
When scars cannot be placed in borders of aesthetic
units, they are aligned parallel to relaxed skin tension
lines (RSTLs), which are curvilinear in the cheek (Fig.
20-2). RSTLs are a result of the intrinsic elasticity of the
skin and are perpendicular to lines of maximal extensibil­
ity.3 Therefore, wound closure oriented in an axis parallel
to RSTLs results in less wound closure tension and
more favorable scar camouflage. Wrinkles located in the
lateral canthal region are largely due to the action of the
trigeminal nerve contributes to the sensory supply of the
lateral cheek through the auriculotemporal nerve and of
the inferior cheek through the mental nerve.
Flap Planning
The aesthetic units of the cheek vary in terms of skin
color, texture, and thickness. These factors determine the
preferred reconstructive option. To select the best option,
it is helpful to assess the mobility and laxity of skin sur­
rounding the defect and to determine which facial struc­
tures may be distorted by secondary tissue movement.
Particularly important in this regard are the nasal ala,
lips, and lower eyelid. It is also important to mentally
FIGURE 20-1  ■  Aesthetic boundaries of cheek aesthetic region: inferior bony orbital rim, nasofacial sulcus, melolabial crease, labio­
mandibular crease, inferior border of mandible, preauricular crease, and line from lateral canthus to root of helix. Aesthetic region
of cheek based on inherent mobility and thickness of skin may be divided into units: infraorbital (medial, buccal), zygomatic, and
mandibular (lateral).
Forehead
Brow
Periorbital
Temple
Zygomatic
Nasal
Mandibular
Chin
Upper Lip
Lower Lip
Infraorbital
Ear

532
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
results in a defect with 45° beveled edges. Failure to
remove this beveled tissue at the time of reconstruction
may cause a barrier to precise wound edge apposition and
eversion. “Freshening the edges” of the defect by perpen­
dicularly excising the beveled tissue margins is a useful
technique for providing healthy viable wound margins.
However, if skin grafting is selected for repair of the
defect, the beveled edge is advantageous and may be
intentionally maintained to lessen the discrepancy in
thickness between the skin graft and the native cheek
skin. Postoperative radiation therapy is at times indi­
cated, and in this setting, the reliability of the method of
reconstruction selected must be considered.
The patient’s health history and social habits are
factors that influence the options for reconstruction of
cutaneous defects of the cheek. Patients with a prior
history of irradiation, smoking, or diabetes mellitus may
exhibit impaired wound healing. In these circumstances,
the most reliable flap is selected. When a patient is dia­
betic, blood glucose levels should be optimally controlled
before surgery. For patients who smoke, every effort is
made to encourage the patient to stop smoking.
Patients receiving immunosuppressive therapy, most
notably, those with a transplanted organ, often have his­
tologically aggressive skin cancers coupled with impaired
healing capabilities. In these patients, there is a high
probability for development of other cutaneous malig­
nant neoplasms. There is also an increased likelihood of
local flap necrosis compared with patients not taking
immunosuppressive medications. All of these factors may
lead the surgeon to select a reconstructive option that
sacrifices aesthetic results in exchange for tissue preserva­
tion with the knowledge that additional flaps will be nec­
essary in the future to treat additional cutaneous malignant
neoplasms.
The size of a cutaneous cheek defect is an important
factor affecting the surgical approach to reconstruction
of the cheek. When the defect occupies more than
50% of the surface area of an aesthetic unit, the remain­
ing skin of the unit may occasionally be removed and the
entire unit covered with a cutaneous flap. For smaller
defects, repairs are designed that preserve the remaining
normal tissue and place scars at the cheek perimeter or
parallel with RSTLs.
MEDIAL CHEEK DEFECTS
The medial cheek aesthetic unit consists of the skin cov­
ering the melolabial fold and the skin adjacent to the
nose. In reconstruction of cutaneous defects of the medial
aesthetic unit, skin is recruited from the lateral and infe­
rior portions of the cheek. These areas provide a rela­
tively mobile reservoir of skin. The areas that may be
distorted by secondary tissue movement include the nasal
ala, alar-facial sulcus, lower eyelid, upper lip, and melo­
labial crease.
Healing by secondary intention of small defects of
the medial cheek (1 cm or less) can result in an acceptable
appearance, particularly on concave surfaces such as
the perialar and melolabial regions. However, most
skin defects of the cheek do not heal with an acceptable
orbicularis oculi muscle and provide a useful site in which
to place incisions. In general, the boundaries of cheek
aesthetic units and facial creases are more favorable loca­
tions than the RSTLs for positioning of scars.3
A number of clinical factors influence the method
selected for reconstruction of cutaneous defects of the
cheek. The etiology of the defect is important to consider
in evaluating reconstructive options. This is particularly
important when one is reconstructing defects after surgi­
cal excision of melanoma. In these cases, primary wound
closure, healing by secondary intention, or skin grafting
may be the preferred method of repair if the risk of recur­
rent disease is high. Whereas these methods of wound
repair may offer poorer aesthetic results, they may clini­
cally provide for better tumor surveillance. This decision
must be individualized; however, it may be prudent to
choose the simplest option, reserving local flap recon­
struction for a second stage after an appropriate time
interval to ensure that recurrence of the melanoma is
unlikely. Nonmelanoma skin cancer, primarily basal cell
carcinoma and squamous cell carcinoma, is often treated
with micrographic surgery, with a cure rate approaching
99%. Given the low rates of recurrence, the procedure
that provides the most aesthetically appealing result can
be selected within the confines of the patient’s desires and
general health condition. Micrographic surgery typically
FIGURE 20-2  ■  Configuration of relaxed skin tension lines
(RSTLs), which are perpendicular to lines of maximal extensibil­
ity (LME). Elliptical excisions parallel to RSTLs result in less
wound closure tension because skin recruitment is in axis of
LME.
LME
RSTL

20  RECONSTRUCTION OF THE CHEEK
533
the cheek aesthetic region or parallel to RSTLs. An
example is a defect adjacent to the junction of the cheek
and nasal sidewall (nasofacial sulcus) repaired with primary
wound closure, resulting in a scar positioned in the sulcus,
thus providing excellent camouflage (Fig. 20-3). Because
most cutaneous defects created by micrographic surgery
are circular, an ellipse can be designed such that the
resulting scar is parallel to RSTLs. When the ends of
the ellipse encroach on a facial structure or extend beyond
the borders of an aesthetic unit, an M-plasty may be used
to shorten the length of the closure. This technique elimi­
nates or reduces the necessity of the scar’s crossing bound­
aries of aesthetic units (Fig. 20-4).
aesthetic result when they are allowed to heal by second­
ary intention. This may be related to facial motion and
the slightly convex surface topography of the cheek.
Primary wound closure is an excellent option for repair
of smaller cutaneous defects of the cheek. Typically, it
results in a linear suture line with minimal tension on the
closure because wide skin undermining is possible. In
general, undermining up to 4 cm beyond the borders of
the defect improves tissue recruitment, whereas under­
mining more widely adds little to decreasing wound
closure tension (see discussion of this in Chapters 3 and
6).4 Primary wound closure is a particularly good option
when the resulting scar can be placed in the borders of
FIGURE 20-3  ■  Various reconstructive techniques for small and medium-sized defects of cheek: primary closure (A); primary closure
with asymmetric skin undermining (B; shaded area represents greater undermining); elliptical closure with M-plasty (C); rhombic
flaps (D); advancement with M-plasty (E); and primary closure with asymmetric skin undermining (F).
A
D
E
F
C
B
FIGURE 20-4  ■  A, A 3 × 2-cm skin defect of inferior medial cheek. Primary wound closure planned with bilateral M-plasties designed.
B, Wound repaired. C, Postoperative result at 3 weeks. (Courtesy of Shan R. Baker, MD.)
A
B
C

534
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
excellent scar camouflage as the borders of the region are
where natural shadows or lines of topographic transition
occur. Primary wound closure is a particularly useful
technique when defects are on or adjacent to the superior
aspect of the melolabial fold (Fig. 20-6). When defects
are not directly in the junction of the cheek with the lips
or nose, the intervening skin may sometimes be excised
to position the suture line in the aesthetic border of the
medial cheek. Defects that are adjacent to the nasofacial
sulcus are particularly amenable to primary wound
closure (Fig. 20-7). In such cases, the skin lateral to the
wound is advanced medially and anchored to the perios­
teum at the nasofacial sulcus by a 4-0 long-lasting absorb­
able suture. This may prevent effacement of the nasofacial
sulcus and reduce wound closure tension.
Transposition flaps are useful for repair of medium-
sized defects of the medial cheek (Fig. 20-8). However,
advancement flaps or rotation advancement flaps are
easier to design and to dissect because of the considerable
mobility of the skin of the medial cheek (Fig. 20-9). This
mobility is related to the ample subcutaneous fat beneath
the skin of the medial cheek. Although the type of flap
selected depends on the position and size of the defect,
flaps used to repair medial cutaneous cheek defects gen­
erally involve some component of pivotal and advance­
ment motion (Fig. 20-10). As the diameter of the medial
cheek defect increases, the length of the laterally based
flap increases, resulting in a flap with more medial
advancement and less pivotal movement (see Fig. 20-10).
The V-Y subcutaneous tissue pedicle island advance­
ment flap is an effective way of reconstructing small
defects of the medial cheek adjacent to the alae (Fig.
20-5). The flap is designed as an island of skin with a
triangle shape, preserving the subcutaneous tissue beneath
the skin island. Extending the incision used to create the
flap to the proper depth is important. If incisions are too
shallow, the ability to advance the flap will be restricted;
and if incisions are too deep, the nerve supply to the facial
musculature may be compromised. The flap is advanced
and the wound closed so that the suture line assumes a
Y-shaped configuration. The blood supply to the flap is
from perforators that enter the subcutaneous tissue
pedicle. The margins of the flap can be conservatively
undermined to allow better mobilization and skin edge
eversion during wound closure. The island flap is particu­
larly useful for repair of defects adjacent to the nasal alae
(see discussion in Chapters 6, 9, and 12). This area has a
natural triangle shape, and part of the resulting scar will
typically be in the melolabial crease.5
Medium-sized (2 to 3 cm) medial cheek cutaneous
defects can be reconstructed by a number of different
methods. Primary wound closure with extended incisions
to remove standing cutaneous deformities may be used
when defects are located near the border of the cheek
aesthetic region. The surgeon may use asymmetric or
differential undermining of the wound margins to posi­
tion the wound closure suture line at or parallel to the
border of the aesthetic region. This approach may provide
FIGURE 20-5  ■  A, A 2.5 × 1.5-cm skin defect of medial cheek. V-Y subcutaneous tissue pedicle island advancement flap designed for
repair. B, Flap dissected before transfer. C, Flap in place. D, Postoperative result at 5 months.
A
B
C
D

20  RECONSTRUCTION OF THE CHEEK
535
FIGURE 20-6  ■  A, B, A 3 × 2-cm skin defect of medial cheek involving melolabial crease. Wound closed primarily. Standing cutaneous
deformity (broken line) excised in melolabial crease. C, D, Postoperative views at 7 months. Scar is in aesthetic boundary of melo­
labial crease. No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

536
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 20-7  ■  A, A 4 × 2-cm skin defect of medial cheek. Wound closed primarily. Anticipated standing cutaneous deformity marked
with horizontal lines. B, Postoperative result at 2 months. (Courtesy of Shan R. Baker, MD.)
A
B
FIGURE 20-8  ■  A, A 1.5 × 1.5-cm skin defect of medial cheek. Transposition flap designed for repair. Anticipated standing cutaneous
deformity marked inferior and lateral to defect. B, Flap in place. C, Postoperative result at 2 months. (Courtesy of Shan R. Baker, MD.)
A
B
C

20  RECONSTRUCTION OF THE CHEEK
537
FIGURE 20-9  ■  Unipedicle
advancement
flap
designed to repair medial cheek defect. Standing
cutaneous deformities excised at base of flap.
FIGURE 20-10  ■  Dynamics of rotation advancement
flaps. A, Rotation (pivotal) flaps are drawn using
radius (R) that is 2.5 to 3 times diameter (D) of
defect. Location of pivotal points (A1-A4) may be
modified to cause flap design to change from pure
pivotal (A1) to primarily advancement (A4). Note
that as pivotal points progress from A1 to A4, base
and tip of modified flaps become wider and flap is
designed for greater advancement and less pivotal
movement. B, If pivotal point (A1-A3) is moved on
a line perpendicular to vertical axis of defect, flap
will manifest greater advancement and less pivotal
movement. (From Murakami CS, Nishioka GJ: Essen­
tial concepts in the design of local skin flaps. Facial
Plast Surg Clin North Am 4:455, 1996.)
A
A
A
A
Length
approximately 4 times
diameter of defect
----------
Possible
back-cut
A
B
R = 2.5 to 3 times
diameter
of defect
D
~ 30
1
2
3
4
A1
A1
A1
A2
A2
A2
A3
A3
A3
A4

538
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
medial to the defect should be sacrificed to position inci­
sions at the nasofacial junction (see Fig. 20-12). Widen­
ing the initial defect to the position of the nasofacial
sulcus allows the standing cutaneous deformity that forms
from advancement inferior to the defect to be excised in
the melolabial crease. Another consideration is whether
to excise eyelid skin to position the scar in a subciliary
position (see Fig. 20-12). Placement of the incision in the
subciliary line results in a less conspicuous scar and avoids
persistent lower eyelid edema but requires the removal
Regardless of the amount of rotation or advancement, it
is essential to minimize an inferiorly oriented vector of
tension that increases the risk of postoperative lower lid
retraction (Figs. 20-11 and 20-12). The flap is typically
undermined in the subcutaneous tissue plane, but SMAS
flaps may also be elevated to correct contour defects or
to reduce wound closure tension. When using any cheek
flap to repair defects adjacent to the nose or lower eyelid,
the surgeon must make several decisions about flap
design. First, the surgeon must decide whether the tissue
FIGURE 20-11  ■  A, A 2 × 2.5-cm defect of medial cheek and eyelid. Rotation advancement flap designed for repair. B, Rotation advance­
ment flap elevated in subcutaneous plane, with greater degree of advancement as flap is extended laterally toward preauricular
crease. Flap reflected inferiorly. C, Flap in place. Standing cutaneous deformity at base maintained to optimize vascularity to distal
aspect of flap. Deformity removed 2 to 3 weeks later. D, Postoperative result at 6 months.
A
B
C
D

20  RECONSTRUCTION OF THE CHEEK
539
and patients with poor orbicularis muscle tone, the eyelid
skin should not be excised. If in doubt, it is far better to
preserve all of the skin of the eyelid and to attempt to
position scars along the inferior bony orbital rim in
the aesthetic border between the cheek and the eyelid.
Some authors advocate routine lateral canthopexy to
tighten the lower eyelid to prevent retraction when cheek
advancement flaps are used to repair cheek defects in the
vicinity of the lower eyelid.6 Regardless of incision place­
ment, it is important to anchor the flap to the periosteum
of the inferior bony orbital rim to prevent excessive
downward traction on the eyelid. The superior medial tip
of an advancement flap may be de-epithelialized and the
of normal eyelid skin. A disadvantage of advancing cheek
skin to the level of the subciliary line is a greater risk of
ectropion or inferior eyelid retraction, particularly in
older individuals with poor muscle tone. The ability of
the eyelid to tolerate scar contraction can be estimated
by the snap test in a fashion similar to evaluation of the
muscle tone of the eyelid before blepharoplasty surgery.
The subciliary line is the preferred location for position­
ing of scars in younger patients because of the excellent
scar camouflage it provides. Properly performed advance­
ment flaps using suture suspension of the flap to the
periosteum of the bony orbital rim rarely lead to prob­
lems with eyelid retraction. However, in older patients
FIGURE 20-12  ■  A, A 4 × 3-cm medial cheek defect. Rotation flap designed for repair. Incision for flap placed in subciliary line. Naso­
facial sulcus and melolabial crease marked. Skin between defect and nasofacial sulcus and melolabial crease removed to position
advancing border of flap in aesthetic boundary. B, Incision for flap extended to preauricular crease and posterior auricular sulcus.
Anticipated standing cutaneous deformity marked with horizontal lines on melolabial fold. C, D, Flap in position. Note incision lines
at level of lateral canthus. Medial border of flap positioned in nasofacial sulcus and melolabial crease. E, Postoperative result with
normal eyelid position and well-camouflaged scars.
A
B
C
D
E

540
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
techniques such as periosteal anchoring sutures, flap tip
de-epithelialization with medial canthal anchoring, and
lateral canthoplasty may be used in conjunction with the
flap for optimal results.7
Medium-sized cutaneous defects of the medial cheek
can often be easily repaired with a V-Y subcutaneous
tissue pedicle island advancement flap (Fig. 20-16). In the
medial cheek, the flap depends on the sliding motion of
its subcutaneous tissue pedicle for advancement. The
region of the face with the most abundant fat is the
medial cheek. Thus, island advancement flaps are effec­
tive methods of repairing skin and soft tissue defects of
the medial cheek and lateral upper lip. The flap is par­
ticularly well suited for cutaneous defects immediately
adjacent to the alae (Fig. 20-17; see also Fig. 20-5). This
flap is discussed in detail in Chapter 12.
Reconstruction of large (more than 3 cm) medial
cheek defects presents a greater challenge to the surgeon
than repair of smaller cutaneous defects. Reconstruction
can frequently be accomplished by transferring the lateral
cheek skin medially in the form of a rotation flap (Fig.
20-18). Rotation flaps are pivotal flaps with a curvilinear
border. The incision for creating such flaps usually
extends to the preauricular crease and then inferiorly into
the neck. Larger medial cheek cutaneous defects repaired
with lateral cheek skin are usually reconstructed with
peninsula of dermal tissue used to anchor the flap to the
periosteum of the medial canthal region to provide addi­
tional medial support to the flap.
Inferiorly based pivotal advancement flaps are com­
monly used for reconstruction of the medial cheek, espe­
cially for defects located in the superior aspect of the
medial cheek unit. The flap is dissected by making a
single incision in the nasofacial sulcus and melolabial
crease, maintaining the nasolabial isthmus (Fig. 20-13).
The flap is undermined in the subcutaneous tissue plane
and advanced superiorly and pivoted laterally. A standing
cutaneous deformity develops superior and lateral to the
defect. Depending on the location of the defect, the
deformity may be excised, placing the resulting scar at
the eyelid-cheek junction line or in the subciliary line
(Figs. 20-14 and 20-15). This is in contrast to laterally
based cheek rotation advancement flaps used to repair the
same defect that develops standing cutaneous deformities
inferiorly and medially at the base of the flap (see Fig.
20-11). An equalizing Burow triangle excision, Z-plasty,
or back cut may be made at the inferior aspect of the
incision used to create the inferiorly based pivotal
advancement flaps to improve tissue movement and to
decrease wound closure tension. Similar to other cheek
flaps, inferiorly based pivotal advancement flaps are at
risk for causing lower eyelid malposition. As a result,
FIGURE 20-13  ■  Pivotal advancement cheek flap. Incision for flap is in or parallel to nasofacial sulcus and melolabial crease for vari­
able distances, depending on size of flap. Back cut or Z-plasty may be used to reduce tension on closure. An equalizing Burow
triangle is excised to facilitate wound closure. Standing cutaneous deformity formed by advancement and pivotal movement of flap
excised lateral to defect.

Equalizing
triangle
Z-plasty optional
Back-cut optional

20  RECONSTRUCTION OF THE CHEEK
541
A
B
C
D
FIGURE 20-14  ■  A-C, Melanoma in situ of medial cheek. A 5 × 3-cm area is marked for excision by the square technique to ensure
tumor-free margins. Pivotal advancement flap designed for repair of defect after resection of lesion. Anticipated standing cutaneous
deformity marked with vertical lines. Z-plasty designed at base of flap to eliminate need for an equalizing Burow triangle. D, E, Mela­
noma excised, flap dissected in subcutaneous plane. F, Flap transferred to recipient site. G, H, Postoperative views at 8 months. No
revision surgery performed. (Courtesy of Shan R. Baker, MD.)
Continued

542
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
E
F
G
H
FIGURE 20-14, cont’d

20  RECONSTRUCTION OF THE CHEEK
543
cheek, giving rise to suture lines outlining both flaps
rather than a single suture line necessary for a standard
cervicofacial rotation advancement flap (Fig. 20-20).8
With larger defects, significant pivotal and advancement
tissue movement of the flap is required, resulting in a
standing cutaneous deformity inferior to the leading
border of the flap. The deformity can be excised primar­
ily, with the incision optimally placed in or parallel to the
melolabial crease. In patients who have tenuous flaps or
are at risk for ischemia (prior irradiation, smokers), the
standing cutaneous deformity can be left in place and
excised at a later date once the flap has healed sufficiently
and survival is ensured (see Fig. 20-20). The cervicofacial
rotation advancement flap is most frequently elevated in
the subcutaneous tissue plane, preserving the subdermal
plexus. Alternatively, the flap may be elevated in the sub-
SMAS plane when a deep defect requires a thicker flap
to avoid a contour irregularity (see discussion of contour
defects). Anchoring the flap to the periosteum located at
the inferior bony orbital rim and the nasofacial sulcus
with long-lasting absorbable sutures minimizes distortion
of adjacent facial structures and retraction of the lower
eyelid. A back cut or an equalizing Burow triangle exci­
sion at the base of the flap is also useful to decrease
wound closure tension.
Sizable cutaneous defects of the medial cheek may be
reconstructed with very large V-Y subcutaneous tissue
pedicle island advancement flaps. This is because of the
ample subcutaneous fat in the medial cheek. The abundant
fat affords considerable advancement of an island of skin
based on a subcutaneous pedicle (Fig. 20-21). The limiting
factor for use of such flaps is the superior extent of the
defect. It is usually not possible to advance island cheek
flaps superior to the level of the inferior bony orbital rim.
local flaps that exhibit both pivotal and advancement
movement to maximize the transfer of skin from the
regions of the posterior cheek and superior neck (Fig.
20-19). A standing cutaneous deformity in or parallel to
the melolabial crease usually develops. For larger flaps,
this deformity is often maintained at the time of initial
repair to optimize vascularity to the distal aspects of the
flap. It is then excised a few weeks postoperatively under
local anesthesia.
The cervicofacial rotation advancement flap is a work­
horse flap for reconstruction of large defects of the medial
cheek. Depending on the location of the defect and its
size, the flap is designed with incisions positioned either
at the inferior bony orbital rim or in the subciliary line
as discussed with cheek advancement flaps. If a subciliary
incision is used, it is carried out beyond the lateral canthus
in a curvilinear fashion. A tendency to drift inferiorly
with the lateral incision should be avoided to help prevent
lateral lower lid retraction on wound healing. Extending
the lateral incision slightly higher than the lateral palpe­
bral fissure allows the incision to be hidden in the crow’s-
feet wrinkles and provides added support to the lower
eyelid when the flap is transferred. From this lateral
extension, the incision curves inferiorly to the preauricu­
lar crease. Once the incision reaches the lobule of the ear,
it may be carried inferiorly and medially into the neck or
extend behind the ear in the postauricular sulcus and
along the hairline (see Fig. 20-19).7 The posterior exten­
sion of the incision helps camouflage part of the donor
site scar behind the ear and along the postauricular hair­
line. When the incision is positioned behind the ear, the
flap can be designed as a large modified bilobe flap. This
style of flap is useful in the repair of large defects; however,
the aesthetic advantage of using a postauricular incision
may be lost when the two flaps are transferred to the
FIGURE 20-15  ■  A, A 3 × 1.5-cm skin defect of medial cheek and lower eyelid. Pivotal advancement cheek flap designed for repair.
Incision with back cut placed in nasofacial sulcus and superior melolabial crease (broken line). Standing cutaneous deformity excised
laterally parallel to inferior bony orbital rim. B, C, Postoperative result with normal eyelid position.
A
B
C
Text continued on p. 550

544
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 20-16  ■  A, A 3 × 2-cm skin defect of medial cheek. B, Subcutaneous tissue pedicle island advancement flap designed for
repair. Area marked with vertical lines excised to create square defect. Stippled area on flap indicates degree of subcutaneous
undermining of flap. Nonstippled area marks location of flap’s subcutaneous tissue pedicle. C, Flap advanced and wound closed.
D, Postoperative result at 1 year, 3 months. No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D