Operative Technique in Plastic Surgery – Kevin C.Chung

the overall health and stability of the patient’s dentition.
■ When indicated, selected dental (periapical or bite-wing) radiographs are
obtained (FIG 1B).
SURGICAL MANAGEMENT
■ Equipment (FIG 2)
■ Erich arch bars
FIG 1 • A. Occlusion prior to mandibular resection. B.
Periapical radiograph.
■ Stainless steel ligature wire (24 gauge)
■ Wire cutters
■ Needle holders
■ Band pusher
■ Elastics (red rubber whistle tip catheter size 14 French, cut in 3-mm thickness)

FIG 2 • Tools necessary for MMF.
T E C H N I Q U E S
■ Intermaxillary Fixation
■ The patient’s preoperative occlusal relationship is confirmed.
■ The preoperative imaging is reviewed.
■ The Erich arch bars are measured and cut to fit the contour of the remaining
dentition of the maxilla and mandible.
■ The ligature wires are cut to approximately 15 cm (for posterior and 1–2 cm
shorter for anterior teeth) and stretched to prevent loosening after placement.
■ The arch bar is placed on the maxilla and mandible with the lugs positioned
apically (TECH FIG 1).
■ The arch bar is anchored to periodontally sound teeth by passing the ligature
wire through the interproximal space and circumferentially fixed by twisting
the two ends together in a clockwise direction until tight.1
■ A band pusher is used to assist in placing the ligature wire as apically as
possible on the lingual/palatal aspect to ensure a secure fit.
■ The excess length is cut leaving the terminal segment (approximately 1.5
cm), which is then curved to form a rosette to prevent trauma to the adjacent
soft tissue.
■ Following application of the arch bars, the bars are tested for stability. At
least three wire loops are usually employed to ensure proper fixation.
■ Elastic bands are placed on the opposing lugs of the maxilla and mandible to

complete the fixation in appropriate occlusal relationship.
TECH FIG 1 • A. Placement of arch bars on the
mandible and maxilla. Note apical and opposite
orientation of the lugs. B. Placement of bands on arch
bars completing MMF.
PEARLS AND PITFALLS
Indication
■ To maintain preoperative occlusal status
Technique
■ Arch bars are cut to the appropriate size and bent to the shape of
the mandible and maxilla.
■ Arch bars should be securely affixed to the mandible and maxilla.
Loose bars can be uncomfortable and may result in loss of
alignment.
■ Band pushers are helpful for this.
■ Wires are cut short and capped with bone wax or other material to
avoid injuring/irritating the lips.
Postoperative
care
■ Topical anesthesia is very helpful and facilitates removal of the
bars.
■ Radiographic evaluation may be performed to confirm proper
alignment and healing.
■ Oral hygiene is important to avoid infections and pain.
POSTOPERATIVE CARE
■ The Eric arch bars are removed approximately 1 week following placement (or
when fracture healing has been confirmed in cases where the mandible fracture

is not repaired with plates/screws, and MMF is used as the primary means of
repair).
■ Dental x-rays may be obtained to confirm proper alignment of the mandible
(FIG 3A).
■ Prior to removal of the Erich arch bars, topical anesthetic may be applied to
the gingival area or local anesthesia provided via gingival infiltration for
patient’s comfort.
■ The ligature wires are cut with either a wire cutter or high-speed handpiece
and removed with a needle holder.
■ The arch bars are released and removed from the maxilla and mandible.
■ The oral cavity is carefully inspected to ensure that it is free of debris and
materials (FIG 3B).
■ The oral cavity is carefully irrigated using saline and suctioned.
■ Postoperative panoramic radiograph is obtained.
■ Following removal of MMF, the patient is advised to maintain a soft diet and
to chew on the contralateral side.
FIG 3 • A. Postoperative panorex image demonstrating
fibula flap for reconstruction and restoration of
occlusion. B. After removal of arch bars, occlusion is
maintained.
■ Oral hygiene instructions are provided to include brushing all remaining teeth
after meals and at bedtime using an ultrasoft toothbrush.
OUTCOMES
■ In most cases, MMF has excellent outcomes and patients recover satisfactorily.
Irritation and discomfort are common and should be treated symptomatically;

in most cases, the bars are removed in a week.
■ MMF may decrease ventilatory capacity and should be used with caution in
patients with reduced pulmonary function particularly if the airway is not
secured.2
COMPLICATIONS
■ The technique of MMF is safe and, in general, well tolerated.
■ Complications related to MMF are relatively rare and include pain,
gingivitis/periodontitis, and irritation of the buccal mucosa.
■ Malocclusion is a potential complication but is more commonly related to the
techniques used for mandibular stabilization. If MMF alone is used for the
treatment of mandibular fractures, then malocclusion may occur particularly in
poorly aligned comminuted fractures.
REFERENCES
1. Aldegheri A, Blanc JL. The pearl steel wire: a simplified appliance for
maxillomandibular fixation. Br J Oral Maxillofac Surg. 1999;37:117-118.
2. Akhiwu BI, Saheeb DB, Akhiwu HO, et al. The effects of maxillomandibular
fixation on ventilatory functions in adult Nigerians. J Health Res Rev.
2017;4:84-87.

15
CHAPTER
Section VI: Lip
Repair of Lip Commissure
Defects with Estlander Flaps
Simon G. Talbot and Julian J. Pribaz
DEFINITION
■ Defects of the lips may occur from malignancy (most frequently squamous
cell carcinoma followed by basal cell carcinoma), trauma, vascular
malformations, or infections.1
■ There is disagreement in the literature about terminology.
■ Here, we refer to a lip switch flap not involving the commissure (either lower
to upper lip as originally described or vice versa) as an Abbe flap.
■ We refer to a lip switch involving the commissure (either upper to lower or
vice versa, as both were described in the original paper) as an Estlander flap.
■ We have chosen to not use the terms “reverse Abbe” and or “Abbe-
Estlander,” which are sometimes used elsewhere to refer to upper to lower
flaps excluding the commissure.
ANATOMY1
■ The lips include multiple layers of tissue: skin/subcutis, muscle, submucosa,
and mucosa.
■ The vermilion forms a wide boundary between the mucosa and skin.
Meticulous repair of the white roll (the external border of the vermilion and
skin) is critical as defects in this border are easily noticed.
■ Lip function is controlled by the orbicularis oris muscles (sphincteric function)
and numerous muscles of facial expression (elevation and depression
functions).
■ Elevators include levator labii superioris, levator anguli oris, zygomaticus

major and minor, levator anguli superioris, and mentalis muscles.
■ Depressors include depressor anguli oris, depressor labii inferioris, and
platysma muscles.
■ Key external landmarks of the lips include Cupid’s bow, the philtral columns,
the central tubercle, the white roll, and the commissure.
■ Arterial supply is through the facial artery branching into the superior and
inferior labial arteries. These run just deep to the mucosa in the submucosal
layer just deep to the orbicularis oris muscle, at the level of the mucosal-
vermilion junction (FIG 1).
■ Venous drainage does not follow the arterial pattern, but a dense plexus exists
in the lips.
■ Sensation is supplied by the infraorbital branch (upper lip) and mental branch
(lower lip) of the trigeminal nerve.
■ Motor function to the orbicularis oris is supplied by the buccal branches of the
facial nerve.
■ Additional muscles of facial expression are supplied by the zygomatic and
mandibular branches.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Because of the unique anatomy and appearance of the lips, when defects
involving the lips are too large to close directly, local flaps using the similar-
appearing “like tissue” from the opposite lip are ideal.
■ Estlander flaps are suited for patients presenting with a full-thickness defect of
the lateral lip up to and including the commissure.
■ Defects up to a quarter of the upper lip and one-third of the lower lip can
usually be closed directly.
■ Flap closure is more appropriate for defects of half to three-quarters of the
upper or lower lip (FIG 2).
■ Larger defects may require additional or distant flaps.
■ Similar to an Abbe flap, the Estlander flap is a cross-lip flap. However,
whereas the Abbe flap can rotate clockwise or anticlockwise based on either
labial artery, the Estlander flap rotates around the commissure and can be based
only on the contralateral labial artery as the ipsilateral vessel has usually been
removed with the tumor extirpation.
■ A second-stage procedure to divide and inset the flap and re-establish the
commissure is required, and this can be safely done at 3 to 4 weeks.

■ Estlander flaps can be used to reconstruct either upper or lower lip defects.2
FIG 1 • Cross-sectional anatomy of lower lip.

FIG 2 • Defect after Mohs resection of infiltrating basal
cell carcinoma.
IMAGING
■ Imaging may be required for oncologic workup or as indicated by trauma.
However, for operative planning, no imaging is necessary.
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative markings may be aided by the use of a template (a sterile
Esmarch is ideal for this purpose).
■ Unlike with an Abbe flap, markings for an Estlander flap should not traverse
the vermillion, as this will subsequently form the new oral commissure.
Positioning
■ A nasal intubation is preferred with the tube secured to the nasal septum using
an absorbable suture.
■ The operating table is turned 90 degrees away from the anesthesiologist with
the operative side of the mouth toward the center of the room. A standard head
drape is used.
Approach
■ A superiorly or inferiorly based flap can be performed depending on the
location of the defect.
T E C H N I Q U E S
■ Estlander Flap for the Upper Lip
■ Incisions should use natural skin creases, such as the mental crease where
possible.
■ The triangular flap should be marked and should be the same height and half
the width of the defect (to share the horizontal deficiency between the upper
and lower lips).

■ A concurrent cheek advancement flap (and a Burow triangle resection from
the lateral alar/medial cheek) reduces the defect and size of flap/donor site
required (TECH FIG 1A).
■ Often, the Burow triangle is not resected but used as an inferiorly based
flap that is advanced medially with the cheek flap and can be useful to
repair the nostril sill (TECH FIG 1B).
■ Needlepoint cautery allows precise dissection.
■ The labial artery must be preserved. This should not be skeletonized to
preserve a sufficient plexus of veins for drainage.
■ The flap is rotated about the commissure and sutured in place.
■ A layered closure is performed taking care to approximate the orbicularis
oris and precisely close the vermilion at the white roll (TECH FIG 1C,D).
■ Later, a commissure-plasty in which the base of the flap is divided and inset
and the commissure re-established is required (TECH FIG 1E).

TECH FIG 1 • A. Operative markings. B.
Advancement of Burow flap. C. Estlander flap
elevation and transposition. D. Final flap inset. E.
Division and inset of flap with commissure-plasty.
■ Estlander Flap for Lower Lip
■ A case showing Estlander flaps used for the lower lip is shown in TECH
FIG 2.

TECH FIG 2 • A. Patient with loss of lower lip post
necrotizing infection. B. Upper lip–to–lower lip
Estlander flap. C. After commissure-plasty.
PEARLS AND PITFALLS
Hemostasis
■ Good hemostasis is critical to prevent this highly vascular area from
ongoing bleeding.
Pedicle
■ The labial artery must be preserved and not skeletonized;
maintenance of adequate mucosa aids with venous drainage.
Technique
■ If congestion occurs, the flap inset can be taken down and a delayed
inset performed when choke vessels have opened.
Technique
■ A concurrent cheek advancement flap can reduce the size of the
defect and flap/donor site required.
Technique
■ A Schuchardt advancement using an incision in the labiomental fold
can additionally help with closure of a lower lip defect.
Caveats
■ Smoking can severely impair vascularity of the flap and should be
strictly avoided both preoperatively and postoperatively.

FIG 3 • A,B. Postoperative appearance of the patient in
TECH FIG 1 after division and inset with commissure-
plasty. C. Preoperative smile. D. Postoperatively, she
has elevator weakness due to loss of levator labii
superioris during tumor excision.
POSTOPERATIVE CARE
■ Bacitracin ointment is applied to suture lines.
■ Sutures are removed at 7 to 10 days.
■ Stretching of the mouth is avoided until full healing.
OUTCOMES
■ The Estlander flap provides a relatively simple reconstruction of large defects
of the lateral upper or lower lip involving the commissure (FIG 3A,B).
■ Minor revisions may be required, including resuspension and tightening of lip
elevators and revision of any contractures at the commissure to improve
symmetry and widen the aperture.
■ Sensory and motor recovery occurs over months in the order of pain, touch,

and temperature.3
■ Because of rearrangement of the surrounding muscles of facial expression,
animation may be altered (FIG 3C,D).
COMPLICATIONS
■ Arterial compromise or venous congestion may occur if vascularity is not
maintained.
■ When more than half the width of the lip requires reconstruction, this flap may
not be large enough to prevent significant microstomia.
REFERENCES
1. Yih WY, Howerton DW. A regional approach to reconstruction of the upper
lip. J Oral Maxillofac Surg. 1997;55(4):383-389.
2. Estlander JA. Methode d’autoplastie de la joue ou d’une levre par un lambeau
emprunte a l’autre levre. Rev Mens Med Chir. 1877;1:344.
3. Anvar BA, Evans BC, Evans GR. Lip reconstruction. Plast Reconstr Surg.
2007;120(4):57e-64e.

16
CHAPTER
Repair of Lip Defects With
Karapandzic Flaps
Simon G. Talbot and Julian J. Pribaz
DEFINITION
■ Defects of the lips may occur from malignancy (most frequently squamous
cell carcinoma followed by basal cell carcinoma), trauma, vascular
malformations, or infections.
■ A Karapandzic flap is either a single/unilateral or a paired/bilateral innervated
musculocutaneous rotation flap used to reconstruct subtotal lower lip defects.
■ A reverse Karapandzic flap can be used to reconstruct an upper lip defect.
Combined upper and lower lip defects have been reconstructed with
simultaneous upper and lower flaps.
■ Midline defects are preferred for this method of reconstruction; lateral or
commissure defects may result in significant asymmetry.
ANATOMY
■ The unique anatomy of the lips make the use of adjacent “like” lip tissue ideal
for reconstruction.
■ The lips include multiple layers of tissue: skin/subcutis, muscle, submucosa,
and mucosa.
■ Karapandzic flaps maintain continuity and innervation of the orbicularis oris
muscle. This is an advantage over flaps that replace a lip defect with cheek
tissue excluding the orbicularis.
■ The vermilion forms a wide boundary between the skin and mucosa.
Meticulous repair of the white roll (the external border of the vermilion and
skin) is critical as defects in this border are easily noticed.
■ The original description of the Karapandzic flap references the robust labial
artery circulation.1

■ In the very old, irradiated, or those requiring bilateral flaps, the labial artery
alone may be insufficient, hence the benefit of keeping an intact mucosa for
additional vascularity when designing Karapandzic flaps.
■ The modiolus can be thought of as a circle, and a defect in this circle may be
closed by rotating the remaining edges around the circumference to close the
defect.
■ Reapproximation of the orbicularis oris and preservation of the buccinator
along with maintenance of nerves allows for early intrinsic muscle function
(FIG 1).
■ Some authors recommend the use of a nerve stimulator to help protect native
innervation.2
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients will present with a large, subtotal, or total lip defect.
FIG 1 • Facial nerve anatomy and distribution of perioral
facial nerve branches to be preserved in Karapandzic
flap.

IMAGING
■ Imaging may be required for oncologic reasons but is not routinely required
for flap planning.
SURGICAL MANAGEMENT
Preoperative Planning
■ Markings include a skin incision parallel to the lip margin; the vertical
dimension of the flap is determined by the vertical dimension of the lip defect
(FIG 2).
FIG 2 • Preoperative appearance and markings for
unilateral Karapandzic flap.
■ The flaps are extended laterally and vertically. Where possible, incisions are
hidden in the melolabial folds and/or mental crease.
Positioning
■ A nasal intubation is preferred to prevent distortion of the lips. The
endotracheal tube should run vertically upward to avoid interference with the
operative field.
■ The operating table is turned 90 or 180 degrees from the anesthesiologist. A
standard head drape is placed.

Approach
■ A single or bilateral Karapandzic flap may be sufficient for medium to large
lip defects.
■ Where this is inadequate, combinations of Karapandzic flaps and an Abbe
flap may be needed.
■ Extended Karapandzic flaps may also facilitate larger defects to be
reconstructed. This technique uses medial cheek elements (as an extension of
the primary flaps) to form the central lower lip elements with a mucosal
advancement forming the vermilion.3
T E C H N I Q U E S
■ Bilateral Karapandzic Flaps for Closure of Large
Midline Lower Lip Defect
■ Markings are drawn as described (TECH FIG 1A).
■ Judicious local anesthesia with epinephrine can be used to aid hemostasis
but should be kept away from the facial artery pedicle.
■ Marked incisions are made, and dissection proceeds carefully through the
subcutaneous fat (TECH FIG 1B).
■ The facial artery is located deep to the facial muscles and enters the skin
from below. Similarly, the branches of the facial nerve are located deep to the
musculature. These branches are dissected bluntly (often with a mosquito)
preferably with loupe magnification.
■ In this manner, the skin, subcutaneous tissues, and facial muscles are
incised, but the nerves and vasculature beneath the muscle are preserved
(TECH FIG 1C).
■ Blunt dissection may be possible in the deeper and more superior aspects
of the cheek incisions to easily maintain these structures (TECH FIG 1D).4
■ Although the facial and labial arteries will stretch significantly, if sacrifice is
needed, flap vascularity may be maintained on an intact, large mucosal
pedicle (TECH FIG 1E).
■ Only the advancing 2 to 3 cm of the mucosa is incised but the rest is left
intact, to help with perfusion and venous drainage.

■ Mucosa, muscle, and skin are closed in layers.
■ For the donor area, the skin incision is repaired but the incised muscle is
left free, thus preventing tension on the closure of the flap.
■ An intrinsic discrepancy between the cheek and flap lengths can be
minimized with excision of the Burow triangles (TECH FIG 1F–H).
TECH FIG 1 • A. Markings for bilateral Karapandzic
flap. B. Bilateral flap incisions are made. C.
Neurovascular bundles are preserved. D. Flaps are
elevated on neurovascular pedicles, maintaining
mucosa where possible. E. Flap transposition. F.
Removal of the Burrow triangles offsets the
discrepancy between the cheek and flap lengths. G,H.

The incisions are closed in layers.
PEARLS AND PITFALLS
Hemostasis
■ Local anesthesia with epinephrine can be injected away from the
pedicle.
Pedicle
■ Visible facial artery branches and nerves should be kept intact with
careful blunt dissection using loupe magnification.
■ Perfusion and venous drainage is maintained by not dividing mucosa
excessively, just the advancing edge.
Technique
■ Excision of the Burow triangles can help share length discrepancies
while closing.
Caveats
■ Smoking can severely impair vascularity of the flap and should be
strictly avoided both pre- and postoperatively.
POSTOPERATIVE CARE
■ Bacitracin ointment is applied to external suture lines.
■ Sutures are removed at 7 to 10 days.
■ Stretching of the mouth is avoided until full healing.
■ No specific therapy is required.
OUTCOMES
■ In patients with large initial defects, this technique can lead to microstomia.
However, this is relatively uncommon due to the elasticity of normal lip tissue.
■ Using “like” lip tissue and intrinsic musculature for this reconstruction is
typically superior functionally and esthetically to using distant flaps.
■ There is tightness of the lower lip with lack of projection relative to the upper
lip, which improves with time and with subsequent fat grafting and vermilion
advancement (FIG 3).
COMPLICATIONS
■ Microstomia may be corrected with a staged commissureplasty. This can be
performed through a Y-to-V flap or through excising a lateral wedge and
advancing mucosal flaps.

■ Effacement of the gingivobuccal sulcus can occur and may be revised with a
skin graft internally in the sulcus.2
FIG 3 • A. Early postoperative appearance. B.
Appearance and function may be improved with fat
grafting and mucosal advancement. C. Late
postoperative appearance and function.
REFERENCES
1. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast
Surg. 1974;27(1):93-97.
2. Baumann D, Robb G. Lip reconstruction. Semin Plast Surg. 2008; 22(4):269-
280.
3. Hanasono MM, Langstein HN. Extended Karapandzic flaps for near-total and
total lower lip defects. Plast Reconstr Surg. 2011;127(3):1199-1205.
4. Anvar BA, Evans BC, Evans GR. Lip reconstruction. Plast Reconstr Surg.
2007;120(4):57e-64e.

17
CHAPTER
Repair of Lip Defects With
the Abbe Flap
Robert Beinrauh and Joseph H. Dayan
DEFINITION
■ A full-thickness portion of the lower lip, which includes the mucosa,
orbicularis oris muscle, and skin with vermilion, based on the right or left
inferior labial artery with mucosal venous attachments1
■ Used in reconstruction of defects of the upper lip (which do not involve the
commissure) between one-third and one-half of the entire lip
■ A reverse Abbe flap (Estlander-Abbe flap) is the exact same flap only taken
from the upper lip to reconstruct lower lip defects not involving the
commissure.
■ We will use the technique for the traditional Abbe flap for this chapter, but
recognize the reverse flap is the same technique based on the superior labial
artery.
ANATOMY
■ The lips are a sphincter composed of a concentric ring of mucosa, muscle, and
skin, which form a tight seal to prevent liquid from escaping the oral chamber
and also to produce the labial sounds used in speech.
■ Orbicularis oris muscle:
■ A circumferential ring of muscle around the mouth that functions to compress
and purse the lips together
■ The muscle fibers run horizontally on the upper and lower lips and begin at
the modiolus.
■ There is an oblique extension of the muscle that runs from the commissure to
the anterior nasal septum and nasal floor.
■ The inferior labial artery branches from the facial artery at the angle of the

mouth.
■ The artery runs inside the lip several millimeters inferior and anterior to the
vermilion/mucosal junction of the posterior lip2 (FIG 1).
PATHOGENESIS
■ Lip deformities can be congenital or acquired.
■ Congenital deformities are most commonly cleft lip defects.
■ Acquired deformities are most commonly due to traumatic or neoplastic
etiologies.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Abbe flap is an excellent choice for defects of up to approximately 50% of the
upper or lower lip.
■ Upper lip defects of 25% or less and lower lip defects of 33% or less can be
closed primarily. However, the Abbe flap may be useful even in these
relatively small defects if the philtral column is involved and requires
reconstruction.
FIG 1 • Cross section of the lip showing inferior labial

artery.
■ Lip defects larger than 50% of the lip may require either larger flaps, staged
reconstruction, or a flap from a distant tissue site. However, there is some
patient-to-patient variability in these size considerations due to anatomic
considerations (ie, the baseline size of the lower lip) and the degree of skin
laxity.
■ The Abbe flap is used for defects that do not involve the lip commissure. The
Estlander flap is more useful for more lateral defects that involve the
commissure. Abbe flap is excellent for reconstruction of bilateral cleft lip
patients with scarred or short philtrums.3
IMAGING
■ No imaging is necessary for the Abbe flap. However, a pencil Doppler can be
helpful to confirm position of inferior labial artery.
SURGICAL MANAGEMENT
Preoperative Planning
■ Size of the defect and layers of lip involved must be assessed.
■ The orbicularis oris muscle must be reconstructed to restore lip competence
and avoid cosmetic deformities (eg, whistle deformity) with lip movement.
■ In general, the size of the lower lip Abbe should be less than 30% of the width
of the lower lip to avoid microstomia. However, as noted, there is some
variability based on skin laxity and anatomic considerations.
Positioning
■ Supine position and prep as for any facial procedure
Approach
■ Measure defect and use template of the wound to design the resection size of
the lower lip.
■ The flap should be designed so that it will easily rotate into the defect without
tension.
■ The flap should be located in an area with similar vermilion thickness as the
edges of the defect.
■ Make the horizontal size of the lower lip flap dimension 50% of the horizontal

size of the upper lip defect.4
■ Do not make the inferior extent of the flap extend beyond the mental crease.
■ Drive the incision laterally along the mental crease.
■ Note position of inferior labial artery with Doppler prior to incision.
T E C H N I Q U E S
■ Donor-Site Preparation
■ Use of loupe magnification for the procedure is recommended.
■ The donor site should be prepared first.
■ Freshen the edges if needed with a no. 15 blade scalpel and create
hemostasis with cautery.
■ Use a 25-gauge needle dipped in methylthioninium chloride to mark the
white roll of your defect as well as of the lower lip.
■ The incision at the vermilion should be a perpendicular cut so that the
Abbe flap will approximate into the vermilion in a straight line.
■ Measure the recipient site width. The lower lip flap markings should be
approximately half this diameter of the defect (TECH FIG 1). Avoid
harvesting a very narrow (less than 0.5 cm) flap.
■ The vertical extent of the defect should match the Abbe flap exactly.

TECH FIG 1 • Markings for Abbe flap donor site.
■ Recipient Site Preparation
■ Mark out the Abbe flap to your specifications.
■ Use a 25-gauge needle dipped in methylthioninium chloride to mark the
white roll of your defect as well as of the lower lip.
■ Mark the white roll where you will incise with the methylene blue and then
mark the white roll on either side of the incision so that you will have a
guide to approximate the white rolls during the approximation of the Abbe
flap into the defect as well as approximation of the donor site white roll
following rotation of the flap (TECH FIG 2A).
■ Take care not to incise through the mental crease of the chin pad. Drive this
incision laterally (TECH FIG 2B).
■ The donor flap should be located opposite the defect to facilitate easy
rotation.
■ Keep the pedicle as lateral as possible when the donor site is closed to allow
the patient to eat and drink for 2 weeks while the pedicle is maintained.
■ Doppler the artery on the side of the inferior lip at the site that will retain the
pedicle.
■ Use 2 to 3 cc of local anesthetic with epinephrine in the inferior portion of
the flap to maintain a bloodless dissection.

TECH FIG 2 • A. The white rolls are marked with
methylene blue at both the donor and recipient sites to
facilitate approximation. B. The scar should be driven
laterally at the mental crease.
■ Raising the Flap
■ Begin the dissection on the nonpedicle side of the lower lip flap.
■ Compress the inferior labial artery with one hand and have the assistant hold
the lip opposite to the mark to compress the other side of the inferior labial
artery.
■ Incise the skin and vermilion with a no. 15 blade scalpel.
■ Use needle-tip cautery to cauterize each end of the inferior labial artery.
■ Use this opportunity to note the position of the artery to the mucosa and
vermilion as it will be analogous to the more important contralateral
pedicle side.
■ Dissect the nonpedicled side through the muscle and the mucosa with the
cautery to achieve a through-and-through separation of tissue.
■ As you begin the incision of the pedicle side of the flap, make an incision
through the anterior portion of the vermilion and white roll as well as the
skin.
■ Do not incise too deep at this point.
■ Only through the skin and dermis

■ Begin the dissection of tissue at the inferior aspect of the flap and work your
way superiorly.
■ As you near the pedicle, stop using cautery and begin to slowly spread the
tissue in a horizontal direction with blunt tip tenotomy scissors.
■ Release only the amount of orbicularis oris muscle that is needed to
facilitate rotation at this time.
TECH FIG 3 • The posterior vermilion and mucosa are
kept intact around the inferior labial artery for rotation.
■ Leave the posterior vermilion and mucosa intact around the inferior labial
artery (TECH FIG 3).
■ The artery does not need to be visualized.
■ Use a Doppler to monitor position of the inferior labial artery as necessary.
■ Flap Placement and Closure
■ We prefer temporary closure of the lower lip donor site with a 4-0 Vicryl

(Ethicon, Branchburg, NJ) to help facilitate the rotation (TECH FIG 4A).
■ Replace this suture with the 5-0 Prolene (Ethicon, Branchburg, NJ) at final
closure.
■ Once the flap is rotated, suture the white roll together using 5-0 Prolene
(Ethicon, Branchburg, NJ) suture.
■ This placement must be as exact as possible.
■ Suture the vermilion of the flap to maintain its thickness and position.
■ Suture the mucosa in horizontal mattress fashion.
■ The closure of the donor site mucosa is important to make watertight so as
not to develop leakage of saliva.
■ The orbicularis oris is closed next using 4-0 Vicryl suture.
■ The dermal layer is closed using 5-0 Monocryl suture.
■ The skin is then approximated using 5-0 Prolene suture in an interrupted
fashion.
■ Dissolvable suture can be used for this step in small children who will not
tolerate suture removal postoperatively.
■ The lower lip donor site is closed in an identical fashion (TECH FIG 4B).
TECH FIG 4 • A. Rotation of the Abbe flap into the
recipient site. The donor site has been temporarily
closed. B. Final closure of both sites, showing the
pedicle.

PEARLS AND PITFALLS
Patient
selection
■ Abbe flap is not a good option if the defect involves the commissure or
resection of the lower lip will exceed about 30% of the total lip as
microstomia may result.
Design
■ The flap must be designed to facilitate rotation into the defect. Failure
to do this will result in tension on the pedicle and ischemia.
Technique
■ Leave the inferior labial artery pedicle together with the posterior
vermilion and mucosa to facilitate venous drainage as well as to avoid
tension and kinking of the artery.
Closure
■ It is essential to approximate all of the lip elements as well as possible
during the first procedure.
■ The second-stage surgery will have scar tissue and swelling to contend
with, which will hinder achievement of a good cosmetic result.
Ischemia
■ If flap shows signs of ischemia upon rotation, place flap back into
original position and treat it as a delay. Attempt rotation again in 10–14
days.
FIG 2 • Results 2 months postoperatively at rest (A) and
with mouth open (B).
POSTOPERATIVE CARE
■ There is no need to place additional fixation to keep the mouth shut.
■ The patient may have a full liquid diet.
■ Start with a clear liquid diet postoperatively to avoid emesis.

■ Use antibiotic ointment 3 times a day.
■ Division of the pedicle should occur at approximately 14 to 21 days.
■ Restoration of white roll of vermilion of both upper and lower lip should be
done at this time if it was not completed at the first stage.
■ Revision of the lower lip donor vermilion can be done at this stage.
■ Reserve revision of the upper lip Abbe flap until the future when a more
adequate blood supply is established (FIG 2).
COMPLICATIONS
■ Injury to the inferior labial artery pedicle
■ Microstomia
■ Ischemia of the flap upon rotation
■ Infection
■ Salivary leak
■ Inadequate cosmetic restoration of vermilion lip elements
■ Scarring of the donor site
REFERENCES
1. Abbe RA. New plastic operation for relief of deformity due to double harelip.
Med Rec. 1898;53:477.
2. Edizer M, Mağden O, Tayfur V, et al. Arterial anatomy of the lower lip: a
cadaveric study. Plast Reconstr Surg. 2003;111(7):2176-2181.
3. Koshy JC, Ellsworth WA, Sharabi SE, et al. Bilateral cleft lip revisions: the
Abbe flap. Plast Reconstr Surg. 2010;126(1):221-227.
4. Anvar BA, Evans BC, Evans GR. Lip reconstruction. Plast Reconstr Surg.
2007;120(4):57e-64e.

18
CHAPTER
Lower Lip Reconstruction
With the Nasolabial Flap
George D. Xipoleas and Matthew S. Kilgo
DEFINITION
■ The nasolabial flap is a versatile random pattern superiorly or inferiorly based
flap that can be used to reconstruct defects of the lower lip.1–3
■ The nasolabial flap can be used to reconstruct defects spanning the entire
transverse dimension (approximately 7 cm) of the lip.
■ In most cases, the flap can be used to reconstruct the entire vertical
dimension (approximately 2.0 cm) of the lower lip.
ANATOMY
■ The lower lip is composed of the intraoral mucosa, vermilion, and
skin/subcutaneous tissue extending inferiorly to the labiomental fold.
■ The most distinguishing feature of the lip is the vermilion, a modified
mucosa that covers the free margin of the lip and is adapted to external
exposure.
• There are relatively few salivary glands beneath the vermilion in contrast to
the mucosa.
■ Musculature of the lower lip (FIG 1A)
■ The body of the lower lip is predominantly composed of the orbicularis oris.
• The primary muscle responsible for oral competence. It compressed and
protrudes the lips and creates the oral sphincter.
• The orbicularis oris muscle has two points of origin.
• The peripheral fiber originates from the modiolus where they interdigitate
with the fibers of the adjacent muscles of facial expression (buccinators,
levator anguli oris, depressor anguli oris, levator labii superioris, depressor
labii inferioris, zygomaticus minor, and zygomaticus major). This is

considered the peripheral portion of the muscle.
• The central fibers are restricted to the lip proper and are considered the
labial portion of the muscle.
• The muscle fibers interdigitate in the midline and insert into the mucosa.
■ The mentalis muscle elevates and protrudes the lower lip.
■ Originates from the incisive fossa of the mandible
■ Inserts into the skin of the chin
■ The depressor labii inferiors muscle draws the lower lip downward and
laterally.
■ It originates from the mandible adjacent to the mental foramen.
■ It inserts into the skin of the lower lip.
■ Innervation of the lower lip (FIG 1B):
■ Motor innervation to the lower orbicularis oris is from the marginal
mandibular and buccal branches of the facial nerve.
■ Motor innervation to the depressor labii inferioris and mentalis is from the
marginal mandibular branch of the facial nerve (cranial nerve 7).
■ Sensory innervation of the lower lip is from the mental branch (V3—third
division) of the trigeminal nerve (cranial nerve 5).
■ Blood supply of the lower lip (FIG 1C):
■ Paired lower labial arteries that are branches of the facial artery
• They course horizontally across the lip in the submucosal plane, posterior to
the orbicularis muscle at approximately the same level as the anterior
vermilion line.
■ Lymphatic drainage (see FIG 1C):
■ Drainage occurs via the submandibular and submental lymph nodes.
■ The nasolabial crease is an anatomic landmark created by the insertion of the
superficial muscular aponeurotic system (SMAS) into the skin junction of the
cutaneous lip and the cheek.
■ Marks the division of the cheek lateral to the fold and the lip and nose medial
to the fold
■ Medial to the crease, the skin of the lip is tightly attached to the orbicularis
oris muscle.
■ Lateral to the crease, the skin of the cheek is loosely attached to the deep
muscular fascia, and there is an abundance of subcutaneous tissue and skin
laxity.

PATHOGENESIS
■ The majority of lip defects in adults are secondary to excision of malignant
tumors. Other causes of lip defects include vascular malformations, congenital
defects, and trauma.
■ Neoplasms of the lip are primarily related to actinic changes.
■ Upward of 90% of lower lip neoplasms are squamous cell carcinomas
(SCCs) with the remainder being made up of basal cell carcinomas (BCCs),
salivary gland carcinomas, and melanomas.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A detailed history and physical examination are important to determine the
type of lesion and intervention.
■ The physical examination should be directed not only to the lips but to the oral
mucosa and to the lymphatic drainage basins, ie, the submandibular and
submental nodes.

Levator labii superioris alaeque nasi muscle Levator labii| superioris muscle Zygomaticus minor muscle Zygomaticus major muscle Risorius muscle Depressor septi muscle Depressor A anguli oris muscle Cutaneous innervation Auriculotemporal nerve - Zygomaticotemporal nerve Lacrimal nerve Infratrochlear nerve Zygomaticofacial nerve- Infraorbital nerve Nasal nerve Buccal nerve Mental nerve B Superficial blood supply External nasal artery Angular artery Lateral nasal artery Buccal artery anastomosis Septal artery Superior labial artery Facial artery Inferior labial artery Compressor naris muscle Levator anguli oris muscle Dilator naris muscle Buccinator muscle Orbicularis oris muscle Depressor labii inferioris muscle Mentalis muscle Facial nerve distribution Temporal branch Zygomatic branch Buccal branch Cervical branch Marginal mandibular branch Lymphatic drainage - Maxillary nodes - Buccinator nodes - Submandibular nodes - Deep cervical nodes - Lymphatic vessels to submental nodes

FIG 1 • A. Musculature of the face. B. Motor and
sensory innervation of the face. C. Blood supply and
lymphatic drainage of the face. The nasolabial flap is a
random pattern flap and does not need a perforating
blood vessel to be found for viability of the flap.2
■ What is the patient’s age, sex, and skin type?
■ Cancers of the lip are most common in lighter skin males in their sixth
decade. There is a 6:1 ratio of SCC in males to females.
■ Does the patient have a history of prolonged or repeated sun exposure?
■ Sun exposure is the most important risk factor in the development of skin
cancers.
■ One-third of patients have outdoor occupations or outdoor pastimes.
■ The lip is susceptible to metaplasia because it lacks the pigmented layer for
protection.
■ How did the lesion present, how long has the lesion been present and how has
the lesion changed?
■ Patients will typically report a history of a nonhealing “scabbed” or “crusted”
lesion that bleeds when the scab is removed.
■ Long-standing lesions with no changes in size or characteristics are less
likely to be malignant.
■ Long-standing nonhealing wounds are more likely to be malignant.
■ Increases in size, changes in color, consistency, and mobility may be an
indication of malignant degeneration.
■ Where is the lesion located? Is it mobile or fixed? Is there any associated
adenopathy?
■ It is important to determine the location of the lesion and the structures
involved:
• That is, the vermilion, mucosa, or muscle
■ Most tumors grow slowly and may be freely mobile, whereas others will
grow rapidly, infiltrating adjacent tissue.
■ In the lower lip, perineural spread along the mental nerve can also occur.
■ In the lower lip, SCC is much more common and will spread via lymphatic
drainage to the submandibular or submental nodes.

IMAGING
■ Imaging will be dictated by the pathology of the lesion. If the lesion is benign
or a basal cell carcinoma, imaging is usually not necessary because it does not
typically spread to distant sites. If the lesion is a more aggressive tumor,
imaging may be appropriate.
■ CT scan or MRI can be used to determine local/regional spread into the soft
tissue and lymph node basins.
■ A panorex can be undertaken if the tumor is felt to be fixed to the mandible
or if there are paresthesias in the mental nerve distribution.
DIFFERENTIAL DIAGNOSIS
■ Most lesions of the lower lips are malignant SCC. Biopsy should be
undertaken to determine the identity of the lesion. The differential includes
both benign and malignant lesions.
■ Basal cell carcinoma
■ Melanoma
■ Sebaceous adenoma (benign)
■ Hemangioma (benign)
■ Venous lake (benign)
■ Pyogenic granuloma (benign)
■ Merkel cell carcinoma (malignant)
■ Dermatofibrosarcoma protuberans (malignant)
■ Microcystic adnexal carcinoma (malignant)
NONOPERATIVE MANAGEMENT
■ Radiation therapy is a nonoperative treatment option for basal cell or
squamous cell cancers that may be useful for patients who cannot undergo
surgical excision of malignant lesions or are not suitable reconstruction
candidates due to medical comorbidities or other factors.
■ Radiation has an equivalent 5-year survival when compared to surgery in
lesions that are less than 3 cm in diameter.
■ Radiation, however, may result in local tissue changes that may complicate
reconstruction if surgical excision is necessary.
■ Cryotherapy or curettage may also be possible depending on the pathology of
the lesion.
SURGICAL MANAGEMENT

■ Basal cell carcinoma:
■ Nodular type BCC can be excised with 2-mm margins.
■ Squamous cell carcinoma:
■ Lesions less than 1.5 cm in diameter can be excised with 10-mm margins.
■ In both the cases of BCC and SCC, Mohs surgery can be employed.
■ Melanoma:
■ In situ lesions—5-mm margins
■ Up to 1 mm depth—1-cm margins
■ 1- to 2-mm depth—1- to 2-cm margins
■ 2- to 4-mm depth—2-cm margins
■ Definitive reconstruction of the lip should be delayed until the final margins
are cancer-free.
Preoperative Planning
■ The size of the defect should be evaluated.
■ Facial examination should be performed to assess the laxity in the nasolabial
crease and the amount of tissue in the nasolabial fold.
■ Determination if a unilateral flap or bilateral flaps will be needed. Bilateral
flaps can be used to reconstruct the entire width of the upper lip.
■ If the patient has vascular compromise or is a smoker, then a delay procedure
should be considered.
■ The type of anesthesia should be discussed with the planning:
■ Local with sedation vs general anesthesia
Positioning
■ The patient is positioned supine on the operating room table.
■ The head is stabilized in a foam ring.
■ The face is prepped with dilute Betadine.
■ Eye shields or Steri-Strips are placed over the lids to protect the eyes.
■ The face is draped bilaterally from tragus to tragus and from forehead to chin
to visualize the entire face and provide access to both nasolabial folds.
Approach
■ Care should be taken that the margins of the lip are negative for malignancy
before definitive reconstruction be undertaken.
■ Once definitive measurements are known, lower lip reconstruction can

proceed with various techniques. Consideration should be given to the size of
the defect and the types of tissue that needs to be replaced.
■ Often, smaller lesions can be repaired primarily or with lip advancement
flaps, without the use of local tissue flaps.
• Defects less than 33% of the total lower lip width can be repaired primarily.
■ If a local flap is necessary, usually for defects greater than 33%, care should
be taken to consider what type of tissues are missing.
• If the mucosal aspect of the lip has been violated, mucosal advancement
flaps can be used to resurface the area of the wet/dry border of the lip.
• Local cheek, lip, or nasolabial flaps can be used unilaterally or bilaterally to
reconstruct large defects.3
T E C H N I Q U E S
■ A banner-shaped flap is designed in the nasolabial fold with the nasolabial
crease serving as the medial border and superior border of the flap.
■ The width of the flap, at its widest point should not exceed 2.5 cm in
middle-aged people (TECH FIG 1); however, the width can be increased
to 3.5 cm in the elderly due to increasing skin redundancy and laxity.
■ The flap is based immediately superior to the lateral aspect of the defect to
minimize the creation of a standing cutaneous deformity. Placing the flap
base superiorly and laterally to the commissure prevents downward traction
on the flap.
■ The flap is injected with 1% lidocaine with epinephrine to aid in hemostasis
and is elevated in the subcutaneous plane. The distal tip is tapered for ease of
closure of the donor site.
■ Meticulous hemostasis is obtained with the bipolar electrocautery.
■ The donor site may be undermined for tension-free closure and is repaired
in a layered fashion with deep absorbable sutures and cutaneous permanent
sutures removed within 1 week.
■ A 0.5-cm portion of the donor site may be left open at the pivot point to
reduce the amount of tension on the flap.
■ The flap is transposed into the lip defect and sutured in placed with deep
absorbable sutures consisting of cutaneous absorbable sutures on the mucosal
side of the defect and interrupted permanent sutures on the skin surface.

■ If the commissure remains intact, the pedicle can be divided 10 to 14 days
after the transfer. Longer time periods may be required for patients who
have been previously treated with radiation or have scarring of the
periorbital area.
■ In defects that are vertically short, a single flap may suffice to adequately
restore the full lip height.
■ When larger vertical defects exist, bilateral flaps may be interposed to
reconstruct the vertical dimensions of the lip, with one flap serving as skin
coverage and the other as lining.
TECH FIG 1 • A. The width of the flap (y) should not
exceed 2.5 to 3.5 cm, depending on the age of the
patient. B. If the height of the defect (y) exceeds 2.5 to
3.5 cm, or if the length of the defect (x) exceeds 7 cm,
bilateral nasolabial flaps should be used to cover the
defect adequately.
PEARLS AND PITFALLS
Local
anesthesia
■ Use local anesthesia with epinephrine for vasoconstriction.
Blood supply
■ The nasolabial flap has a robust subdermal blood supply. There is
no need to incorporate a named vessel into the flap.

Delay the flap
when
necessary
■ If the vascularity of the flap is questionable, lay back down into
the donor site and perform delay procedure.
Do not short-
change
yourself
■ The nasolabial flap has distinct dimensions. If the defect is larger
than the unilateral nasolabial flap will accommodate, use bilateral
nasolabial flaps.
Pathology
■ Proper pathology is needed for margins. Do not perform the
procedure unless the margins are cancer free.
Hemostasis
in the lip
■ Obtain meticulous hemostasis in the lip wound bed. A hematoma
in the lip bed could compromise the flap.
POSTOPERATIVE CARE
■ The procedure may be performed as an outpatient.
■ The patient applies bacitracin BID to the suture lines.
■ Normal oral hygiene is maintained.
■ Chlorhexidine swish and spit is added as well to the oral regimen.
■ Liquid diet is prescribed for 3 days followed by soft diet for 2 weeks after
which the patient returns to a normal diet.
OUTCOMES
■ Functional oral aperture without microstomia
■ Normal oral hygiene and use of dentures
■ Aesthetically acceptable results
■ Normal speech
COMPLICATIONS
■ Include
■ Oral incompetence
■ Drooling
■ Flap loss
■ Tight lower lip if flap is designed too small
REFERENCES
1. Fujimori R. Gate flap for the total reconstruction of the lower lip. Br J Plast
Surg. 1980;33:340.

2. Haynes B, Boyd JB. The nasolabial flap: axial or random? Arch Otolaryngol
Head Neck Surg. 1988;114:1389.
3. Ruskin GH, Carlsen BT, Miller TA. Nasolabial flap reconstruction of large
defects of the lower lip. Plast Reconstr Surg. 2001;2:810.

19
CHAPTER
Lip Reconstruction With
Radial Forearm Free Flap
Vishal Thanik
DEFINITION
■ Lip reconstruction is restoration of form and function after loss from a number
of causes, the most common being oncologic resection and trauma.
■ The lips are critical functional units in the processes of speech and
alimentation and are one of the prime conveyors of emotion in the human face.
They are also a focus of beauty in cultures worldwide.
■ Reconstructive options in lip reconstruction are determined primarily by size
and location of the defect; as defects become larger in more critical locations,
functional outcome becomes paramount and aesthetic quality diminishes.
■ Smaller defects typically can be addressed with local flaps, and in general, the
use of free flaps is reserved for defects that cannot be reconstructed with local
tissue alone.
ANATOMY
■ The lips are a trilaminar structure containing mucosa, muscle, and skin.
■ External anatomy (FIG 1A)
■ Upper lip—base of nose to nasolabial fold
■ Lower lip—mental crease to nasolabial fold
■ Corners of the lip referred to as commissures
■ Skin transitions to mucosa at the vermilion border, with the transition skin
referred to as the white roll.
■ Midline of the upper lip has a curve referred to as the “Cupid’s bow.”
■ Cupid’s bow progresses vertically to the philtrum, a depression that is
bordered on either side by the philtral columns.
■ The vermilion is a specialized mucosal surface that does not contain minor

salivary glands.
■ Internal anatomy (FIG 1B)
■ Muscular anatomy of the lip functions as a specialized sphincteric system.
■ Orbicularis oris forms a sphincteric ring and is the major muscle of the
trilaminar structure.
■ Major elevators of the lip are the zygomaticus major and levator anguli oris,
with zygomaticus minor and levator labii superioris as secondary elevators.
■ Major depressor of the lip is the depressor anguli oris, with contributions
from the depressor labii inferioris, mentalis, and platysma.
■ The modiolus is just lateral to the commissure and is the confluence of
muscle fibers to the dermis, the functional insertion of the levator and
depressor muscles.
■ Innervation
■ Sensory innervation to the upper lip is provided by the maxillary branches of
the trigeminal nerve, whereas the lower lip is supplied by the mandibular
branches.
■ Motor innervation is via branches of the facial nerve.
FIG 1 • A. External anatomy of the lip. B. Musculature
of the lip.
■ Vascular supply
■ The facial artery is the main blood supply to the lip and branch, diving and
entering the lips laterally, becoming the superior and inferior labial arteries.
These vessels can run between the mucosa and orbicularis muscle or through

the muscle depending on the patient.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Understanding the underlying etiology of the defect is paramount. Traumatic
wounds can generally be reconstructed immediately after adequate
debridement and ruling out of concomitant injuries that could delay treatment.
With oncologic defects, margin status and need for further excision or adjuvant
therapy should be assessed prior to reconstruction.
■ A full history should be established, with particular attention paid to previous
lip/facial reconstruction, smoking and comorbid status, and any history of
radiation therapy of the head and neck.
■ Physical examination requires assessment of the defect and the surrounding
tissues.
■ Assessment of the size and location of the defect, as well as the size of the
opposite, typically normal lip
■ Evaluation of the depth of injury, including status of the orbicularis oris
■ Evaluation of the opposite lip for concomitant injury, typically in trauma
■ Neurovascular examination, inventorying sensibility and perfusion of the
remaining lip
■ Evaluation of donor sites if free flap reconstruction is warranted
IMAGING
■ Imaging is typically unnecessary prior to lip reconstruction.
■ In patients with traumatic lip defects, head CT and C-spine imaging may be
performed to rule out concomitant injuries.
Surgical Management
■ Operative management of lip defects depends on the location, size, and
thickness of the defect.
■ Partial-thickness defects of the lip and vermilion, if small (generally less than
30% of the lip), can be converted into full-thickness defects and closed
primarily in a V-shaped manner.
■ Larger partial-thickness defects of the vermilion that are not amenable to V-
excision and closure are best managed with mucosal advancement flaps from
the labial or buccal surface. Other options include mucosal V-Y advancement
flaps or cross-lip mucosal flaps.1,2
■ Large, full-thickness defects of the lip are considered those that are 80% or

more. For defects of this size, free flap reconstruction is usually indicated.
Another option in some patients, particularly those who are not free flap
candidates, is bilateral nasolabial flaps or other local approaches.
■ Lower lip defects are more common than the upper lip defects due to increased
sun exposure.
■ Full-thickness lower lip defects reconstructed with free flaps are difficult due
to the potential for lip incontinence and benefit from suspension of the flap
with a tendon or fascia graft. Upper lip defects typically do not require tendon
grafting.
■ The radial forearm flap is the workhorse flap in lip reconstruction because of
its thinness and pliability, ability to easily integrate the palmaris tendon, and
long pedicle length, which facilitates anastomosis in the neck or superficial
temporal system.3,4
■ Other flap options include anterolateral thigh flap, parascapular flap, and
lateral arm flap. In thin individuals, rectus abdominis and gracilis have also
been described.5–7
■ Innervation of the flap can be achieved by harvesting the lateral antebrachial
cutaneous nerve with the flap and coapt to the mental nerve for sensory
reinnervation.
Preoperative Planning—Radial Forearm Flap
■ Evaluation of potential recipient vessel site should be performed, including
assessment if any previous neck dissection has been performed.
■ The size of the defect needs to be established. Typically, the remaining edges
retract with the cheek, making the defect appear larger than it actually is. The
lip edges should be pulled to resting tension, and the opposite lip can be used
for confirmation.
■ The width of the flap can be undersized somewhat to the size of the defect, but
the height should be modestly oversized to compensate for tension by the
palmaris as well as postoperative scarring.
■ The height of the mucosal and skin defect should both be measured because
they are not typically equal.
■ Use of a template to size the defect is advised.
■ Presence of palmaris tendon should be confirmed by physical examination.
■ In the absence of the palmaris tendon, the plantaris tendon or fascia lata can be
utilized through a separate site.

■ Allen test should be performed on the forearm to ensure adequate perfusion of
the first three digits with radial artery occlusion.
Positioning
■ The patient should be placed supine. A foam donut is helpful for positioning of
the head.
■ The nondominant hand should be abducted on an arm board for radial forearm
harvest.
Approach
■ For radial forearm free flap, a two-team approach can be applied, with one
team harvesting the flap while the other debrides and prepares the defect and
recipient vessels.
T E C H N I Q U E S
■ Radial Forearm Free Flap
■ Based on the designed template, the radial forearm flap should be marked on
the nondominant arm.
■ Palmaris tendon should be centered at the junction between the mucosal and
skin elements, ie, the fold-over point.
■ The radial artery is placed on the side of the flap that will be the external
skin.
■ Cephalic vein is typically marked and included in the flap if possible.
■ Flap is raised under tourniquet control after limb elevation.
■ Circumferential incisions are made into the subcutaneous fat; care is taken to
identify and preserve the cephalic vein and lateral antebrachial cutaneous
nerve.
■ Dissection begins on the ulnar border of the flap in a subfascial plane.
Dissection proceeds radially in this plane with care taken to preserve the
paratenon.
■ When the palmaris tendon is encountered, its most distal portion at the
palmar aponeurosis should be identified and divided, leaving a cuff of
palmaris distal to the distal flap edge.

■ Dissection proceeds in a deeper plane incorporating the palmaris and its
sheath. Once radial to the palmaris, the previous plane can be re-established
until the intramuscular septum and radial artery are encountered.
■ Dissection now proceeds from the radial incision. The brachioradialis tendon
is identified and retracted radially, giving exposure to the septum and radial
artery.
■ The cutaneous branch of the radial nerve should be protected.
■ The distal portion of the radial artery pedicle can be clipped and divided and
the septum can be elevated deep to the vascular pedicle. Branches to the
periosteum of the radius and to flexor muscles of the forearm should be
ligated and divided.
■ A lazy-S incision is carried proximally along the ulnar border of the
brachioradialis to the origin of the radial artery.
■ Distal to proximal dissection continues along the vascular pedicle, cephalic
vein, and lateral antebrachial cutaneous nerve.
■ Once adequate pedicle length is obtained, the flap is harvested with either tie
or double clip.
■ Donor site is closed with unmeshed split-thickness skin graft. VAC dressing
and splint are applied (TECH FIG 1).
TECH FIG 1 • Skin graft closure of the donor site.
Note the slightly more proximal location of the skin
paddle to allow for increased length of palmaris
distally.

■ Recipient Site Preparation and Insetting
■ A multitude of recipient vessels from branches of the external carotid system
and jugular vein can be utilized.
■ If concomitant nodal dissection has been performed, that exposure can be
utilized.
■ In the absence of neck incision, a transverse neck incision and exposure of
the facial artery can be used (TECH FIG 2A).
■ For inset of the flap, the flap should be folded along the axis of the palmaris
tendon (TECH FIG 2B–D).
■ Suspension of the palmaris sling is routed through the remaining orbicularis
muscle and/or modioli and sutured to itself, allowing for a dynamic
suspension (TECH FIG 2E).
■ Tension on the palmaris is critical, with a slight overcorrection performed.8
■ Microneural anastomosis of the lateral antebrachial cutaneous nerve and the
mental nerve should be performed if available.
TECH FIG 2 • A. Markings for resection and