FIGURE 1.1 Diagram of bilateral nasolabial transposition flaps. The flaps are designed with incisions lying in the melolabial folds and flaps transposed over the adjacent alar bases to meet in the midline of the upper lip. A. Bilateral nasolabial flaps outlined. B. Flaps advanced and sutured together to create a new vermilion border and fill the defect.
FIGURE 1.2 A. Central defect of the upper lip involving entire philtrum and extending superiorly to the nasal base. Incisions are marked for bilateral nasolabial transposition flap reconstruction. B. Bilateral nasolabial transposition flaps are raised after incisions through the melolabial creases and excision of partial-thickness triangles inferiorly. Flaps are raised in a subcutaneous plane taking care not to violate the underlying mucosa. C. Flaps are advanced toward the midline and closed in layers with careful realignment of the vermilion border and subnasale. Note that bilateral incisions lie within the melolabial creases to help with eventual camouflage of the scar.
Reconstruction of a subtotal and total defect of the upper lip requires two local regional flaps. Bilateral nasolabial flaps provide ample tissue but, unfortunately, are adynamic. On the side of less involvement, the reverse Karapandzic flap is used to transfer innervated elements of the remaining orbicularis oris to restore some sphincteric function. The original fan flap has been modified by eliminating the through and through incision and instead creating two advancement-rotation flaps. The cutaneous–subcutaneous flap provides external coverage of the new lip, while the mucosal muscular flap replaces the internal lining of the lip and creates a new vermilion border. The skin component is preplanned while the internal component is created by making sequential mucosal incisions as necessary to achieve flap advancement and coverage. Moreover, this flap transfers with it the modiolus (which is 1.5 cm beyond the anterior commissure), which carries elevator and depressor muscles and the buccinator muscle providing some dynamic activity.
When nasolabial flaps are used, a new oral commissure is created unilaterally or bilaterally. The two flaps are advanced and sutured together, and the cheek flap is sutured to the opposite lip at the point where the new commissure is to be created. This entails a deep suture of 3-0 Vicryl. The skin is attached with a 5-0 nylon suture and 4-0 chromic sutures after the mucosal flap has been advanced to create a new vermilion border. Care must be taken to ensure that the new vermilion border is correctly realigned. Closure should be performed in three layers consisting of mucosa, subcutaneous tissue, and skin using 4-0 chromic, 3-0 Vicryl, and 5-0 nylon sutures, respectively. Steri-Strips can be used to reinforce the incision if under moderate tension; otherwise, bacitracin ointment may be applied following closure.
Circumoral Rotation–Advancement Flap: Karapandzic Flap
The Karapandzic flap is an advancement–rotation flap based on the superior and inferior labial arteries and nasoseptal artery branches. A distinguishing feature of this flap is the preservation of the neurovascular innervation of the orbicularis oris muscle during transfer to reconstitute a functional oral sphincter. This flap also transfers with it the modiolus of the lip, with its attached muscles and adjacent decussating fibers, which while producing misdirection of muscular fibers and proprioceptive elements, nevertheless recreates a functional oral unit. Its greatest application is with unilateral flaps to reconstruct small to moderate defects of the lower lip although a modification can be used for upper lip reconstruction (reverse Karapandzic). The Karapandzic flap is generally not used to reconstruct defects of the lateral lip and oral commissure.
Good functional outcomes have been reported in case series of patients undergoing Karapandzic reconstruction of lip defects with up to 75% of patients regaining normal postoperative speech and oral competence. When rotational flaps are used as the exclusive method of reconstruction in the repair of large defects, commissuroplasty and commissurotomy are necessary to correct the resultant severe microstomia. Other disadvantages relate to aesthetic concerns, including the potential for an unsightly perioral scar as well as rounding of the commissure.
Description of Technique: Karapandzic Flap
The patient is placed under general anesthesia and may be intubated transorally; however, a nasotracheal tube secured superiorly away from the surgical field is preferable. The patient is then prepped and draped in standard sterile fashion with the lower two-thirds of the face and upper neck exposed. Surgical technique involves bilateral circumoral incisions around the defect along the nasolabial folds from the lower to upper lip (Fig. 1.3). Blunt dissection is then carried out within the orbicularis oris to mobilize muscle fibers while preserving the major neurovasculature bundles typically located near the oral commissures. The mucosa should not be violated during the course of dissection until the flaps are completely raised and advanced together under appropriate tension. Care must be taken to ensure that the new vermilion border is correctly realigned. Closure should be performed in three layers consisting of mucosa, subcutaneous tissue, and skin using 4-0 chromic, 3-0 Vicryl, and 5-0 nylon sutures, respectively. Steri-Strips can be used to reinforce the incision if under moderate tension; otherwise, Bacitracin ointment may be applied following closure.
FIGURE 1.3 Diagram of proposed Karapandzic flap for repair of right subtotal defect of the lower lip. A. Bilateral circumoral incisions outlined. B. Orbicularis oris muscle bluntly dissected to expose nerve. C. Flaps advanced and vermilion border aligned. D. Completed layered closure.
Transoral Cross-Lip Flaps: Abbe and Estlander Flaps
The transoral cross-lip or lip-switch flaps were devised in the mid 1800s and are still used today for reconstruction of the lip (Figs. 1.4 and 1.5). They provide a reliable method of restoring medium-sized lip defects with or without oral commissure involvement and can also be used in combination with other locoregional flaps for subtotal and total lip reconstruction. Advantages include good color match and skin texture from the opposing lip as well as the ability to position the incision in a natural skin crease, which leads to more favorable scar formation. Drawbacks are the need for a two-stage procedure when using the Abbe flap for central lip defects, possible distortion of upper lip subunits when using this as a donor site for lower lip repair, and the potential need for a revision commissuroplasty with the Estlander flap. Overall, even 200 years after its initial development, the transoral cross-lip flap has endured the test of time and is still commonly employed in major lip repair by today’s reconstructive surgeons.
FIGURE 1.4 Abbe flap. A. Central area of resection of upper lip outlined. Area of lower lip to be transposed outlined. B. Lower lip donor flap sutured into upper lip defect. C. Pedicle divided after 2-3 weeks. (From Thorne CH (ed). Grabb and Smith’s Plastic Surgery, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2014.)
FIGURE 1.5 Estlander flap. A. Donor flap from upper lip including the commissure is outlined for lateral defect. B. Flap transfered into long lip defect. Note rounding of commissure. (From Thorne CH (ed). Grabb and Smith’s Plastic Surgery, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2014.)
Description of Technique: Abbe and Estlander Flaps
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