Dr. Rasel lip reconstruction cme DDCH, Dhaka, Bangladesh

Different approaches of lip reconstruction

1. WELCOME TO WEEKLY CME OF UNIT-2 PRESENTER DR. A.F.M. SHAKILUR RAHMAN FCPS PART-2 TRAINEE DEPT. OF ORAL & MAXILLOFACIAL SURGERY. DHAKA DENTAL COLLEGE & HOSPITAL.

2. LIP RECONSTRUCTION BASED ON DEFECT SIZE

3. INTRODUCTION The principles of management of lip cancer require resection with negative margins and reconstruction of the defect to restore form and function. Whether the defect is acquired by ablation or trauma, is based upon the size, location, and integrity of the local anatomy.

4. Defects Less than One-Third of the Lip Option- Wedge Excision with Primary Closure. - “V”, “W”, Pentagon, Shield excision. Lateral (Rectangular) Advancement Flaps.

5. Defects One-Third to Two- Thirds of the Lip Lip-Switch Flaps(Cross-Lip Flaps) Abbe flap Estlander flap Stein flap Johanson Stair-Step Flap. Fernandes flap.

6. Defects Half to Two-Thirds of the Lip Karapandzic Flap. Webster-Modified Bernard Flap. Gillies “Fan” Flap. McGregor Flap.

7. Defects Greater Than Two- Thirds of the Lip Free flaps - Radial forearm free flap. Antero-lateral thigh flap . Bilateral Gillie’s fan flap. McGregor flap. Karapandzic flap.

8. Vermilionectomy or Lip Shave a. Incision line- vermilion border anteriorly , Wet- dry line – posteriorly . b. The vermilion is excised in a submucosal plane. c. Resected vermilion specimen. d. The lip mucosa may be undermined in a submucosal plane (between the submucosa and orbicularis oris muscle). The mucusa is advanced anteriorly and sutured to the skin with interrupted 5-0 prolene suture, which are later removed after one week.

9. “V” Excision ( a ) Squamous cell carcinoma of lower lip with actinic changes of remainder of lip vermilion. ( b ) Excision margins are marked out with a vermilionectomy incorporated into the resection. (c) Excised specimen with suture marking orientation . (d) The orbicularis oris muscle is reapproximated primarily with 3-0 vicryl suture. (e) The reconstruction is completed by reapproximating the skin.and lip mucosa, and then advancing the lip mucosa anteriorly to the skin edge.

10. “W” Excision ( a ) The incision is marked out. A vermilionectomy is incorporated into the resection. ( b ) Completed resection, which produced a full-thickness defect. ( c ) The orbicularis oris muscle is reapproximated first, followed by primary closure of the skin and mucosa. The lip mucosa is then advanced anteriorly to the skin edge. ( d ) Healed wound. Note the new lower lip “vermilion” is thinned due to scar contracture and the inward rolling of the lower lip skin.

11. Shield Excision Pentagonal Excision

12. Lateral advancement flap a ) The lesion is excised in a full-thickness fashion and the wound edges are advanced medially. Burow’s triangles (of skin and subcutaneous tissue) may be incorporated into the resection to prevent bunching of the tissue during wound advancement and closure. ( b ) The wound is closed in three layers and results in a T-shaped scar

13. Abbe flap ( a ) The full-thickness triangular excision of the upper lip is marked out, followed by the incision of the lower lip. The lower lip incision is also made in a full-thickness fashion, however it stops at the vermillion border to preserve the vascular pedicle, which is typically based medially. Here, the base of lower lip flap is made almost equal to the width of the defect to help preserve symmetry of the more conspicuous upper lip. The base can also be made smaller to “share” the tissue loss between both lips. This is more important when rotating upper lip flaps into lower lip defects. ( b ) The lower lip flap is then rotated superiorly and inset into the upper lip defect. The lower lip defect is closed primarily . ( c ) After three to four weeks of healing, the vermillion tissue pedicle is divided and inset

14. Estlander flap a ) The full-thickness excision of the lower lip and incision of the upper lip are marked out. The upper lip flap is made approximately one-half the width of the lower lip defect. The upper lip incision ends at the vermilion border to preserve the medially-based pedicle based on the superior labial artery. ( b ) The flap is rotated inferiorly and inset into the lower lip defect. Note that the commissure will always be blunted with this flap . ( c ) Here a lower lip flap is used to reconstruct an upper lip defect. Note that its base is made equal the defect width to preserve upper lip symmetry. ( d ) The flap is rotated superiorly and inset.

15. Stein flap (a) The Stein flap uses two symmetrical triangular flaps from the central upper lip to reconstruct a defect of the central lower lip. The incisions are placed at the philtral columns . ( b ) The flaps are rotated and inset into the lower lip defect. Note that the patient now has two laterally-based vermilion pedicles . ( c ) Like the Abbe flap, once sufficient collateral circulation has formed, the vermillion pedicles are divided and inset.

16. Johanson flap- (a ) Pre-operative photo of squamous cell carcinoma of lower lip. ( b ) Excision and fl ap design is marked. ( c ) The lesion is excised in a full-thickness fashion and combined with a vermilionectomy . ( d ) Excisions of skin and subcutaneous tissue are made below each step and the skin flaps are undermined laterally. ( e ) The wound is primarily-closed in a layered fashion and the mucosa is advanced and reapproximated to the skin edge to close the vermilionectomy defect. ( f ) Healed wound a few weeks after suture removal. The scar will continue to fade and flatten with time

17. Fernandes flap a ) Excision and flap design are marked. ( b ) A full-thickness defect is created, and skin and subcutaneous tissue are excised to allow medial flap advancement. ( c ) The wound is closed in layers and the scar is placed at the labiomental crease .

18. Karapandzic flap- (a ) Excision and flap design are marked . The incision is carried along the labiomental crease and then turns superiorly to follow the nasolabial creases. ( b ) Large lower lip defect. ( c ) The flaps are advanced medially and the defect is closed in a layered fashion.

19. Gillies fan flap ( a ) A curvilinear incision is extended laterally and then superiorly to follow the naso -labial fold. ( b ) A full-thickness flap is then raised and rotated medially to bring lip and cheek tissue to the defect . ( c )Because the Gillies flap rotates tissue around the corner of the mouth, it will result in blunting of the oral commissure .

20. Webstar Bernard flap (a )Excision and flap design are marked. Crescent triangular excisions of skin and subcutaneous tissue are created at the nasolabial and labiomental folds bilaterally to allow for medial advancement of the flaps. ( b ) Final reconstruction