lip.pptx

lip anatomy, reconstruction

1. LIP RECONSTRUCTION

2. Lip Embryology Around 4 th week- A series of swellings appear around the stomodeum--Frontonasal process, b/l maxillary process, Mandibular process Nasal placode arise as thickenings on either side of frontonasal process Fusion of paired maxillary prominence with paired medial nasal prominences form upper lip Lower lip - M idline fusion of the mandibular processes L ateral fusion of the mandibular and maxillary processes forms the commissures of the mouth.

3. Lip Anatomy Trilamilar structure - mucosa, muscle, and skin The boundaries of the upper lip are defined by the base of the nose centrally and by the nasolabial folds laterally The inferior margin of the lower lip is defined by the mental crease ( labiomental crease) that separates the lip from the chin.

4. Vermillion is composed of thin keratinized stratified squamous epithelium mucosa that lacks pilosebaceous units, eccrine glands, and salivary glands. The pink-to-red color of the vermilion lip is due to the extensive superficial vasculature that underlies a very thin epithelial structure. This vascular bed and neural plexus makes the vermilion highly sensate The line separating this dry portion from intraoral labial mucosa is called the wet line . A fine line of pale skin, white roll , accentuates the color difference between the vermilion and skin. The wet, or mucosal, lip abuts the teeth and contains minor salivary glands, which empty onto its surface. The red line is where the upper and lower lips meet, and this line corresponds to the transition zone between the vermilion lip and the mucosal lip

5. Average philtral height is between 18 to 20 mm Average upper lip vermillion height falls between 7 to 8 mm 12.2mm for the lower lip Average upper lip length at rest position(from nasal base to inferior border of the upper lip at the midline)-20 mm in females and 23 mm in males The lip line is considered ideal when the inferior vermillion border of the upper lip reaches the gingival margin during smile The average female lip line is 1.5 mm higher than the male one; therefore, 1-2 mm gingival display during maximum smile is considered normal for females

6. C ross-sectional anatomy of the lips From superficial to deep, consists of skin (epidermis, dermis, subcutaneous tissue), orbicularis oris muscle fibers, and submucosal and mucosal layers. Lips are surrounded by skin externally and transition to internal mucosa at the mucocutaneous ridge or vermilion border

7. Aesthetic unit U pper lip consists of a middle and 2 lateral aesthetic subunits demarcated by the philtral ridges medially and the nasolabial folds laterally. L ower lip is composed of a single subunit

8. Modiolous It is a 1 cm-thick fibrovascular region of muscle fiber intersection formed by the interlacing of a number of muscles that attach frmly to the dermis,lie just lateral to the angle of the mouth opposite the second upper premolar tooth Approximately 1.5 cm lateral to the oral commissure

9. Orbicularis Oris Muscle In the upper lip, the orbicularis oris fibers decussate in the midline and have dermal insertions approximately 4 to 5 mm lateral from the midline. This serves to pull the skin medially at these dermal insertion points, forming the philtral columns. The central region ( philtral groove) is devoid of dermal attachments and is pulled into a concave depression. O rbicularis oris principally composes the body of the lip. Deep fibers provide the oral cavity sphincter function, whereas the superficial fibers perform fine movements. S uperficial fibers - protrude the lips away from the facial plane, whereas the deep and oblique fibers approximate the lips to the alveolar arch

10. Perioral Musculature

11. Elevators Muscle Origin Insertion Innervation Levator labii superioris Infraorbital margin of maxilla Upper lip orbicularis modiolus Buccal branch Levator anguli oris Infraorbita margin of maxilla modiolus Buccal branch Levator labi superioris alaque nasi Frontal process of maxilla Nasal cartilage Buccal branch Zygomaticus Minor Zygoma posterior to zygomaticomaxillary suture Upper lip skin Buccal branch Zygomaticus Major Zygoma anterior to temporal zygomatic suture modiolus Buccal branch

12. Depressor Muscle Origin Insertion Innervation Depressor anguli oris Mental tubercle on mandible Modiolus Mandibular branch Depressor labii inferioris Oblique line of mandible Lower lip skin Mandibular branch Platysma Skin over deltopectoral region Mandible Cervical branch

13. Perioral musculature C lassified into 3 groups based on insertion. Group I muscles insert into the modiolus G roup II muscles insert into the upper lip Group III muscles insert into the lower lip.

14. Arterial supply S uperior labial arteries from each side generally anastomose in the midportion of the upper lip, coursing between the mucosa and orbicularis muscle Inferior labial artery, on the other hand, routinely courses between the mucosa of the inner aspect of the lip and the muscle. Venous drainage runs with the arteries but, in the upper lip, can drain to the cavernous sinus via the ophthalmic vein, providing a route for labial infections to spread intracranially

15. Lymphatic drainage U pper lip, except the midline, drains ipsilaterally to the submandibular nodes with some drainage to the periparotid nodes and occasionally to the submental nodes Lower lip drains bilaterally to the submental nodes in the center and submandibular nodes laterally

16. Nerve Supply Motor: Facial nerve – Buccal branch – Elevators & orbicularis oris Marginal Mandibular - Depressors Sensory: Trigeminal – Maxillary – Infraorbital nerve – upper lip Mandibular – inferior alveolar – mental nerve – Lower lip

17. Lip Function Speech articulation Oral competence Sensation allows the lips to monitor the texture and temperature of substances before oral intake L ower lip functions as a dam that retains saliva and prevents drooling. U pper lip contributes to oral competence by providing opposition to the lower lip to effect closure. Sensation allows the lips to monitor the texture and temperature of substances prior to oral intake

18. Goal of Lip Reconstruction Three-layered closure. Accurate alignment of vermillion. Preserve or restore the labial vestibule

19. Lip defects are classified based on anatomic location, thickness, and size of the defect. Options include secondary intention healing, skin grafts, primary closure, local flaps, and free flaps. R econstruction ladder starts with the simplest procedures, moving up to the most complex. Defect-specific reconstruction of the lip

20. Defect-specific reconstruction of the lip The first choice is to use the remaining lip segment and if the defect size allows This choice assumes that there is enough lip to effect the repair while not creating microstomia D efect is full thickness and whether all three elements, skin, muscle and mucosa, need to be replaced Regardless of what the defect is, local tissue is the best option and is the perfect match in terms of color, thickness and composition Defects of the upper lip of less than 25% can be closed by direct approximation. For the lower lip , a slightly larger defect, up to 30% , can be closed directly For through-and-through defects, if there is insufficient lip to effect a direct closure, the next choice becomes the opposite lip Sometimes, however, there simply is not enough lip tissue to achieve this, then necessary to use tissue from the adjacent cheek , nasolabial region or neck When a defect takes up a substantial portion of an esthetic subunit, replacement of the entire subunit may provide the best cosmetic result.

21. The relaxed skin tension lines and facial wrinkles run parallel in the perioral region and generally perpendicular to the vermilion. Vertical scars are favorable for these esthetic reasons, as well as the fact that they tend to maintain lip height Reconstructive ladder Secondary intention healing Skin graft Primary closure Local flap Free flap r

22. Vermilion Defects Vermilion consists of specialized stratified squamous epithelium. The junction between the vermilion and white lip (white roll) is smooth and seamless; any abnormality is immediately obvious Indication - excision of very superficial lesions in the vermillion or to remove dysplastic tissue with malignant potential (actinic cheilitis)

23. Vermilion Defects Healing by secondary intention Small, partial-thickness defects, isolated to the vermilion or extending marginally to cutaneous lip not involving underlying orbicularis muscle may heal nicely through secondary intention. Wound contraction is still a disadvantage and should be anticipated Primary closure S mall vermilion defect in which the remaining vermilion shape and contour is not distorted Small lesions and scar of vermilion can be excised in fusiform fashion and closed primarily. Incisions should be placed in the radially oriented in RSTLs, and the mucocutaneous line should be avoided for optimal closure and cosmetic result. May cause redundant vermilion Mucosal V-Y advancement Mucosal advancement flap Mucosal cross lip flap

24. Mucosal V-Y advancement Small defect or volume deficiency of the vermilion may be restored using adjacent oral mucosa by V-Y advancement flaps movement No complications, such as vascular compromise, microstomia, retracted scars, or hypomobility, in restoration of vermilion V-shaped incision to the level of the orbicularis oris with the apex of incision positioned toward the gingivolabial sulcus, creating an island flap Pedicled on the underlying deep tissue. The triangular-shaped island is advanced into the adjacent recipient site, maintaining sufficient deep-tissue attachments to ensure its viability. The donor site is closed primarily in a Y configuration. In some cases, horizontal movement is used using a single or bilateral opposing island flap

25. Mucosal advancement flap Mucosal advancement flap. ( A ) Outline of cheilitis and severe dysplasia. ( B ) Vermillion excision. ( C ) Labial mucosal advancement. ( D ) Closure. ( E ) Six months postoperatively. ( F ) Diagrammatical depiction

26. R epairing small defects isolated to the vermilion ( reconstruction of a vermilionectomy of either lips of diffuse actinic chelitis ) I ncision is made along the vermilion border -- the labial mucosa is undermined in a plane deep to minor salivary glands and superficial to posterior surface of orbicularis oris muscle -- mucosal lining of the vestibule is mobilized and advanced forward to resurface the defect and remaining muscle Most patients regain some degree of sensation within months Di sadvantages – D istortion of the anterior vermilion line caused by wound contraction change in hair growth direction T hinning of the lip M ucosal retraction D ecreased mucosal sensation Color mismatch D ryness Excessive lip fullness from flap over advancement Limitations – Difficulty in reconstructing the fullness of the white roll because of scar contraction D ifficulty in accurately repositioning the anterior vermilion line when there is a skin defect adjacent to lip margin Inability to restore muscle bulk in defects involving the orbicularis- oris muscle

27. Mucosal cross lip flap Mucosal cross lip flap. The arrow shows the bipedicle flap being transferred to the upper lip.

28. Linear band of mucosa harvested from the vermilion or labial mucosa of the opposing lip A s a single pedicle flap or double pedicle (bucket handle) for reconstruction of a larger defect. Harvested from the region immediately posterior to the posterior vermilion line of donor lip Width of band is determined by the width of vermilion defect and by what will allow for donor site wound closure Dissected and elevated in the plane superficial to the muscle; however, the muscle and labial artery can be included. Raised, rotated, and transferred across the oral aperture and sutured into the opposing vermilion defect. D onor site is closed primarily if it is the buccal vestibule or using a mucosal advancement at the vermilion Division of the pedicle is performed after 2 to 3 weeks as the second stage. 2-stage surgery, patient discomfort and restricted mouth opening are the disadvantages of this technique.

29. Partial-Thickness Defect D efects limited to the tissue superficial to the orbicularis oris muscle and usually cause no functional problem. The basic challenge for the surgeon is esthetics. A perilabial partial-thickness defect can be closed primarily or with a variety of transposition flaps. When using local tissue for reconstruction, only the skin and subcutaneous tissue is used and underlying muscles remain intact. P referred to confine tissue movement within the aesthetic region unless it causes distortion. Conversion of partial-thickness defect to full thickness facilitates re-approximation, particularly when the vermilion is involved

30. Primary closure Small cutaneous defects in the lower lip and lateral subunit of the upper lip can be repaired by primary closure. Excellent cosmetic results may be achieved by designing fusiform excisions parallel to RSTLs, confined within the boundaries of the facial aesthetic subunits. An M- plasty at the end of the excision is useful to avoid extension of the incision beyond the aesthetic borders. If the lesion crosses the vermilion, the incision must cross the mucocutaneous line at 90 degree. In horizontal lesions, a Z- plasty may be used to disperse wounds and scars Cutaneous defects less than 50% of the width of philtrum may be reconstructed by primary closure; however, it can cause flattening of cupid’s bow or an upward pull of the vermilion caused by wound contraction

31. ( A–C ) Primary closure of vermilion with conversion of partial thickness. ( A ) Partial-thickness dog bite. ( B, C ) Tissue undermined and closed primarily

32. Primary closure

33. Island advancement flap Small to medium cutaneous defects involving lateral lips can be repaired by a subcutaneous island pedicled flap The flap is dissected down to the orbicularis oris muscle, maintaining a deep pedicle. The underlying facial musculature should not be violated. The flap is then advanced into the excision site and the donor site is closed in a V-Y fashion. Some remaining normal skin may be removed in order to position the final scar into the nasal base or aesthetic boundaries Intralabial transposition flap, labial rotational and advancement flap, melolabial transposition flap, and chin and submandibular transposition flap are also possible options

34. Island advancement flap. ( A ) BCC upper lip. An 86-year-old man with multiple prior surgeries. ( B ) BCC demarcated with flaps outlined. ( C ) BCC excised. ( D ) Advancement flaps raised bilaterally. ( E ) Closure. ( F ) Six months postoperatively.

35. Full-Thickness Defect

36. Small full-thickness defects: primary closure Full-thickness defect reconstruction requires replacement of skin, muscle, mucosa, or a reasonable substitute and multilayer repair. C lassified according to the size and location of the defect Small full-thickness defects: primary closure

37. Optimal primary repair requires the approximation of at least 4 tissue layers: mucosa, muscle, subcutaneous tissue, and skin epithelium. The anterior vermilion line is the principal landmark of the lip, and its location at the edge of the wound needs to be identified and marked before incision to avoid distortion during injection and dissection. Meticulous closure of the vermilion is critical, both anteriorly and posteriorly, to prevent asymmetry. Early approximation of the vermilion border is recommended as a guide for closure of the other layers and maximizes the cosmetic outcome. Precise anastomosis of the orbicularis oris muscle ends is important to reconstitute the oral sphincter and prevent notched or retracted vermilion Aesthetic wound closure can be achieved by undermining the skin and mucosal edge of the wound and closure of epithelium with slight skin eversion.

38. Z- plasty may be combined with design or performed as a secondary procedure. A V-shape (wedge) excision is the most common and simplest method to repair small lip defects and malignancies. The wedge resection is designed with the incisions perpendicular to the red lip, tapered as they enter the white lip. The excision is parallel to RSTLs, which are oriented vertically in the central portion and skewed in the lateral region of lip. The apex of the wedge should not exceed 30 and not cross the mental crease to avoid a conspicuous cutaneous deformity and scar. If both of these conditions cannot be met, another modification, such as a W- or U-shape design, should be used. A vermilionectomy can be performed at the same time as the wedge excision Attention should be given to the alignment of the vermilion and orbicularis muscle .

39. A W-shaped excision is a modification of a wedge excision that allows greater resection and preserves the integrity of the aesthetic subunit without extending the incisions beyond the mental or melolabial creases. The excision is planned, with the apices of the W oriented away from the vermilion border with each angle less than 30 In laterally located defects, the angle formed by the lateral subunit should be larger and obliquely oriented to properly align the closure Aesthetic results in the upper lip are often less satisfactory, in part, because of the specific aesthetic subunits and that the upper lip is able to withstand less tissue loss. Less satisfactory aesthetic result is particularly noticeable in mid upper lip defects at the philtrum and cupid’s bow.

40. ( A–F ) Wedge excision upper lip with primary closure. ( E,F ) Patient 3 months postoperatively. ( A–E ) Primary closure. Combination of V-shape (wedge) excision and vermilionectomy

41. Medium full-thickness defects of lip For upto two-thirds the width (30%–60% of lip length) of either upper or lower lip. Depending on the site of the defect, 2 major techniques are available to reconstruct these defects: I. Lip switch/cross lip flap (3 most common are the Abbe, Estlander , and Stein) II. Circumoral advancement or rotational flap

42. Lip-switch (cross-lip) flaps Axial flaps based on the labial arteries

43. Abbe flap

44. Described by Sabattini in 1836 and then by Abbe in 1898 for reconstruction of full-thickness defects affecting 30% to 60% of the width of either lip medial to the commissure Transfer of triangular shaped full thickness segment of lip tissue from lower lip to a full thickness upper lip defect Width of flap is one half width of the defect Labial artery is preserved on one side to serve as the pedicle of the interpolated flap Flap pivoted 180 degree on its pedicle Venous drainage by small veins parallel the course of the artery Approximately 5 mm of vermilion mucosa should be preserved for adequate blood supply.

45. Flap donor site closed primarily After 3 weeks pedicle is divided and the flap inset Cross lip flap may be pedicled medially or laterally except when defect is placed extreme laterally, in which flap is based medially First sign of motor reinnervation begin to appear a few months after flap transfer Bilateral Abbe flaps are advised for large central defects of the lower lip to avoid upper lip asymmetry Stein flap - a double Abbe flap.2 smaller symmetric flaps that form the central portion of the upper lip to reconstruct the lower lip. D isadvantages – D amage to the artery on elevation of the flap Relative microstomia 2-stage surgery R isk of injuring the flap by opening the mouth prolonged phase of denervation Thickened appearance caused by scar and trapdoor deformity.

46. Estlander

47. Similar to the Abbe flap but has its point of rotation at the commissure R epairing a defect involving the oral commissure of either lips and transfers a full-thickness lip flap around the oral commissure on a small medially vascular pedicle containing the labial artery Its dimension is equivalent in height and half the width of the defect It is usually designed as a triangle but can be modified to lie within the melolabial crease to reduce scarring N o pedicle division is necessary as the flap is rotated, performed as a one stage reconstruction Only suited for repair of defect involving lateral portion of either lip M ajor disadvantages of this flap are a blunted oral commissure and prolonged denervation (lasting 6–18 months). The blunted commissure frequently diminishes over time and revision commissuroplasty is rarely required

48. Bilateral lip advancement (lower lip)/Fernandes flap ( A ) Flap design. ( B ) Full-thickness defect, with excision of skin and subcutaneous tissue for advancement of flaps. ( C ) Closed in layers; scar in labiomental crease Full-thickness defects, measuring up to one-half of the lower lip may be reconstructed with unilateral or bilateral lip advancement wide, rectangular wedge of the tissue is excised Unilateral or bilateral full thickness advancement flaps are created by an inferior arc shape releasing the incision along the labiomental crease flaps are advanced medially around the mental prominence to close the defect. Incisional release at the commissure or removal of crescents around the mental prominence to mobilize the flap

49. Stair step flap . ( A ) Flap design. ( B ) Tumor excision and flap raised with excision of skin and subcutaneous tissue at each step. ( C ) Closure in layers. ( D ) Three weeks postoperatively.

50. Defect that is too wide to close directly but not wide enough to require transfer tissue by other flap designs Usually for smaller defects but capable of reconstructing a defect involving one-half to two-thirds of the lower lip Lower lip lesion is resected using a rectangular-shaped excision. E xcision of 2–4 small rectangles (skin & subcutaneous tissue) arranged in a stair-step fashion that descend from medial to lateral at a 45° angle from either side of the base of the defect following the aesthetic border of the chin. first horizontal incision is made parallel to the vermillion border and is approximately half of the width of the resected region W idth of each step is approximately one-half of its height At the termination of the incisions, bilateral, small triangles are excised with its apex located inferiorly As the lip segments are advanced, the series of rectangular and terminal triangles are closed, creating a stair-step wound closure line. unilaterally for lateral defects or bilaterally to close central defects

51. D rawback – G eometric scar that is unnatural to the lower face and does not follow the mental crease A dvantage – Minimized scar contracture unchanged muscle fibers direction P reserved innervation and vascularity of the flap owing to its broad pedicle I ntact commissures

52. Gillies flap Gillies fan flap. 1 and 2, Z- plasty is incorporated to the facilitated movement of the flap

53. R otation advancement flap described by Gillies and Millard in 1957 , centered on the labial commissure for closing large lateral defects of the lip Designed to transfer the remaining lip segment from one side of a defect together with the lateral portion of the opposing lip around the commissure. It is based on the superior labial artery and has a narrow pedicle This composite flap is created by full-thickness lip incisions from the inferior aspect of the defect, which extends laterally around the commissure and superiorly into the melolabial fold essentially paralleling the orbicularis- oris . A secondary incision is made toward the superior vermilion without compromising the superior labial artery. Then the flap is rotated and advanced to close the defect, and the layer closure is performed

54. Advantages – More available tissue from the nasolabial region, one stage reconstruction surgery, and maintained orbicularis- oris continuity. Limitation - microstomia, blunted commissure, vermilion deficiency, denervation of the orbicularis oris can lead to oral incompetence however, partial reinnervation seems to occur in 12 to 18 months. The Gillies flap can be used bilaterally or in combination with other flaps to restore large full thickness lip defects of up to 80% of the lip. Z- plasty may be incorporated to the facilitated movement of the flap.

55. McGregor flap Rectangular composite flap, based on the labial artery, created by a full-thickness lip incision and transfers the tissue from the melolabial region to the defect of the upper lip. McGregor has modified the Gillies technique to reconstruct upper lip defects, rather than rotating the flap about a point adjacent to the commissure, the flap is rotated about the commissure. This method brings the medial margin of the flap up to form the new vermilion border I ndicated - lateral upper lip defect when there is not sufficient tissue without recruitment of cheek tissue. This technique fails to reconstruct the muscle of the sphincter and the vermilion. disadvantage of this modification is that the fibers of the orbicularis oris are distorted as they rotate 90 degrees, which can alter sphincter function. Needs to be combined by other techniques mucosal advancement to reconstruct the vermilion. It can be used bilaterally for large upper lip full- thickness defects

56. Karapandzic Flap Labiomental crease  Melolabial crease

57. F ull-thickness cuts of the Gillies flap are eliminated in favor of partial-thickness incisions that preserve the radial neurovascular pedicle. Muscle fibers are mobilized by blunt dissection, and neurovascular structures are preserved. The primary advantage of the Karapandzic flap over the Gillies fan flap is the preservation of neurovascular pedicles and a functional lip. Separate Incision made through skin of flap and separate incision through mucosa on deep surface of flap Separation of subcutaneous tissue and muscle of flap by blunt dissection Reattach various muscle of facial expression to orbicularis oris in anatomical orientation Restoration of central full thickness defects of either lip is to design b/l flap of similar size(mirror image) to insure symmetry. Incision end at nasal alae Microstomia and rounding of the commissures are problems associated with this method

58. Large full-thickness defect Total lip reconstruction - biggest functional and cosmetic reconstruction challenge The defects usually involve the lower lip. Defects greater than two-thirds of the lip need transfer of adjacent cheek tissue or tissue from distant sites to prevent microstomia. If there is a lack of residual lip tissue, microvascular free tissue transfer must be considered. Potential complications of total lip reconstruction include hypertrophic scarring, disfigurement, loss of sensation, microstomia, loss of oral competence, and loss of natural gingivobuccal sulcus and difficulty in denture placement challenging.

59. Bilateral cheek advancement flaps (Bernard–von Burow ) Horizontal full- or partial-thickness incision extended laterally from the commissure and excision of the skin and subcutaneous triangles (von Burow triangles) at the superior and inferior margin of the flap to facilitate advancement Upper lip reconstruction is accomplished with the excision of 4 triangles and lower lip reconstruction with the excision of 3 triangles Preserve sensory innervation, technically difficult, and oral function is fair at best. F ails to restore the vermilion and needs to be combined with other techniques, such as a buccal mucosal flap or tongue flap, to reconstruct the missing vermilion. This technique is better suited for upper lip reconstruction because of less risk for the development of postoperative oral incompetence.

60. Webster ( A–D ) Webster Technique. ( A ) Large SCC. ( B ) Resection with flap design. The crescents are areas of skin and subcutaneous tissue that will be excised for flap advancement. ( C ) Closure: note the microstomia that will improve with time. ( D ) Postoperative results a few weeks later M odification of Bernard von Burrow for reconstruction of the lower lip by using a more linear horizontal advancement of the cheek, placing scar lines in natural facial skin creases and avoiding the violation of the aesthetic region of the chin Triangular excisions along the nasolabial fold with excision only through skin and subcutaneous tissue to minimizes the tendency for vertical deficiency of the lower lip and provides better muscle function.

61. Distant flap Distant flaps are used if adjacent local tissue is unavailable Flaps from the scalp, forehead, submandibular, deltopectoral, pectoralis-major, sternocleidomastoid, and cervicodeltopectoral flaps These flaps provide tissue for wound closure and lip restoration; but compared with local techniques, they are not capable of restoring adequate function and satisfactory cosmetics

62. Microvascular reconstruction R adial forearm free flap is most commonly used. RAFF along with the palmaris longus tendon - anchors to the orbicularis muscle and/or modiolus - as a sling between 2 commissures - provide static support for oral competence. It may also be fashioned to the nasolabial or malar periosteum. Alternatively, the flexor carpi radialis tendon or a nonvascularized folded fascia lata graft can be used as a sling over which the radial forearm flap is draped. A s a sensate free flap by performing anastomosis of the lateral antebrachial cutaneous nerve to the mental nerve to restore some competence and sensation (Sakai et al 1989)

63. Commissuroplasty Estlander cross-lip flap and other methods can cause blunting and distortion of lip commissures and shortening of oral fissure that require secondary correction. Gillies and Millard (1957) described excising a triangular segment of skin lateral to the rounded commissure, raising and rotating a vermilion flap from the lower (or upper) lip to reconstruct the opposite vermilion and mobilizing a mucosal flap to form the vermilion of the other lip.

64. S implest method of commissureplasty (Converse 1959, Weerda 1983) - making a horizontal full-thickness incision at the level of the blunted commissure, in the direction of the oral fissure, which extends laterally to the point corresponding in position of the contralateral normal commissure. Epithelium above and below the incision is removed; the labial mucosa is then mobilized and advanced forward on each side of the incision to restore a vermilion surface.

65. A Simple ‘‘Fishtail Flap’’ for Surgical Correction of Microstomia