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Figure 3 (A) Options for W-lip closure, opposing advancement flap repair, and cross-lip flap are all being considered for this patient as the lip cancer is about to be resected. (B) Note divergent outline planned along mental crease for possible opposing advancement flap repair versus circumoral Karapandzic flaps.

Figure 3 (A) Options for W-lip closure, opposing advancement flap repair, and cross-lip flap are all being considered for this patient as the lip cancer is about to be resected. (B) Note divergent outline planned along mental crease for possible opposing advancement flap repair versus circumoral Karapandzic flaps.

RECONSTRUCTIVE OPTIONS Primary Cutaneous Lip Repair

Closure of a smaller cutaneous defect is best done with a basic fusiform design, with the long axis preferably placed in parallel with the relaxed skin tension line appropriate for that particular site of the lip. Orientation of the long axis in the fusiform design should be made progressively more oblique for defects that approach closer to the oral commissure on either side, similar to what is seen with the natural lip rhytids. Either end of a fusiform may be modified with an M-plasty design to limit extension of the long axis beyond a desired point, however one has to then deal with two diverging angles of closure. Defects of as much as 2 cm can generally be closed in primary fashion, though sometimes the repaired lip may appear to be somewhat tight until the wound site is fully matured. The end of a fusiform may have to be carried over the free margin of the lip in order to minimize distortion of the vermilion as the skin margins are pulled together over the lip muscle.

Skin Grafts

A skin graft may be used to restore a cutaneous defect of either lip. A full-thickness skin graft is more often preferred as they tend to offer a better match of color and thickness and undergo less eventual contraction than split-thickness skin grafts. With placement of any skin graft in the lip, this author advises that it be made large and set into the defect with a minimum of stretching, so that there will be less ultimate contraction of the grafted defect site. Any skin graft placed on the lip will require some manner of adequate immobilization until it becomes sufficiently attached to that site. A split-thickness skin graft, dermal, or allograft are the common modalities used in restoration of the buccal surface of the lip where the consequences of contraction and poorer match are not generally seen. A skin graft placed on the external surface of the lip will tend to look better if it somehow restores a full aesthetic unit rather than filling a random defect. One site in which a skin graft may offer the best means of restoration is the central portion of the philtrum (Fig. 4A and B).

Local cutaneous flap transfers may be done with a variety of designs within the confines of the lip complex. Due to the relaxed skin tension lines of the lip, vertical scar lines are better accepted than those that are more horizontal, unless they are placed along the melolabial or mental creases. Local flaps brought into the lip complex should not violate the anatomy of the outlining lip creases or distort the normal patterns of bearding.

Primary closure of a defect in the upper lip can be more difficult due to the effects of pulling on the philtrum and nasal base. Rotation/advancement of tissue from the region immediately inferolateral is an excellent option for repair of many defects, particularly if they involve the more lateral portion of the upper lip (Fig. 5A-C). Often an ideal option for local cutaneous repair within the lip complex is the use of two opposing flaps, borrowing skin of various amounts from both sides of the defect. Transfer of such flaps employs varying degrees of advancement and rotation, particularly if tissue is transferred around the oral commissure (Fig. 6A-C). It is important to consider how tissue transfer from the central region of the lip will affect the philtrum and nasal base. Continuing a release incision beneath the nasal base may actually allow a stretching out of the philtrum rather than a pulling to one side.

Figure 4 (A) Mohs defect involves lower half of philtrum with slight extension into vermilion. (B) Result with full-thickness skin graft at about eight months.

Transfer of cutaneous tissue in the lateral portion of the lip will occasionally result in a hooding or upturn of the oral commissure, which may resolve gradually secondary to the natural pulling of the lip musculature over time or be corrected with a later revision procedure.

Vermilion Repair

Restoration of the vermilion surface of the lip is most often accomplished with forward advancement of mucosa from the inner surface of the lip (Fig. 7A and B). The mucosal surface of the lip offers a tissue that is very similar to the vermilion, though is commonly appears to be slightly more shiny and red, particularly when compared to vermilion that has become more faded with solar exposure over time. This method of repair involves raising a composite of mucosa and submucosal tissue from the posterior or deep surface of the orbicularis oris muscle and advancing the flap forward, usually to the anterior vermilion line. While flap elevation has traditionally been done with sharp dissection, sensory function may be better preserved by raising

Island Flap Definition

Figure 5 Illustration of labial rotation/advancement flap. (A) Basic outline for flap. Triangular excision may be done at distal margin, though not generally necessary. Triangle taken at base of defect to facilitate comfortable closure in the vertical plane. (B) Transfer of flap. Note that width of flap must be adequate to fill in more medial region of upper lip. Flap outline will normally have to extend a slight distance into the cheek to allow for this width. (C) Closure facilitated by smaller rotation/advancement of flap from central region of lip with care to minimize distortion of philtrum and nasal base.

Figure 5 Illustration of labial rotation/advancement flap. (A) Basic outline for flap. Triangular excision may be done at distal margin, though not generally necessary. Triangle taken at base of defect to facilitate comfortable closure in the vertical plane. (B) Transfer of flap. Note that width of flap must be adequate to fill in more medial region of upper lip. Flap outline will normally have to extend a slight distance into the cheek to allow for this width. (C) Closure facilitated by smaller rotation/advancement of flap from central region of lip with care to minimize distortion of philtrum and nasal base.

the flap with a meticulous spreading technique, taking care to identify and preserve as many of the fine neural structures as possible. These structures are then freed up enough so that they can be stretched along with the flap at the time of flap transfer. This author advocates minimal flap dissection with belief that there will be less eventual flap contraction as the wound matures over time. With flap contraction the lip may become slightly thickened in appearance and whisker hairs could begin to bother the opposing lip as the anterior vermilion line gets pulled back slightly (Fig. 7C). A later, less aggressive readvancement of the mucosa could be considered, though is seldom necessary.

Restoration of the vermilion may also be done with two-staged transfer of mucosal tissue from the opposing lip. This method of transfer can be designed either as a smaller flap using a single pedicle or a much longer flap designed initially with

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