Evaluation And Planning

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Aesthetics and function are both very important in lip reconstruction. The surgeon should plan to place lines of incision compatible with the creases that surround the lip, the relaxed skin tension lines respective to that part of the lip, or to the anterior vermilion line for optimal scar camouflage. Incision lines hi the central region of the upper lip may in some cases be made compatible with the vertical lines of the philtrum.

Reconstruction of smaller defects of the lip can generally be done with readjustment of tissue from within the lip complex, restoring lip with adjacent lip tissue. Restoration of an intact lip muscle sphincter is strongly preferred, unless doing so would result in an excessive microstomia. Reconstructions that produce an adynamic lip segment are generally less ideal as they are more likely to result in functional incompetence. Some patients do function reasonably well with an ady-namic lip segment, particularly if the reconstructed lip is suspended or reconstructed to reduce lip laxity. The importance of maintaining muscle function is relatively greater in the lower lip. Problems with oral competence are more likely to occur in reconstructions of the lower lip and in reconstructions that involve larger portions of either lip.

In general it is best if the muscles of facial expression that surround the lip complex sustain minimal adverse change. When tissue is taken from the cheek for full-thickness lip repair, there is little appreciable gain that can be made by including facial musculature in the composite flap. In all reconstructions consideration should be given to how scar contraction will eventually affect the final result in both static and dynamic situations.

Aesthetic reconstruction of the upper lip requires some special considerations. The greatest problem in many upper lip repairs becomes how to prevent distortion of or restore the philtrum. In many cases it is not restored completely, an issue that tends to be less noted in older patients. Distortion of the nasal base can also produce a visible deformity and potentially impairment the nasal airway as well. In males, it is also important to recognize that while most of the upper lip skin is bearded, skin immediately below and lateral to the nasal ala on both sides is not. Transfer of either bearded or nonbearded skin into the wrong site can in some cases produce significant cosmetic detraction.

The bilateral melolabial (nasolabial) creases and, to a sometimes lesser extent, the mental crease are facial landmarks that tend to be very apparent. Even relatively minor distortion of their shape may be readily noted. While these are often excellent sites for camouflage of scars, they are lines that should be strongly considered and kept natural in any aesthetic lip repair. It should be recognized that the most superior part of the melolabial crease rises on both sides and does not attach to the ala until it reaches its upper margin (Fig. 2B). It is also important to recognize that as it descends, the natural melolabial crease passes relatively close to the oral commissure on both sides. Flaps designed from this region of the lip will commonly need to include some amount of cheek tissue lateral to the actual melolabial crease if they are to fit into most lip defects.

With tissue transfer, it is necessary to recognize that there is a natural disparity in thickness to lip tissue about the mouth opening. Lip tissue near the oral commissure on either side is appreciably thinner than lip tissue from the central region. Accommodation must be made for this, particularly in approximation at the free margin of the lip.

When planning for anything more than a simple lip reconstruction, it is normally helpful to consider a variety of repair methods so that the best choice can be made (Fig. 3A and B). Defects that are skin only should be addressed with repairs done similar to those in other skin areas. With full-thickness repairs first consideration is usually given to primary closure. If this is not suitable, then consideration is made for some method of flap reconstruction. A first preference is normally given to flap designs that involve movement of tissue from within the lip complex, with thoughts of confining scars to this aesthetic unit and also attempt to restore a complete, circumoral muscle sphincter. If these initial choices are likely to result in excessive microstomia, consideration should then be given to various flap designs that can provide a satisfactory restoration using tissue from the adjacent cheeks, chin or some more distant site. Reconstruction of a total lip defect presents a very serious challenge, as all available methods of repair impart some detractive consequences.

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