What are the principles of lip reconstruction?

Principles of Lip Reconstruction

Lip reconstruction requires a careful balance between functional restoration and aesthetic considerations, with the primary goal of maintaining oral competence while preserving normal appearance. 1

Fundamental Principles

• Tissue conservation should be the first priority whenever feasible to maintain sphincteric function and balance appearance 1
• The lips deserve special consideration due to their critical role in cosmesis and function, with distortion potentially resulting in significant functional and aesthetic impairment 2
• Local tissue should be used whenever possible to provide the least donor site morbidity and the best overall tissue color and texture match 3
• Dynamic reconstruction should be attempted whenever possible to preserve function 3

Functional Considerations

• Primary goals include restoration of oral competence, maintenance of oral opening, and preservation of speech abilities 3
• Maintaining the ability to eat and drink without leakage is essential for nutrition and quality of life 1
• Preservation of sensory function should be considered when possible 1
• Avoiding microstomia (restricted mouth opening) is critical for long-term function 4

Aesthetic Considerations

• Reconstruction should restore normal anatomic relations for both active (smile) and passive (form) cosmetic outcomes 3
• The division of lips into aesthetic subunits is beneficial in designing reconstruction procedures 5:
  • Upper lip: two lateral subunits and a median subunit (philtrum)
  • Lower lip: single aesthetic subunit 5
• Matching tissue size, texture, and color is essential for optimal cosmetic results 1
• Scars should be placed along natural boundaries when possible, such as the vermilion border or philtral columns 2

Reconstruction Approach Based on Defect Size

Vermilion Defects

• Lesions located exclusively on the vermilion can be removed using a transverse mucosal incision to hide the scar at the junction of the vermilion and vestibular mucosa 2
• Lesions traversing both vermilion and cutaneous tissues may require a vertical incision 2

Small Defects (<1/3 of lip)

• Primary closure is often possible with careful undermining and mobilization of adjacent tissue 3
• Early surgical resection may be considered for small lesions in cosmetically favorable areas 2

Medium Defects (1/3 to 2/3 of lip)

• Local flap techniques are preferred, including:
  • Webster-Bernard cheek advancement flaps 6
  • Abbe cross-lip flaps (borrowing tissue from the opposing lip) 6
  • Karapandzic rotation advancement flaps (preserves neurovascular supply) 6

Large Defects (>2/3 of lip)

• Bulkier lesions that cause lengthening of the lip or cross the vermilion-cutaneous border are best addressed using a wedge excision 2
• For extensive defects, consider:
  • Combined local flaps 3
  • Free tissue transfer for total or near-total lip reconstruction 6
  • Innovative techniques such as split zygomaticus major muscle sling reconstruction 4

Post-Reconstruction Care

• Lubricate lips with lip balm or lip cream to promote healing 7
• Maintain good oral hygiene with a soft toothbrush and mild fluoride-containing toothpaste 7
• Avoid irritants that may delay healing, including spicy foods, hot foods and drinks, and citrus fruits 7

Common Pitfalls and Considerations

• Debulking lip lesions while preserving vermilion can be exceedingly difficult due to the challenge of separating tissue from orbicularis oris muscle 2
• Eversion of the lower lip may require excision of a mucosal strip, while correction of inversion may require a dermal implant or graft 2
• Setting the "white roll" (ridge at the vermilion-cutaneous border) and restoring normal sublabial concavity can be particularly challenging 2
• Failure to consider functional needs (e.g., denture use) can lead to poor outcomes 3
• Inadequate assessment of local tissue characteristics (skin laxity) and previous treatments (surgery/radiation) can compromise results 3