Nasolabial (Gate) Skin-Muscle-Mucosal Flap to Lower Lip

EDITORIAL COMMENT

This procedure certainly accomplishes what it sets out to do; however, the editors are concerned with the innervation to the upper lip unless care is taken not to damage the muscle while making the nasolabial incisions.

There are only a few reports in the literature on total lower lip reconstruction using innervated muscle-bearing flaps (1, 2). However, when planning a complete reconstruction of the lower lip, the following points should be considered: First, the flaps used should be local flaps, including innervated muscle. Second, all the suture lines should be in natural facial creases or follow the function lines of the various facial aesthetic units. Finally, the flaps should be large enough to replace tissue loss.

INDICATIONS

Some previous techniques (3, 4, 5), although producing excellent functional and aesthetic results, created a tight lower lip with obvious protrusion of the upper lip. Other procedures also produced a large dog-ear on either side of the mentolabial groove, requiring that large amounts of skin be discarded postoperatively for correction.

The gate flap (6), which uses a flap from each nasolabial fold, is an improvement over previous procedures. The main advantages of this design are (a) the flap can be made 3 cm larger than nasolabial rotation flaps, (b) rotation of the flap is possible without the formation of a dog-ear, (c) the flap contains innervated muscle, and (d) the procedure can be carried out in one stage.

OPERATIVE TECHNIQUE

The whole of the affected lower lip is excised as a rectangle (Fig. 168.1A, BB‘DD‘). The inferior margin of resection (DD‘) follows the mentolabial groove. Whenever possible, a 3- to 4-mm-wide strip of labial mucous membrane is left attached near the labioalveolar sulcus. The lateral margin of resection (BD and B‘D‘) is usually placed 0.5 to 1.0 cm laterally to perpendiculars dropped from the labial commissures (OO′), but it may extend 2 cm laterally in older patients with wrinkled faces. The width of the nasolabial skin-muscle-mucosal flaps (BC = DE, B‘C′ = D‘E‘) is usually 3 cm, and the suture lines of the flap donor sites (AED, A‘E‘D‘) should follow the natural nasolabial fold. The dotted lines (AlB, AmC, A‘l‘B‘, A‘m‘C′) represent incisions made through the mucous membrane, which should be about 1 cm wider than the flap itself, so excess mucous membrane can be available for reconstruction of the new red lip.

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