CHAPTER Although an unfavorable outcome is something we strive to avoid, the reason for suboptimal results can be multifactorial. Sometimes, despite the best of intentions, the most fastidious technique, and the most careful planning, things go wrong. In cases such as this, there is really nothing the surgeon can do; the patient may pick at a wound, hematomas happen, infection is always a threat. Generally, the surgeon cannot control these things. The purpose of this chapter is to address issues that surgeons can control and to point out pitfalls that can trip up even the best surgeon. This chapter addresses why results of lip and cheek reconstruction may disappoint and what the surgeon can do to either avoid these problems or manage them. The face is how individuals present themselves and how others know and recognize them. Both the lips and the cheeks play an important role in this region of anatomy, and reconstructing them predictably is the reconstructive surgeon’s goal. Injury, disease, or surgical trauma can result in significant changes to the face that can profoundly affect the patient, not only in terms of appearance but even more importantly, in terms of function. This can have a significant effect on self-perception and quality of life. As far as the lip is concerned, subtle changes in the appearance of the vermilion border, oral commissures, or Cupid’s bow are easily detected by even the most casual observer. Loss of labial competence may interfere with the ability to articulate, whistle, suck, kiss, control salivary secretions, and eat. In fact, many patients who have problems with lip function and lip continence avoid eating in public because they are “awkward,” drool, and embarrass themselves and others. Neuromuscular injury can lead to facial asymmetry at rest and, even more particularly, during facial animation, and distressing functional disabilities are common. Lip reconstruction is not new. Surgeons have been trying to functionally and cosmetically reconstruct lips for centuries. For smaller defects, reconstruction can be very effective. However, where larger defects are concerned, reconstructing an aesthetically pleasing as well as a functional lip becomes increasingly difficult. The cheek, on the other hand, although it occupies a very prominent position in the face, is often thought of as a fairly innocuous part of the facial anatomy and is not afforded the same attention to detail in terms of reconstruction as, for example, the nose, the ear, the eyelid, or the lip. Plastic surgeons are often called on to reconstruct the cheek, and although it does not compare in intricacy and visual impact with the eyelid, nose, or lip, skillful restoration is nevertheless imperative. It is a less intricate piece of anatomy than other areas, but it is nevertheless a major contributor to facial appearance. Several aspects of the cheek are important. These include skin color, contour, and movement. It is also important that the cheek be symmetrical with the other side of the face, because asymmetry is a feature that catches the eye and bestows a sense of the abnormal, wherever it is encountered. One aspect of the cheek is that, unlike the central facial structures (the nose and lips), the cheeks are often viewed separately if, for example, the head is turned to one side or the other, as frequently happens in normal social interactions. So all aspects of both cheeks, in this situation, are not seen together. This is in contrast, for example, to the nose, where the right and left alae are instantly comparable. Thus a reasonably accurate replica of the intact contralateral cheek will result in a very satisfactory reconstruction, whereas a less than accurate alar reconstruction will provide a less than satisfactory result. Summary Box Common Problems with Lip and Cheek Reconstruction Lip • Notching of the lip • Blunting of the oral commissure • Microstomia resulting from large resections • Loss of oral continence Cheek • Ectropion of the lower eyelid • Excessive bulk of the flap reconstruction • Poor color match of regional or free flaps As with all reconstructions, it is important to consider what tissue is being replaced. In the case of the cheek, this is easy to see on first impression. The cheek consists of a soft tissue envelope of skin, subcutaneous tissue, muscle, and buccal mucosa draped over a bony framework, the most projecting part of which is the zygomatic prominence. Within this soft tissue is embedded the parotid gland and duct, the facial nerve, and the buccal fat pad. Furthermore, the texture of the cheek must be considered. On a woman it is smooth and soft. On a man it is partially hair-bearing and less smooth. Although contour and shape are important features, the aspect of cheek recon struction that commonly has a poor result is in skin color (Fig. 53.1a). In fact, skin color can be the cause of a poor result in any area of facial reconstruction. Skin color that is totally different from the native skin in an otherwise excellent reconstruction will stand out as a poor result. However, there are ways to address this. Choosing local tissue for the reconstruction brings in tissue of the same characteristics in terms of texture and color and is the best solution if it is possible. However, sometimes distant tissue must be used that brings its own characteristics with it. In terms of color disparity, deepithelializing any flap and replacing the skin cover with a split calvarial graft from the parietal scalp will alter the color of a nonmatching flap to match the facial skin color1,2 (Fig. 53.1b). This results in a major improvement in the perception of the reconstruction. Under normal circumstances reconstructive options are selected based on tissue availability and often size. In the head and neck in general and in the face in particular the fact that the reconstruction is going to be the visual evidence of what surgery the patient has undergone also must be considered. The surgeon can think of the cheek as a separate aesthetic unit, but reconstruction of the cheek typically affects nearby units—for example, the pull on the lower eyelid from a cheek advancement flap. Also, reconstruction may include an adjacent structure such as part of the nose or an eyelid. Disease and trauma do not respect aesthetic subunits! Reconstruction of the underlying bony skeleton is obviously an important part of cheek reconstruction and is an area that, in the past, was neglected. When reconstructing any body part it is important to take stock of what tissue is missing and what needs to be reconstructed. In most cases it is necessary to replace what is missing, and this includes bone. This chapter does not discuss maxillary reconstruction, but this may form part of the reconstruction requirements of the cheek, and failure to reconstruct a bony defect will result in major problems when combined with postoperative and postradiotherapy scarring (Fig. 53.2). Fig. 53.1 (a) This cheek was reconstructed with a free parascapular flap. Despite the fact that the defect was adequately covered, the difference in color between the flap and the native skin would never resolve and would render this an unfavorable outcome. (b) The flap has been deepithelialized and resurfaced with a split-thickness skin graft from the parietal scalp. This vastly improves the appearance of the reconstruction. Fig. 53.2 This patient has had a maxillectomy defect reconstructed with a muscle flap. The soft tissues, including the muscle, have retracted after radiation, and the patient has lost facial projection and facial height. Without a bony foundation, such a deformity will always ensue and is very difficult to rectify. Fig. 53.3 This 37-year-old woman has sustained facial burns. Her lips do not close and her teeth are exposed, making dental hygiene impossible and rendering the patient susceptible to caries. Fig. 53.4 This patient has had his lip cancer resected. The reconstruction was made with a Karapandzic flap. However, failure to properly repair the orbicularis oris muscle has resulted in a very visible scar that could have been avoided. Many procedures have been described to reconstruct various lip defects, and some of the oldest remain effective and in use today. In fact, most of the reconstructive techniques in present use are modifications or refinements of techniques that were described in the medical literature over the past two centuries. As already mentioned, the lips not only have unique functional requirements but also occupy the central aesthetic unit of the face so that any irregularity of the lips, even if function is not affected, is instantly recognizable. A detailed description of the various techniques used in lip reconstruction is beyond the scope of this chapter. Rather, this chapter focuses on areas where mistakes are commonly made that can adversely affect outcome. As already mentioned, the lips are an important aesthetic feature of the lower face, and any deformity of the lips is instantly recognizable. Even minor deformities are easily noticed. More important, however, are the functional characteristics of the lips. The lips play a very important part in speech articulation, as anyone who has tried to speak after extensive local anesthesia at the dentist can attest. The lips are also vital for the maintenance of oral competence.3,4 Sensation allows the lips to monitor the texture and temperature of substances before oral intake. The goals of lip reconstruction are many. The most important of these is function. No matter how good a reconstructed lip looks, if it cannot maintain oral competence, the reconstruction is a failure. Maintenance of oral competence is vital. It is important that the lips close, not only to maintain oral competence but also to protect the dentition. Teeth degenerate if exposed, and as a result patients de velop extensive dental caries, cavities, root exposure, gingivitis, and other conditions (Fig. 53.3). Also important is maintenance of an adequate oral aperture to facilitate oral hygiene and to accommodate removable dentures. The labial vestibule is an important feature of labial anatomy, and its preservation or re-creation is important for oral hygiene, dental care, and denture fitting. To achieve these functions, preservation of labial sensation is important, and because of the vital role of the lips in facial aesthetics, maximizing cosmesis is one of the key goals of reconstruction.5,6 If the orbicularis oris muscle has been disrupted it is vitally important to restore continuity of that muscle if at all possible. Failure to do so can result in notching or, at the very least, an unsightly scar7 (Fig. 53.4). Careful reapproximation of muscle edges with intact motor innervation usually results in complete restoration of dynamic orbicularis function. Although some authors contend that the upper lip functions primarily as a curtain that could be replaced with a static flap reconstruction, there is no doubt that a completely intact sphincter with active function and sensation yields the best functional result.8,9 Fig. 53.5 (a) A patient with extreme microstomia after a burn injury. This extent of microstomia needs to be released. (b) The release was maintained with splinting. (c) At 15-year follow-up showing maintenance of commissuroplasty. If reconstruction of the sphincter is not feasible, an adynamic reconstruction must be pursued that provides some degree of oral competence, as in the case, for example, of free flap reconstruction. In free flap lip reconstruction it is important to use a tendon (usually the palmaris) to drape the flap over and to maintain tension in the palmaris by weaving it through the intact orbicularis on either side of the resection so that when the orbicularis contracts, it also pulls on the tendon and tenses the reconstructed lip. In repairing or reconstructing the lips, one of the main dangers is resulting microstomia. Although patients can function reasonably well with a small degree of microstomia, it is very important to minimize it, because not only may it interfere with function but, as already mentioned, it can also hamper oral hygiene. Patients should be counseled before surgery that denture insertion and removal may be difficult, or, quite simply, not possible (Fig. 53.5). Decreases in the shape or depth of the labial vestibule can exacerbate oral incompetence and drooling and may preclude patients from wearing a removable prosthesis. Preservation of labial sensation is vitally important to maximize oral competence and to fulfill its other sensory roles.10,11 Because of the anatomic configuration of the upper lip and, specifically, because of its aesthetic subunit structure, its reconstruction presents certain aesthetic challenges that are not of concern during lower lip reconstruction. Loss of the philtral columns and Cupid’s bow creates a noticeable cosmetic deformity that presents a significant reconstructive challenge. In profile, the upper lip should protrude in front of the lower lip, so a reconstruction that results in excisional tightness with reduction or elimination of this relationship not only is undesirable, but will certainly result in an inferior aesthetic outcome. Thus although it may not be necessary to insert extra tissue, such as a cross-lip flap, to close the defect, it may be necessary to preserve the normal relationship of the upper to lower lip and thereby to preserve aesthetic balance. In contrast, the lower lip is better able to withstand tissue loss without significant changes in its profile appear ance and can sustain a loss of one third of its breadth before tightness or asymmetry begins to show. Early lip reconstruction techniques focused primarily on primary closure of the surgical defect, whereas more contemporary techniques attempt to address the importance of an aesthetic, functional result. Reconstruction of the aesthetic subunits as described by Burget and Menick8 is helpful, and aesthetic features such as Cupid’s bow and the philtral columns must be carefully restored. Failure to restore these landmarks results in an abnormal appearance that is instantly detectable. One of the features that is readily picked up by the human eye is asymmetry. Surgery that results in asymmetry is typically more noticeable than symmetrical alterations. As an example, rounding of both commissures is less obvious than rounding of one side. Whenever possible, the height, projection, and relationship between the upper and lower lips should also be preserved or replicated. This is most easily achieved by using tissue from the adjacent or opposing lip.12,13 Reconstructive choice is important when considering the lip. In the case of trauma, the damage is already done, and the surgeon’s task is to repair and reconstruct the lip so that it is as functional and aesthetically pleasing as possible. For patients facing lip resection for disease, the task is no different; the surgeon must reconstruct the lip to be as functional and aesthetically pleasing as possible. However, in the latter case the surgeon has the luxury of planning what reconstruction will best suit the patient. The choice depends on multiple factors, such as prognosis, general medical condition, availability of local tissue, history of prior radiation, and comorbidities. The lips are somewhat unique, however, in that the need to reconstruct the lips is very different from, for example, the need to reconstruct a breast. Oral competence is vital for normal eating, articulation, and communication, so the option to not reconstruct the lip is essentially nonexistent. Fig. 53.6 The difference between a V-shaped wedge and a W-shaped wedge is depicted. If this patient had a V-shaped wedge, the scar would extend into the chin subunit, whereas use of a W-shaped design prevents that extension of the scar and results in a better outcome. After injury or after surgical resection for disease, there are several options for reconstruction of the lips.14,15 The first choice, of course, is to use the remaining lip segment if the defect size allows. This is by far the best option. This choice assumes that there is enough lip to effect the repair without creating microstomia. Another consideration is whether the defect 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, because it replaces what has been lost 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. However, if this resection includes the philtrum, then that structure needs to be reconstructed and, as already alluded, the relationship between upper and lower lips needs to be maintained. For the lower lip, a slightly larger defect, up to 30%, can be closed directly. Once again, care must be taken to ensure accurate closure of all layers. Repair of the orbicularis oris and reconstitution of the circumoral sphincter are the most important aspects of a functional repair. Failure to properly repair all of these structures will result in an unfavorable outcome. As already mentioned, failure to repair the orbicularis can result in an obvious scar that is easily seen on animation. It is also important to plan the scars. A V-shaped wedge design usually permits closure of smaller defects, whereas a W-shaped excision facilitates the closure of larger defects. Furthermore, this modification will generally allow for the scar to be kept above the mental crease. This improves the cosmetic appearance of the repair, because it preserves the integrity of the chin aesthetic subunit (Fig. 53.6). Failure to align the vermilion properly can result in a very visible scar that would otherwise not be noticed. Notching, for example, can be the result of scar contracture; a straight-line repair that looks great initially may contract and produce a notch, a situation that can be avoided if a z-plasty is incorporated into the repair. Lip-switch (cross-lip) flaps fulfill the requirement of providing tissue of like composition and appearance. These are axial flaps based on the labial arteries. They replace like tissue with like, replacing the trilaminar defect in one lip with trilaminar tissue from the other. The classic Abbé flap can reconstruct medial or lateral lip defects with a full-thickness composite flap that reconstructs all three layers and restores continuity of the vermilion, whereas the Estlander flap is essentially a circumcommisural lip-switch flap similarly supplied by the labial artery.16 Surgical technique is important, and there are a few technical principles that are important to follow to achieve optimal results. My personal approach is as follows: 1. The width of the flap does not need to be as big as the width of the defect. This technical trick allows for repair of the defect by taking advantage of the inherent elasticity of the lip tissues while, at the same time, reducing the amount of tissue that has to be sacrificed from the donor lip, thereby making closure of the secondary defect easier. Thus both lips end up a little smaller, but by taking some tissue from both lips, better balance between the two lips is maintained. 2. The height of the flap needs to match that of the defect. Although less width may be acceptable, less height will result in some element of notching and will produce a significantly inferior result. 3. The position of the flap relative to the opposite lip is an important technical point to appreciate. This refers particularly to the Abbé flap and is important because the position of the flap determines the position of the pedicle. Essentially the pedicle should be placed roughly opposite the midposition of the defect, because the flap will be half the width of the defect, so when the secondary defect is closed, the pedicle ends up being in precise alignment with one end of the defect (Fig. 53.7). Pedicle division is performed 14 to 21 days later. With the Abbé flap, it is also important not to overly skeletonize the pedicle or the labial artery. This can result in injury to the pedicle and possible avulsion. Leaving a cuff of tissue around the vessel will mitigate this problem. A useful trick to determine the position of the pedicle is to note the position of the labial artery when cutting the nonpedicle side of the flap. Adhering to the aesthetic subunit principle, Burget and Menick8 suggested that defects constituting more than half of a topographic subunit of the upper lip necessitate removal of the remaining portions of the subunit. This will allow reconstruction of the entire subunit to be performed by using a foil template of the defect to design the Abbé flap in the lower lip so that exactly the amount of tissue resected from one lip is transferred from the other. However, this approach may have some limitations in terms of the amount of tissue available to reconstruct a given defect, and a combination of both methods is probably the most expedient approach.
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Reconstruction of the Lip and Cheek
Avoiding and Managing Unfavorable Results and Complications
Lip Reconstruction
Lip Function
Goals of Lip Reconstruction
Preoperative Planning
Surgical Considerations
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