Lip lesions are typically due to trauma, infection, or tumors. Defects under one-fourth to one-third of the total lip length can be closed primarily. This involves the apposition of the lateral margins from the wound on sides and direct layered closure. The muscle is approximated with interrupted deep absorbable sutures. The white roll is closely approximated and then the labial mucosa and vermilion are closed. Finally, your skin is closed with fine nonabsorbable sutures.
Ideally, primary closure should cause minimal aesthetic and functional deformity; however, it can sometimes result in decrease in the oral aperture as well as asymmetry of the involved lip. Furthermore, primary closure in the upper lip could be problematic because opposing the edges of a big wound may create unfavorable distortion from the philtrum.
The vermilion spans the entire length of the oral aperture, becoming increasingly narrow and tapering laterally since it approaches the commissure on sides. It forms the transition zone between skin and mucosa of the inner mouth. Defects involving the vermilion ranges from superficial, such as leukoplakia in which there is limited compromise from the integument, to significant, in which tissue deficit extends to deeper muscle and mucosal tissue. Although small defects of the vermilion can be primarily closed or left alone to heal by secondary intention, larger defects require reconstruction.
Precise alignment from the vermilion-cutaneous margin on both sides ensures a curvilinear appearance from the border and avoids step-offs or lip notches after healing. The standard labial mucosal advancement flap can replace vermilion resections that span the whole length of the lower lip. The mucosa on the buccal top of the lower lip is undermined and advanced to the previous mucocutaneous junction.
Maximal use of blunt undermining helps to preserve sensory innervation of the vermilion-to-be. Additional advancement can be achieved using a transverse incision in the gingivobuccal sulcus and in the process creating a bipedicled mucosa flap based laterally. Extensive flap mobilization usually results in an insensate flap.
A notched appearance from the vermilion can result from scar contractures or vermilion volume deficiency (because of previous surgery or trauma). Scar contractures can be released having a Z-plasty. This process recruits vermilion tissue on each side of the scar to functionally lengthen the scar in the antero-posterior and supero-inferior direction. A notched appearance because of volume deficiency could be corrected having a local musculomucosal V-Y advancement flap.
The next option of donor tissue is a flap from the ventral top of the tongue but it's less than ideal due to color mismatch. Pribaz described the facial artery musculomucosal (FAMM) flap, which is a based on the facial artery and is used to reconstruct defects involving vermilion, lip, palate and a host of other oral structures. Labia minora grafts may also be used to reconstruct the vermilion.
Commissure deformities often result from electrical burns, trauma, or reconstructive lip surgery. For post-burn commissure contractures, splinting techniques have reduced the need for surgical correction. Nevertheless, repairing deformities that don't react to conservative measures remains complex.
The intricate network of adjoining perioral muscle tissue in the modiolus (that is crucial for oral competence and facial animation) is nearly impossible to reconstruct. Furthermore, the contralateral commissure may be the gold standard of comparison when looking for the outcomes of the unilateral reconstruction, thus leaving little room for discrepancy.
Various approaches attempt to repair mucosal defects involving the commissure including the simple rhomboid flap, in which intraoral mucosa is advanced to reconstruct the commissure angles after an incision is built to widen the commissure laterally. The tongue flap may also be used when the mucosal defect is thick in the region of the commissure. Despite many proposed techniques, commissure reconstruction remains a hard task and attempts at reconstruction often yield poor results.
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