CHAPTER 48
Surgical Management of Lip Cancer

Terence E. Johnson,¹ Michael Grau, Jr.,² Craig Salt,³ and Robert M. Laughlin²

¹Department of Otolaryngology, Naval Medical Center San Diego, San Diego, California, USA

²Department of Oral and Maxillofacial Surgery, Naval Medical Center San Diego, San Diego, California, USA

³Department of Plastic Surgery, Naval Medical Center San Diego, San Diego, California, USA

Lip Switch Flaps: Abbe and Estlander Flaps

A method of achieving immediate reconstruction of lip resections with primary reconstruction of the upper or lower lips utilizing tissue from the opposite lip.

• Abbe flap: A segment of the opposing (donor) lip is rotated to reconstruct the resected (recipient) lip. The Abbe flap is primarily utilized for resections not involving the oral commissure. There are numerous variations of the Abbe flap.
• Estlander flap: Similar to the Abbe flap, but involves rotating the opposing (donor) lip around the oral commissure to reconstruct the resected (recipient) lip. Utilized for resections involving the oral commissure. Frequently requires a secondary commissuroplasty.

Indications

1. Defects of one-half to two-thirds of the upper or lower lip as a result of pathology or trauma
2. The Abbe (Sabattini) flap is utilized for medial defects
3. The Abbe flap can also be used during secondary reconstruction of the philtrum in bilateral cleft lip patients
4. The Estlander flap is utilized for lateral defects with commissure involvement. This area is difficult to reconstruct due to the complex muscle interdigitations and functional importance

Contraindications

1. Patient who is unable to tolerate closure of lips for 2–3 weeks
2. Cases with evidence of damage to the proposed vascular pedicle
3. Defects of the lip greater than two-thirds of the total lip length

Flap Anatomy

The labial artery serves as the pedicle of the interpolated flap and venous drainage is provided by small veins parallel with the labial artery.

Surgical Technique: Abbe Flap

1. The patient is positioned supine on the operating table. The surgical site is prepped and draped in a ­sterile fashion.
2. The height and width of the defect are measured. A flap is designed on the opposite lip directly adjacent to the defect. The height of the flap will be 1:1, and the ratio of the width of the flap will be 1:1/2 of the defect.
3. Pertinent surgical anatomy and flap design are marked with methylene blue and a 30-gauge needle. Key areas to mark include the vermillion borders on both sides of the defect and both sides of the donor site. This will allow for the correct reapproximation of the donor site after flap harvest and inset of the flap to the defect.
4. Local anesthetic containing epinephrine is injected within the surgical site. Local anesthetic is only injected after the defect is measured, and the donor flap has been designed to avoid distortion to the tissues.
5. A full-thickness flap is developed from the donor site. The labial artery is visualized and divided only on one side of the flap (typically the lateral side, preserving the medial side).
6. The flap is elevated from the donor site, maintaining the vascular pedicle and a small cuff of muscle.
7. The flap is rotated into the defect. Care must be taken to ensure the vascular pedicle does not kink or occlude arterial flow to the flap. Adequacy of the arterial flow may be verified by Doppler ultrasound.
8. The donor site is closed in three layers from the inside out (mucosa, muscle, and skin). Vermillion border alignment is critical. The use of the previously marked vermillion border with methylene blue may assist with proper alignment.
9. The flap is then serially inset, in a three-layer closure, paying close attention to accurately align the vermillion border.
10. The vascular pedicle is left attached for 2–3 weeks to establish sufficient collateral vascularity prior to final division of the pedicle.
11. After a minimum of 14 days, the pedicle is isolated and temporarily occluded with a vascular tie. The flap should be observed for venous congestion and/or vascular insufficiency. If no congestion or insufficiency is noted, the pedicle is ligated and transected under local anesthesia. Minor trimming may be required to provide optimal aesthetic contour.

Surgical Technique: Estlander Flap

1. For the Estlander flap, the same sequence is utilized as with the Abbe flap.
2. Care must be taken to ensure the vascular pedicle does not kink or occlude arterial flow to the flap. The adequacy of arterial flow may be verified by Doppler ultrasound.
3. A secondary commissuroplasty is often required after the procedure to reestablish a normal-appearing commissure.

Postoperative Management

Care must be taken to ensure minimal oral opening to limit or minimize tension on the vascular pedicle. The patient may be placed in maxillomandibular fixation with Erich arch bars, Ivy loops, orthodontic brackets, or internal maxillomandibular fixation screws. The use of chin dressings extending to the cheeks, or jaw bras, may also be useful to limit opening.

Complications

1. Vascular compromise: Either venous congestion and/or vascular insufficiency.
2. Asymmetry of the lips: Results from inadequate or excessive donor flap harvest.
3. Significant notching of the lips: Results from misalignment of the orbicularis oris.

Key Points

1. Care must be taken during dissection to preserve the vascular pedicle. A small muscle cuff around the artery helps to preserve the venous system.
2. The flap width is designed on the unaffected lip to be approximately one-half the width of the defect to preserve lip proportions. The height of the flap should approximate the height of the defect.
3. As the flap rotates approximately 180° on its pedicle, care must be taken to ensure that vascular compromise has not been introduced from torsion of the pedicle.
4. The flap should remain in place and attached for 2–3 weeks (14–21 days) to establish sufficient collateral vascularity prior to final division of the pedicle.
5. Patient's opening should be limited during initial healing to avoid tension on the pedicle.

References

1. Baker, S.R., 2007. Local flaps in facial reconstruction. St. Louis, MO: Mosby/Elsevier.
2. Butler, C., Procedures in reconstructive surgery: head and neck reconstruction. Philadelphia: Saunders/Elsevier, 2009.
3. Papel, I.D., 2002. Facial plastic and reconstructive surgery, 2nd ed. New York: Thieme.
4. Stauch, B., 2009. Grabb's encyclopedia of flaps, head and neck. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins.

Full-thickness Wedge Resection (V Shaped, V-Y Shaped, and W Shaped)

Full-thickness wedge resection for ablative treatment of lip cancer with immediate reconstruction utilizing primary closure.

Indications

1. Full-thickness defects of less than one-third of the upper or lower lip as a result of pathology or trauma
2. Full-thickness wedge resections are typically used for midline or para-midline defects, but may be utilized in the lateral region of the lip with minor design modifications

Contraindications

1. Defects of the lip greater than one-third
2. Areas where non-full-thickness resections were performed

Flap Anatomy

The labial artery serves as the primary blood supply to the lips. Venous drainage is provided by small veins in parallel with the labial artery. The layers of the lips are the epithelium of the skin, subcutaneous tissues including the deep dermis, orbicularis oris, and mucosa.

Surgical Technique: Full-thickness V Shaped Wedge Resection

1. The patient is positioned supine on the operating table. The surgical site is prepped and draped in a sterile fashion.
2. The height and width of the defect are measured.
3. The flap is designed to extend from the complete height of the lip from the vermillion border to the labio-mental fold. The apex of the V-shaped design should be centered directly over the center of the lesion to be resected (Figure 48.1 [all figures appear in Case Report 48.1]). For lesions within the lateral lip region, the design should be slightly skewed to better parallel the natural skin tension lines in this region.
4. Pertinent surgical anatomy may be marked with methylene blue and a 30-gauge needle. Key areas to mark include the surgical margins and the vermillion borders on both sides of the anticipated surgical defect in order to allow for the correct reapproximation of the vermillion border after the resection is completed.
5. Local anesthetic containing epinephrine is injected within the surgical site. However, local anesthetic should only be injected after the defect is measured and marked and the proposed flap design is outlined, to avoid any distortion of the tissues.

6. A full-thickness resection of the lesion is performed (Figure 48.2) and sent for final pathology (Figure 48.3).

7. Adequate hemostasis is achieved through bipolar electrocautery.
8. The orbicularis muscle is identified on both medial and lateral aspects of the surgical defect. The mucosa and the subcutaneous tissues are sharply dissected off the muscle for approximately 1 cm to allow for isolation of the orbicularis muscle.
9. The orbicularis muscle is reapproximated with resorable sutures in an interrupted fashion. Alignment of the muscle is critical, as misalignments and improper approximation may result in notch defects.
10. The vermillion border is aligned with either resorbable or nonresorbable sutures. Accurate alignment of the vermillion is critical for postoperative aesthetics. The remaining layers (the mucosa, subcutaneous tissue and skin) are closed in a standard layered fashion.

Figure 48.1. The resection design is marked prior to the administration of local anesthetic to avoid distortion of the tissues. The apex of the resection extends to the submental crease.

Figure 48.2. A full-thickness V-shaped wedge resection with 10 mm margins is performed. Hemostasis is achieved with bipolar cautery, and frozen margins are taken from the periphery of the defect site.

Figure 48.3. The final specimen is sent to pathology.

Figure 48.4. The defect is repaired primarily with a layered closure. Care is taken to align the vermilion border for optimal aesthetics and to reapproximate the orbicularis oris muscle to minimize notch defects.

Postoperative Management

1. Care must be taken to ensure minimal oral opening to limit or minimize tension to sutures.
2. Antibiotic ointments are recommended for skin incisions for a period not to exceed 3 days.

Complications

1. Asymmetry of the lips: Typically results from inadequate or excessive tissue removal, incorrect alignment of the vermilion border and/or failure to accurately reapproximate any of the 4 layers (skin, subcutaneous tissue, orbicularis oris muscle or mucosa) upon closure of the surgical site.
2. Significant notching of the vermillion: Results from misalignment of the orbicularis oris muscle.

Key Points

1. Care must be taken during dissection to preserve the orbicularis oris muscle. Approximately 1 cm of muscle length should be visualized to ensure correct realignment.
2. The vertical arms for the V shape and lateral arms for the W-shaped designs should extend to the labio-mental fold and should parallel the resting skin tension lines.
3. A meticulous reapproximation of all four layers—mucosa, muscle, subcutaneous tissues, and skin—is paramount to providing an optimal aesthetic outcome.
4. Lip defects that involve less than one-half of the original length of the lip are frequently treated with either V– or W-shaped full-thickness wedge resections and closed primarily. Defects one-half to two-thirds of the original lip length may be reconstructed with Abbe (not involving the oral commissure) and Estlander (involving the oral commissure) flaps.

---

Case Report

Case Report 48.1. A 29-year-old male presents with a chief complaint of a nonhealing ulceration to his lower lip. On exam, the mass measured 1.8 cm in its greatest dimension and was located along the vermillion border. The commissure was uninvolved. An incisional biopsy was performed that revealed a well-differentiated ­squamous cell carcinoma of the lower lip. The mass was classified as a T1N0M0. A full-thickness V-shaped resection was performed with 1.0 cm margins. All frozen margins taken intraoperatively were negative, and the resection was primarily reconstructed with a layered closure. (See Figures 48.1, 48.2, 48.3, 48.4, and 48.5.)

---

Figure 48.5. Four-month postoperative result.

References

1. Baker, S.R., 2007. Local flaps in facial reconstruction. St. Louis, MO: Mosby/Elsevier.
2. Butler, C., Procedures in reconstructive surgery: head and neck reconstruction. Philadelphia: Saunders/Elsevier, 2009.
3. Papel, I.D., 2002. Facial plastic and reconstructive surgery, 2nd ed. New York: Thieme.