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Page 2 of 6 Kannan et al. Plast Aesthet Res 2018;5:4 I http://dx.doi.org/10.20517/2347-9264.2018.02

Keywords: Peri-commisural reconstruction, Abbe flap, Estlander flap, labio-mandibular flap

INTRODUCTION
Upper lip reconstruction is a surgical challenge due to the high level of lip anatomy detail. This has led to
the development of a “like for like” reconstruction using the “Abbe” or “Estlander” flap for upper lip and
commissural defects respectively. The latter flap has the disadvantage of causing microstomia, while the
Abbe flap has the additional hassle of being a two-stage lip-switch technique. In the vast majority of these
cases, the primary indication is post-oncological reconstruction e.g. following skin cancer excisions. This
brings to bear the next question, i.e. do these tumours necessitate full-thickness lip excisions, as they rarely
involve oral mucosa.

An alternative reconstructive option here would be the use of perforator flaps for partial-thickness defects.
[1]
One option to consider here would be the superior labial artery perforator flap for upper lip defects .
However, as with islanded flaps, they tend to develop lymphoedema and patients are often left with an
unaesthetic appearance. Leaving a small skin bridge should reduce this risk but this cannot be done in a
conventional manner as the length:width ratio philosophy will not allow for it. However, with the application
[2]
of the perforator-plus concept , such a combination is possible.
In this article, we describe the use of flaps based on a combination of traditional aesthetic sub-units; the
labio-mandibular fold (LMF) and the naso-labial fold but tempered with the perforator-plus concept for an
ideal blend of “beauty and blood supply”.

METHODS
In a retrospective case review over 12 months at our institution (2016-2017), we performed seven cases of upper
lip reconstruction (n = 7), all as part of post-oncological reconstruction. These defects were reconstructed
using a rotation-advancement flap in the supra-muscular plane, raised from within the skin of the LMF
with sparing of the vermilion border of the lip. Just lateral to the oral commissure, a musculo-cutaneous
perforator, arising from the modiolus is consistently found and preserved. Once this modiolar perforator
is identified, the entire flap is advanced into the defect to close the primary defect first. As the flap then
overlaps the oral commissure, a Y-V advancement of the oral commissure is performed, just proximal to the
modiolar perforator, to translate the angle of the mouth laterally and re-establish the aesthetics of the oral
commissure. This corrects microstomia and re-establishes lip aesthetics as graphically illustrated in Figure 1.

Case illustrations
An 80-year old lady presented with a 15 mm × 10 mm superficial basal cell carcinoma of the right upper
lip [Figure 2], which was excised with part of the orbicularis oris and preservation of the oral mucosa. This
resulted in a 23 mm × 18 mm defect over the upper lip, which was reconstructed with a labio-mandibular
flap. As shown in Figure 3, the outer border of the flap is along the LMF whilst the inner margin is at the
vermilion border of the lip. The “length:width” ratio of the flap is approximately 4:1 and once inset, sets in
seamlessly along the aesthetic lines of the lip and the LMF. Once healed, the scars are hardly discernible as
they sit along the wrinkle lines of the upper lip and the LMF, as shown in Figure 4.

The usefulness of the labio-mandibular flap is illustrated once more in another case wherein a large skin
tumour, as is shown in Figure 5, involved 40% of the upper lip with infiltration of the orbicularis oris beneath
the tumour. Conventionally, this would have required a wedge excision and reconstruction with an Abbe
flap, in two stages. Following excision of the lesion with a smaller section of the orbicularis oris, a labio-
mandibular flap was raised and advanced into the defect [Figure 6]. Postoperative images [Figure 7] show