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ReconstructionSite: lip

Lip reconstruction

Lip reconstruction must restore three things: oral competence, dynamic function (eating, speaking, expression), and the visual continuity of the vermilion border. Defect size relative to the lip determines the technique — small defects close primarily, intermediate defects need cross-lip flaps, and subtotal defects need bilateral cheek advancement with Burow's triangle excisions (Bernard-Burow-Webster) or microsurgical reconstruction.

CurrentLast reviewed 22 March 2026

Anatomy

The lip has skin (cutaneous lip), vermilion (dry and wet), and oral mucosa. The orbicularis oris is the sphincter that drives oral competence. Blood supply is from the superior and inferior labial arteries (branches of the facial artery), running between the orbicularis and the mucosa just deep to the wet–dry junction. Sensory innervation is from V2 (infraorbital, superior) and V3 (mental, inferior).

Critical landmarks: vermilion border (white roll), Cupid's bow, philtral columns, commissures, mental crease.

By defect size

< 1/3 lip width

  • Primary closure in V or W configuration aligned with mental crease for lower lip; respect vermilion border alignment.
  • Vermilion advancement for vermilion-only defects.
  • Karapandzic flap can be used for smaller defects too if neuromuscular preservation is preferred.

1/3 to 2/3 lip width

  • Karapandzic flap — circumoral neurovascular myocutaneous flap; preserves orbicularis innervation and blood supply; restores dynamic function. Workhorse for upper or lower lip defects 1/3 – 2/3.
  • Abbe flap — full-thickness lip-switch flap from the opposite lip on a labial artery pedicle; for central upper lip philtral defects. Two-stage with division at 2–3 weeks.
  • Estlander flap — modification of Abbe involving the commissure; single-stage for the flap itself but commonly needs a second-stage commissuroplasty for symmetry; creates microstomia and rounds the commissure.

> 2/3 (subtotal / total)

  • Bernard-Burow-Webster cheiloplasty — bilateral cheek advancement with Burow's triangle excisions at the alar bases and lateral commissural region, plus mucosal turnover for vermilion. Achieves total lower lip reconstruction at the expense of microstomia and reduced animation. Distinct from the cervicofacial rotation flap (a larger cheek/neck rotation flap typically used for cheek defects).
  • Free radial forearm flap ± palmaris longus tendon sling — for subtotal / total lower lip; tendon sling provides static support for oral competence.
  • Free anterolateral thigh (ALT) flap — for very large composite defects.

Vermilion-only reconstruction

  • Vermilionectomy with mucosal advancement — for diffuse actinic cheilitis or extensive Bowen's of vermilion. Mucosa from inner lip is advanced to recreate the vermilion. Patient needs to be counselled about colour mismatch and dryness.
  • Tongue flap — historic; rarely needed now.
  • Buccal mucosa free graft — for partial vermilion defects.

Commissure

  • Commissure defects after Estlander flap may need a commissuroplasty (Z-plasty or Converse procedure) for symmetry.
  • Microstomia (chronic functional limitation) may require commissural release after reconstruction.
Clinical pearlLip Mohs first, then reconstruct

For high-risk lower lip cSCC, achieve clear margins with Mohs or staged excision before committing to a major reconstructive plan. Reconstructing into incomplete excision is unforgiving.

Common pitfalls

  • Vermilion border misalignment — always tattoo / mark before excision and inset.
  • Microstomia after Bernard-Webster or bilateral Estlander — counsel pre-operatively.
  • Drooling and oral incontinence after subtotal lower lip reconstruction without dynamic restoration — consider tendon sling.
  • Smoking, radiotherapy field, anticoagulation — risk factors for flap failure.

References

  1. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg; 1974;27:93–7.
  2. Closmann JJ et al. Comparison of Abbe-Estlander and Karapandzic flaps in lip reconstruction. J Oral Maxillofac Surg; 2008.
  3. Coppit GL, Lin DT, Burkey BB. Current concepts in lip reconstruction. Curr Opin Otolaryngol Head Neck Surg; 2004;12:281–7.

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