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Research Article| Volume 31, ISSUE 1, P13-17, March 2020

Lip reconstruction using the Sabattini-Abbé cross-lip flap

  • Tom Shokri
    Affiliations
    Department of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
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  • Jessyka G. Lighthall
    Correspondence
    Address reprint requests and correspondence: Jessyka G. Lighthall, MD, FACS, Penn State College of Medicine, The Milton S. Hershey Medical Center, Department of Otolaryngology-Head and Neck Surgery, 500 University Drive, MC H091, Hershey PA, 17033.
    Affiliations
    Department of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
    Search for articles by this author
Published:January 05, 2020DOI:https://doi.org/10.1016/j.otot.2019.12.004

      Abstract

      Functional reconstruction, with aesthetic restoration, of lip defects presents a significant challenge to the reconstructive surgeon. The upper and lower lip are distinctly prominent anatomical units of the lower third of the face. Reconstitution of these structures is of critical importance in oral competence, articulation, and facial form. Herein, we describe the Sabatini-Abbe cross lip flap for reconstruction of full-thickness composite lip defects.

      Keywords

      Introduction

      The lips are important anatomically distinct subunits within the lower face. Due to their prominence, and their location within an observational center of the face, even minor defects may result in conspicuous deformities.
      • Coppit G.L.
      • Lin D.T.
      • Burkey B.B.
      Current concepts in lip reconstruction.
      The lips serve a defining role in facial aesthetics, the concept of modern beauty and the expression of emotion. Functionally, the lips play an integral role in articulation and deglutition, due to their function as an oral sphincter. Lip reconstruction therefore presents a particular challenge to the facial reconstructive surgeon seeking to restore both form and function.
      Descriptions of lip reconstruction date back to BC 3000 in the Sanskrit writings of Sushruta.
      • Mazzola R.F.
      • Lupo G.
      Evolving concepts in lip reconstruction.
      ,
      • Zide B.M.
      Deformities of the lips and cheeks.
      However, techniques employed today are principally derived from those developed in the early 19th century. Early documentation of lip reconstruction in Western literature date to the 1st century. These techniques primarily involved a v-shaped wedge excision of the lip with primary closure and are credited to the early medical writings of Lewis in 1768.
      • Zide B.M.
      Deformities of the lips and cheeks.
      Sabattini first described the cross-lip flap in 1837 and involved transfer of a triangular full-thickness segment of lower lip to reconstruct a defect of the upper lip.
      • Sabattini P.
      Cenno storico dell'origine e progressi della rinoplastica e cheiloplastica.
      Several modifications of his technique shortly followed, primarily by Abbé
      • Abbe R.
      A new plastic operation for the relief of the deformity due to double hairlip.
      and Estlander.
      • Estlander J.
      Eine Methods ans der einen Lippe Substanzverluste der anderen zu ersetzen.
      Abbé in 1898 designed the flap as smaller in width in comparison to the defect, approximately one-half the width, and based it on the labial artery of the opposite lip.
      • Sabattini P.
      Cenno storico dell'origine e progressi della rinoplastica e cheiloplastica.
      ,
      • Abbe R.
      A new plastic operation for the relief of the deformity due to double hairlip.
      In this way, the upper and lower lips would be of equal width following repair. Although, the original procedure described reconstruction of the upper lip, more often there is a need to reconstruct a defect of the lower lip, due to the greater frequency of malignancy. As mentioned, the labial artery of the opposite lip serves as the pedicle of this interpolated flap. Venous drainage is provided by small venous vessels that parallel the arterial pedicle. The triangular flap is rotated 180° about its pedicle and inserted within the opposing lip defect. The resultant donor site is closed primarily and in approximately 3 weeks, the pedicle is divided and the flap is inset. This article serves to describe the anatomy and technical aspects of the Sabattini-Abbé flap (referred to hereafter as the Abbé flap) for the repair of full thickness lip defects.

      Anatomy

      Development of facial structures begins in the early embryonic period. The mandible and maxilla are derivations of the first pharyngeal arch. The upper lip develops from fusion of several embryologic structures including the maxillary, medial nasal prominence, and the intermaxillary segment. The oral commissure develops similarly from fusion of lateral embryologic structures of the maxillary and mandibular processes. The lower lip and mandible are derived from the mandibular process. The lip extends from the area of the subnasale to the mental crease and from one commissure to the contralateral. The cutaneous lip and vermilion are separated by a pale border of tissue referred to as the “white roll.” The “dry vermilion” is separated from the intraoral labial mucosa, or “wet lip,” by the “red line.” The vermilion lacks adnexal structures and is comprised of keratinized stratified squamous epithelium overlying a highly vascular plexus, which gives the lips their red rosy hue. The upper lip is generally shaped like an M, with its 2 apices forming the lower extent of the philtral columns. The upper lip apices with the intervening central depression are conjointly referred to as Cupid's bow. The prominence within the center of the upper lips is referred to as the tubercle. The philtral columns are separated by the philtral grooves and extend superiorly to the columella. The upper lip is divided into 3 aesthetic subunits: the central philtrum and paired lateral units which extend from the philtral columns to the melolabial folds. It is important to note that relaxed tension lines are radially oriented around the mouth. These elegant topographical landmarks pose a reconstructive challenge for the surgeon (Figure 1).
      The lower lip, in comparison, is generally more simplistic in terms of surface anatomy. The border between the lip and chin is demarcated by the mental crease. This corresponds intraorally to the lowest aspect of the gingival sulcus. The underlying musculature of the lip is intricate, involving multiple paired muscles that function in elevation, depression, and sphincteric action. The modiolus is a fibrous band within the deep layer of soft tissue at the corner of the mouth that serves as both the insertion and origin of the perioral muscles. The orbicularis oris muscle comprises the bulk of the tissue of the lip and is the primary sphincteric muscle of the oral aperture. Deep fibers of the orbicularis are oriented in a horizontal fashion and therefore serve to compress the lips and provide the majority of the sphincteric function. Superficial muscular fibers are responsible for the more granular movements and serve an important role in facial expression. Oblique fibers interdigitate between these 2 layers and evert the lip resulting in a distinctive pout on profile view.
      • Schulte D.L.
      • Sherris D.A.
      • Kasperbauer J.L.
      The anatomical basis of the Abbé flap.
      Importantly, the orbicularis oris muscle displays a resting tone which may result in defects appearing larger due to the lateral force vectors pulling on wound edges. This should be taken into consideration when planning repair. Furthermore, the orbicularis should be reapproximated well in order to reconstitute the above mentioned muscle actions. Both upper and lower lips derive their blood supply from the facial artery via the superior and inferior labial branches. These arteries are located between the orbicularis oris muscle and the intraoral mucosal surface, at the level of the vermilion-cutaneous border (Figure 2). Venous drainage corresponds to that of the arteries.
      Figure 2
      Figure 2Cross-sectional lower lip anatomy; labial artery corresponding to vermilion border between orbicularis and intraoral labial mucosa. (With permission McCarn, Kate E., MD; Park, Stephen S., MD. Lip Reconstruction. Otolaryngologic Clinics of North America Published April 1, 2007. Volume 40, Issue 2. Pages 361-380. © 2007.)

      Reconstructive considerations

      The lip reconstruction paradigm is centered upon the horizontal extent of the lip defect. Defects are correspondingly categorized as small, medium, or large. Small defects involve less than or equal to one-third of the upper or lower lip width. Medium, or intermediate, defects involve one-third to two-thirds of the lip. Large defects are considered those greater than two-thirds of the horizontal lip (Figure 3).
      • Renner G.J.
      Reconstruction of the lip.
      A subclass of defects are those that involve the vermilion of the upper or lower lip. Compliance with the subunit principle, whereby the complete subunit is reconstructed if greater than 50% of the subunit is involved, will enhance aesthetics. A full discussion of the reconstructive paradigm is beyond the scope of this article. Cross-lip flaps, the Abbé flap in particular, are ideally utilized in medium-sized full-thickness defects.
      Figure 3
      Figure 3Full thickness lower lip reconstruction paradigm based upon the width of the defect. (With permission McCarn, Kate E., MD; Park, Stephen S., MD. Lip Reconstruction. Otolaryngologic Clinics of North America Published April 1, 2007. Volume 40, Issue 2. Pages 361-380. Ⓡ 2007.)

      Technique

      The Abbé flap is traditionally a triangular flap designed from the opposite lip, pedicled on the labial artery, and is one-half to one-third the width of the primary defect. The height of the defect will determine the height of the harvested flap. The vascular pedicle is based on the contralateral opposite-lip labial artery. Therefore, an Abbé flap on the left lower lip is pedicled upon the right superior labial artery. However, multiple variations on the flap design and side of pedicle may be employed. An Abbé flap reconstruction is implemented in defects medial to the oral commissure while the Estlander flap is used for those involving the oral commissure (discussed elsewhere in this issue).
      The appropriate landmarks, including philtrum, nasal sill, vermilion border, white roll, bilateral commissures, alar groove, and melolabial folds are appropriately demarcated with ink or methylene blue prior to injection of local anesthetic (Figure 4a and b). When demarcating the base of the flap, the point of rotation should be placed closest to the commissure in order to ensure more proximal pedicle blood supply. Incisions are made through the skin, lip, and mucosa, leaving the attachment to the lip laterally, pedicled on the corresponding labial artery. The labial arteries lie at the level of the vermillion border, and meticulous dissection of the orbicularis oris muscle at this level must be performed to preserve the vascular pedicle deep to the muscle. Approximately 5mm of vermilion mucosa should be preserved, if possible, due to its contribution to the venous vascular supply.
      • Burget G.C.
      Aesthetic restoration of the nose.
      • Weerda H.
      Reconstructive Facial Plastic Surgery: A Problem-Solving Manual.
      • Kriet J.D.
      • Cupp C.L.
      • Sherris D.A.
      • et al.
      The extended abbe flap.
      • Matin M.B.
      • Dillon J.
      Lip reconstruction.
      Figure 4
      Figure 4Abbé flap reconstruction of intermediate lip defect. (a) Right upper lip defect (b) Additional upper lip excision and flap design from lower lip (c) Cross-lip flap elevated and rotated into the defect with laterally-based pedicle (d) Flap in place and donor site closed Note pedicle spanning the oral aperture.
      Once appropriately dissected out, the flap is mobilized and the labial artery contralateral to the pedicle, which may be left intact until this point, is ligated and divided. The flap is then rotated 180° and inset (Figure 4c). The nasal spine or pyriform aperture periosteum may be employed as an anchor point for the tip of the flap. The orbicularis oris muscle of the recipient and donor is meticulously sutured in order to reconstitute the muscular oral sphincter (Figure 4c and d). Close attention is paid to maintain the continuity of the white roll along the donor-recipient interface. The wet and dry vermilions are then approximated in a similar fashion using resorbable suture of the operating surgeon's choosing. The donor-site lip is then reapproximated in a similar 3-layer fashion.
      Postoperatively, the patient is counseled regarding avoidance of excessive mouth opening. The patient is placed on a soft or liquid diet to minimize tension forces placed on the pedicle. After an adequate amount of time for vascularization, approximately 3 weeks, a second stage procedure is performed to divide and inset the pedicle (Figure 5).
      Figure 5
      Figure 5Abbé flap pedicle divided and flap inset 3 weeks after original procedure.

      Modifications

      Upper lip defects require special consideration due to the complexity of the anatomical landmarks and multiple subunits involved. Several modifications of the Abbé flap have been described including extended flaps that may be used in composite reconstruction based upon the vertical labiomental artery, a division off the inferior labial artery, which supplies the lower lip and chin extending to the submentum.
      • Kriet J.D.
      • Cupp C.L.
      • Sherris D.A.
      • et al.
      The extended Abbe flap.
      This extension of the Abbé flap is useful for reconstruction of defects involving the central face, including the columella, peri-alar, and premaxillary subsites.
      • Kriet J.D.
      • Cupp C.L.
      • Sherris D.A.
      • et al.
      The extended Abbe flap.
      Modifications of this technique have been used in correction of secondary cleft lip and nasal deformities.
      • Cutting C.B.
      • Warren S.M.
      Extended Abbe flap for secondary correction of the bilateral cleft lip.
      • Takato T.
      • Yonehara Y.
      • Susami T.
      • et al.
      Modification of the Abbe flap for reconstruction of the vermilion tubercle and Cupid's bow in cleft lip patients.
      • Lo L.J.
      • Kane A.A.
      • Chen Y.R.
      Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbe flap revisited.

      Complications

      Cross-lip flap reconstruction involves full thickness transfer of tissue with resultant denervation of the involved musculature. Motor reinnervation has been confirmed to occur in several months, based on electrophysiologic studies with return of normal movement within the first postoperative year.
      • Smith J.W.
      The anatomical and physiologic acclimatization of tissue transplanted by the lip switch technique.
      • Thompson N.
      • Pollard A.C.
      Motor function in Abbe flaps: A histochemical study of motor reinnervation in transplanted muscle tissue of the lips in man.
      The extent, however, of muscle contraction that returns is variable and dependent on technique. Persistence of motor weakness may result in deficiency of the oral sphincter and resultant issues with oral competence. Return of sensory function is witnessed within the first 2-3 months after flap transfer.
      • Smith J.W.
      The anatomical and physiologic acclimatization of tissue transplanted by the lip switch technique.
      However, patients may display hypoesthesia or hyperesthesia to temperature in the initial year following reconstruction, which tends to dissipate with time.
      • Lo L.J.
      • Kane A.A.
      • Chen Y.R.
      Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbe flap revisited.
      • Smith J.W.
      The anatomical and physiologic acclimatization of tissue transplanted by the lip switch technique.
      • Thompson N.
      • Pollard A.C.
      Motor function in Abbe flaps: A histochemical study of motor reinnervation in transplanted muscle tissue of the lips in man.
      A risk of trap-door deformity may exist secondary to restricted lymphatic drainage due to scar formation. The application of cross-lip flap reconstruction may result in variable degrees of microstomia depending on initial defect size. This risk can be mitigated with appropriate patient selection and surgical planning, with use of cross-lip flaps in intermediate defects with acceptable resultant microstomia.
      • Renner G.J.
      Reconstruction of the lip.

      Conclusion

      Lip reconstruction poses a difficult challenge for the facial surgeon. The lips are prominent aesthetic facial units and serve an important functional purpose as well. Reconstruction should be tailored to the location and size of the defect. Reconstructive efforts should also aim to optimize the sphincteric function of the lips for both deglutition and labial articulation while minimizing microstomia. The Sabattini-Abbé flap offers a nice, vascularized composite reconstruction option to accomplish these goals.

      Disclosure

      The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

      References

        • Coppit G.L.
        • Lin D.T.
        • Burkey B.B.
        Current concepts in lip reconstruction.
        Curr Opin Otolaryngol Head Neck Surg. 2004; 12: 281-287
        • Mazzola R.F.
        • Lupo G.
        Evolving concepts in lip reconstruction.
        Clin Plast Surg. 1984; 11: 583
        • Zide B.M.
        Deformities of the lips and cheeks.
        in: McCarthy J.G. Plastic Surgery. WB Saunders, Philadelphia, PA1990
        • Sabattini P.
        Cenno storico dell'origine e progressi della rinoplastica e cheiloplastica.
        Belle Arti, Bologna1838
        • Abbe R.
        A new plastic operation for the relief of the deformity due to double hairlip.
        Med Rec. 1889; 53
        • Estlander J.
        Eine Methods ans der einen Lippe Substanzverluste der anderen zu ersetzen.
        Arch Klin Chir. 1872; 14
        • Schulte D.L.
        • Sherris D.A.
        • Kasperbauer J.L.
        The anatomical basis of the Abbé flap.
        Laryngoscope. 2001; 111: 382-386
        • Renner G.J.
        Reconstruction of the lip.
        in: Baker S. Local Flaps in Facial Reconstruction. 2nd ed. Mosby, Philadelphia, PA2007: 475-524
        • Burget G.C.
        Aesthetic restoration of the nose.
        Clin Plast Surg. 1985; 12: 463-480
        • Weerda H.
        Reconstructive Facial Plastic Surgery: A Problem-Solving Manual.
        Thieme, New York2001
        • Kriet J.D.
        • Cupp C.L.
        • Sherris D.A.
        • et al.
        The extended abbe flap.
        Laryngoscope. 1995; 105: 988-992
        • Matin M.B.
        • Dillon J.
        Lip reconstruction.
        Oral Maxillofac Surg Clin North Am. 2014; 26: 335-357
        • Kriet J.D.
        • Cupp C.L.
        • Sherris D.A.
        • et al.
        The extended Abbe flap.
        Laryngoscope. 1995; 105: 988-992
        • Cutting C.B.
        • Warren S.M.
        Extended Abbe flap for secondary correction of the bilateral cleft lip.
        J Craniofac Surg. 2013; 24: 75-78
        • Takato T.
        • Yonehara Y.
        • Susami T.
        • et al.
        Modification of the Abbe flap for reconstruction of the vermilion tubercle and Cupid's bow in cleft lip patients.
        J Oral Maxillofac Surg. 1996; 54: 256-261
        • Lo L.J.
        • Kane A.A.
        • Chen Y.R.
        Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbe flap revisited.
        Plast Reconstr Surg. 2003; 112: 1219-1227
        • Smith J.W.
        The anatomical and physiologic acclimatization of tissue transplanted by the lip switch technique.
        Plast Reconstr Surg. 1960; 26: 40
        • Thompson N.
        • Pollard A.C.
        Motor function in Abbe flaps: A histochemical study of motor reinnervation in transplanted muscle tissue of the lips in man.
        Br J Plast Surg. 1961; 14: 66
        • Renner G.J.
        Reconstruction of the lip.
        in: Baker S.R. Local Flaps in Facial Reconstruction. 3rd ed. Mosby, St Louis (MO)2014: 481-529