-------------------------------------------------------------------------------- TITLE: LIP RECONSTRUCTION SOURCE: GRAND ROUNDS PRESENTATION DATE: MARCH 1, 1989 RESIDENT PHYSICIAN: Mark L. Nichols, M.D. FACULTY: Karen H. Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. -------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. HISTORICAL PERSPECTIVE A. SACRED TEXTS OF SUSRUTA -INDIA 1000 B.C. First mention of labial repair B. CELSUS -25 A.D. Closure of lip defects with 2 parallel incisions on the cheek. C. TAGLIACOZZI - 1597 Upper and lower lip repair by distant tissue transfer from the forearm. D. LOUIS - 1768 First wedge excision and direct closure of the lip E. DIFFENBACH - 1834 Lateral advancement cheek flap F. VON BURROW - 1838 Excision of 2-4 skin triangles to facilitate flap advancement. G. VON BRUNS - 1859 Nasolabial flaps for lower lip repair H. ESTLANDER - 1872 Full thickness triangular flap from the lateral side of the upper lip to repair a lower lip defect. I. ABBE - 1897 (SABATTINI - 1838, STEIN - 1848) Rotation of a triangular flap from the lower to the upper lip. J. GILLIES - 1957 Fan Flap K. KARAPANDZIC - 1974 Myocutaneous local flap - oral sphincteric reconstruction L. HARI AND OHMORI - 1974 First free flap with microvascular suture of the upper lip. II. ANATOMY Lips - Forms the anterior boundary of the oral vestibule, begin at the junction of the vermilion border with the skin. A. MUSCULATURE - ORBICULARIS ORIS - From the second brachial arch. It forms the sphincter encircling the oral aperture. Its fibers decussate in the midline. B. NERVOUS INNERVATION 1. SENSORY a. Infraorbital Branch Of The Maxillary Nerve (V2) -sensory to most of the upper lip b. Buccal Branch Of The Mandibular Nerve (V3) -sensory to the oral commissure region c. Mental Branch Of The Mandibular Nerve (V3) -sensory to the lower lip -pathway of spread of lip cancer into the mandible 2. MOTOR - FACIAL NERVE (CN VII) a. Buccal Branch - motor to the upper lip b. Mandibular / Cervical Branches - motor to the lower lip and platysma respectively C. VASCULAR SUPPLY 1. Inferior and Superior Labial Arteries and Veins a. Branches of the Facial Arteries and Veins D. LYMPHATIC SUPPLY 1. A capillary network of lymphatics exists beneath the vermilion. 2. The medial portion of the lower lip drains to the submental nodes. 3. The lateral portion / commissure of the lip drains into the submandibular nodes. 4. Anastomosis of lip lymphatics in the midline - Bilateral metastasis from midline tumors 5. Upper lip lymphatics drain into the preauricular, infraparotid, submandibular, and submental nodes. - lymphatics of the upper lip do not cross the midline 6. Second order lymphatic drainage - to upper and middle deep jugular chain III. AESTHETIC AND FUNCTIONAL ASPECTS OF RECONSTRUCTION A. EXTERNAL ANATOMIC LANDMARKS 1. Nasal Ala a. rim b. base c. nostril sill d. columella base 2. Philtrum a. groove b. ridge 3. Cupid's Bow a. apex b. tubercle c. base of the arch d. mucocutaneous ridge B. AESTHETIC ASPECTS 1. The upper lip protrudes beyond the lower lip. 2. The lower lip is minimally hidden by an overhanging upper lip. 3. The upper lip is cosmetically more important than the lower lip. - Has symmetry based on Cupid's Bow and the Philtrum C. FUNCTIONAL ASPECTS 1. The lips provide an important sphincteric function. 2. Functionally, the lower lip is more important than the upper lip in maintaining secretions and prevention of drooling. 3. The lips have an important function in articulation and speech 4. General Guideline: Reduction to less than 50% of the pre-operative stoma will produce significant dysfunction, especially in denture wearers. D. AESTHETICS OF AGING 1. Normal facial atrophy occurs with aging a. Causes the upper lip to invert slightly b. The lower lip is slightly fuller and at each commissure is tucked behind the upper lip. IV. LIP RECONSTRUCTION A. SURGICAL CONSIDERATIONS 1. Factors To Be Considered a. Age and Sex of the Patient 1. elderly - loose soft tissues - greater ability for advancement, rotation and transposition flaps - less conspicuous scarring 2. males - restoration of hair bearing skin 3. females - able to apply cosmetics for camouflage b. Location of the Defect 1. upper lip - difficulty in maintaining symmetry - can resect little tissue without causing asymmetry 2. lower lip - no symmetry, frequent donor site 3. commissure - difficult site for repair and maintenance of symmetry c. Extent of the Defect - Rule of Thirds 1. 1/3 of lower lip / 25% of upper lip -wedge with primary closure 2. 1/3 - 2/3 lip - lip switch or local advancement flap 3. > 2/3 lip - local or distant tissues d. Condition and Availability of Local and Regional Tissues 1. free of tumor 2. prior irradiation ? 3. myocutaneous flaps 2. Favorable Skin Tension Lines ( FTSL ) a. Favorable Sites For Incisions 1. Run vertically on the lip within mucosa and skin. 2. Radiate outward from the lips to nose and chin. b. Other Favorable Sites for Incision 1. Junction or Boundary of Aesthetic Areas 1. Vermilion Border 2. Nasolabial Junction 3. Lip - Chin, Lip - Cheek 4. Philtral Crest - Groove 3. Ideal Reconstruction a. Ablation and Reconstruction - same procedure b. The lip should have sensation, motion, prevent drooling, permit speech and have a reasonable cosmetic appearance. c. There should be an adequate oral aperture (access) d. Whenever possible, full thickness skin flaps ( skin, muscle, and mucosa ) should be used. e. Should provide sufficient mucosa contiguous to the commissure to avoid contracture. f. The donor tissues in order of preference are: - the remainder of the targeted lip - the opposite lip - adjacent cheek - distant flaps B. CONDITIONS REQUIRING RECONSTRUCTION 1. Congenital Deformities - not discussed in this lecture a. Cleft Lip and Palate b. Congenital Lip Pits and Sinuses 2. Trauma a. Lacerations 1. Importance of closure in layers ( especially the orbicularis oris muscle ) for a competent stoma, copious irrigation, debridement. 2. Some advocate loose approximation of the buccal mucosa for drainage. 3. Perfect alignment of the white roll, and vermilion border - first suture is placed here. 4. If an avulsion can primarily reapproximate if less than 30% of the upper or lower lip missing. b. Electrical Burns 1. Usually seen in children age 1 - 4 years 2. Lips and commissures wet - damage localized here 3. Conservative therapy initially a. topical antibiotics, peroxide b. await eschar separation with wound demarcation c. hospitalization advocated by some for 3 - 4 days - if labial artery is involved, when eschar separates - hemorrhage d. late reconstruction 3. Neoplasms a. Basal Cell Carcinoma, Squamous Cell Carcinoma, Leukoplakia b. Most malignancies involve the lower lip c. Risk factors - cigarette smokers, sun exposure C. SURGICAL PROCEDURES 1. Mucosal Reconstruction a. V-Y Advancement Flap Indications - Fill in small deficiencies of the vermilion Advantages - Simple Technique Disadvantages - Inadequate advancement if V is too small with incomplete filling of defect - Labial notching with contracture may occur Technique 1. Mark out the defect 2. V is drawn - apex is toward buccal sulcus 3. V is incised with elevation of mucosa at the deep submucosal level 4. V is always closed as a Y with mucosal advancement 5. Always advance more mucosa than needed - to prevent recurrence of deformity b. Variations of The V-Y Advancement Flap Triangular Island Advancement Flap Indications - Mucosal defect which extends to the mucocutaneous junction Disadvantages - if the pedicle too narrow ischemia with flap necrosis - lip notching if a contracture Technique 1. Oral edge of the defect becomes the base of the triangle. 2. Island flap raised by incising a V into the buccal sulcus. 3. Flap advancement on a submucosal pedicle to close the defect in a V-Y fashion. c. Simple Mucosal Advancement Indications - Mucosal defects without the need for bulk Disadvantages - Intraoral mucosa different from lip mucosa, tends to dry out - Must keep lip mucosa lubricated Technique 1. Mucosa advanced and sutured to the skin of the lip with or without undermining. Use a fine running absorbable suture. Variations - Rotational and Rhomboidal Mucosal Flaps d. Tongue Flap Indications - Loss of lower lip mucosa and muscle with a need for reconstruction Advantage - Provides mucosa and bulk in reconstruction Disadvantages - Flap may detach from the lip - may bite through the flap Technique 1. Undersurface of the tongue - mucosa provides a better color and texture match for the vermilion. 2. Flap outlined on the undersurface of the tongue, incised, elevated and based anteriorly. 3. Posterior flap margin brought out anteriorly and sutured to the skin at the margin of the defect. 4. The flap is left in place for 10 days, then is divided, adequate amounts of mucosa being transferred to fill in the defect. 5. The tongue incision is closed with absorbable sutures. 6. Jackson advocates acrylic bite blocks being cemented to the lower molars to prevent biting through the flap. e. Anteriorly Based Lateral Tongue Flaps Indications - Significant upper lip mucosa defect with limited ability to advance intraoral mucosa. Advantages - Provides Bulk Disadvantages - Greater tension and weight - Tends to pull off readily - Difficulty constructing a Cupid's Bow - Texture, color differences Technique 1. The lateral tongue flaps marked, incised and elevated. 2. The flaps are rotated up and sutured in the midline end to end. 3. The flaps are then sutured to the skin margins. 4. Tongue defects are closed primarily. 5. The flap pedicles are divided after 10 days trimmed and sutured into the lips. f. Lip Shave - Vermilionectomy Indications - Superficial Carcinoma, Leukoplakia, or Erythroplakia of the Lip Disadvantage - Some flattening of the natural contour of the lip. Technique 1. The vermilion is excised with variable amounts of underlying muscle, at least 0.3 - 0.5 cm beyond the leukoplakia. 2. The remaining normal buccal mucosa is extensively undermined. 3. The mucosa is advanced and approximated to the skin with 5 - 0 nylon. 4. Tongue flaps may be used and offer the advantage of restoration of bulk. 5. For best color match, the entire vermilion should be excised and replaced. 2. PARTIAL AND FULL THICKNESS DEFECT RECONSTRUCTION a. Free Full Thickness Skin Graft Indications - When only skin is involved by a lesion and the defect is too large for direct closure. Disadvantages - If poor hemostasis - loss of graft - Loss of a portion of the graft which causes scarring with traction on the free lip margin. Technique 1. The defect to be replaced should correspond to a cosmetic unit. 2. Full thickness post-auricular or supraclavicular skin is excised. 3. The graft is fitted to the defect and secured with a bolster. b. Wedge Excision with Primary Closure Indications - Small and superficial lesions not exceeding one-third of the lip may be excised and allow direct approximation. Advantages - Primary closure using adjacent tissues Technique 1. The vermilion border is marked by tattooing with methylene blue. 2. If a wedge excision - the lesion is excised beginning from the apex outward. 3. Labial artery bleeding is controlled by digital pressure. 4. All layers: skin, muscle and mucosa are cut at once. 5. The defect is approximated beginning with the mucosal layer. The skin and vermilion is reapproximated - the first suture is placed at the vermilion border. Variations 1. V or shield shaped excision - for lesions which invade more deeply. 2. W - shaped excision - for small and superficial lesions, allows for excision with adequate margins and the maximal amount of normal tissue being preserved. 3. Rectangular excision with short bilateral advancement flaps - for large and more bulky lesions at the upper limits of excision with primary closure. c. Nasolabial Flaps - Von Bruns 1859 ( Transposition Flaps) Indications - Large, deep and complex defects involving greater than 2/3 of the lateral lip - Alternative to the Estlander Operation Advantages - provides hairbearing skin in males - provides adequate amounts of lip tissue for large defects, bilateral flaps can be used Disadvantages - Pincushioning of flap margins may occur - Color and texture differences in the female patient - Some asymmetry of the nasolabial areas may be noted - Sectioning motor and sensory nerves as well as muscle of the lip - Tendency to tense the upper lip Features - Can be inferiorly or superiorly based - Can be performed in one or two stages Technique Inferiorly Based ( original Von Bruns ) 1. A curvilinear incision is made in the nasolabial fold from lateral commissure of the mouth to the alar base, curving laterally then inferiorly to end at the lateral commissure. 2. The flap is raised and rotated 90 degrees to reconstruct the lower lip. 3. Secondary defect is closed by direct approximation in the nasolabial fold. 4. Two flaps may be raised to replace complete loss of the lower lip. 5. Vermilion is reconstructed by mucosal advancement or tongue flaps. Superiorly Based ( 2 ) Stage Partial Thickness Flap 1. The incision begins at the alar base extending inferiorly in the nasolabial fold curving laterally at the lateral commissure and continuing superiorly. 2. Flap is elevated above the facial musculature 3. Transposition of the flap medially to close the defect. 4. The donor defect is closed directly in the nasolabial fold which helps to rotate the flap to the upper lip defect. 5. The flap is divided and inset at 10 - 14 days 6. The unused portion of the flap pedicle is returned to the nasolabial region. d. Perialar Crescentic Advancement Flap Indications - Unilateral defect of one - third of the lateral lip - Defects greater than one - third if bilateral advancement flaps are used Advantages - Closes large defects without deformity of the alar base, lip or oral commissure - One stage reconstruction - Good aesthetic position Disadvantages - With reconstruction of large defects the nasolabial fold may be partially obliterated. - May not be hairbearing skin in males - Color differences of cheek skin - The lip is not augmented - Tightness of the upper lip exists with a smaller oral aperture. Technique 1. The defect is triangulated with the base oriented superiorly, the long axis is oriented diagonally. 2. At the lateral triangle base, an ellipse of skin ( Burrow's Triangle ) is outlined in the paranasal region, excised and the cheek is undermined. 3. The skin is advanced without tension into the defect. 4. The defect is sutured beginning at the superior portion of the ellipse, this advances the flap. 5. If the defect is close to the mucocutaneous junction, ellipses must be made inferior and superior to the lesion. The inferior ellipse extends lateral and inferior to the commissure. The skin is excised, cheek skin is undermined and advanced, with closure in the nasolabial line. If a Full Thickness Defect: 1 Full thickness of lip and cheek is excised 2. Mucosa of the apex of the gingivobuccal sulcus is incised, the cheek is elevated further laterally. 3. The full-thickness cheek flap is advanced medially and closed in layers, allowing advancement of the remaining portions of the upper lip to fill in the defect. Bilateral Perialar Crescentic Flap 1. Burrow's triangles (crescents) are excised around the nasal ala bilaterally, contiguous with the upper lip defect. 2. The remainder of the procedure is essentially the same. 3. The lip is reapproximated after flap advancement. e. Abbe Flap ( 1898 ) Indications - For replacement of one - third to one half of the upper or lower lip. Advantages - Allows immediate reconstruction - Allows continuity of oral stoma - Donor site is closed primarily Disadvantages - Patient must be cooperative Disadvantages - Limitation of oral movement - Requires division at a later date Technique 1. Proposed defect is outlined and excised as a rectangle, W or V shaped pattern. 2. Rotation point arbitrarily chosen to allow greatest opening during lip adherence. 3. The flap may be W, V or rectangular shaped, designed of equal height and one-half the width of the defect. 4. The lip flap is grasped, all layers are incised at once, away from the pedicle, noting the position of the labial artery. 5. The other side of the lip flap is incised from the apex outward leaving a small amount of cuff of muscle around the vascular pedicle. 6. The flap is transposed to the opposite lip and closed in layers, vermillion border is approximated first. 7. The flap is left pedicled for 10-14 days, then is tested by clamping with a rubber band. If clamping is tolerated, then the pedicle is divided, trimmed and closed. 8. Can be combined with other procedures, i.e. perialar crescentic advancement flaps to reduce the upper lip defect size, and thus minimize the size of the Abbe flap. 9. In uncooperative patients - can use Ivy loops, IMF to stabilize until flap is healed. f. Estlander Flap ( 1872 ) Indications - Defects adjacent to the commissure involving 1/2 - 2/3 of the lip. Advantages - Essentially the same as Abbe flap - local flap - simple technique Disadvantage - Oral commissure distortion, requiring revision - possible microstomia Technique 1. Defect is outlined and excised. 2. Flap extending from the commissure of equal height and 1/2 of the width of the defect is outlined on the opposite lip. 3. Full thickness incision is made sparing the vascular pedicle and vermilion. 4. The flap is rotated to fill in the defect and closed in layers. g. Gillies Technique for Revision of the Rounded Commissure Indications - For correction of the rounded or distorted oral commissure, i.e. Estlander flap. Technique 1. A small triangle of skin is excised adjacent to the rounded commissure. 2. An incision is made along the vermilion border of the lower lip at an angle. 3. The underlying orbicularis muscle is horizontally divided at the new commissure. 4. The detached lower vermilion is rotated upward to form a portion of the upper lip vermilion and commissure. 5. The buccal mucosa inside the lower lip is undermined, elevated and advanced to form the vermilion of the lower lip. h. Karapandzic Flap ( 1974 ) Indications - Can be used to reconstruct as much as 3/4 of the lower lip. - Reversed Karapandzic flap for upper lip reconstruction. Advantages - Preservation of sensory / motor function as well as vascular supply to the lip. - Provides a complete oral sphincter, oral competence. Disadvantages - The reconstructed upper lip is somewhat tight, and is not aesthetically satisfactory (reverse technique). - The oral aperture is small - problem for denture wearers. Technique 1. Transverse incisions are made from the base of the defect extending around the commissures into the upper lip, equidistant from the free lip margin. 2. The orbicularis muscle fibers are spread apart longitudinally with blunt dissection to the submucosal level, leaving the neurovascular structures intact. 3. The mucosa is divided approximately 1 - 2 cm from the edge of the defect. 4. The edges of the defect are advanced and approximated, defects are closed in layers. 5. A single Karapandzic flap can be used to reconstruct defects but asymmetry of the commissure results. i. Fan Flap (Gillies) Indications: Unilateral Fan Flap - defect up to 1/2 of the lower lip Modified Fan Flap - Similar to the above, used when resection extends to the commissure. Bilateral Fan Flap - For total defects of the lower or upper lip. Advantages: - Brings more tissue into the lip region. - Little or no decrease in the size of the stoma. - Donor defect closes directly - Commissure and width of the mouth remains unchanged. Disadvantages: - Little or no muscular function because of denervation. - Problems with oral competence - Some blunting or obliteration of the nasolabial folds. - Poor sensation Technique 1. Full thickness incisions made around the commissures extending onto the upper lip, at the nasolabial fold the incision is back cut and advanced almost to the vermilion border of the upper lip. 2. The flap is now pedicled on labial vessels and can be advanced unilaterally or bilaterally and closed in layers. 3. The Modified Fan Flap differs from the Classic Fan Flap in that the flap rotates around the angle of the mouth to fill in a defect. 4. The vermilion is reconstructed by mucosal advancement or a tongue mucosal flap (better result), which is divided at 10-14 days. j. Webster Cheek Advancement Flap Indications: - Total lower lip reconstruction Disadvantages: - Tight lower lip - Bulky upper lip - Lower lip function is poor with less competence. - Bilateral Fan Flap - Gives a much better reconstruction. Technique: 1. Total lower lip is resected. 2. Horizontal incisions are extended laterally from the base of the defect and the commissures. 3. Four Burrow's triangles are excised above and below the lateral aspect of the flaps. 4. The flaps are advanced bilaterally and closed in layers, the triangles are closed. 5. The vermilion is reconstructed by mucosal advancement or a tongue flap. k. Bernard - Burrow Flap Indications: - Defects of 2/3 or more of the lower lip. Disadvantages: - Little or no muscular function - Problem with oral competence Technique: 1. The lower lip excision is completed, Burrow's triangles are formed. 2. Incisions are extended laterally from the base of the defect. 3. The buccal mucosa from the base of the excised Burrow's triangles are rotated inferiorly over the free margin of the triangle and used to reconstitute the lateral vermilion of the lip. 4. The two flaps are advanced medially, the triangles close and the flaps are approximated in layers. 3. DISTANT FLAPS - Least Satisfactory Method Of Reconstruction a. Upper Lip Reconstruction - Visor Flaps Indications: - Inadequate adjacent cheek tissue for reconstruction. Total loss of lip. Advantages: - Provides hair bearing skin to the lip - Provides a large amount of tissue for reconstruction. Disadvantages - Donor site deformity - Staged reconstruction necessary Technique 1. The Bitemporal Visor Flap is elevated, tubed and sutured into the upper lip defect. 2. The scalp donor site is closed with a split thickness skin graft. 3. In four weeks, the visor flap can be divided, the pedicle should be tested by clamping prior to division. The remainder of the bitemporal flap is returned to its donor site after division of its pedicles. 4. The inner surface of the lip can be lined by skin or mucosal grafts. b. Deltopectoral Flap - lower lip reconstruction Advantages / Disadvantages - same as Visor flap - Infrequently used - Used for extensive skin loss involving the lower lip and adjacent areas. - Allows for folding to provide lining as well as covering to the lip region. FUTURE ADVANCES: Microvascular anastomosis and free flap techniques may become standard ancillary methods of lip reconstruction. Microvascular free flap anastomosis with reconstruction of the upper lip and commissure first described by Harii and Ohmori in 1974. They were able to transfer a hair bearing flap to this region. Recent case report of a full-thickness amputation of the lower lip and chin in a 12 year old boy with microvascular reanastomosis to the labial vessels. There was almost complete return of motor and sensory function even though no neural anastomosis was performed. -------------------------------------------------------------------------------- BIBLIOGRAPHY 1. Bailey, B.J., Management of Carcinoma of The Lip, Laryngoscope, Feb. 1977, No.2 , pp. 250-260. 2. Baker, S.R., Malignant Neoplasms Of The Oral Cavity, Chapter 73 , Otolaryngology - Head and Neck Surgery , Cummings et. al., Vol. 2 ,pp. 1282-1284, Mosby, 1986. 3. Baker, S.R., Options For Reconstruction In Head and Neck Surgery, Otolaryngology - Head and Neck Surgery, Update Vol I., Cummings et. al., pp. 202-213, Mosby, 1989. 4. Bone, R.C., Reconstruction Of The Lip After Ablation Of Malignant Disease, Chapter 1, The Oral Cavity, pp. 163-169, Vol. I Aesthetic Surgery, Plastic and Reconstructive Surgery of The Head and Neck, Third International Symposium, Bernstein, L. et. al., Grune and Stratton, 1981. 5. Converse, J.M., et. al., Deformities, Techniques For The Repair Of Defects Of The Lips and Cheeks, Chapter 32, pp. 1540-1579, Reconstructive Plastic Surgery, Vol. 3, 2nd. Ed., Saunders, 1977. 6. Evans, D.M., et.al., Malignant Tumors of The Lips, pp. 531- 553, Operative Surgery, Head and Neck Part II, Vol. 10, 3rd. Ed., Butterworths, London, 1979. 7. Gullane, P., et. al., Minor and Major Lip Reconstruction, J. Otol., 12:2, 1983, pp.75-82. 8. Jackson, I.T., Lip Reconstruction, Chapter 8, Local Flaps in Head and Neck Reconstruction, pp. 327-412, Mosby, 1985. 9. Kohle, P.S., et. al., Reconstruction of The Vermilion After "Lip Shave", Brit. J. Plast. Surg., 41:8-73., 1988. 10. Lesavoy, M.A., Lip Deformities and Their Reconstruction, Chapter 7, pp. 95-116, Reconstruction of the Head and Neck, Williams and Wilkins, 1982. 11. Lore, J.M., The Lips, Chapter 9, pp. 376-402, An Atlas of Head and Neck Surgery, Saunders, 1988. 12. Mc Gregor, I.A., The Lips - Repair of Losses, pp. 321-344, Operative Surgery, Plastic Surgery, Vol. 17, 3rd. Ed., Butterworths, London, 1979. 13. Naumann, H.A., Surgical Management of Defects of The Scalp, Face, Cheeks and Lips, Chapter 2, pp. 80-98, Head and Neck Surgery, Vol. I, Saunders, 1980. 14. Panje, W.R., Lip Reconstruction, Oto Clin N. Amer., Vol. 15, No. 1, pp.169-178, Feb. 1982, Saunders. 15. Sakai, S., et.al., Bilateral Island Vermilion Flaps for Vermilion Border Reconstruction, Ann. Plast. Surg., 20:5, 459-461, May 1988. 16. Schaefer, M.E., Ed., Lip Surgery, Clinics in Plastic Surgery, 11:4, pp. 571-651, Oct. 1984, Saunders. 17. Schubert, W., et. al., Use of The Labial Artery for Replantation of The Lip and Chin, Ann. Plast. Surg., 20:3, pp. 256-260, March 1988. 18. Ward, P.H., Ed. et.al., Plastic and Reconstructive Surgery of The Head and Neck, Vol. 2, Chapters 96-99, pp.655-683, Mosby, 1984. 19. Wilson, J.S., et.al., Reconstruction of The Lower Lip, Head and Neck Surgery, 4:29-44, 1981. 20. Yarrington, C.T., et. al., Reconstruction Following Lip Resection, Oto. Clin. N. Amer., 16:2, pp.407-421, Saunders, 1983. ----------------------------------END------------------------------------------