Estlander Flap


Estlander (35) described a single-stage full-thickness cross-lip flap based on the labial artery for closure of lower lip defects near the commissure of the mouth. As with the Abbe flap, the width of the flap should be one-half the width of the defect, and the height should equal the height of the defect. The Estlander flap transfers the lateral portions of the opposite lip around the existing commissure to replace the missing lip tissue. Blunting of the commissure is expected and secondary revisions are usually necessary.


The Estlander flap is indicated for full-thickness lateral defects involving up to one-


The Estlander flap provides nearly identical tissue to that lost including red lip, orbi-cularis oris muscle, and intraoral mucosa. Balance between the lips is preserved because the resulting length of the donor lip is proportional to the length of the recipient lip. The new lip segment regains motor innervation within 8 weeks (34). @

Estlander Flap
Figure 21 A superiorly based Estlander flap for repair of a lower lateral lip defect. Note how the donor site scar falls within the nasolabial crease.


The modiolus is disrupted, altering the functionality of the lip elevators and depressors. The Estlander flap blunts the ipsilateral commissure and a secondary commis-suroplasty is usually necessary. The return of motor and sensory innervation is variable. Like the Abbe; flap, the Estlander flap may result in significant microstomia and trap door scarring.

Bernard-Von Burow Cheek Advancement


Bernard and Von Burow were two 19th century surgeons who described the use of cheek tissue advancement using perioral triangular excisions of redundant tissue to close large full-thickness lip defects (36). To reconstruct large upper lip defects,

Burow's triangles are placed lateral to the alae and oral commissures. For lower lip defects, the Burow's triangles are placed at the oral commissures and the defect is excised in the shape of a large 'V' that includes much of the chin tissue inferior -g to the lip. The mucosa in the depth of the triangles is incised and left pedicled |

inferiorly; this excess mucosa is draped anteriorly after flap inset to form the »

new vermilion.

The Webster modification of the Bernard flap was described for lower lip ^

d reconstruction (37). It spares the facial musculature, including the orbicularis oris >3

and the neurovascular structures, by excising skin only within the Burow's triangles.

The underlying muscles and neurovascular structures are released similarly to the

Karapandzic flap. The Burow's triangles are also placed more laterally and their §

bases tilted slightly superolateral with respect to the oral commissures to fall within

Webster Bernard Flap
Figure 22 The Webster modification of the Bernard flap for repair of an extensive lower lip and chin defect. See text for details.

the melolabial fold. The requirement of a V-shaped defect is abandoned in favor of a chin-sparing rectangular defect. Two additional Burow's triangles (skin only) are placed opposite the inferior aspect of the defect within the buccolabial folds. Mucosal-only incisions are made under the upper Burow's triangles to create excess mucosa that is pedicled inferiorly to drape over the new lip margin.


This flap was originally described to reconstruct subtotal and total defects of the upper or lower lip. The Webster cheiloplasty is indicated for lower lip defects, especially subtotal defects of the central lower lip (Fig. 22). Total lower lip reconstruction may be facilitated by a cross-lip Abbe; flap to augment the central part of the lower lip, reduce tension on the closure, and reduce the size of the upper lip to more closely match the deficient lower lip (38). Modified Bernard flaps (muscle and nerve sparing) for subtotal or total upper lip defects may also be augmented with a cross-lip flap to the philtrum.


The modified Bernard flap preserves the integrity and position of the modioli and creates a functional lip. Limiting its use to subtotal defects of the lip will result in a satisfactory repair. These defects may also be repaired with a Karapandzic flap; however, the Bernard flap will not result in microstomia.


The original Bernard-von Burow flap resulted in denervation of the orbicularis oris, interruption of the sensory supply to both the upper and lower lips, and disruption of the modioli. These problems are avoided using the modified flaps. A large amount of healthy tissue must be discarded in the nasolabial and mentolabial folds. If defects involving greater than two-thirds of the lip are reconstructed using this technique, a tight lip deficient in tissue often results. Solving this problem by using cross-lip flaps results in a new set of problems inherent in the use of the Abbe flap. Use of a cross-lip flap may be particularly problematic if the donor site is from the upper lip, because this would disrupt the philtrum.

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  • mariam
    Is estlander flap usually one or 2 stages?
    3 months ago

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