Mustarde Cheek Rotation Flap for Lower Eyelid Repair


A Mustarde; cheek flap is a large rotation flap with its leading edge at the lateral canthus extending laterally and arching like a Tenzel flap (12). The incision is then continued laterally to the preauricular crease toward the level of the earlobe. A wide subcutaneous undermining proceeds, the extent of which is determined by the laxity of the skin and the extent of the defect. The posterior lamella must be reconstituted and Mustarde recommends a composite graft of nasal septal cartilage and mucosa. The mucosa should be harvested in excess to cover the lid margin, and the nasal sep-tal cartilage must be thinned to 1 mm and be oversized with respect to normal tarsus to extend to the lower orbital rim.


The Mustarde cheek rotation flap is indicated in lower eyelid defects involving over 75% of the lid margin. This flap may best be reserved for patients who cannot undergo a two-staged operation (Hughes tarsoconjunctival flap) or when an extensive lower lid defect extends over 7 mm below the lid margin (13).


The advantages to using this flap include the ability to apply it to very extensive and total lower lid defects; use of cheek tissue and sparing of the upper lid as a donor site; and the use of incisions that are well-hidden following the borders of the cheek topographical unit.


This flap leaves a large segment of the lid margin with little structural support potentially resulting in eyelid malposition including entropion or ectropion.

Bipedicle |

Description I

The bipedicled flap transfers tissue from the upper eyelid to the lower eyelid in two stages (Fig. 8). The skin bridges medially and laterally remain intact after the first ^

stage and are divided and discarded during the second stage 2-3 weeks later. The >3

flap may be composed of skin and orbicularis oculi muscle only (Tripier flap) or the full-thickness of the upper eyelid including a portion of the upper tarsus

(14). If tarsus is harvested, the marginal arcade must be preserved. Leaving at least §

5 mm of upper tarsus will preserve the marginal arcade and the stability of the

Tripier Flap
Figure 8 Two-staged bipedicled flap for defect in lower eyelid.

upper eyelid margin. The initial incision for the Tripier flap is oriented along the -g supratarsal crease and the superior incision is 10-15 mm above and parallel to the |

inferior incision. The donor site of the partial-thickness Tripier flap is closed pri- »

marily as in standard blepharoplasty. The donor site of the full-thickness flap c requires a complex layer repair including pushing back or recessing the upper lid ^

retractors and suturing the free conjunctival edge to the upper border of the >3

remaining tarsus. The upper lid retractors are then sutured to the conjunctiva at |

their recessed position and the skin is closed primarily. A laterally based composite o unipedicle flap may be designed for marginal defects of the temporal lower eyelid (4). §


The bipedicled flap is indicated for horizontal lower eyelid defects limited to 10-15 mm in height. Non-marginal anterior lamella defects may be repaired with a partial-thickness flap. Marginal defects, if repaired with a partial-thickness flap, will require an autogenous composite graft (e.g., a nasal septal cartilage-mucosal graft). A full-thickness bipedicled flap will reconstitute both the anterior and posterior lamellae.


The advantages of the bipedicled flap are that it provides tissue with excellent texture, color, and thickness. It may be single-staged for total marginal defects using the full-thickness bipedicled flap. The tarsus incorporated into the flap provides support for the lower eyelid margin. The nature of the transposition provides good support laterally and medially to the newly reconstructed lid margin.


The upper eyelid may be malpositioned or lagophthalmus may result from harvest of the full-thickness flap. The height of the defect that can be repaired is limited to 10-15 mm. No eyelashes are included in the flap for marginal repairs.


More than 90% of lip defects involve the lower lip because the majority of lip carcinomas occur in this area. Basic goals in lower lip reconstruction are the prevention of drooling and re-establishment of the continuity of the lips. A variety of local and regional flaps are capable of meeting these goals. However, with the recent advent of several innervated local flaps and modified versions of previously nondynamic and nonsensate flaps, function and cosmesis are now of primary importance. Although not yet within reach, the ideal lip repair results in a completely functional lip demonstrating normal sphincteric and complex motor actions with identical texture and color to the missing lip segment. There should be no donor site morbidity or noticeable scar, and the flap should be reliable, easily harvested, and sensate.

Lip Anatomy

The lips are paired mobile folds covered externally by skin and internally by mucous membrane encompassing a highly muscular inner layer. The upper lip extends to the base of the nose medially and to the nasolabial folds lateral. The lower lip is separated from the chin by the mentolabial sulcus (mental crease) (15). The surface anat- | omy of the lip consists of the topographical subunits, oral commissures, red-lip margin, inner vermilion line, philtrum, red line, white line, and Cupid's bow c (Fig. 9). Burget et al. (16) have organized the upper lip into topographical subunits ^ including two lateral subunits and two medial subunits. The borders of a lateral subunit are the ipsilateral philtral column, nostril sill, alar base, melolabial fold, and inner vermilion line. The borders of a medial subunit are the ipsilateral philtral column, nostril sill, midphiltral trough, and inner vermilion line. The oral commissures demarcate the upper lip aesthetic subunits from the lower lip subunits. When more @

Figure 9 Topographical subunits of the lip.

than 50% of a subunit is missing, superior aesthetic results will be obtained if the entire subunit is replaced. The lower lip includes two lateral subunits and a central subunit. The borders of a lateral subunit are the labiomental crease, mandibular margin, mental crease, and inner vermilion line. The lateral subunits meet in the mid-line over the mental crease and central subunit. The mental crease defines the central subunit as it courses horizontally under the mid-portion of the lower lip and descends inferolateral to the mandibular margin (17).

The red-lip margin is the vermilion surface external to the occlusal surface of the upper and lower lips (inner vermilion line). It is composed of modified mucosal epithelium devoid of minor salivary glands. The perioral skin meets the deep red color of the vermilion at the red line. Just outside the red line is a raised surface prominence of paler skin that forms the white line. Malalignment or deformity of the white line is very noticeable and careful reapproximation of this line during lip reconstruction is essential. The philtrum, above the midline of the upper lip, is defined by vertical raised skin prominences forming the philtral columns and the portion of the white line inferiorly forming a gentle curve known as Cupid's bow.

The layers of the lip include the vermilion, orbicularis oris muscle, labial glands, and oral mucosa. The orbicularis oris muscle is an oral sphincter but is not simply a sheet of continuous muscle fibers that encircle the mouth. The oral sphincter is a complex composite of muscle fibers including those of the orbicularis oris that radiate from dense fibromuscular masses (the modioli) located approximately 1.25 cm lateral to the oral commissures. The modioli are focal points of transit, insertion, and decussation of several different muscles that together result in the complex movements associated with the lip (Fig. 10). The orbicularis oris muscle |

fibers radiate from the modioli and converge in the midline of each lip. The muscle »

fibers that travel under the red-lip margin represent the pars marginalis component of the orbicularis oris muscle. The pars marginalis consists of a single (in some races a double) band of narrow muscle fibers within the red-lip margin. The pars margin-alis is unique to higher primates and is essential to normal vocalization and production of some musical tones. The peripheral component of the orbicularis oris muscle is the pars peripheralis; these fibers aggregate into cylindrical bundles that fan out from each modiolus from the white line to the peripheral areas of the upper and

Modioli Anatomy
Figure 10 The modioli: note the common insertion of the facial mimetic muscles.

lower lips (Fig. 11). On sagittal section, the pars peripheralis as it approaches the red-lip margin and the pars marginalis are classically described as resembling the shank and curved portions of a hook. The buccinator muscle forms a large part of the oral sphincter, its peripheral fibers passing directly into the upper and lower lips, and its central fibers decussating at the modioli before passing into the lips (18). Superficial to the buccinator muscle course fascicles from the levator anguli oris and depressor anguli oris, inserting and crossing at the modioli. Entering the orbicularis obliquely, the zygomaticus major, levator labii superioris, and depressor labii inferioris contribute other superficial fascicles. The motor supply to all these muscles is from the buccal and mandibular branches of the facial nerve. Sensation is mediated through the infraorbital and mental branches of the trigeminal nerve. The labial arteries are branches of the facial artery that course immediately beneath the labial mucosa deep to the inner vermilion line.

Vermilion Line

Vermilion Defects

Partial-thickness defects involving the vermilion and white line that can be closed primarily should be repaired in line with the resting skin tension lines (RSTLs); extension beyond the borders of the surrounding topographical subunits (e.g., mental crease) should be avoided. The RSTLs radiate out from the white line and tend to follow the fine rhytids in this area. If the partial-thickness defect involves the underlying orbicularis muscle and superficial repair would leave an adynamic segment of lip, consideration should be given to converting it into a full-thickness defect to allow approximation of the orbicularis oris muscle to maintain oral competence. More extensive partial-thickness vermilion defects may be repaired with a variety of flaps including mucosal advancement from the labial mucosal behind the inner vermilion line, skin grafting with tattooing, and ventral or marginal musculomucosal tongue flaps. Vermilion mucosal defects may be repaired with mucosal advancement; however, if the vermilion defect is thick, involving submucosal tissues, then a more substantial musculomucosal tongue or cheek flap is preferred. Tongue flaps must be designed carefully to ensure their viability. The median raphe separates the vascular-ity of the tongue in the sagittal plane with very poor collateral circulation. For this reason, tongue flaps should be designed longitudinally along the margin of the tongue, or transversely, across the median raphe, as a bipedicled flap (19). Tongue flaps for vermilion reconstruction should be obtained from the undersurface or margin of the tongue because these surfaces are smooth and resemble vermilion. Underlying tongue muscle should be selectively harvested to provide sufficient bulk to the new vermilion. The undersurface of the tongue can be transferred to the lower lip vermilion surface using staged marginal and ventral bipedicled tongue flaps (Fig. 12). The second stage, usually 3 weeks later, is for flap division and inset; the defect on the undersurface of the tongue can be left to heal by secondary intention. For upper lip defects, the tongue tip may be sutured to the vermilion and severed 3 weeks later.

Full-thickness vermilion-only defects that are limited to one-half the length of the lip may be repaired with unilateral or bilateral full-thickness vermilion advance-

Figure 12 Staged ventral tongue flap for lip vermilion reconstruction. Upper photographs 5

show incision in ventral tongue (A) and intermediate attachment to lower lip (B). Lower |

photographs (C, D) show lower lip after detachment from the tongue.

Figure 13 Patient with a verrucous growth of the left lower lip. After resection, this patient
Figure 14 Sliding vermilion advancement flap for repair of a lower lip defect.

ment flaps (Figs. 13, 14). Sliding vermilion advancement flaps for full-thickness vermilion defects of the lower lip take advantage of the elasticity of completely released segment of vermilion. The vermilion is released by full-thickness cuts at the white line to the oral commissure, being careful to angle the cut appropriately to include the labial artery. The flaps are then simply brought together on stretch and all incisions are sutured primarily (20).

Commissure Reconstruction

Some local flaps (e.g., Estlander flap or Karapandzic flap) result in a blunted or -g rounded commissure that requires secondary revision. Most commonly, revision involves lateral horizontal transection through a point corresponding to the desired location of the buccal angle. Buccal mucosa is advanced anteriorly to form the new red lip. Converse described a method of commissuroplasty that removed a triangular unit of skin and subcutaneous tissue lateral to the blunted region and advancement of the underlying mucosa to form the new redlip (21). |

Commissure defects are most commonly secondary to trauma, especially electrical burns. An electrical burn injury affects the lower lip and commissure most severely. The commissure becomes rounded with adjacent cutaneous and subcutaneous scarring that pulls the uninjured surrounding lip and cheek tissues inward, resulting in excessive bulk and anteromedial rotation of the affected commissure. Delayed reconstruction in these cases is preferred in contrast to immediate reconstruction for cases due to cancer resection. The early use of an oral splint may reduce the need for extensive reconstructive surgery in milder cases. A restored commissure should ideally be symmetrical with respect to the opposite side in repose and during mouth opening, with no webbing, and with a normal well-defined vermilion. The lateral extent of the commissures should fall in line with the medial aspect of the cornea. The variety of reconstructive methods described for this injury is evidence for the fact that there is no 'best' technique and the ideal result is seldom achieved. In general, the techniques involve some degree of scar release and excision; formation of a more naturally placed commissure; and mucosal, adjacent vermilion, or tongue flaps to form the new vermilion.

Despite the plethora of available techniques, some basic tenets should be considered. Adequate release of all contracted tissues including mucosa and muscle should be performed initially to reduce the excess bulk by allowing the tissues of the cheek and adjacent lip to retract back to their normal positions. A limited amount of indurated fibrous tissue should be excised. If an excessive amount of scar tissue is removed, the commissure will thicken as cheek and adjacent lip are again pulled into the area postoperatively. The opened commissure is deficient of tissue; therefore, buccal mucosal, adjacent vermilion, or ventral tongue flaps must be recruited. Using adjacent buccal mucosal or vermilion may be counterproductive since they are harvested from a region that is already deficient of tissue. A staged, anteriorly based, ventral tongue flap avoids the use of adjacent tissue and may be the best choice, especially for more significant injuries (22).

Full-Thickness Defects

The factors influencing lip reconstruction are the extent and location of the lip defect, associated bony defects of the anterior arch of the mandible, prior neck dissection, and the quality and quantity of adjacent lip and cheek tissues. Definitive repair at the time of cancer resection is customary because, with the selective use of Mohs' micrographic surgery and frozen section control of surgical margins, the risk of recurrence requiring further surgery is rare.

Defects involving up to one-third of the length of the lip can be closed primarily with a pentagonal wedge excision keeping the edges of the vermilion parallel and wedging out a triangle of skin below the white line (Fig. 15). Primary closure of defects involving up to one-half of the lip is possible in selected patients with significant lip laxity. Two techniques that allow primary lip closure for defects involving -g one-half the lower lip that cannot undergo simple closure are the staircase technique and bilateral lip advancement flaps. The staircase technique is employed for rectangular defects and involve lateral advancement flaps from the remaining parts of the lower lip and chin prepared by stepwise incisions. Defects can be closed with either d unilateral or bilateral flaps. The rectangles are excised below the steps down to the orbicularis oris muscle (originally these were described as full-thickness [23]) to allow |

the remaining lip segments to advance medially (24). Rectangular defects can be o repaired using full-thickness bilateral advancement flaps of the remaining lower lip by extending the horizontal limits of the base of the defect laterally along the mental

Figure 15 Pentagonal closure of a lip defect. Note the pentagonal wedge of tissue excised to allow closure and accurate alignment of the white line.

creases. After full release of the lateral lip segments they are advanced toward the midline and sutured in layers (Fig. 16).

Defects involving over one-half of the lip require tissue recruitment from the opposite lip (e.g., Karapandzic or cross-lip flap); the perioral area (e.g., steeple, depressor anguli oris, or facial platysmal flap); or the cheek (e.g., modified Bernard or fan flap). These local flaps are functional (sensory and motor) and the resulting scars often fall on the borders of the lip topographical subunits. The steeple flap and cross-lip flaps (Abbe and Estlander) depend upon reinnervation from the

Scapular Soft Tissue Flap

Figure 16 Rectangular lip defects closed with horizontally advanced tissue. This patient had an extensive lower lip/mandible defect. The lip was originally closed primarily after transfer of a composite scapular free flap (left photograph). A second-stage procedure involving horizontal advancement of the adjacent lip and chin soft tissues resulted in improved appearance and function of the lower lip (right photograph).

Figure 16 Rectangular lip defects closed with horizontally advanced tissue. This patient had an extensive lower lip/mandible defect. The lip was originally closed primarily after transfer of a composite scapular free flap (left photograph). A second-stage procedure involving horizontal advancement of the adjacent lip and chin soft tissues resulted in improved appearance and function of the lower lip (right photograph).

Table 1 Flap Selection for Lower Lip Reconstruction

Lower lip defect Repair

Lateral 1 /3 to 2/3 Depressor anguli oris flap

Innervated facial platysmal flap Central 1/3 to 2/3 Karapandzic flap

Modified Bernard flap Total Bilateral depressor anguli oris flap

Bilateral innervated platysmal flap surrounding lip tissue that may be partial and delayed for several months. Tobin (25) has created a useful paradigm for flap selection in lower lip reconstruction to maximize postoperative lip function and cosmesis (Table 1).

Associated bony defects of the anterior arch of the mandible and prior neck dissection may affect the choice of flap for lip repair. Mandibular arch resection for cancer requiring lip resection often results in large lower lip tissue deficiencies that include the depressor anguli oris and facial platysmal, eliminating the use of the perioral flaps that are based on these muscles. The soft tissue component of the free flap may be available for lip reconstruction. However, these tissues are usually excessively thick and nonsensate, with the exception of the osteocutaneous radial forearm flap that is rarely used for mandibular arch defects. Perioral and cheek flaps are still preferred despite underlying bone reconstruction and the availability of the soft tissue component of the free flap. If local tissue is unavailable, concurrent or subsequent transfer of a sensate radial forearm free flap is satisfactory (26,27).

Prior or simultaneous neck dissection should have little bearing on the choice of flap for lip reconstruction unless the marginal mandibular nerve is disrupted, in which case the functional local flaps that depend upon this nerve for movement would be less effective (e.g., depressor anguli oris and facial platysmal). The modified Bernard flap and the Karapandzic flap would also be expected to result in a poorly functioning lip, but may benefit from the remaining buccal branches for orbicularis oris muscle tone and movement. More commonly, the facial artery is divided, jeopardizing the vascular supply to the perioral and cheek flaps. However, retrograde collateral flow through the facial arterial branches from the angular, infraorbital, dorsal nasal, and transverse facial vessels is sufficient to supply the majority of these flaps (28). Nevertheless, the facial artery should be preserved, if possible.

The quality and quantity of adjacent lip and cheek tissue may be diminished, most commonly by the presence of inelastic and fibrotic skin secondary to irradiation or dysplastic changes in the skin of the cheek or opposite lip. When local flaps -g are unavailable, regional or free tissue transfers must be considered. The most com- | mon regional flaps for subtotal or total lower lip reconstruction include the staged paired deltopectoral flap, and the pectoralis flap (29,30). These flaps have several c inherent deficiencies including poor color match, no movement, no sensation, multi-

d ple stages, marginal distal viability, and excess bulk. Regional flaps for the upper lip include the staged temporal forehead (unipedicled or bipedicled) and staged bipe-dicled-scalping flap. These flaps can bring hair-bearing skin to the upper lip, and o may be satisfactory because limited sphincteric movement and absence of sensation are better tolerated in the upper lip. Scalp flaps used to reconstruct the lips are axial based on the posterior branch of the superficial temporal artery. For full-thickness lip defects, additional flaps or skin grafts must furnish an inner lining. Although these flaps result in adequate lip replacement with hair-bearing potential, they suffer from requiring a staged procedure and significant donor site morbidity. The radial forearm free flap for both total and subtotal upper and lower lip defects is superior to regional flap repair (Figs. 17-19). It is potentially sensate, appropriately thin to

Regional Flap Surgery

Figure 17 Upper lip defect closed with a radial forearm free flap. This patient received d radiation therapy as a teenager to control facial acne. He had multiple skin cancers throughout g his face and extensive scarring within his upper lip, causing permanent retraction of this structure (upper left photo). The skin and upper lip were resected within the aesthetic unit 5

(upper right photo) and a radial forearm free flap was fashioned using a template. It was used |

to repair the missing lip and skin, providing a long-term solution (lower photo). @

Figure 17 Upper lip defect closed with a radial forearm free flap. This patient received d radiation therapy as a teenager to control facial acne. He had multiple skin cancers throughout g his face and extensive scarring within his upper lip, causing permanent retraction of this structure (upper left photo). The skin and upper lip were resected within the aesthetic unit 5

(upper right photo) and a radial forearm free flap was fashioned using a template. It was used |

to repair the missing lip and skin, providing a long-term solution (lower photo). @

Figure 18 A patient with extensive squamous cell cancer of the lower lip requiring total excision of his lower lip, underlying mucosa, and adjacent chin (left photo). A sensate radial forearm free flap was planned with harvest of the palmaris tendon to support the free edge of the new lip/vermilion.
Mustard Suture

Figure 19 Patient in Figure 18 during (left photo) and after (right photo) flap transfer. Note in left photo the red rubber tube attached to the palmaris tendon. The flap is folded over this tendon, providing extra- and intraoral coverage and the tendon is secured with permanent suture to the modioli. The patient also underwent vermilionplasty using a staged ventral tongue flap.

Figure 19 Patient in Figure 18 during (left photo) and after (right photo) flap transfer. Note in left photo the red rubber tube attached to the palmaris tendon. The flap is folded over this tendon, providing extra- and intraoral coverage and the tendon is secured with permanent suture to the modioli. The patient also underwent vermilionplasty using a staged ventral tongue flap.

fold on itself at the free lip margin for interior lip coverage, and can be supported using the palmaris tendon draped under the free lip margin (its ends sutured to the modioli or zygomatic-malar complexes).

Karapandzic Flap I

Description %

Karapandzic originally described this flap in 1974 as a means of perioral lip advance- .3 ment that maintains the sensory and motor function of the orbicularis oris muscle and perioral skin (31). The technique consists of bilateral circumoral incisions from o the edge of the defect maintaining an equal distance from the white line to a point just §

medial to the nasolabial fold (i.e., the width of the flap is equal to the height of the @

Figure 20 A Karapandzic flap used for repair of a subtotal lower lip defect.

defect) (Fig. 20). The neurovascular structures at the outer edges of the defect and at the corners of the lips are preserved and the orbicularis oris is selectively cut and released around these structures to allow flap rotation. Only the superficial fibers of the orbicularis oris muscle are cut at the commissures to preserve the radiating deeper fibers of the buccinator muscle. To minimize the rounded appearance of the commissures, the distal cut ends of the zygomaticus major muscles may be sutured relative to the new position of the commissures. Limited gingival labial sulcus muco-sal incisions are necessary to facilitate movement of the lip tissues toward the defect.


The procedure may be used in any patient with a full-thickness lip defect involving the vermilion and perioral skin. However, the degree of postoperative microstomia is proportional to the length of the defect. Therefore, the Karapandzic flap is mainly indicated for defects involving up to two-thirds of the lower lip and up to one-half of the upper lip. Rectangular defects are most amenable to this type of repair.


The main advantage of the Karapandzic flap is that is maintains a continuous circle of functioning orbicularis oris muscle and sensate perioral skin that results in a functional reconstruction.


The main disadvantage of the Karapandzic flap is that the oral cavity aperture will be smaller (microstomia), thus impeding oral access, which is especially significant in patients with dentures. The nature of the incisions can result in a clown-like appearance. The location of the modioli is altered and the new commissures often take on a | rounded appearance that may require commissuroplasty. £

Abbe Flap 1

Description |

The Abbe; flap is a two-stage full-thickness lip switch flap based on the labial artery o taken from the opposing lip medial to the oral commissure (32). The shape and size §

of the flap depend upon the dimensions of the defect; however, the height of the flap @

should be equal to the height of the defect, and the width of the flap should be half the width of the defect. The flap is transposed 180 degrees and after 7-10 days the pedicle is divided and the lips are closed in layers.


The Abbe; flap is indicated for full-thickness central defects involving up to one-half of either lip. This flap may be used to reconstitute a missing philtrum. A unique use of an Abbe flap described by Millard involves transfer from the central lower lip to the central upper lip in patients with a tight upper lip after unilateral cleft lip repair. This relieves the tension on the upper lip and provides a philtrum with the philtral columns corresponding to the vertical scars resulting from flap placement (33).


The Abbe flap provides nearly identical tissue to that lost including red lip, orbicu-laris oris muscle, and intraoral mucosa. 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 and sensation within several months (34).


This is a two-stage procedure that requires the placement of a temporary pedicle that partially blocks the oral aperture. Although motor reinnervation occurs, the quality is variable and may result in an adynamic or poorly functioning segment of lip. Return of sensation may take several months, returning in the order of pain, touch, and temperature (cold, then hot). The continuity of the orbicularis oris in the normal lip is disrupted, potentially resulting in muscle denervation and dysfunction. The oral aperture is reduced, and repair of larger defects in some patients may result in significant microstomia. The scar in the recipient lip often results in bunching up of the flap tissue causing a trap door deformity.

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