Lip Reconstruction
Yamilet Tirado, M.D.
October 6, 2005

The lip is an important functional and aesthetic facial feature used for relatively simple tasks, such as retaining oral contents, as well as for complex functions, such as smiling, kissing and expressing emotion. The lip has a defining role in the concept of modern beauty. The upper lip is cosmetically more complex than the lower lip because it has a symmetry that is based on Cupid's bow and the philtrum.

Function, of course, follows form. The lips function as a sphincter for retaining oral contents during mastication. They are important for articulation and speech and during phonation of certain sounds, such as letters "M", "P" and "B". The lower lip has more contributions functionally as it maintain secretions inside the oral cavity and prevents drooling.

Facial development starts in the early embryonic period. The upper lip develops from the fusion of the maxillary and medial nasal prominences and the intermaxillary segment. The commissure is formed by the fusion of the lateral portion of the maxillary processes with the mandibular processes. The lower lip and mandible are derived from the mandibular process, which develops as a single structure that crosses the midline.

The lip encompasses the area from the subnasale to the mental crease and from commissure to commissure. The skin and vermillion are separated by a paler rim of tissue called the white roll, which is also well known as dermal roll. The red line separates the dry vermilion from the intraoral labial mucosa, also known as "wet lip." The upper lip is shaped like an elongated M, the apices of which form the lower extent of the philtral columns. The apices of the upper lip along with the central depression are referred to collectively as Cupid's bow. The tubercle is the prominence in the center of the upper lip. The philtral columns extend up to the columella and are separated by the philtral groove. The upper lip is divided into three esthetic subunits: the central philtrum, and the paired lateral units spanning from the philtral columns to the meliolabial folds. Relaxed skin tensions are oriented radially around the mouth and should be considered when planning perioral incisions to achieve the best cosmetic result. The lower lip is slightly shorter than the upper lip and varies in width along its length. The mental crease demarcates the border between the lip and chin and corresponds to the lowest extent of the gingival sulcus.

The musculature of the lip is complex. It includes the orbicularis oris and a dozen paired muscles whose actions are elevation, depression and sphincteric. The orbicularis oris makes up the bulk of the tissue of the lip and acts as the sphincter muscle to the oral aperture. One effect of this muscle that we should take into consideration when planning a repair is that its resting tone can make defects of the lip appear larger than they actually are by pulling on wound edges. The deep fibers of the orbicularis oris are oriented horizontally and act to compress the lips and provide sphincter function, whereas the superficial fibers are responsible for finer movements. The oblique fibers act to evert the lips. The depressors of the lip include the depressor anguli oris, mentalis, depressor labii inferioris and the platysma. The elevators of the lip include the levator anguli oris, zygomaticus and risorius.

The sensory innervation to the upper lip is via the infraorbital branch of the trigeminal nerve. The mental branch of the trigeminal nerve provides sensory innervation to the lower lip. Motor innervation to the muscles of the lips is via the buccal and marginal mandibular branches of the facial nerve. Nerves enter deep to the muscle with the exception of the mentalis muscle, which receives its innervation superficially from the marginal mandibular nerve.

The blood supply to both lips is derived from the facial artery via the superior and the inferior labial branches. The labial arteries are more frequently located between the orbicularis oris and the mucosal surface of the lip. Venous drainage generally runs with the arteries; however the upper lip can drain via the ophthalmic vein to the cavernous sinus, providing a route for labial infections to spread intracranially. The embryologic boundary between the left and the right upper lip causes lymphatic drainage to occur ipsilaterally. The lower lip has no such boundary and can drain bilaterally to cervical lymph nodes.

Neoplastic disorders make up the majority of lip pathology encountered by surgeons, but other disease processes, such as trauma and congenital disorders can involve the lip and require surgical repair. SCC is the most common malignancy affecting the lip. Ninety percent of all squamous cell carcinomas occur in the lower lip, as it receives more UV exposure than does the upper lip. Other malignancies affecting the lip include basal cell carcinomas and melanoma, among others. Trauma to the lip occurs frequently and from a multitude causes, including automobile accidents, interpersonal violence, animal bites, and electrical burns, which are very common in toddlers. Such injuries are characterized by local tissue destruction and hemorrhage that may occur 5-10 days following the accident.

The lip may be involved in many other disease processes that may or may not require surgical intervention. Among them are angular cheilitis, hemangiomas, nevi, labial melanotic macules and infectious processes such as herpes labialis.

The first mention of a labial repair was made in India back in 1000 b.c.e. Most modern techniques were developed during the nineteenth century and have continually evolved since that time. The fist wedge excision and closure was made by Louis in 1768. Von Burrow also contributed to this procedure with the excision of skin triangles to facilitate flap advancement. Estlander and Abbe described their procedures back in 1872 and 1897, respectively. Karapandzic described his myocutaneous flap for large to near total lip defects in 1974. This was also the year when Hari and Ohmory performed the first free flap with microvascular suture of the upper lip. Since then, many other techniques and modifications have been developed to recreate a lip that not only approximates the normal anatomic form but also functions similar to the premorbid situation.

Before proceeding with a lip reconstruction, there are many factors that need to be considered. The age and sex of the patient become a determinant factor when repairing a lip defect. An elderly patient, for example, has more loose soft tissue from the relaxed skin tension lines as a result of dynamic facial movements that result in a better ability for advancement, rotation and transposition of the tissues. After repair, it also has less conspicuous scarring. In males we need to consider hair bearing skin prior to advancement or rotation of flaps. On the other hand, women have the ability to apply cosmetics for camouflage, such as lip liner and permanent tattooing.

Other surgical considerations are the location and the extent of the defect. Size and thickness should be taken into consideration to plan the appropriate procedure for repair.

Functional and cosmetic considerations are paramount when planning the repair of a lip defect. The basic principles of wound closure apply to repairs of the lip. Careful evaluation, debridement, hemostasis alignment of the vermilion border and approximation of the muscular layer are the keys for a functionally and esthetically pleasing result. Ideally, one must realign all muscle fibers along their original direction and preserve lip height. Unrepaired muscular defects can contract during the healing process and create a visible notch along the wet lip border. As we have previously discussed, the lip has several important functions that need to be maintained as much as possible after a repair. Microstomia is an important complication of lip repair that can hinder oral hygiene and the use of dentures. Wound tension and oral incontinence are among other complications.

Topographic boundaries and esthetic units of the lip must be recognized and respected when planning a surgical repair. It is prudent to mark important structures before the injection of any local anesthetic. Even small discrepancies between or within these important landmarks are obvious to a casual observer. The melolabial fold, mental crease and philtral ridges are esthetic subunit boundaries of the lip region that are useful for camouflaging scars. It is best to avoid crossing boundaries. When a defect takes up a substantial portion of an esthetic subunit, entire replacement may provide the best cosmetic outcome.

Algorithms to lip reconstruction will be discussed next. First, we will start the discussion with lower lip reconstruction and finally with upper lip reconstruction.

Lower lip defects are divided into mucosa and lower lip subunit defects. Superficial defects of the mucosa and their respective repairs will be discussed first. The lower lip subunit defects can be divided between partial and full thickness defects. Partial thickness defects are repaired based in the location of the defect, while full thickness defects are repaired based on the size of the defect.

Small areas of the lip or vermillion that do not involve the underlying orbicularis muscle may heal nicely through second intention. Skin only defects of the lower lip are less common, and can usually be closed primarily or with local skin flaps. Certain tumors affecting only mucosa, leukoplakia or actinic damage can be treated with vermilionectomy. However, if there is not enough local mucosa for advancement, a pedicle flap can be elevated from the ventral or dorsal surface of the anterior tongue.

A vermilionectomy can be done in the upper or lower lips, or to recreate the mucosa of the lip in near total or total lip reconstruction. In this procedure, the mucosa is excised from the mucocutaneous junction posteriorly as far as the lesion extends, and to the depth of the orbicularis oris musculature. The mucosa on the buccal surface of the lip is then sharply and bluntly undermined and advanced to the previous mucocutaneous junction. Minimizing the amount of mucosa sharply elevated maximizes the preservation of cutaneous sensory innervation to the mucosa and future lip sensation.

A wide variety of mucosal and tongue flaps have been described for lip reconstruction. In an article published in 2004 in the Journal of Craniofacial Surgery, the authors described a case of an extensive lower lip defect reconstructed with buccal mucosa and a tongue flap. The patient underwent a two-stage procedure for reconstruction of the lower lip. First, a vestibuloplasty was performed using a buccal mucosal flap and then, the vermillion was surgically repaired using a flap from the ventral surface of the tongue. The flap was divided after 10 to 14 days, during which time the patient was instructed to not bite through the pedicle. Among the advantages of this procedure are the good color and texture match and contribution in bulk that tongue flaps provide. They concluded that this procedure has a high success rate, and that the tongue is an exc ellent site for repair of intraoral defects because of its rich supply, mobility and close proximity to the lesion.

Partial thickness defects of the lower lip subunit will depend on the area where the defect is located.

Lesions adjacent to the labiomental crease or the vermilion are closed using an A to T flap. The releasing incisions are placed in the labiomental crease or the vermilion border respectively, depending on the location of the lesion. The primary defect is then closed parallel to relaxed skin tension lines. Central superficial lesions of the lower lip are closed with unilateral or bilateral advancement flaps, which are incised in the labiomental crease and at the vermilion border, and extended onto the cheek skin as needed. Lateral lower lip defects not corresponding to the described defects can be closed with either advancement or rotation flaps.

Because of the great elasticity of the lower lip, full thickness lesions are divided in size and their repair depends on the extent of the defect.

Lesions less than a one-third of the lower lip can be excised and repaired primarily. For the smallest lesions, a standard V excision is often used. The V excision should not cross the labiomental crease, and should be planned so as to parallel relaxed skin tension lines. The mucocutaneous skin line should be marked prior to all full thickness lip excisions to facilitate exact alignment.

For more centrally located lesions occupying up to one-half the lower lip, a rectangular excision with full thickness bilateral advancement flaps incised in the labiomental sulcus will facilitate closure.

Lesions up to one-half of the lower lip, which are laterally located and not involving the oral commissure, can be closed with the Abbe Flap. The flap is planned about one-half the size of the defect and is incised full thickness down one side, along the inferior most aspect, and three-fourths up the other side. The flap is left pedicled on a small amount of mucosa and the labial artery. A study published in 2001 by Douglas Schoulte at Mayo Clinic, suggest that knowledge of the artery’s location with respect to easily identifiable landmarks will help to avoid complications such as necrosis of the pedicle. As previous descriptions of the location of the superior and inferior labial arteries were not that accurate, the authors performed detailed anatomical dissections of the mid and lower face of injected cadaver heads to provide anatomical description of these arteries. Among their results, they found that the superior labial artery was found constantly within 10mm of the free margin of the upper lip.

Lesions up to one-half of the lower lip that are laterally located and involving one oral commissure are best treated with an Estlander flap. The incision is placed in the melolabial crease and, unlike the Abbe Flap, is designed with a height 1-2mms higher than the height of the defect. A commissuroplasty is performed approximately 3 months later to recreate the oral commissure.

In full thickness lesions up to two-thirds of the lower lip, the Karapandzic flap provides complete oral sphincter and good oral competence. This technique is more favorable for more central lesions. A complete lip is formed by rotating bilateral flaps of the upper lip and perioral tissue. It is also very important to identify and preserve the neurovascular bundle supply to the orbicularis oris muscle. Our recent experience with the Karapandzic technique at the Veterans Hospital in a patient with a right laterally located squamous cell carcinoma of the lower lip showed that this technique provides a satisfactory aesthetic and functional repair. A full thickness defect involving two-thirds of the lower lip was created after lesion was removed. The patient is seen here in POD #8 and POD#15 with no evidence of microstomia or rounding of the commissures, which are common complications associated with this method.

Defects comprising more than two-thirds of the lip generally require new tissues that are recruited regionally or distantly to prevent microstomia. Many methods have been proposed for the reconstruction of subtotal and total defects of the lower lip. The challenge when repairing larger defects is to achieve an adequate stomal aperture, prevent oral incontinence and allow normal phonation.

Regional flaps such as Guilles fan flap and Bernard-Burrow-Webster flap can be used for subtotal and total lower lip defects. Guilles described a rotation-advancement flap centered on the labial commissure for closing large lateral defects of the lip. The advantage of this technique is that the continuity of the orbicularis oris is largely maintained and it can also be used bilaterally or with other methods to close even larger defects. However, this flap has several limitations, including microstomia, denervation and a rounded commissure. Bernard originally described a horizontal advancement flap of cheek tissue to reconstruct the lower lip. This flap has been modified by many surgeons to reach its modern form. To minimize damage to underlying neurovascular structures within the cheek, skin alone can be excised from the Burrow’s triangles. When performed bilaterally, this technique can close total or near total defects of the lower lip.

Distant flaps can be used when adjacent local tissue is unavailable for reconstruction owing to trauma or extensive disease involvement. Common distant flaps include bipedicle flaps from the submental region or anterior scalp. These flaps have little bulk or muscular function and are adynamic flaps that only provide lip height coverage. Deltopectoral flaps and pectoralis major myocutaneous flaps have been described for reconstruction of total lower lip defects. They can be used to provide bulk but have little sphincter function. On the other hand, microvascular flaps can address the issues of maintaining oral sphincter function and providing bulk simultaneously.

The palmaris longus flap, which is one of the most commonly used microvascular flaps in lip reconstruction, uses a radial forearm palmaris longus tendon, which is anchored to the periosteum, and the flap is suspended and folded over it. This flap is thin and pliable, and satisfies many of the goals of lower lip reconstruction; however the reconstructed lip is static and functional return may be incomplete. It also has a tendency to develop significant edema and thickness after radiation therapy, as can be seen in this case. Surprisingly, the color match of the forearm is acceptable in many cases. It also can be innervated by anastomosing one of the sensory nerves of the forearm to the inferior alveolar nerve.

In a clinical series of 12 patients with lip cancer published in 2004, the authors studied the outcomes of a refinement made to the composite radial forearm flap-palmaris longus free flap technique. In their technique, the palmaris longus tendon was anchored with adequate tension to the intact orbicularis muscle of the upper lip. This procedure was used in 12 patients between the ages of 48-65 years. Six patients had cancer of the lower lip, five patients had gingival cancer involving the lip and one patient had primary gum cancer that extended to the lower lip. A radial forearm palmaris longus free flap was used in all cases for reconstruction of the defect. Free flap survival was 100%. At the time of final evaluation, which was a one-year after the operation, all patients had good oral continence at rest and had achieved sufficient oral competence when eating. Also, all patients regained normal or near-normal speech and had an acceptable appearance. The authors recommend the described refinement to this technique for patients who need large lower lip resection as it provides functional recovery.

Other free flaps are described in the literature. The rectus abdominis myocutaneous flap for example, is more appropriate when the defect extends well beyond the lip region and into the perioral tissue. A review article published in 2005 by Langstein and Robb, presented a case report that showed a defect of the upper and lower lips along with cheek after resection of extensive squamous cell carcinoma that was reconstructed with a rectus abdominis flap. The flap was suspended with an Alloderm sling. Early result demonstrated healed wound but poor color match. On the other hand, the gracilis muscle flap provides a functional oral sphincter, as the muscle flap is used in a circular fashion. However, the resulting mass movement of muscle may be too coarse for the subtle movement required of the lips and many authors believe that strategies will need to be developed to refine this process.

Upper lip reconstruction is complicated by the intricate anatomy of the perioral and nasal regions as well as important landmarks previously described that must be considered in planning any repair. The reconstruction is different in males and females by virtue of the location of hair bearing skin in men. Defects can be divided between mucosa, philtral and lateral subunits defects. The lateral subunit defects are divided in partial or full thickness defects. These repairs depend on size and location of the defects, and in the case of full thickness defects, if the philtral subunit is involved or not.

Superficial defects of the vermilion are repaired in a manner similar to defects of the lower lip, which is by second intention, primary closure or local mucosal advancement.

Small superficial defects involving only the philtral subunit may be allowed to heal by secondary intention. Another option is to excise the entire subunit and place a full thickness skin graft. The typical skin donor site is the preauricular or retroauricular area.

Partial thickness defects of the lateral subunit are divided in lesions less than 2cm and those larger than 2cm. Lesions less than 2cm are repaired based on the location of the defect. However, in lesions more than 2cm of the lateral subunit, one may consider a complete replacement of the subunit. An inferiorly based melolabial flap can be used to cover the entire lateral aesthetic unit in patients with adequate cheek laxity.

Lesions adjacent to the philtrum can be closed with an advancement flap with crescenteric skin excision around the alar base. If possible, the vertical scar is placed precisely at the philtral edge. Those lesions adjacent to the vermilion can be closed with the previously described A to T flap technique to avoid crossing the vermilion. The releasing incision for the A to T flap is made at the vermilion border for camouflage.

When the lesions are adjacent to the meliolabial fold, they can be easily closed primarily in a radially oriented closure. When lesions are in the midportion, an inferiorly based flap can be used. However, both of these lesions can also be closed with a laterally based rotation flap.

In a retrospective study in 2000 of patients that underwent lip reconstruction after Moh’s surgery, the authors studied the surgical outcomes and patient satisfaction with composite resection and primary closure. A total of 27 patients underwent Moh’s surgery during 1993-1997, but only 12 patients were selected. All selected patients had lesions less or equal to one-third of the upper lip. They found that all patients were satisfied with their lip function and all but one were satisfied with their lip appearance. They recommended this technique as it offers a superior method of reconstruction for upper lip defects less or equal to one-third.

Full thickness defects of the lateral subunits can be divided into those involving or not involving the philtrum. When lesions do not involve the philtrum, they can be repaired with techniques already described. However, the defects involving the philtrum can become very complex and may require combinations of previously described techniques or local or distant flaps for appropriate closure.

There are alternative techniques for upper lip reconstruction. In this case report, the authors used free superficial temporal artery hair-bearing flaps to reconstruct the upper lips in male patients. The moustache outline was defined based on parietal or occipital branch of the superficial temporal artery. This case was followed up for 18 years and the authors concluded that the free temporal scalp hair–bearing flap offers a reasonable alternative to conventional techniques in the reconstruction of large defects of the male upper lip.

Back to our case presentation, after VG was carefully evaluated, the defect was closed primarily with bilateral advancements flaps incised in the labiomental sulcus. The wound was closed in three layers. The patient tolerated the procedure well and was discharged home with oral and topical antibiotics. VG was seen in our clinics for follow-up one week after repair and was found to have a satisfactory aesthetic and functional repair. There was a difference in volume between the upper and lower lip. However, no microstomia, speech difficulty or wound tension were observed. The patient was able to maintain oral competence and was satisfied with the final result.

In conclusion, the main goals of reconstruction remain the restoration of oral competence, maintenance of oral opening and restoration of normal anatomic relations. The reconstruction should be tailored to the individual needs of the patient. Local tissue should be used whenever possible to provide the least donor site morbidity and the best tissue match. Dynamic reconstruction should be attempted whenever possible.

Case Presentation:

VG is a 32-year-old Hispanic male with no significant past medical history who presented to Ben Taub General Hospital emergency room July 10th secondary to aggravated assault. He sustained an avulsion of the lower lip by a human bite. The Otolaryngology service was consulted to care for this problem.

Upon arrival to the emergency room, he received broad-spectrum antibiotics, pain medications and tetanus toxin by the general surgery service.

On initial evaluation his symptoms included pain, drooling and oral sphincter dysfunction. Upon physical examination he had a large centrally located full thickness avulsion approximately involving one-half of the lower lip. The commissure was intact bilaterally. After physical examination, appropriate wound care was given.

The defect was closed primarily with bilateral advancements flaps incised in the labiomental sulcus. The wound was closed in three layers. The patient tolerated the procedure well and was discharged home with oral and topical antibiotics.

VG was seen in our clinics for follow up one week after repair and was found to have satisfactory aesthetic and functional repair. There was a difference in volume between the upper and lower lip; however, no microstomia, speech difficulty or wound tension were observed. The patient was able to maintain oral competence and was satisfied with the final result.

Bibliography:

Adler N, Amir A, Hauben D. Modified von Bruns’ technique for total lower lip reconstruction. Dermatol Surg 2004;30:433-437.

Akbas H, Keskin M, Guneren E, Eroglu L, Demir A. Reconstruciton of columella, membranous spectum, and upper lip in a single stage operation. Br J Plast Surg 2003;56:291-292.

Chang KP, Lai CS, Tsai CC, Lin TM, Lin SD. Total upper lip reconstruction with a free temporal scalp flap: Long-term follow-up. Head Neck 2003;25:602-605.

Coppit GL, Lin DT, Burkey BB. Current concepts in lip reconstruction. Cur Opin Otolaryngol Head Neck Surg 2004;12:281-287.

de Chalain T, Black P. Secondary reconstruction of asymmetric volume deficts of the lips: A transverse twist flap technique. Br J Plast Surg 2004;57:330-335.

Galyon SW, Frodel JL. Lip and perioral defects. Otolaryngol Clin North Am 2001;34:647-

Godek CP, Weinzweig J, Bartlett SP. Lip reconstruction following Mohs’ surgery: The role for composite resection and primary closure. Plast Reconstr Surg 2000;106:798-804.

Hitoshi O, Koichi M, Yoshiyuki T, Hiroto I, Hideaki S, Mikio K. A case of lower lip defect reconstructed with buccal mucosa and a tongue flap. J Craniofac Surg 2004;15:614-617.

Jallali N, Malata CM. Reconstruction of concomitant total loss of the upper and lower lips with a free vertical rectus abdominis flap. Microsurgery 2005;25:118-120.

Jaquet Y, Pasche P, Brossard E, Monnier P, Lang FJ. Meyer’s surgical procedure for the treatment of lip carcinoma. Eur Arch Otorhinolaryngol 2005;262:11-16.

Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: A clinical series. Plast Reconstr Surg 2004;113:19-23.

Katou F, Shirai N, Kamakura S, Ohki H, Motegi K. Full thickness reconstruction of cheek defect involving oral commissure with forearm tendinocutaneous flap. Br J Oral Maxillofac Surg 1996;34:26-27.

Khan MI, Hussain M, Jamil M, Arif M, Raza A, Chaudhary MA. Squamous cell carcinoma lower lip – an experience with Karapandzic technique. J Coll Physicians Surg Pak 2005;15:123-124.

Langstein HN, Robb GL. Lip and perioral reconstruction. Clin Plast Surg 2005;32:431-445.

Larrabee WR Jr, Makielski KH, Henderson J. Surgical Anatomy of the Face, 2 nd ed. Philadelphia: Lippincott, Williams & Wilkins; 2004.

Lengele BG, Testelin S, Bayet B, Devauchelle B. Total lower lip functional reconstruction with a prefabricated gracilis muscle free flap. Int J Oral Maxillofac Surg 2004;33:396-401.

Lore JM, Medina JE. An Atlas of Head and Neck Surgery. Philadelphia: Elsevier Saunders; 2005.

Lydiatt W. Management of lower lip cancer: A retrospective analysis of 118 patients and review of the literature. Arch Facial Plast Surg 2003;5:533.

McCarn KE, Park SS. Lip reconstruction. Facial Plast Surg Clin North Am 2005;13:301-314.

Moschella F, Cordova A. “Depressor flaps” for large defects of the lower lip and mental region. Plast Reconstr Surg 2005;115:252-256.

Ozdemir R, Ortak T, Kocer U, Celebioglu S, Sensoz O, Tiftikcioglu YO. Total lower lip reconstruction using sensate composite radial forearm flap. J Craniofac Surg 2003;14:393-405.

Rhee ST , Colville C, Buchman SR. Conservative management of large avulsions of the lip and local landmarks. Pediatr Emerg Care 2004;20:40-42.

Robinson JK. Segmental reconstruction of the face. Dermatol Surg 2004;30:67-74.

Schulte DL, Sherris DA, Kasperbauer JL. The anatomical basis of the Abbe flap. Laryngoscope 2001;111:382-386.

Webster RC, White MF. Flaps for lip reconstruction. In: Grabb WC, Myers MB (editors). Skin Flaps. Boston: Little, Brown and Company; 1975. pp. 365-372.

Williams EF 3 rd, Hove C. Lip reconstruction. In: Papel ID (editor). Facial Plastic and Reconstructive Surgery, 2 nd edition. New York: Thieme; 2002. pp. 634-645.

Yamauchi M, Yotsuyanagi T, Yokoi K, Urushidate S, Yamashita K, Higuma Y. One-stage reconstruction of a large defect of the lower lip and oral commissure. Br J Plast Surg 2005;58:614-618.

Yano K, Hosokawa K, Kubo T. Combined tongue flap and V-Y advancement flap for lower lip defects. Br J Plast Surg 2005;58:258-262.

Yokoo S, Tahara S, Tsuji Y, Nomura T, Hashikawa K, Hanagaki H, Furudoi S, Umeda M, Komori T. Functional and aesthetic reconstruction of full-thickness cheek, oral commissure and vermillion. J Craniomaxillofac Surg 2001;29:344-350.

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