Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e294ee297

CASE REPORT

The inferior labial artery island flap

Koichiro Oki, Rei Ogawa*, Feng Lu, Hiko Hyakusoku

Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School Hospital,1-1-5 Sendagi Bunkyo-ku, Tokyo, Japan

Received 25 February 2007; accepted 15 September 2007

KEYWORDSInferior labial flap;Labial artery flap;Abbe flap;Upper lip reconstruction

* Corresponding author. Tel.: þ813076.

E-mail address: r.ogawa@nms.ac.j

1748-6815/$-seefrontmatterª2009Bridoi:10.1016/j.bjps.2007.09.062

Summary The Abbe flap procedure has typically been indicated in cases of tissue defects ofthe upper lip after injury or tumour excision. However, this method requires two-stage recon-struction. In this report, we describe for the first time a novel one-stage reconstructionmethod using the inferior labial artery island flap. A 54-year-old man presented with a left up-per lip defect and a scar contracture between the upper lip and the left cheek. We planned toreconstruct the lip defect using the inferior labial artery island flap. The inferior labial arteryisland flap was harvested with a vascular pedicle, and the vascular pedicle was returnedthrough the inside of the flap. The flap survived completely, and liquid leakage from the lipand the appearance of the injured area were clearly improved. For this new technique, weconverted the inferior labial flap to a vascular pedicled island flap, which increased its flexi-bility. This long vascular pedicle could be returned through the inside of the flap. Thus, thisflap appears to be ideal for one-stage reconstructions of full-thickness upper lip defects.ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

The Abbe flap1 procedure is usually indicated in cases of tis-sue defects of the upper lip after injury or tumour excision,but it requires two-stage reconstruction. In this report, wedescribe for the first time a novel one-stage reconstructionusing the inferior labial artery island flap.

The inferior labial artery island flap is harvested witha vascular pedicle, and the vascular pedicle is returnedthrough the inside of the flap (Figure 1). This technique isideal for one-stage reconstructions of full-thickness upperlip defects.

3 5814 6208; fax: þ81 5685

p (R. Ogawa).

tishAssociationofPlastic,Reconstruc

Case report

A 54-year-old man presented with a left upper lip defectand a scar contracture between the upper lip and the leftcheek, which resulted from an avulsion injury due toa motor vehicle accident. The lip defect caused liquidleakage from the mouth. Thus, we planned to reconstructthe lip defect using the inferior labial artery island flap.

Doppler flowmetry was used to mark the course of thelabial artery preoperatively (Figure 2). A 12-mm wide flapwas designed centrally on the lower lip, including notonly the mucosa but also skin and the orbicularis oris mus-cle, and was cut down to the mentolabial fold. The inferiorlabial artery was found in a facial compartment on the

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 1 Schema of the upper lip reconstruction using the inferior labial island flap. In this technique, the long vascular pediclecan be returned through the inside of the flap.

The inferior labial artery island flap e295

posterior part of the orbicularis oris muscle. The veins weremore haphazardly arranged around the artery, in the loosetissue under the vermilion epithelium and in the intermus-cular septa. The muscle cuff surrounding the labial vesselswas then removed by careful dissection and only the labialvessels were left embedded in the pedicle. After confirmingthe inferior labial vessels, the flap was completely elevated

Figure 2 Flap design. The flap was designed to include notonly mucosa but also skin of the lower lip. Doppler ultrasoundwas used to mark the course of the labial arterypreoperatively.

with the pedicle, including one artery and two veins, ofapproximately 3 cm in length (Figure 3).

After removal of the scar on the recipient site, the highlymobile flap resulting from this division could be insertedinto the recipient site on the upper lip in one stage. Thevermilion borders and thickness between the flap and upperlip could be adjusted in this stage. The vascular pedicle wasburied under the vermilion mucosa without any tissuetightness. The vascular pedicle length was 3 cm, but wecould confirm 6 mm of redundancy when the mouth wasclosed. This redundancy was useful for releasing tensionwhen the mouth was open. The donor defect was closedprimarily and the flap survived completely. At the 2 monthfollow-up, liquid leakage from the lip defect was improved.Dysfunction of the orbicularis oris muscle was not observed,and sensory function was recovered within 3 months. Thepatient was satisfied not only with the function but alsowith the appearance of his lip (Figure 4).

Discussion

Abbe’s cross-lip flap, which was described in 1898,1 remainsthe method of choice for repair of upper lip defects, cleftlip deformity, and trauma or tumour resection around thelip. McGregor pointed out the importance of dividing allthe skin of the Abbe flap and making the surface componentof the pedicle entirely mucosal.2 Millard also emphasisedthe value of a narrow pedicle, but did not suggest com-pletely severing the mucosa.3 In 1989, Holmstrom pre-sented a technique in which the mucosa is cut around thewhole circumference of the pedicle,4 essentially convertingthe Abbe flap to an island flap.

Figure 3 Intraoperative view. After confirming the inferior la-bial vessels, the flap was completely elevated with a pedicle, in-cludingonearteryand two veins, of approximately 3 cmin length.

e296 K. Oki et al.

On the other hand, a one-stage lip-switch operation forreconstructing a lip defect was reported by Ohtsuka in1985.5 One-stage reconstruction of the lip is challenging be-cause both lip function and acceptable aesthetic appear-ance must be simultaneously considered during repair.Ohtsuka pointed out the importance of the oral mucosalpedicle for the venous drainage of the flap. A minute ve-nous network surrounding the artery in the vascular pediclewas thought to play an important role in venous drainage.In Ohtsuka’s procedure, the orbicularis oris muscle is notdamaged during elevation of the pedicle, and the distalportion of the flap is incised a little closer to the mucousmembrane to allow the de-epithelialised vascular pedicleto pass through it.

Hu also reported a one-stage procedure involving aninferior labial flap with a mucosal pedicle in 1993.6 How-ever, after this operation, venous drainage of the lip wascompromised because no axial vein accompanied the labialartery. As a result of the slender pedicle, various degrees ofvenous congestion, and even necrosis of the Abbe flap, of-ten occurred.

Figure 4 Preoperative and 2 month postoperative view. At theimproved. The patient was satisfied with the function and appeara

In contrast, the present technique involves cutting theskin and mucosa around the whole circumference of thevascular pedicle. Furthermore, the labial vessels, includ-ing one artery and two veins, were confirmed between thecentre of the lower lip and the oral commissure. In thistechnique, the inferior labial flap was converted toa vascular pedicled island flap, which increases itsflexibility. This long vascular pedicle could be returnedthrough the inside of the flap, which had been dividedbetween the vermilion mucosa and the orbicularis orismuscles. Accordingly, the vermilion border and white lipof the flap could be fitted to the defect of the upper lip inone stage.

In 2001, Shulte reported that the course of the inferiorlabial artery varies up to 15 mm from the free margin of thelower lip.7 In 2003, Edizer also pointed out that this regiondoes not have a constant arterial distribution; the inferiorlabial artery can have different unilateral or bilateral loca-tions.8 However, in 2004, Kawai mentioned that the inferiorlabial artery was derived from the facial artery or superiorlabial artery, and the presence of this artery was confirmedin all the fresh cadavers evaluated for this purpose.9 Wetherefore suggest use of preoperative Doppler flowmetryto improve the safety associated with creating inferior la-bial artery flaps.

Venous dissection of the vascular pedicle requiresa delicate technique. In the present case, two veins,located in the submucosal tissue and intermuscular septa,were detected around the inferior labial artery. Otsuka andSong suggested that the venous plexus of the mucosalpedicle was important for the venous drainage of this flap;however, they had removed the orbicularis oris muscle.5,6

Nonetheless, we recommend that, if the labial veins arenot confirmed during the vascular-pedicle elevation, thesubmucosal tissue and the orbicularis oris muscle cuffaround the labial artery be preserved for venous drainageof this flap.4 Moreover, we could confirm that there wasno dysfunction of the orbicularis oris muscle, and the recov-ery of sensory function was not different from that seen af-ter a conventional Abbe flap.

Further investigation is necessary to elucidate factorssuch as the venous drainage system. However, the inferiorlabial artery island flap appears to be ideal for one-stagereconstructions of full-thickness upper lip defects.

2 month follow-up, liquid leakage from the lip defect wasnce of his lip.

The inferior labial artery island flap e297

References

1. Abbe RA. A plastic operation for the relief of deformity due todouble harelip. Med Rec 1898;531:477e8.

2. McGregor IA. The Abbe flap; its use in single and double lipclefts. Br J Plast Surg 1963;16:46e59.

3. Millard Jr DR, McLaughlin CA. Abbe flap on mucosal pedicle. AnnPlast Surg 1979;3:544e8.

4. Holmstrom H. The Abbe flap converted to an island flap. ScandJ Plast Reconstr Surg 1986;20:51e4.

5. Ohtsuka H. One-stage lip-switch operation. Plast Reconstr Surg1985;76:613e5.

6. Hu H, Song R, Sun G. One-stage inferior labial flap and its perti-nent anatomic study. Plast Reconstr Surg 1993;91:618e23.

7. Schulte DL, Sherris DA, Kasperbauer JL. The anatomical basis ofthe Abbe flap. Laryngoscope 2001;111:382e6.

8. Edizer M, Magden O, Tayfur V, et al. Arterial anatomy of the lowerlip: a cadaveric study. Plast Reconstr Surg 2003;111:2176e81.

9. Kawai K, Imanishi N, Nakajima H, et al. Arterial anatomy of thelower lip. Scand J Plast Reconstr Surg Hand Surg 2004;38:135e9.