Abbe’s flap- An excellent reconstruction option for lip defects
-Abbe’s flap- An excellent reconstruction option for lip defects
Lip reconstruction techniques have evolved since ancient times. These are one of the most important aesthetic units of the face as they perform dynamic functions of deglutition and speech also contribute majorly to facial expressions. The shape and the thickness of the upper lip is not uniform and is described as having three topographical units (philtral column, nostril sill, alar base). The lower lip is a separate unit in itself with a boat shape of varying thickness with greatest bulk in the center. It is also well known that lip tissue is unique to this region of our body. Owing to all these facts when the lip defect is small “Abbe’s flap” provides an excellent option.
Here we present a case of lip defect of around 2/3 length of tissue loss of central part of upper lip due to road traffic accident. A lip switch flap was planned from the lower lip to replace complete unit of central philtrum, tubercle and philtral columns.
Lips are small but most complex and unique in structure. The exact replication of the tissue is impossible and the functions performed by the lips cannot be performed by any other anatomical unit. Lips perform a range of motions and functions that contribute to a complete well being of a person. Therefore when lip defects are to be reconstructed the goal is to restore function as well as aesthetics. For defects that range between 1/3rd to 2/3rd length of the Abbe cross-lip transposition flap is an excellent choice for reconstruction 1,2 .
A 35 year old male patient reported to the Dept. of Oral and Maxillofacial surgery, Sri Aurobindo College of Dentistry, after a road traffic accident with severe soft tissue injury on face. History revealed that the patient had been taken for emergency treatment to a nearby hospital and reported two days later to our hospital.
On examination there were abrasions on the middle one third and lower one third of the face. The upper lip was covered with cotton dressing and the wound was infected (fig1). There was gross edema on the middle one third of the face. Intra-orally the occlusion was normal and oral hygiene was poor. Clinically no bony fractures were present. Diagnostic radiographs were advised that confirmed the same.
The soft tissue wounds were debrided and the cotton dressing over the upper lip was removed. The injury to the upper lip was severe and there was a full thickness defect noted at the centre of the upper lip. There was complete loss of the philtral columns and the central portion of the aesthetic unit of philtrum (fig2). There was complete absence of the cupid’s bow,vermillion border,and wetline.
As the wound was infected, it was decided to treat the wound according to the delayed primary healing (tertiary wound healing) process and reconstruction of the defect with a suitable flap was planned for a later date.
As the defect of the upper lip was about 2/3rd of the whole length of the lip and also the lower lip was not injured the reconstruction was planned with Abbe cross- lip transposition flap. This flap has the muscle, vermillion and tissues all native to the lip itself and therefore has a huge advantage over any other local flaps.
When the wound was healthy and the margins of the wound were well defined, the defect was assessed and the flap was designed and outlined as shown in (fig3). A full thickness flap was raised along with the muscle component carefully preserving the pedicle of the labial artery. The flap was rotated and the adjacent tissues of the defects was dissected and advanced to achieve a primary closure at the site of the defect (fig4 ,fig5). The flap was closed in layers to maintain the continuity of muscle for good functioning postoperatively. The flap healed well.
After 14 days, division of the flap was carried out under local anesthesia and the immediate post operative result were as shown in( fig6). Late post operative result showed good anatomy of cupids bow, philtral columns, continuity of vermillion border, white roll and wet line contributing to excellent aesthetics. Excellent lip competence as seen in (fig7) proves a good return of function of the lips after lip exercises were advised. A very naturally appearing lip was achieved as seen in late (3 month)post-op results (fig8).
The reconstruction of lip defects aims to preserve function and cosmesis and this requires a complete familiarity about the surface anatomy, muscular attachments and neurovascular anatomy. Though major lip defects are encountered due to lip cancers, the lip is also an area which is very commonly injured during road traffic accidents along with other maxillofacial injuries.
This fap was first described by Robert Abbe in 1898 3. This is a flap which is based on labial artery and is well suited for reconstruction of both upper and lower lips. A significant advantage of this flap is that a vertical segment of vermillion as well as cutaneaous lip tissue is replaced, but it is well suited for central full thickness defects that do not involve the commisure4 .
There are various modifications of this flap which are efficiently applied to various locations of the lip. When the defect is in lower lip the flap is designed preserving the central unit of upper lip and a slight assymmetry of the upper lip can occur. The flap is versatile and can be used for bilateral cleft lip repairs effectively as reported by Broadbentan colleagues5 .
Usually the traditional inferiroly based flap can be extended to include skin from the chin to resurface a defect extending in to the nasal floor6 as reported by kriet JD and associates7 .The flap is outlined so that the height of the flap should be equal to the vertical dimension of the defect7. On the medial side of the flap, the extent of incision maintains the supporting labial vessel which is located deep to the vermillion. The Abbes flap has one more advantage that it can be used in combination with other flaps like cheeck advancement flap8 , bilateral advancement flaps, or along with Eastlander flap for involvement of the commisure.
It is important to design a siutable flap for reconstruction as they impact the ultimate easthetic and functional outcome. Abbe’s flap provides a dynamic reconstruction with remaining lip tissue and therefore provides a superior result in terms of appearance and function in smaller lip defects.
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3. Robert Abbe .A musculocutaneous labial flap.1898 ;53;477.American Jr of Plas.Surg.
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6.Donald Baumman, Geoffrey Robb. lip reconstruction;Semin Plast Surg.2008 November;22(4):269-280.
7.Kriet JD,Cupp C L,Sherris DA, Murakami CS. The extended abbe flap. Laryngoscope 1995;105:988-992.
8.Van Dorpe EJ.Simultaneous repair of the upper lip and nostril floor after tumour excision..Plastic Recontr Surg 1977;90:381-383.