Reconstruction of lower lip with myomucosal advancement flap

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1 ORIGINAL ARTICLE Reconstruction of lower lip with myomucosal advancement flap Daghan Isik, MD, 1 * M. Fatih Garca, MD, 2 Cengiz Durucu, MD, 3 Ugur Goktas, MD, 4 Bekir Atik, MD 1 1 Department of Plastic and Reconstructive Surgery, Medical School of Yuzuncu Yil University, Van, Turkey, 2 Department of Otolaryngology, Medical School of Yuzuncu Yil University, Van, Turkey, 3 Department of Otolaryngology, Medical School of Gaziantep University, Gaziantep, Turkey, 4 Department of Anesthesiology, Medical School of Yuzuncu Yil University, Van, Turkey. Accepted 6 September 2011 Published online 23 November 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI /hed ABSTRACT: Background. In this article, a new surgical procedure that can be used for reconstruction of lower lip defects of any size is described. Methods. In this prospective study, the surgical procedure was applied in 16 patients. In this procedure, the mucosa and the orbicularis oris muscle of the lower lip are repaired with a composite flap, and the skin defect is closed using local skin flaps. The patients were assessed in terms of complications, mouth opening, sphincter function of the mouth, and sensation in the lower lip. Results. The aesthetic results obtained in all patients were satisfactory. Sufficient oral sphincter function was achieved in all patients. Conclusion. Reconstruction of lower lip defects using the procedure described here can be performed in patients with lower lip defects of any size as long as the mucosal and skin repair lines are not superimposed. This procedure yielded good sphincter function and aesthetic results. VC 2011 Wiley Periodicals, Inc. Head Neck 34: , 2012 KEY WORDS: lower lip reconstruction, myomucosal advancement flap, random flap, local flap, lower lip The most important cause of lower lip defects is tumor ablation. 1,2 Full-thickness defects that are smaller than 30% of the lower lip can be repaired primarily. 3 5 Local flaps are used for lower lip defects involving between 30% and 80% of the lower lip, 5 11 whereas lower lip defects with over 80% involvement are frequently repaired with free flaps The purpose of lower lip reconstruction is to achieve a sufficient oral orifice, appropriate muscle repair to restore oral functions, and reconstruction using a tissue with sensation and an aesthetic outcome. Reconstructive surgeons have implemented repair procedures that mainly use adjacent tissues because it is thought that these techniques provide reconstruction results that include all of the intended characteristics. 3 11,17,18 Despite the significant number of procedures that have been described, new procedures are needed that can be used for the reconstruction of lower lip defects of all sizes. Furthermore, procedures that enable the use of local tissues instead of free flaps are greatly preferred, especially for extensive lower lip defects. In general, almost all local reconstruction procedures aim at transferring lower lip mucosa, muscle, and skin tissue, collectively. In the procedure described in this article, lower lip defects were considered to have been composed of 2 separate defects, namely a myomucosal defect and a skin defect; the myomucosal defect was repaired with a myomucosal advancement flap *Corresponding author: D. Isik, Department of Plastic and Reconstructive Surgery, Medical School of Yuzuncu Yil University, Van, Turkey. daghanmd@yahoo.co.uk (MAF), while the skin defect was closed with local skin flaps. Reverse transposition flaps, rotation flaps, and bilobed flaps were used as local skin flaps. PATIENTS AND METHODS In this prospective study, the surgical procedure was applied to all patients (16 patients; 4 women and 12 men) who were referred to our hospital with lower lip cancer or with skin cancer around the mouth involving the lower lip between June 2006 and December The patients were between 35 and 72 years of age (mean age, 55.5 years). In all of the patients, the lower lip defect developed due to excision of squamous cell carcinoma. In 7 patients, the lower lip defect was found to involve 30% to 60% of the lower lip; in 4 patients, it involved 60% to 90%; and in the remaining 5 patients, it involved 90% or more (total or near total). The maximum mouth orifice was measured in each patient at the sixth postoperative month. This value was obtained by measuring the maximum distance between the lower and upper lip while the patients opened their mouths maximally. At the sixth postoperative month, a questionnaire was given to the patients to assess their satisfaction with the results of the surgery in terms of oral function and aesthetics. In this questionnaire, the participants reported their satisfaction with postoperative mouth opening, the position of the lips during talking, the sensation in the lower lip, movements related to whistling and laughing, and esthetic satisfaction compared to the preoperative conditions. The participants scored these items as very good: 5, good: 4, moderate: 3, bad: 2, and very bad: HEAD & NECK DOI /HED NOVEMBER 2012

2 MYOMUCOSAL ADVANCEMENT FLAP TABLE 1. Characteristics of patients with lower lip cancer treated with lower lip reconstruction. Patient no. Sex/ age Surgical procedure Lower lip defect, % Skin flap Complication 1 M / Rotation None 2 M / Interpolation (bilateral) None* 3 M / Rotation (bilateral) None 4 M / Interpolation Dehiscence in mucosa 5 F / Interpolation None 6 M / Rotation None 7 M / Interpolation None 8 M / Rotation (bilateral) None 9 M / Rotation None 10 M / Rotation (bilateral) 11 F / Bi-lobed flap None 12 M / Interpolation None 13 F / Interpolation None (bilateral) 14 M / Rotation (bilateral) None 15 M / Rotation (bilateral) None 16 F / Interpolation None Marginal necrosis in skin flap Abbreviations: M, male; F, female. * The patient died at the third postoperative month from the primary pulmonary cancer. The myomucosal defect was repaired by MAF in all patients, whereas in 1 patient with a total lower lip defect, the mucosa was reconstructed using MAF and a skin graft. For reconstruction of the skin defects, a rotation flap was used in 8 patients (a bilateral rotation flap was used in 5 patients); in 7 patients, a reverse transposition flap from the adjacent part of the lip was used (the bilateral was used in 2 patients); and in 1 patient, a bi-lobed flap was used (Table 1). All patients were operated on while they were under general anesthesia, except 4 patients who were operated on while they were under local anesthesia. For reconstruction of the mucosa and orbicularis oris, an incision was made starting from 1 side of the defect through the vermillion-skin border; this incision passed through the modiolus and was continued horizontally 1.5 to 4 cm inside the mouth. A second mucosa incision was made inside the mouth, parallel to the first incision, starting from the lower end of the lower lip defect at the level of the lower lip vestibule, extending to the cheek. While the incised rectangular advancement flap was harvested, especially around the modiolus, only the orbicularis oris muscle was included in the mucosal flap. To achieve this, other muscles in this area were not included in the flap and were left in their original positions. If the orbicularis oris muscle is fully dissected between the lower and upper lip lateral to the modiolus while the MAF is harvested, sphincter functions may be lost postoperatively; therefore, the orbicularis oris was not completely cut horizontally, and at least 0.5 cm of muscle tissue was kept intact. In particular, the depressor anguli oris muscles and other muscles responsible for moving the modiolus were not included in the MAF. Another issue in harvesting the MAF was preserving the mental nerve. The mental nerve was preserved in the advancement flap to prevent postsurgical sensory defects in the lower lip mucosa. The mucosal area innervated by the mental nerve was excised together with the tumor. This excision was bilateral in cases of extensive lower lip defects and monolateral in tumors adjacent to the lower lip commissura. In such cases, the mental nerve could not be transferred with the mucosal flap, and it was preserved in its original position to maintain innervation in the related skin area. Horizontal MAFs harvested from both sides were sutured to each other in the midline, and the lower lip vestibule was regenerated inferior to the flaps. Afterward, skin reconstruction was performed over the lower lip reconstruction in which the muscle and mucosa repair was completed. For lower lip skin reconstruction, a transposition flap harvested from the area adjacent to the mouth with a superior pedicle, a rotation flap expanding to the mentum, or a bi-lobed flap including cervical skin were used (Figures 1 and 2). When required, skin residue (dog ear) in the commissura area was excised in a separate session with the patient under local anesthesia. RESULTS Patients were postoperatively followed for 3 months to 2 years (mean, 10.6 months). In all patients, lower lip reconstruction was successfully completed. The aesthetic results obtained in all patients were satisfactory. Oral function after the surgery was nearly normal in all patients (Figures 3 7). The mean postoperative maximum oral orifice was 5.15 cm (range, cm) and sufficient oral sphincter function was achieved in all patients. Deficits in quality-of-life parameters such as speech, ability to retain food under lower lip, and salivation retention were not observed. Oral mucosa sensory functions were intact in all patients at the postoperative follow-up. Except for 2 patients, no complications were seen. In 1 patient with complications, wound dehiscence was observed along the mucosal repair line, and this area was re-sutured with the patient under local anesthesia. In the other patient with complications, the skin defect had been repaired using the rotation flap, and superficial necrosis of 0.5 cm and scar dehiscence were seen on the repair line of the skin tissue. This was repaired by debridement and re-suturing. One patient with lip cancer involving the total lower lip died of primary pulmonary lung cancer approximately 3 months after total lower lip reconstruction with MAF and a bilateral transposition skin flap. From the questionnaire, the mean score for mouth opening was 4.00 points, the mean score for the lower lip position during talking was 4.26 points, the mean score for sensation in the lower lip was 3.93 points, the mean score for movement related to whistling was 3.26 points, the mean score for movement related to laughing was 3.33 points, and the mean score for the esthetic result was 3.53 points. DISCUSSION Many procedures have been described for the reconstruction of lower lip defects, although new techniques HEAD & NECK DOI /HED NOVEMBER

3 ISIK ET AL. FIGURE 1. Schematic diagram of lower lip reconstruction with a bilateral rotation flap and myomucosal advancement flap (MAF). (A) Preoperative anatomy of the lip, (B) appearance of the near-total lower lip defect and planning of the MAF (dotted lines indicate the MAF), (C) view of the myomucosal flap advancement, preserving at least a 0.5 cm of the lateral portion of the orbicularis oris muscle after MAF harvesting, (D) suturation of the myomucosal flaps, (E) planning of the rotation flaps on the mentum, (F) appearance of the harvested rotation flaps, (G) view of the sutured skin flap and cutting of the excess skin, (H) postoperative final view of the patient, (I) appearance of the anatomic placement of the orbicularis oris muscle and mucosa innervation at the end of the surgery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] are still required to close extensive defects with local flaps. In an ideal procedure for total lower lip defects, the surgical technique should be performed using local flaps; satisfactory functional and aesthetic results should be achieved; the risk of complications such as full-thickness wound dehiscence, scar contracture along the repair line, or notching should be low; and donor region morbidity should be limited. Defects involving less than one third of the lower lip can be reconstructed primarily 3 5 ; lower lip defects involving between 30% and 80% of the lower lip can be reconstructed with Karapandzic, Abbe, Estlander, McGregor, or Gillies fan flaps, and Nakajima flaps or Schuchardt flaps. 5,6,11,19 Until now, the most appropriate reconstruction method for total or near-total lower lip defects has been the use of free flaps. In procedures described for lower lip reconstruction with local flaps, the upper lip, cheek, mentum, and lower lip have been used as donors. 5,6,11,19 In all of these conventional techniques, which have been reported to provide positive results, the lower lip mucosa is transferred together with muscles and skin, and lower lip reconstruction is attempted. In our opinion, the most important step in lower lip reconstruction is myomucosal reconstruction. On the other hand, attempting to perform myomucosal reconstruction together with a skin area and through a skin flap maneuver, as is done in conventional procedures, limits the extension and mobility of the muscle and the mucosa to be transferred. The MAF used to reconstruct lower lip defects in this study was first used by Mutaf et al 20 in 1993 to treat lower lip sinuses. Because lower lip sinuses are present in the red region (mucosa) of the inner lip, mucosa reconstruction alone is sufficient, and MAF is an appropriate choice for this reconstruction. Other studies using myomucosal flaps include a unilateral vermillion flap designed by Lane and Kent 21 in 2007 for small mucosal defects of the lower lip and myomucosal vermillion flaps harvested from lower and upper lips by Robotti et al 22 for commissura defects. The possibility of restoring myomucosal and skin regions with separate flaps during lower lip reconstruction with local flaps was proposed by Ducic et al 23 in In patients with lower lip defects involving between 50% and 80% of the tissue, Ducic et al 23 used a split myomucosal flap for muscle and mucosa reconstruction, while primary repair of the skin defect was performed. In their technique, primary repair of the lower lip skin may cause microstomia in lower lip defects involving 80%. Additionally, the suture line of the myomucosal flap is superimposed on the skin suture line. Similarly, in techniques such as Karapandzic, Abbe, Estlander, McGregor, and Gillies fan flaps, or in the procedures of Nakajima or Schuchardt, where lower lip reconstruction is performed with composite flaps containing mucosa, muscle, and skin tissues, the lower lip mucosa suture line is superimposed by the skin repair suture line. As a result, even very small healing scar defects along the lower lip repair 1564 HEAD & NECK DOI /HED NOVEMBER 2012

4 MYOMUCOSAL ADVANCEMENT FLAP FIGURE 2. Diagram of lower lip cancer reconstruction with a unilateral transposition flap and myomucosal advancement flap (MAF) application. (A) Preoperative anatomy of the lip, (B) appearance of the lower lip defect and planning of the operation (dotted lines indicate the MAF, straight lines indicate the skin flap), (C) view of the myomucosal flap advancement, preserving at least a 0.5 cm lateral portion of the orbicularis oris muscle after MAF harvesting, (D) suturation of the myomucosal flaps, (E) suturation of the transposition flap onto the defect region, (F) postoperative appearance, (G) postoperative anatomic appearance of the orbicularis oris muscles and mental nerve. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] FIGURE 3. Lower lip reconstruction with myomucosal advancement flap (MAF) and a bilateral rotation flap in a patient with lower lip cancer. (A) Appearance of preoperative lower lip cancer in a patient (line indicates the planned excision; mucosal invasion is seen in the small photo), (B) view of the near-total lower lip defect, (C and D) appearance of the left and right harvested MAF with total cancer excision consisting of mandibular periosteum, (E and F) suturation of the myomucosal flaps to each other and testing of the vermillion reconstruction, (G) appearance of the key suture in the skin rotation flaps (the dotted line shows the planned excision of the excess skin in the skin flaps), (H) final appearance of the reconstructed lower lip at end of the surgery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] HEAD & NECK DOI /HED NOVEMBER

5 ISIK ET AL. FIGURE 4. (A) Postoperative photo of the patient in Figure 3 1 year after the surgery with acceptable neutral positioning, (B) sphincter function, (C) and maximal mouth opening. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] line may lead to full-thickness wound dehiscence or orocutaneous fistula formation. Another disadvantage of this approach is the risk of causing a vertical scar on the lower lip, which, in time, has the potential to lead to a contracture or notching at the midline. In 2007, Koc et al 24 performed lower lip repair with z-plasty to prevent scar contracture. In the technique described in the present article, mucosa and skin repair lines did not superimpose, and the risk of postoperative fistulization and scar contracture after lower lip reconstruction was decreased. Accordingly, in this trial, wound dehiscence was seen along the skin repair line in 1 patient with complications and along the mucosal repair line in the other, but these complications did not lead to complete dehiscence along the repair line. The most important indicator of a functional lower lip reconstruction is restoration of the oral sphincter function. In patients with lower lip defects involving less than 70% of the lower lip, this function can be restored by a number of techniques, but in extensive defects, the number of surgical techniques restoring oral sphincter function is limited. Tobin 25 tried to restore oral functions by using the bilateral depressor anguli oris muscle in near-total lower lip defects. However, in the procedure described by Tobin, 25 a mimic muscle that has a key role in oral functions is sacrificed. In lower lip skin reconstructions performed either by using free flaps, by transferring free muscle flaps together with skin flaps, 12,13 or through reposition of adjacent muscles, restoration of oral sphincter function is attempted. Despite the fact that lower lip reconstruction with free flaps is an important option in total lower lip defects, at sites further away from the peripheral tissue, the color, thickness, and hairiness of the transferred tissue may be different, and the aesthetic result of reconstruction is poor. However, synchronization between the oral muscles and the muscles transferred as free flaps is not clear. Unsatisfactory aesthetic and functional results and the need for microsurgery equipment and an experienced team are serious disadvantages of the techniques involving free flaps. In this article, a local reconstruction option has been presented for near-total or total lower lip defects. In terms of aesthetic and functional outcomes, this novel technique seems to be superior to total or near-total reconstruction FIGURE 5. Diagram showing lower lip reconstruction with a unilateral transposition flap and myomucosal advancement flap (MAF). (A) Planning of the operation and the appearance of the cancer, (B) appearance of a 50% defect in the lower lip after cancer removal, (C) view of the harvested MAFs, (D) final appearance of the reconstructed lower lip at the end of the surgical operation, (E, F, G and H) photos of the patient 6 months after the surgery show normal function of the lip. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 1566 HEAD & NECK DOI /HED NOVEMBER 2012

6 MYOMUCOSAL ADVANCEMENT FLAP FIGURE 6. Lower lip reconstruction with myomucosal advancement flap (MAF) and a bi-lobed flap. (A, B, and C) Preoperative appearance of the patient with skin cancer involving the mandible and the vestibule in the mouth, (D) view of the skin, muscle, mucosa, and mandible defect after cancer removal, (E) repairing the bone defect with a reconstruction plaque, (F) planning of the bilobed skin flap, (G) appearance of the harvested MAFs, (H) testing the closure of the MAF, (I) final view at the end of the surgery, (J, K, and L) photos of the patient at 3 postoperative months. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] involving free flaps. On the other hand, in very extensive tissue defects where the peripheral anatomic regions of the cheek or the mentum are also affected, it seems that distant tissue transfer remains the best reconstruction option. An MAF is a horizontal musculomucosal advancement flap that is prepared from the lower lip mucosa with the pedicle portion in the cheek mucosa. While the orbicularis oris muscle is advanced, a maximum of 1 cm of this muscle is excised between the upper and lower lip with an incision in the modiolus. Although the internal muscle fibers of the orbicularis oris adjacent to the vermillion are excised, the external fibers remain intact; therefore, the oral sphincter function can be restored. Mucosal reconstruction with an MAF and closing of the skin using a skin flap prevents microstomia in these patients. Especially in extensive lower lip defects, if the modiolus mucosa is not included in the advancement flap while the mucosa is advanced or skin defect is primarily restored, the risk of microstomia is increased. In the current study, the patients gave a score of 4 of 5 points to the postoperative mouth opening compared to preoperative mouth opening. According to this result, mouth opening after this surgery is sufficient. The modiolus is a functional and aesthetic unit of the mouth to which a number of mimic muscles providing upper, lower, and lateral movements are attached. In a number of lower lip reconstruction techniques, destruction of the anatomic features of the modiolus is avoided. On the other hand, in techniques involving Karapandzic and Gillies fan flaps and Estlander flaps, the anatomic localization of the modiolus is displaced. 5,9,11 Additional interventions are required in these procedures to restore the localization of the modiolus. During MAF, the mucosa of the modiolus is transferred with the HEAD & NECK DOI /HED NOVEMBER

7 ISIK ET AL. orbicularis oris muscle, but the depressor anguli oris muscle is dissected from the modiolus and left in place. Other muscles providing motility to the modiolus with lateral and superior localization are outside the surgical intervention area and therefore not affected. As a result, in this technique, all muscles providing motility to the modiolus are preserved in their anatomic localizations. In this study, the patients reported that their oral functions (talking, whistling, and laughing) and aesthetic results were sufficient; lip movement associated with talking was given the highest score (4.26 points). Another important issue in lower lip reconstruction is the innervation of the lower lip mucosa. Uninnervated lips are prone to trauma caused by teeth. In the local neuromusculocutaneous advancement flap described for lower lip reconstruction described by Turgut et al, 4 the authors created an incision in the mucosa starting from the lower lip vestibule, and they advanced the skin, muscle, and mucosa as a composite flap along the midline while preserving the mental nerve. As a result, they provided sensorial innervation of the newly formed lower lip. Moschella and Cordova 29 reported that preserving the mental nerve is required in lower lip reconstruction; in cases in which it cannot be preserved, lower lip innervation may be provided by the buccal nerve. The mental nerve innervates the vermillion and the lower lip mucosa in the oral mucosa, while the commissura region and the mucosa of the cheek are innervated by the buccal nerve. 30 In the technique described in this article, the mental nerve that innervates the lower lip mucosa is preserved. The mucosa region is only innervated by bilateral excision of the mental nerve in patients with extensive defects. In these patients, sensorial innervation of a random pattern of myomucosal flaps harvested from both cheeks for lower lip mucosal reconstruction is provided by the buccal nerve instead of the mental nerve; therefore, no sensorial innervation deficiency is observed in the newly formed lower lip mucosa. In the presented study, the patients gave a mean score of 3.93 points out of 5 to postoperative lower lip sensation. In patients with lower lip cancer adjacent to 1 of the lip commissures, the lower lip mucosa innervated by the mental nerve is excised unilaterally. In these cases, the myomucosal flap harvested from the cheek adjacent to the defect is innervated by the buccal nerve, whereas the myomucosal flap harvested from the healthy side of the mouth is innervated by the mental nerve. As a result, sensorial innervation of the lower lip is restored. FIGURE 7. Application of the myomucosal advancement flap (MAF) and bilateral transposition technique in a patient with lip cancer involving the total lower lip. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] CONCLUSION A lower lip reconstruction technique that can be used to repair lower lip defects of any size has been described in this study. In this technique, the myomucosal region and the skin of the lower lip are reconstructed with separate flaps. During the transfer of these flaps to the recipient area, suture lines are not superimposed, reducing the risk of complications such as orocutaneous fistula, fullthickness wound dehiscence, scar contracture, and notching. We believe that this technique is a promising option for aesthetic and functional lower lip reconstruction. REFERENCES 1. Cruse CW, Radocha RF. Squamous cell carcinoma of the lip. Plast Reconstr Surg 1987;80: Wechselberger G, Gurunluoglu R, Bauer T, Piza Katzer H, Schoeller T. 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8 MYOMUCOSAL ADVANCEMENT FLAP 17. Cruse CW, Radocha RF. Squamous cell carcinoma of the lip. Plast Reconstr Surg 1987;80: Wechselberger G, Gurunluoglu R, Bauer T, Piza Katzer H, Schoeller T. Functional lower lip reconstruction with bilateral cheek advancement flaps: revisitation of Webster method with a minor modification in the technique. Aesthetic Plast Surg 2002;26: Roldan JC, Teschke M, Fritzer E, et al. Reconstruction of the lower lip: rationale to preserve the aesthetic units of the face. Plast Reconstr Surg 2007;120: Mutaf M, Sens oz O, Ustüner ET. The split-lip advancement technique (SLAT) for the treatment of congenital sinuses of the lower lip. Plast Reconstr Surg 1993;92: Lane JE, Kent DE. Repair of vermilion Mohs defect with unilateral axial myocutaneous advancement flap. Dermatol Surg 2007; 33: Robotti E, Righi B, Carminati M, et al. Oral commissure reconstruction with orbicularis oris elastic musculomucosal flaps. J Plast Reconstr Aesthet Surg 2010;63: Ducic Y, Athre R, Cochran CS. The split orbicularis myomucosal flap for lower lip reconstruction. Arch Facial Plast Surg 2005;7: Koc MN, Orbay H, Uysal AC, Unlu RE, Sensoz O. Z plasty closure of lower lip defects after tumor excision J Craniofac Surg 2007;18: Tobin GR. Functional lower lip and oral sphincter reconstruction with innervated depressor anguli oris flaps. In: Strauch B, Vasconez LO, Hall Findlay EJ, editors. Grabb s Encyclopedia of Flaps. Boston: Little, Brown and Company; pp 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: Shinohara H, Iwasawa M, Kitazawa T, Kushima H. Functional lip reconstruction with a radial forearm free flap combined with a masseter muscle transfer after wide total excision of the chin. Ann Plast Surg 2000;45: Kushima H, Iwasawa M, Kiyono M, Ohtsuka Y, Hataya Y. Functional reconstruction of total lower lip defects with a radial forearm free flap combined with a depressor anguli oris muscle transfer. Ann Plast Surg 1997;39: Moschella F, Cordova A. Depressor flaps for large defects of the lower lip and mental region. Plast Reconstr Surg 2005;115: Larrabee WF Jr, Makielski KH, Henderson JL. Surgical anatomy of the face. Philadelphia: Lippincott Williams & Wilkins; HEAD & NECK DOI /HED NOVEMBER