A prospective clinical study was conducted at the author's private clinic and the plastic surgery department at Tanta University Hospitals in Egypt between February 2008 and July 2020. This study included 128 patients who came to see us with malignant tumors on their upper or lower lips. Local muscle transfer, dermal fat flap, and muco-buccal flap repair were used to achieve a satisfying functional outcome and as visually appealing lips as possible.

Inclusion criteria

When they arrived at our department and a private clinic, all the patients had malignant lip tumors. The ensuing anomalies took up more than half of the damaged lip after the tumors were removed.

Exclusion criteria

Patients with diabetes, connective tissue disease, and aspirin users were excluded from the trial. Patients with metastases, whether local or distant, were also removed from the study.

Name, age, sex, address, phone number, previous drug treatments, and any form of interference, whether surgical or lasers for treatment of the lip tumor, were all taken into consideration for all of the individuals who were chosen. Impact of the tumor on general health, lifestyle, physical, and social activity.

All patients who took part in the study gave their informed consent, which included information about the risks of the study, consent to clinical photography, and the potential of their data being published in medical journals.

Preoperative markings: the upper lip (Fig. 1 )Fig. 1

Operative steps in upper lip reconstruction. a A palpable tumor edge. b A margin of safety, c Triangular de-epithelialization. d Dermal fat flap. e The mucosal triangle of the buccal mucosa. f Muco-buccal flap. g Reducing the risorius in half. h The bottom section of the upper lip that has just formed. l preparing the newly formed upper part of the upper lip. j Closure of both sides

On the upper lip, the tumor's boundaries were evident (Fig. 1a). The safety margin was indicated around one centimeter from the tumor's margins in Fig. 1b. The proposed post-excisional defect was then measured. The layout of the flap was planned to use both the right and left cheeks. Starting at each angle of the mouth, the following approach was performed to mark half of the defect to be fixed on each cheek. A right-angle triangle was painted on the flesh of each cheek. The right angle of the triangle is near the angle of the mouth. Cupid’s bow on the upper lip was pointed in the same direction as the triangle's base, and the triangle was pointing down. The base of each triangle is half the length of the lip deformity that results (Fig. 1c). The same process was used to construct an opposing triangle on the mucosal side. Using the same procedures as in Fig. 1, a similar but somewhat larger opposing triangle was constructed (Fig. 1e). The procedure was repeated on the other cheek.

For both upper and lower lip cases

The procedure was performed under general anesthetic in a sterile environment. Naso-tracheal intubation was utilized to avoid distortion of the tissues of interest and to give clear access to the mouth cavity. With 10% povidone-iodine, the entire face was sterilized. To cover the surrounding area, sterile towels were employed. The skin tumors were excised with an acceptable safety margin before initiating lip restoration, and histological confirmation of tumor-free margins was performed in all instances.

Surgical technique: upper lip (Fig. 1)

On each side of the cheek, the previously mentioned skin triangle was de-epithelialized (Fig. 1c). As illustrated in Fig. 1, the dermal fat flap was then lifted at the same triangle, keeping its base in the direction of Cupid’s bow on the upper lip and supplying random blood supply to the flap (Fig. 1d). After that, we went over to the oral cavity. The somewhat larger previously indicated triangle was elevated on the mucosal side, opposite the previous one, retaining its base in the direction of Cupid’s bow as well (Fig. 1e, f). Reflecting the cutaneous fat flap externally upwards and the muco-buccal flap internally upwards, the muscles up to the risorius muscle were exposed (Fig. 1g). As indicated in Fig. 1, the risorius muscle was divided starting at the angle of the mouth and extended laterally till the end of each triangle's base (Fig. 1g). The cutaneous fat flap was then used to wrap the upper half of the spitted risorius muscle. The mucosal flap was sutured over the dermal fat flap to obtain an appropriate aesthetic upper lip contour, as shown in Fig. 1h. As a result, the bottom half of the newly styled upper lip was completed. Another triangle of skin and subcutaneous tissue was taken from the upper half of the newly created lip at the nasolabial fold (Fig. 1g). The entire section, including the risorius muscle, was relocated medially after the base of the triangle was surgically removed (Fig. 1h). The operation was repeated on the other cheek. To cover the lip defect, the two newly formed segments were advanced medially and sutured together, mucosa to mucosa and the risorius of one side to the risorius of the other side, to produce a sphincter as a replacement for the excised orbicularis orris muscle (Fig. 1i). On both sides at the upper part of the newly formed lip, the remaining parts of the levator labii superioris, levator labii superioris alaeque nasi, zygomaticus minor, and zygomaticus major are re-sutured to the dermis of the upper part of the newly formed lip. The freshly created upper lip skin, as well as the consequent triangles, were then closed, resulting in the construction of a new upper lip, as seen in Fig. 1j. Following that, the dressing was put on. All patients were given a single dose of a broad-spectrum antibiotic for 3 days after surgery.

Preoperative markings: lower lip (Fig. 2)Fig. 2

Marking and operative steps of lower lip reconstruction. a Palpable edge of the tumor. b Safety margin. c De-epithelialized triangle. d Dermal fat flap. e Muco-buccal flap. f Reflecting both flaps downwards. g Cutting through the risorius. h Formation of the upper part of the newly formed lip. i Mento-labial incision and subcutaneous muscle cutting. j Left lateral view after closure

The edge of the tumor at the lower lip is seen in Fig. 2a. The one-centimeter safety zone surrounding the tumor’s edge is shown in Fig. 2b. The potential post-excision fault was then assessed. During the flap plan, each cheek limb is half the length of the horizontal lip deficiency. Starting at each mouth angle, the following process was performed to mark half of the defect to be fixed on each cheek. A right-angled triangle was drawn on the flesh of each cheek. The right angle of the triangle is stated near the mouth. The base of the triangle was facing upwards, in the same direction as Cupid’s lower lip bow, as shown in Fig. 2c, d. The base length of each triangle is equal to half of the resulting lip deformity. A comparable but somewhat larger opposite triangle was created on the mucosal side, using the same approaches as in Fig. 2e. The operation was repeated on the other cheek.

Surgical technique: lower lip (Fig. 2)

The edge of the tumor at the lower lip is seen in Fig. 2a. The one-centimeter safety zone surrounding the tumor's edge is shown in Fig. 2b. On each side of the cheek, the previously marked skin triangle was de-epithelialized (Fig. 2c). The dermal fat flap was then elevated in the same triangle, preserving its base in the direction of Cupid’s bow and supplying the flap with random blood supply (Fig. 2d). Following that, we'll look at the oral cavity. The somewhat larger, previously sketched triangle was elevated on the mucosal side opposite the prior one, keeping its base in the Cupid’s bow orientation (Fig. 2e). Internally reflecting the muco-buccal flap downwards and externally reflecting the dermal fat flap downwards helped expose the muscles up to the risorius muscle in Fig. 2f. In Fig. 2, the risorius muscle was divided starting at the angle of the mouth and extending laterally to the base of each triangle (Fig. 2g). The cutaneous fat flap was then used to repair the lower section of the divided risorius muscle. The mucosal flap was sutured over the dermal fat flap to obtain an appropriate aesthetic lip contour (Fig. 2h). The skin and muscles at the level of the lower border of the jaw were separated through an incision made at the mento-labial sulcus at the lower region of the newly formed lip. The mucous membrane and remaining depressor labii and depressor labii angularis sections were severed at this level, but the skin above it was left intact (Fig. 2). The platysma muscle, which is connected to the mouth's angle, is also retained. The newly formed lip segments on both sides were advanced medially and sutured together. On one side, the lower half of the risorius links to the lower half of the risorius on the other side, developing the oral sphincter's lowest portion (as a substitute for the excised orbicularis orris sphincter). The remaining part of the depressor labii was sutured to the remaining origin of mentalis, and the remaining part of the depressor labii angularis was sutured to the remaining part of the depressor labii angularis was sutured to the remaining part of the depressor labii Finally, the skin and mucus membrane triangles were closed, and sutures were placed on both sides of the lip skin to close the midline and mento-labial sulcus. As a result, as shown in Fig. 2, a new lower lip has developed (Fig. 2j). Following that, the dressing was put on. All patients were given a single dose of a broad-spectrum antibiotic for 3 days after surgery.

Post-operative care and follow-up

The patients were discharged on the second postoperative day and returned for stitches removal on the seventh postoperative day. Patients were followed up for 2 weeks, 1 month, 3 months, and 6 months or more following discharge from the hospital. After at least 6 months, the following data were collected: The preoperative photography session and the photography session during the last follow-up appointment were both deemed postoperative photographic results if they were done 6 months or more following surgery. Data on the functional and aesthetic outcomes were gathered. Data on unfavorable cosmetic outcomes, Scar issues, oral competence, drooling, and speech difficulties have all been reported. Symptomatic pain, difficulty performing daily tasks, difficulty sleeping in a comfortable position, and a deterioration in the quality of life were also observed. Patient satisfaction was assessed using patient-reported outcome measures (PROMs), which were questionnaires that assessed the patient’s pleasure with the following parameters: functional and aesthetic shape, lifestyle, relatives’ opinions, and overall contentment. The information gathered was categorized and tallied. The patients were asked to rank their level of satisfaction on a scale of 1 (poor), 2 (fair), 3 (good), and 4 (outstanding), with 1 being the lowest and 4 being the highest. Clinical satisfaction was measured using preoperative and late postoperative photographs by three plastic surgeons who were not involved with the study. The results of the preoperative and last follow-up photos were rated as excellent, good, fair, and poor on a scale of 1 to 4.