Accepted Manuscript

Application of Modified Karapandzic Flaps in Large Lower Lip Defects Reconstruction

Weimin Ye, MD Jingzhou Hu, MD, PhD Hanguang Zhu, MD Chenping Zhang, MD,
PhD Zhiyuan Zhang, MD, PhD

PII: S0278-2391(14)00441-8
DOI: 10.1016/j.joms.2014.04.014
Reference: YJOMS 56296

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 12 January 2014

Revised Date: 9 April 2014
Accepted Date: 12 April 2014

Please cite this article as: Ye W, Hu J, Zhu H, Zhang C, Zhang Z, Application of Modified Karapandzic
Flaps in Large Lower Lip Defects Reconstruction, Journal of Oral and Maxillofacial Surgery (2014), doi:
10.1016/j.joms.2014.04.014.

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Application of Modified Karapandzic Flaps in Large Lower Lip Defects Reconstruction

Weimin Ye, MD, Jingzhou Hu, MD, PhD, Hanguang Zhu, MD, Chenping Zhang, MD, PhD and Zhiyuan Zhang,

MD, PhD

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Weimin Ye, MD

Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, Shanghai Jiao Tong

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University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of

Stomatology, 639 Zhizaoju Road, Shanghai 200011, China

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Hanguang Zhu, MD

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Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, Shanghai Jiao Tong
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University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of

Stomatology, 639 Zhizaoju Road, Shanghai 200011, China

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Chenping Zhang, MD, PhD

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Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, Shanghai Jiao Tong
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University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of

Stomatology, 639 Zhizaoju Road, Shanghai 200011, China

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Zhiyuan Zhang, MD, PhD

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Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, Shanghai Jiao Tong

University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of
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Stomatology, 639 Zhizaoju Road, Shanghai 200011, China

Corresponding author: Jingzhou Hu, MD, PhD

Department of Oral and Maxillofacial-Head and Neck Oncology, Ninth People’s Hospital, Shanghai Jiao Tong

University School of Medicine, Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of

Stomatology, 639 Zhizaoju Road, Shanghai 200011, China

Tel: 86-21-23271699-5655
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Fax: 86-21-63135412

e-mail address: huyayi@shsmu.edu.cn

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Application of Modified Karapandzic Flaps in Large Lower Lip Defects Reconstruction

Weimin Ye, MD, Jingzhou Hu, MD, PhD, Hanguang Zhu, MD, Chenping Zhang, MD, PhD and

Zhiyuan Zhang, MD, PhD

Purpose: Reconstruction of lower lip defect with Karapandzic flap often leads to greater rounding

of commissure. The aim of this study was to provide a new design of bilateral Karapandzic flap,

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which is useful in large lower lip defect reconstruction.

Methods: In this retrospective study of case series, a modification of the Karapandzic lip

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reconstruction technique was used with an additional incision to recruit more tissue. The esthetic

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outcome of the reconstruction was assessed in a 4 point scale with regard to the shape of

commissure, lip symmetry, appearance of the scar and lip projection. The functional outcome were

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assessed in terms of speech, preservation of oral competence, lip sensory, facial expression, diet

and denture usage.

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Results: Seventeen lower lip squamous cell carcinoma patients underwent single-stage lip

reconstruction (13 males, 4 females) with an age range of 52 to 82 years. The lip defects post
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tumor resection ranged from 50 to 90% of the lower lips. All patients achieved oral competence,
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without leading to greater rounding of the commissure. The esthetic outcome was considered

excellent/good in 88% of cases and the reconstruction did not lead to functional impairments of
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speech, oral competence, lip sensory, facial expression, diet or denture usage.

Conclusions: Modified bilateral Karapandzic flap is a reliable technique to reconstruct large lip
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defects without leading to rounding of the commissure. With this technique, good esthetic and

functional outcomes could be achieved.

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Introduction

Squamous cell carcinoma (SCC) is the most common malignancy of the lips. About 90% of the

cases are located in the lower lip.1 A large surgical lip defect is often encountered in these patients

and the ideal reconstruction technique would involve not only approximates the normal anatomic

form but also functions similar to the premorbid situation.2 Karapandzic flap was commonly

applied in such cases since it was regarded as a reliable technique with the advantage of replacing

lost tissue with similar tissue from an adjacent donor site and restoring esthetics and function.3
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The main shortcoming of Karapandzic flap is the greater rounding of commissure area.3-6 In

addition, in fabricating Karapandzic flap, some adjacent normal tissue, such as “dog ear” and

Burrow’s triangles had to be excised for better result.2, 7, 8 The purpose of this study is to avoid

these problems. We hypothesize that our modification helps to overcome the shortcomings of

Karapandzic flap. The specific aims of this study were to evaluate the esthetic and functional

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outcome of the reconstruction.

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Patients and Methods

All the patients with lower lip SCC admitted in Shanghai Ninth People’s Hospital, Shanghai Jiao

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Tong University School of Medicine between January 2007 and June 2013 were included in this

study. The inclusion criteria included SCC confirmed by pathology, lip defects post tumor

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resection >50%, no systemic diseases. The demographic factors, T stage of cancer, dimensions of
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resection and complications were analyzed. The esthetic outcome assessments were made by the

clinicians who were not involved in the design and fabricating of the flap. In brief, the assessment
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was adjusted from Ethunandan et al.3 and was presented as a 4 point scale with particular attention

being paid to the shape of commissure, lip symmetry, appearance of the scar and lip projection.
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The functional aspects of the reconstruction were assessed in terms of speech, preservation of oral
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competence, lip sensory, facial expression, diet and denture usage. This study was carried out

according to the recommendations of the Declaration of Helsinki. This study is based on a

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retrospective case series. Due to the retrospective nature of this study, it was granted an exemption

in writing by the Ethics Committee of Shanghai Ninth People’s Hospital, Shanghai Jiao Tong
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University School of Medicine.

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THE MODIFIED KARAPANDZIC FLAP TECHNIQUE

The objective of traditional Karapandzic flap is to separate the orbicularis oris muscle from the

surrounding radial muscles, while maintaining its nerve and blood supply. Thus the lesion is

excised with adequate margins to leave a rectangular full-thickness defect, and the semicircular

incisions are designed around the remaining lips. In designing, the skin incisions are paralleled to

the lip margin, and the width of the lip segments to be transferred should be equal to the vertical

height of the defect. The incision extends around the commissures, often within but sometimes
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crossed the nasolabial fold. The branches of the facial arteries and surrounded nerves should be

identified and preserved. Then the lateral margin of orbicularis oris is detached from their

interwoven connection with the periral muscles. Our modifications of the Karapandzic flap are

presented as follows:

First, two points (A and A’) in the vermilion border are marked and additional incisions are made

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(Fig. 1). The design of the of the bilateral points include the equal length to the vermilion peaks

respectively, and the length along the vermilion between these two points equals to the length of

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remaining tissue vermilion border when the flaps are transferred (usually, the upper lip border is

slightly longer than the lower lip). Then bilateral backcut incisions from the ending of

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semicircular incisions to the determined two points are made. The extended lines are parallel to

the lateral margins of lip defect and vertical to the semicircular line (like those in designing Gillies

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fan flap). The partial-thickness incisions are made by cutting though skin and subcutaneous tissue
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and remained other tissue intact.

Second, vessels beneath the additional incisions should be identified and preserved (Fig. 2). It
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should be noticed that bilateral labial arteries should be carefully preserved. The labial arteries are

along the edge of the lip, lying between the mucous membrane and the orbicularis oris. The other
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procedures were much similar to those of traditional Karapandzic flap. The orbicularis oris is fully
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dissected from adjacent tissue to get full extension. After fully excised, the vessels beneath the

additional incisions will not limit the flap transfer. The procedure of preserving the nerves is
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similar to that in traditional Karapandzic flap.

Third, the defects are closed in layers without discarding skin tissue. The ends of the orbicularis
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oris can be easily sutured after dissection. There is no necessity of removing the redundant skin

since there is no dog ear in this modified technique. And whether the incision of intraoral mucosa
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is needed is relied on the flexibility of mucosa during wound closure (Fig. 3).

Results

Seventeen patients (13 men and 4 women; aged, 52-82 years; mean age, 71 years) with lower lip

SCC received modified bilateral Karapandzic flaps to reconstruct the large lip defects after tumor

resection (Table 1). The extent of resection ranged from 50 to 90% of the lower lip. All the lesions

were excised completely, and the patients undergone slight flap swelling 3-7d after operation,

which turned to normal subsequently. There was no rounding of the commissure or forward
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protruding of lip in this group. The philtrum was preserved (Fig. 4, Fig. 5 and Fig.6) and all the

patients were satisfied with lip symmetry after operation. For the esthetic assessment, ten patients

were considered to have an excellent result, 5 a good result, and 2 a satisfactory result. The

patients who were considered to have satisfactory outcomes were a 69-year-old female and a

65-year-old male with larger tumors (90 and 80% of the lower lip removed, respectively). The

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patients with smaller tumor tended to get higher point evaluation, and there was not any

relationship between the esthetic outcome and demographic variables such as age or gender. None

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of the patients reported abnormal speech or oral competence. There were no lip sensory problems

in these patients, and no patient reported difficulty in carrying out a full range of facial

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expressions comparing to preoperatively (Fig. 7). No patient reported dietary restriction or

difficulty in using routine eating utensils (chopsticks, soup spoon) and no patient suffered from an

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oral hygiene problem related with their mouth opening (Fig. 8). Six patients had a denture
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preoperatively and no one complained difficulty in using their dentures postoperatively.

All the 17 patients received neck dissection plus lip reconstruction in one stage. Postoperative
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radiotherapy was administrated in 11 patients (60-66Gy). No patient undergone infection, drooling

or fistula after the operation. There was no flap failure occurring.

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However, two of the 17 patients demanded a secondary procedure for microstomia. The reasons
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were all based on patients’ esthetic consideration rather than functional.

Discussion
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The Gillies fan flap is a modification of the Esterlander flap technique in which tissue is recruited

from the ipsilateral lip and cheek. The design of Gillies fan flap includes the second incision

towards the vermilion, without compromising the superior (or inferior) labial artery.6 After
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complete these incisions, the flap is rotated and advanced to cover the defect. The advantage of
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Gillies fan flap is that it makes good use of the surrounding tissue, but the orbicularis oris has to

be partially cut off for full advancing, thus, full function and sensation may not return.9 The

Karapandzic flap is an advancement-rotation flap that maintains both lip mobility and sensation,

reuniting the lower lip by means of radially oriented incisions across the outer perioral area.

Karapandzic’s unique contribution has been demonstrated as the orbicularis oris muscle and its

overlying skin can be freed from its tether of surrounding muscle and utilized for reconstruction

without jeopardizing its nerve supply.8 The Karapandzic flap maintains good function, sensation,
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and mobility, but this procedure always leads to operative rounding of the commissure or forward

protruding of lip,3-6 as which recruit only the remaining lip tissue but not the tissue of the check.

Moreover, some adjacent normal tissue had to be excised for better result in fabricating this flap.2,
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In our modification, we adopted the skin incision of Gilles fan flap while still following the

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Karapandzic flap principle of remaining the function of orbicularis oris. That is the reason why we

prefer to define our procedure as “modified Karapandzic flap” rather than “modified Gilles fan

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flap”. This modification takes the advantage of Gillies fan flap of recruiting more tissue from

check, which avoids leading to rounding of the commissure, meanwhile preserving the

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innervations and blood supply of orbicularis oris. Moreover, design of bilateral additional incisions

facilitates the full dissecting of orbicularis oris from adjacent tissue. The full extension of

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orbicularis oris, together with the tension from buccal tissue, makes it possible for the remaining
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tissue to form new commissures. The two points (A and A’) proved to be the locations of newly

formed angle oris. In our group, no patient complained of rounding of the commissure or forward
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protruding of lip, which were frequently occurred after traditional Karapandzic flap

reconstruction.3, 5, 6 This modification also avoids excising the Burow’s triangles laterally when the
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tissue discrepancy cannot be made up over the course of the semicircular incision in Karapandzic
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flap.

The bilateral design guarantees the symmetry appearance and recruiting more tissue. Marking of
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the two points of bilateral symmetry as the ending of additional incisions is the key of the

procedure. No patients of our series complained asymmetry problem after operation. The largest
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defect of the lip that can be repaired with remaining lip tissue or other local tissues is considered to

be 80% as reports.2, 3, 7 In our series, The size of the defects ranged from 50 to 90%.
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It is generatively believed that a stoma that allows entry of a spoon or fork laden with food while

retaining feeling and motion will be adequate for most patients.8 The critical size is influenced by

the laxity of the perioral tissues and the preservation of motor and sensory innervation.3 The

functional and sensory results in our series were satisfied and there was no functional problem as a

result of the relative microstomia. Only 2 of 17 patients demanded secondary procedures for

microstomia. Interestingly, these two patients were considered to have an excellent or a good result

of esthetic assessment by clinicians. Neither these 2 patients had dietary restriction or difficulty in
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speech, nor did they suffer from oral hygiene problems related to their mouth opening. The reasons

of secondary correction were seldom based on cosmetic appearance consideration by patients

themselves.

In the traditional Kazapandzic flap fabricating, the branches of artery and its accompanying vein

were usually, or, at least, partially preserved to maintain the blood supply to the flap.4, 8 In this

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modification, the vessels beneath the additional incisions need not to be ligated for acquiring the

mobility of flap. These vessels turned to be the terminal branch of facial artery. We accentuate to

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preserve the labial artery (and its accompany veins) in dissecting orbicularis oris from its

attachments to radial muscles, for the labial artery has a rich anomotosis with other branches

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arteries of maxillary artery and ophthalmic artery. The septal and alar branches of labial artery

ramify anteroinferiorly in the nasal septum.10 The nasal septum has at least 5 source of blood supply

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of other arteries: (1) anterior ethmoidal artery, (2) posterior ethmoidal artery, (3) sphenopalatine
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artery, (4) greater (anterior division) and lesser (posterior division) palatine arteries, (5) greater

palatine artery. They, together with superior labial artery, share rich anastomosis; 11 Except for
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facial artery, the upper lip is also supplied by infraorbital artery, which derives from maxillary

artery.10 The rich anatomosis of labial arteries and other arteries guarantee the blood supply. There
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were some extreme conditions in our earlier attempts that the arteries beneath the additional
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incisions had been ligated for extension of the flaps. However, the flaps remained healthy and no

ischemia occurred so far as the labial arteries were carefully preserved. It had been reported that
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the Gilles fan flap, with all the other noted branches of arteries except labial artery are ligated,

could still be employed bilaterally for lower or upper lip reconstruction.12, 13 This was contributed
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to the preservation of labial artery. There was no failure in any of the flaps we had performed,

even neither in the 11 patients who underwent radiotherapy 4 weeks after surgery. The excellent
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survival rate of this group demonstrated that this handling of blood supply is feasible.

However, due to the nature of the evaluation, we adopted the methods of esthetic outcome

assessment, which was subjective and might attenuate the strength of the study. In the future work,

some functional indexes, such as mouth opening distance, sensation measurement and

electromyogram, should be applied in the evaluation of this modification.

Conclusion

Modified Karapandzic flap is a reliable technique to reconstruct large lip defect post tumor
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resection with good esthetic and functional outcomes, and without leading to greater rounding of

the commissure and excising adjacent normal tissue.

References

1. Dediol E, Luksic I, Virag M: Treatment of squamous cell carcinoma of the lip. Coll Antropol 32

Suppl 2:199, 2008

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

3. Ethunandan M, Macpherson DW, Santhanam V: Karapandzic flap for reconstruction of lip

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defects. J Oral Maxillofac Surg 65:2512, 2007

4. Karapandzic M: Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 27:93, 1974

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5. Closmann JJ, Pogrel MA, Schmidt BL: Reconstruction of perioral defects following resection for

oral squamous cell carcinoma. J Oral Maxillofac Surg 64:367, 2006

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6. McCarn KE, Park SS: Lip reconstruction. Facial Plast Surg Clin North Am 13:301, 2005
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7. Hanasono MM, Langstein HN: Extended Karapandzic flaps for near-total and total lower lip

defects. Plast Reconstr Surg 127:1199, 2011

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8. Jabaley ME, Orcutt TW, Clement RL: Applications of the Karapandzic principle of lip

reconstruction after excision of lip cancer. Am J Surg 132:529, 1976

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9. Anvar BA, Evans BC, Evans GR: Lip reconstruction. Plast Reconstr Surg 120:57e, 2007
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10. Sandring S: Gray's anotomy. London, Elsevier, 2008, pp 491

11. Stucker FJ, de Souza C, Kenyon GS, Lian TS: Rhinology and Facial Plastic Surgery. Berlin,
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Springer, 2009, pp 152

12. Camacho F, Moreno JC, Conejo-Mir JS: Total upper lip reconstruction with bilateral fan flaps. J
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Dermatol Surg Oncol 18:627, 1992

13. Harris L, Higgins K, Enepekides D: Local flap reconstruction of acquired lip defects. Curr Opin
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Otolaryngol Head Neck Surg 20:254, 2012

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Table
Table 1. Summary of 17 patients underwent operation

No. Gender Age T stage Percent of Esthetic Microstomia Radiotherapy Complications Length of
of lower lip Outcome revision follow up
cancer removed (months)
1 M 65 2 71 Excellent No Yes No 24
2 M 77 1 50 Excellent No No No 36

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3 M 72 2 73 Good No Yes No 24
4 M 79 2 80 Good No Yes No 12

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5 M 52 2 70 Excellent No No No 48
6 F 69 2 90 Satisfactory No Yes No 36
7 M 63 2 67 Excellent Yes Yes No 18

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8 F 77 2 79 Good No Yes No 24
9 M 79 2 72 Excellent No No No 30
10 M 76 2 80 Excellent No Yes No 12

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11 M 68 2 74 Good Yes No No 24
12 F 54 2 81 Good No Yes No 18
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13 M 74 3 90 Excellent No Yes No 18
14 M 82 2 75 Excellent No No No 12
15 F 79 2 73 Excellent No Yes No 12
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16 M 65 2 80 Satisfactory No Yes No 12
17 M 65 2 71 Excellent No No No 6
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Legends

Figure 1. Excision margins and the Karapandzic flap design. A and A’ are the two points in the

vermilion border and will be the locations of newly formed angle oris, B and B’ are lip peaks.

AB=A’B’. Length along the vermilion between A and A’ equals to the length of remaining tissue

vermilion border. The dashed lines are the additional incisions.

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Figure 2. Preservation of branches of vessels and nerves.

Figure 3. Closure of the defect.

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Figure 4. Preoperative appearance.

Figure 5. Immediate postoperative result.

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Figure 6. Postoperative result at rest, 3 months after operation.

Figure 7. Postoperative result of pursing lip, 3 months after operation.

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Figure 8. Postoperative result with mouth open, 3 months after operation.
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Acknowledgements
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This study was supported by grants from Shanghai Leading Academic Discipline Project (No.

S30206).
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