**Region:** Head and Neck # Abbe and Estlander Flaps (Lip Reconstruction) ## Anatomy - Pedicle: superior and inferior labial arteries (branches of the facial artery). Labial vessels run in the submucosal plane just deep to orbicularis oris at the mucosal–vermilion junction and anastomose across the midline to form a vascular continuum (facilitates cross‑lip flap survival) (Hanasono; Talbot/Pribaz; Matros/Pribaz). - Facial artery gives off the labial arteries approximately 1.5 cm lateral to the oral commissure (range reported 9.2–19.8 mm) (Matros/Pribaz). - Superior labial artery lies within ~10 mm of the upper lip vermilion margin; inferior labial artery positioned approximately 4–13 mm from the lower lip margin (Karapandzic; Matros/Pribaz). - Venae comitantes are present but venous drainage is more plexiform; preservation of mucosa and a cuff of muscle aids venous outflow. - Course: facial artery → superior/inferior labial branches coursing horizontally deep to orbicularis oris, then supplying mucosa/vermillion and anastomosing centrally (Abbe/Estlander chapters). - Perforator pattern: labial vessels run intramuscularly/posterior to orbicularis; flap harvest includes muscle cuff rather than isolated septocutaneous perforators (Abbe/Estlander technique descriptions). - Choke vessels/angiosomes: cross‑lip survival relies on midline anastomoses; staged division after 2–3 (Abbe) to 3–4 (Estlander) weeks allows choke vessel recruitment/neovascularization (Hanasono; Talbot/Pribaz). - Nerves: - Sensory: infraorbital nerve (V2) to upper lip; mental nerve (V3) to lower lip (multiple sources). - Motor: buccal and zygomatic branches of facial nerve supply orbicularis and elevators; marginal mandibular supplies depressors. Lip switch flaps cause temporary motor denervation that generally recovers over months (Hanasono; Karapandzic). - Included tissues: - Full‑thickness composite flap: skin (when used), vermilion, mucosa, orbicularis oris muscle (a cuff of muscle is routinely included to protect the labial vessels). - Thickness profile: labial artery lies immediately posterior to orbicularis fibers; include thin cuff of muscle—avoid over‑thinning pedicle to preserve artery + venous plexus (Hanasono; Talbot/Pribaz). - Arc of rotation: Abbe flap typically rotated 180° from central opposite lip to defect; Estlander rotates a triangular wedge about the commissure (pivot at medial aspect) to become the neocommissure. - Common variants/anomalies: - Abbe (central lip switch without commissure), Estlander (cross‑lip involving commissure), reverse/modified versions exist; anatomy is consistent but facial artery location varies (range 9.2–19.8 mm lateral to commissure) (Matros/Pribaz). ## Dissection Steps 1. Positioning, markings, landmarks. - Position: supine; head elevated 20–30° (for Abbe/Abbe planning) (Hanasono). - Airway: nasotracheal intubation preferred and secured (Talbot/Pribaz; Hanasono). - Landmarks: white roll/vermilion border, philtral columns, commissure, nasolabial fold, labiomental crease. - Flap dimensions: - Abbe: design flap in opposite lip with width = half the primary defect width; place pivot medial to defect; flap vertical height set to match defect height (Hanasono). - Estlander: triangular flap same vertical height as defect and ~half the defect width; medial base contains vascular pedicle and will become the neocommissure (Talbot/Pribaz; Hanasono). - Mark course to capture labial artery: for Karapandzic/related markings, place incision at least 1 cm superior to upper lip margin or 1.3 cm inferior to lower lip margin to ensure capture of labial artery (Karapandzic). 2. Plane (suprafascial/subfascial), perforator identification (handheld/IO Doppler). - Flap elevation is full‑thickness through skin/vermillion/mucosa including orbicularis; preserve mucosal layer when possible around pedicle for drainage. - Pedicle location: dissect in submucosal plane deep to orbicularis/just posterior to orbicularis fibers; do not bevel incisions excessively (Hanasono; Talbot/Pribaz). - Perforator identification: routine dissection is by visual/anatomic location rather than selective perforator dissection; a cuff of muscle is left around the pedicle rather than skeletonizing (Hanasono). - Doppler: use if desired for arterial localization (not mandatory in described techniques). 3. Pedicle dissection: exposure, control, division; transfer/inset; perfusion checks. - Dissection: - Begin elevating flap laterally (Abbe) or around entire perimeter (Estlander), leaving pedicle intact medially. - Use needlepoint/precise cautery; bipolar cautery for meticulous hemostasis before transposition (Hanasono; Talbot/Pribaz). - Preserve labial artery with thin cuff of orbicularis—avoid skeletonization to maintain venous plexus. - Transfer/inset: - Abbe: rotate flap 180° into defect; inset in three layers—muscle (interrupted absorbable), mucosa (absorbable), skin (nonabsorbable for external layer). Leave lateral vermilion partially open to accommodate pedicle. - Estlander: rotate triangular flap about commissure; inset in three layers with absorbable for mucosa/muscle and nylon for skin; folded pedicle forms neocommissure. - Perfusion checks: - Clinical assessment (color, turgor, capillary refill). - Expect staged pedicle division once neovascularization established: commonly 2–3 weeks for Abbe and 3–4 weeks for Estlander (Hanasono; Talbot/Pribaz). - If venous congestion/compromise develops, management options include taking down inset and performing delayed inset once choke vessels open (Talbot/Pribaz); in replantation scenarios leech therapy used for venous drainage (Matros/Pribaz). 4. Donor-site closure techniques. - Abbe donor: partial closure at first stage—leave vermilion open for pedicle; donor site heals by secondary intention while pedicle remains. At second stage (2–3 weeks) debride granulation tissue, excise redundant vermilion, and close in layers—precise alignment of white roll essential to avoid protuberance (Hanasono). - Estlander donor: medial cheek advancement with Burow’s triangles as needed; three‑layer primary closure (mucosa, muscle, skin). Burow excisions or perialar crescent extension used when cheek laxity insufficient (Talbot/Pribaz; Hanasono). - When using cheek advancement concurrently, plan Burow’s triangles or crescentic excisions along nasolabial fold for aesthetic closure. ## Indications and Contraindications - Indications: - Full‑thickness lip defects where “like with like” reconstruction is desired. - Abbe: central full‑thickness defects sparing commissures; defects typically between ~30% up to 50% of lip width (Abbe used for defects up to ~50% in some texts; Abbe ideal for central defects) (Hanasono; Matros/Pribaz). - Estlander: full‑thickness lateral defects that include the commissure (useful for lateral defects up to ~1/3 of total lip length when involving commissure; suitable when ipsilateral labial artery has been sacrificed) (Talbot/Pribaz; Hanasono). - Cross‑lip flaps (Abbe/Estlander) indicated when primary advancement would produce unacceptable asymmetry or oral incompetence (Hanasono; Talbot/Pribaz). - Karapandzic described as alternative when preserving neurovascular supply and dynamic function is priority (Karapandzic chapter). - Size limits (from sources): - Primary direct closure: defects <30–35% (upper) and up to ~40% (lower) can often be closed primarily; beyond that consider lip switch or local flaps (Hanasono; Handbook). - Estlander: best for lateral defects including commissure; when more than half the lip width is missing, Estlander may produce microstomia—consider alternatives (Talbot/Pribaz). - Contraindications: - Poor recipient/donor vascularity: severe peripheral vascular disease, active smoking (noted to severely impair flap vascularity), or prior surgery/radiation causing fibrosis—relative contraindications (Talbot/Pribaz). - Inability to tolerate staged procedure or lack of cooperation (Abbe/Estlander are staged; Abbe mandates second stage) (Hanasono). - Insufficient opposite‑lip tissue to harvest without causing unacceptable donor deformity or loss of commissure function. ## Postoperative Care - Immediate care: - Apply bacitracin ointment to suture lines (Talbot/Pribaz). - Maintain soft mechanical diet; avoid mouth stretching maneuvers until fully healed (Talbot/Pribaz). - Sutures removed at 7–10 days (Talbot/Pribaz). - Monitoring: - Clinical monitoring (color, turgor, capillary refill) is the primary method described. Use Doppler if desired, especially for arterial localization intraop—no specific continuous implantable probes mandated in these texts. - For replantation scenarios or venous congestion, leech therapy has been used and hospital observation with serial dressing changes and transfusion support may be required (Matros/Pribaz). - Antithrombotic practice: - Specific systemic antithrombotic protocols are not detailed in the referenced chapters; standard institutional perioperative prophylaxis applies, mindful of staged pedicle division. - Positioning/splinting: - Avoid neck hyperextension; neutral neck facilitates inset and donor closure (Hanasono). - Drains/mobilization/analgesia: - No routine drain recommended for Abbe/Estlander in these chapters; early gentle mobilization of facial expression allowed as tolerated; standard analgesia per institutional protocol. - Second‑stage timing and return‑to‑OR thresholds: - Pedicle division: Abbe typically 2–3 weeks; Estlander often 3–4 weeks (Hanasono; Talbot/Pribaz). - Return to OR for compromised flap: immediate re‑exploration if arterial insufficiency suspected; if venous congestion, options include take down and delayed inset, leech therapy (for replantation), or re‑exploration—texts emphasize early recognition and intervention but do not provide strict timing windows. ## Complications (rates & management) - Complication types (reported/described): - Arterial compromise and venous congestion — risk if pedicle integrity or venous plexus disrupted (Talbot/Pribaz; Hanasono). - Partial flap loss, flap necrosis — not numerically quantified in these sources. - Microstomia — especially when >50% of lip width is reconstructed or with large Karapandzic/cheek‑based flaps (Talbot/Pribaz; Matros/Pribaz). - Donor‑site deformity/protuberance of redundant vermilion if not debrided at second stage (Hanasono). - Altered animation/sensory and motor recovery over months; temporary motor denervation typically resolves over 6–18 months (Hanasono; Karapandzic). - Infection, hematoma, seroma — general wound complications noted but no specific frequencies provided. - Reported frequencies: - The provided chapters do not present numeric complication rates for Abbe/Estlander flaps. - Management algorithms (from texts): - Venous congestion: - Clinical recognition → options include partial/complete take‑down of inset and delayed re‑inset once choke vessels open (Talbot/Pribaz). - In replantation/venous outflow failure, medicinal leeching is an established temporizing measure while neovascularization occurs (Matros/Pribaz). - Arterial thrombosis/insufficiency: - Prompt re‑exploration and revision if arterial flow absent; maintain meticulous pedicle protection intraop to prevent this scenario (Hanasono; Talbot/Pribaz). - Donor‑site protuberance after Abbe: - At second stage debride granulation tissue and excise redundant vermilion prior to final closure to avoid a palpable protuberance (Hanasono). - Microstomia: - Prevention by selecting appropriate flap type; if present, secondary commissuroplasty or Abbe flap (for balance) may be performed; stretching exercises/devices can be attempted (Karapandzic; Matros/Pribaz). ## Key Clinical Pearls - Preserve the labial artery with a thin cuff of orbicularis—do not skeletonize the pedicle; this preserves arterial inflow and venous plexus (Hanasono; Talbot/Pribaz). - Flap sizing rules: - Design cross‑lip flap width ≈ one‑half of defect width to share horizontal deficiency and minimize tension (Abbe/Estlander guidance). - Maintain flap vertical height equal to defect height (Estlander). - Pedicle timing: - Plan staged pedicle division—Abbe ~2–3 weeks, Estlander often 3–4 weeks—allow time for neovascularization/choke vessel opening before division (Hanasono; Talbot/Pribaz). - Mark and protect the white roll precisely; accurate vermilion–cutaneous junction alignment at initial inset prevents obvious aesthetic deformity—avoid suturing directly on the white roll if possible (Matros/Pribaz; Hanasono). - Capture labial artery by incision placement: for Karapandzic style markings place incisions ≥1 cm superior to upper lip margin or ≈1.3 cm inferior to lower lip margin to reliably include labial artery (Karapandzic). - Use concurrent cheek advancement/Burow’s triangle excision to reduce flap/donor size and improve closure while keeping incisions along nasolabial lines when possible (Talbot/Pribaz; Hanasono). - Smoking is a major relative contraindication—advise strict cessation preoperatively and postoperatively to optimize vascularity (Talbot/Pribaz). - If congestion occurs early, loosening/taking down the inset and converting to a delayed inset can salvage the flap while choke vessels develop (Talbot/Pribaz).