Terence E. Johnson,¹ Michael Grau, Jr.,² Craig Salt,³ and Robert M. Laughlin²

¹Department of Otolaryngology, Naval Medical Center San Diego, San Diego, California, USA

²Department of Oral and Maxillofacial Surgery, Naval Medical Center San Diego, San Diego, California, USA

³Department of Plastic Surgery, Naval Medical Center San Diego, San Diego, California, USA

Lip Switch Flaps: Abbe and Estlander Flaps

A method of achieving immediate reconstruction of lip resections with primary reconstruction of the upper or lower lips utilizing tissue from the opposite lip.

• Abbe flap: A segment of the opposing (donor) lip is rotated to reconstruct the resected (recipient) lip. The Abbe flap is primarily utilized for resections not involving the oral commissure. There are numerous variations of the Abbe flap.
• Estlander flap: Similar to the Abbe flap, but involves rotating the opposing (donor) lip around the oral commissure to reconstruct the resected (recipient) lip. Utilized for resections involving the oral commissure. Frequently requires a secondary commissuroplasty.

Indications

1. Defects of one-half to two-thirds of the upper or lower lip as a result of pathology or trauma
2. The Abbe (Sabattini) flap is utilized for medial defects
3. The Abbe flap can also be used during secondary reconstruction of the philtrum in bilateral cleft lip patients
4. The Estlander flap is utilized for lateral defects with commissure involvement. This area is difficult to reconstruct due to the complex muscle interdigitations and functional importance

Contraindications

1. Patient who is unable to tolerate closure of lips for 2–3 weeks
2. Cases with evidence of damage to the proposed vascular pedicle
3. Defects of the lip greater than two-thirds of the total lip length

Flap Anatomy

The labial artery serves as the pedicle of the interpolated flap and venous drainage is provided by small veins parallel with the labial artery.

Surgical Technique: Abbe Flap

1. The patient is positioned supine on the operating table. The surgical site is prepped and draped in a ­sterile fashion.
2. The height and width of the defect are measured. A flap is designed on the opposite lip directly adjacent to the defect. The height of the flap will be 1:1, and the ratio of the width of the flap will be 1:1/2 of the defect.
3. Pertinent surgical anatomy and flap design are marked with methylene blue and a 30-gauge needle. Key areas to mark include the vermillion borders on both sides of the defect and both sides of the donor site. This will allow for the correct reapproximation of the donor site after flap harvest and inset of the flap to the defect.
4. Local anesthetic containing epinephrine is injected within the surgical site. Local anesthetic is only injected after the defect is measured, and the donor flap has been designed to avoid distortion to the tissues.
5. A full-thickness flap is developed from the donor site. The labial artery is visualized and divided only on one side of the flap (typically the lateral side, preserving the medial side).
6. The flap is elevated from the donor site, maintaining the vascular pedicle and a small cuff of muscle.
7. The flap is rotated into the defect. Care must be taken to ensure the vascular pedicle does not kink or occlude arterial flow to the flap. Adequacy of the arterial flow may be verified by Doppler ultrasound.
8. The donor site is closed in three layers from the inside out (mucosa, muscle, and skin). Vermillion border alignment is critical. The use of the previously marked vermillion border with methylene blue may assist with proper alignment.
9. The flap is then serially inset, in a three-layer closure, paying close attention to accurately align the vermillion border.
10. The vascular pedicle is left attached for 2–3 weeks to establish sufficient collateral vascularity prior to final division of the pedicle.
11. After a minimum of 14 days, the pedicle is isolated and temporarily occluded with a vascular tie. The flap should be observed for venous congestion and/or vascular insufficiency. If no congestion or insufficiency is noted, the pedicle is ligated and transected under local anesthesia. Minor trimming may be required to provide optimal aesthetic contour.

Surgical Technique: Estlander Flap

1. For the Estlander flap, the same sequence is utilized as with the Abbe flap.
2. Care must be taken to ensure the vascular pedicle does not kink or occlude arterial flow to the flap. The adequacy of arterial flow may be verified by Doppler ultrasound.
3. A secondary commissuroplasty is often required after the procedure to reestablish a normal-appearing comm/>
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