The lips, like the eyelids, represent a special site; they often have only a modest dermal component, necessitating consideration of alternative repair strategies, and represent a free margin, as they are fixed in place only by muscle. Therefore, any lateral tension across the lips often translates into a long-standing residual pull that does not resolve with time.
Accurate reapproximation of the vermilion border is of critical importance in lip repairs and reconstructions. Similarly, any residual dog ears on the lips, and particularly at the vermilion, do not resolve with time. Therefore, adequately extending linear excisions and performing a wedge resection when needed is of paramount importance.
Appreciating the anatomic subtleties and detail regarding the boundaries of the cosmetic subunits of the lip, while beyond the scope of this book, is a critical prerequisite to approaching any repairs in this cosmetically and functionally sensitive area.
While linear closures are, as always, preferred, the lack of any bony attachments means that residual pull will often not resolve on the lip. Therefore, larger defects may benefit from flap closures, where additional suture techniques, such as the tip stitch, buried tip stitch, vertical mattress tip stitch, or hybrid mattress tip stitch could be useful.
In general, 5-0 or 6-0 absorbable suture material is often used on the lips, as it is elsewhere on the face. Depending on surgeon preference, braided or monofilament suture material may be used.
Since lip repairs are generally approached in a layered fashion, absorbable suture may be used for both muscle and dermal repairs. For full-thickness defects, when the inner mucosal surface needs to be repaired first, fast-absorbing gut may be used first to reapproximate this difficult to reach layer.
For most lip repairs, 6-0 or 7-0 nonabsorbable sutures are generally appropriate. Transepidermal lip repairs often take advantage of the softness of silk suture material; while it is among the most reactive suture materials, its pliability makes it a good choice when repairs on the vermilion and mucosal lip are necessary in order to avoid the poking effect of nylon sutures. Similarly, fast-absorbing gut suture may also be used in these locations, and confers the added advantage that suture removal is not necessary.
Standard buried dermal techniques, such as the set-back dermal and buried vertical mattress approaches, are frequently used on the lips (Figure 6-8). One important exception is around the vermilion border, where overeversion should be assiduously avoided in order to preserve the integrity of the white line. In these areas, buried vertical mattress techniques, or even a simple buried dermal approach, may sometimes be more appropriate. As with the eyelids, since the lips represent a free margin dog ears or marked hyper-eversion may resolve slowly, if at all (Figure 6-8).