Stein's Double Cross-Lip Flaps Combined with Johanson's Step Technique for Subtotal Lower Lip Reconstruction

Background: In a previous study, a single cross-lip flap (Abbe flap) combined with Johanson's step technique for repair of defects of more than 2/3 of the lower lip was superior, in terms of aesthetic and functional outcome, compared with Bernard Webster-related techniques (cheek advancement). Herewith, a double cross-lip flap (Stein procedure) is proposed for repair of subtotal lower lip defects. A systematic review of the Stein procedure is provided. Methods: Two patients underwent a paramedian double cross-lip flap, preserving the aesthetic subunit philtrum column combined with the Johanson's step technique. The aesthetic and functional outcomes and the surgical steps are demonstrated in the videos. An electromyographic study was performed 6 months and 4 years after surgery. A PubMed and a Google Scholar search were performed for the Stein procedure published in 1848. Results: Lip competence was achieved directly after sectioning of the cross-lip pedicles in both patients. Lips progressivity expanded in the first 6 months. No microstomia was observed. Electromyography showed successful reinnervation of the transplanted muscles at 6 months. Four years after surgery, the electromyographic findings were consolidated. Since 1975, 7 articles on the double cross-lip procedure have been published: 4 in English, 1 in French, and 2 in Japanese. None of those articles reported on any supplemental lower lip advancement or on any electromyographic study. Conclusions: The rationale of using 2 cross-lip flaps and a lip-cheek advancement according to Johanson seems to achieve functionally and aesthetically superior results compared with other techniques described for subtotal lower lip reconstruction.