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The last area to be closed in the lip repair is the vermilion. After all other lip units have been reconstructed, it will become evident whether the vermilion can be simply closed or require a local flap or "Z"-plasty to achieve a normal, evenly balanced vermilion contour.

When the lateral lip and philtral vermilion edges meet on an equal basis, when the red roll to white roll distances are equal, a straightforward vermilion closure is all that is necessary (Fig.67 and Fig.68).

A linear deficiency at the junction of the medial and lateral vermilion borders (Fig.69) is the indication for a "Z"-plasty.

Note how the double transposition flaps (Fig.70), in adding length to this linear deficiency, provided a normal anatomic contour of the vermilion border.

Fig. 71 and Fig. 72 show post-op views of two other patients who required "Z"-plasties in order to achieve lip proper balance.

Occasionally, when one side of the lip is stronger than the other, a single transposition flap, from the strong side to the weak side, will suffice (Fig 49). It is important that lip balance be achieved at the time of primary, definitive closure. Any imbalance present at that time will not magically disappear.

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