Lip Reconstruction in Sudan Yields Good Results for Small Defects, Struggles With Large Ones

The lips are among the most demanding structures in the human body to rebuild. They must seal, articulate, express, and animate, all while sitting at the center of the face where every imperfection is visible. A new study from Sudan, published in BMC Plastic and Reconstructive Surgery, offers one of the first systematic looks at how surgeons in a low-resource health system manage acquired lip defects, and the results reveal both the resilience of basic reconstructive techniques and the steep cost of missing advanced technology. Across 60 patients treated at three Khartoum-area hospitals between January 2020 and August 2023, the researchers found that outcomes for small defects matched international standards, while large defects carried significantly higher complication rates and far lower patient satisfaction, largely because microsurgical reconstruction was essentially unavailable.

The retrospective cohort study, led by Samir Faisal Yousif with colleagues Abdelsamie Abdalla Mohamed and Mohammed Yousof Bakhiet, drew patients from Soba University Hospital, Bahri Teaching Hospital, and Sharg al Neel Hospital. The team reviewed the records of every patient with an acquired lip defect who underwent reconstruction during the study window, excluding congenital cases, recurrent tumors, and incomplete files. The cohort skewed slightly male, with 53.3 percent of patients being men, and the average age was 43 years, with ages ranging from 6 to 80. That relatively young mean age, the authors note, likely reflects the burden of trauma among younger Sudanese patients, in contrast to series from other regions where older patients with skin cancers dominate the caseload.

The causes of tissue loss fell into a clear hierarchy. Tumor excision accounted for 58.3 percent of defects, making cancer the leading reason Sudanese patients needed their lips rebuilt. Of the 35 tumor-related cases, 29 involved squamous cell carcinoma and the remainder basal cell carcinoma, the two dominant malignancies of the lip worldwide. Trauma came second at 31.7 percent, a figure that included injuries such as gunshot wounds documented in the study’s clinical photographs. Infection caused 6.7 percent of defects, all attributable to cancrum oris, the devastating gangrenous disease also known as noma that remains endemic in parts of sub-Saharan Africa. Burns accounted for the final 3.3 percent. Interestingly, infection played a smaller role than in neighboring Ethiopia, where noma is a prominent cause of facial tissue loss, a difference the authors attribute to local epidemiology.

The anatomy of the defects followed predictable oncologic and traumatic patterns. The lower lip bore the brunt, affected in 55 percent of patients, because sun-exposed lower lips are the favored site of squamous cell carcinoma. Tumors showed a statistically significant predilection for the lower lip, while traumatic injuries distributed more evenly between upper and lower. Two-thirds of all defects were full-thickness, meaning they penetrated skin, muscle, and mucosa and destroyed the orbicularis oris sphincter that gives the lip its dynamic function. This depth matters enormously: a lip is not merely a cosmetic surface but a muscular valve, and reconstructing it means restoring coordinated muscle, sensation, and lining simultaneously. Notably, 26.7 percent of patients had defects spanning more than two-thirds of the lip, a proportion that signals late presentation and poses the hardest reconstructive challenges.

The surgical strategy followed the classic reconstructive ladder adapted to available resources. Defects involving less than one-third of the lip, which made up 58.3 percent of cases, were managed with primary closure in 25 percent of the cohort, full-thickness skin grafts in 10 percent, mucosal advancement flaps in 11.7 percent, and local flaps such as the Abbe and Estlander cross-lip procedures in the remainder. These techniques borrow tissue from the opposing lip or adjacent cheek, keeping the reconstruction within the specialized tissue of the oral region. For medium defects spanning one to two-thirds of the lip, surgeons turned to the Karapandzic flap, which rotates cheek tissue while preserving its nerve supply and blood supply, alongside the Abbe flap and a single nasolabial flap.

The largest defects demanded regional flaps harvested from distant parts of the body. The deltopectoral flap, raised from the chest wall, was used in 10 percent of patients, and the pectoralis major flap in 5 percent, often for massive defects with associated facial tissue loss. Free tissue transfer, in which a segment of tissue is detached with its blood vessels and reconnected microsurgically at the recipient site, was performed in only 3.3 percent of patients, and only when a mandibular defect required a free fibular flap. The authors are explicit about why: during the study period there was no microsurgical unit or routinely available microscope for free tissue transfer at the participating centers, so reconstruction proceeded with standard instruments and pedicled flaps whose blood supply remains attached at the donor site.

The outcomes tell a story of two very different patient populations. Overall, 78.3 percent of patients experienced no complications, with wound dehiscence at 8.3 percent, total flap necrosis at 3.3 percent, and partial flap loss at 3.4 percent as the main adverse events. Only four patients required revision surgery. Functionally, 80 percent of patients retained unaffected speech, and 75 percent maintained normal oral feeding and lip competence. Patient satisfaction reached 68 percent overall, climbing to 88 percent among those with defects smaller than one-third of the lip, and hitting 93 percent among patients treated with simple direct closure. These figures align closely with complication rates of 15 to 22 percent reported in both international series and other sub-Saharan African studies, suggesting that resource limitations did not compromise the fundamentals of care for smaller defects.

The statistical analysis sharpened the central finding. Early complications were significantly associated with larger defect size, with a Cramer’s V effect size of 0.49, a 95 percent confidence interval of 0.32 to 0.73, and a P value below 0.001, indicating a moderate to strong relationship. Patients with defects exceeding two-thirds of the lip showed high rates of poor oral competence and temporary loss of the oral seal, and dissatisfaction clustered overwhelmingly in this group, with 75 percent of dissatisfied patients belonging to the large-defect category. The deltopectoral flap, despite reliably providing bulk of tissue, produced no satisfied patients in this series, underscoring the aesthetic and functional trade-offs of pedicled chest flaps on the face. Comparable data from Egypt found that only 56 percent of patients with defects larger than two-thirds achieved full functional recovery, confirming that this is a global problem rather than a uniquely Sudanese one.

The authors frame these results as a call to action for surgical capacity building. Restricted access to specialized reconstructive services, limited microsurgical equipment, and delayed presentation driven by referral and socioeconomic barriers all conspired to push patients into the large-defect category, where outcomes deteriorate. Their recommendations are concrete: expanding microsurgical capability, strengthening surgical training, and improving resource allocation could shift large-defect reconstruction away from regional flaps toward free tissue transfer, which offers better contour, function, and satisfaction for extensive defects. They also acknowledge the limitations of their own work, including the small sample size, the retrospective design, the absence of validated satisfaction instruments, and a follow-up period confined to early outcomes at one month, since most patients did not return for long-term review once their wounds had healed.

What makes this study notable is its honesty about context. In high-resource centers, free flaps are used in more than 15 percent of lip reconstructions; in this Sudanese cohort, the figure was 3.3 percent, and even that was driven by jaw involvement rather than lip reconstruction itself. Yet the core message is not one of failure. For the majority of patients, whose defects were small and amenable to primary closure or local flaps, outcomes were indistinguishable from those reported in well-funded hospitals in India, Nigeria, and the United States. The study provides the first local evidence base for planning surgical services in Sudan, and it demonstrates that disciplined application of standard reconstructive principles can deliver functional lips and satisfied patients even where the microscope is absent. The challenge, the authors conclude, is ensuring that patients with the largest and most complex defects are not left behind by the limits of the system around them.

Subject of Research: Outcomes of acquired lip defect reconstruction in a low-resource Sudanese health system

Article Title: Challenges and results of lip defect reconstruction in Sudan: a retrospective cohort study in a low-resource setting

Article References: Challenges and results of lip defect reconstruction in Sudan: a retrospective cohort study in a low-resource setting. (n.d.). https://doi.org/10.1186/s44452-026-00021-z

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00021-z

Keywords: lip reconstruction, Sudan, plastic surgery, reconstructive surgery, local flaps, regional flaps, microsurgery, oral competence, squamous cell carcinoma, low-resource setting, surgical outcomes, patient satisfaction