Total or near total defects of the lower lip may result from trauma, cancer ablation or congenital causes. Defects usually involve the full thickness and include skin, muscle and mucosa. There are a number of techniques for the one stage reconstructions of these defects. Functional reconstruction with a cosmetic acceptable lower lip is a formidable challenge. More than 200 methods have been described since 1000BC. This retrospective series from China looks at a series of 87 patients from January 1993 to December 2013, a 20 year period. All patients had their lip resected for malignancy, as expected the most common cause was squamous cell carcinoma in 79 patients. Fourteen patients had defects more than four-fifths, 64 patients had the whole lower lip resected, and nine patients had defects extending beyond the oral commissures and mental regions. Reconstruction was with bilateral Yu flaps in 61 cases, Y flaps in 16 patients, bilateral Mutaf’s technique in four patients and a free radial forearm flap in six patients. Patients were assessed for drooling and aesthetics with a Patient and Observer Scar Assessment Scale (POSAS). This is a good paper with a large cohort of patients with a difficult surgical problem and a long follow-up. There are no descriptions of surgical technique but an excellent algorithm that can be used to plan reconstruction. Well worth reading to get an overview of this reconstructive dilemma.