RECONSTRUCTIVE CONUNDRUM

Repair of a Large Defect of the Upper Lip

PEDRO REDONDO, MD, PHD*

The author has indicated no significant interest with commercial supporters.

A 77-year-old man with a history of nonmel-anoma skin cancers of the forehead presentedfor treatment of recurrent basal cell carcinoma of the

upper lip. The lesion had been operated on three

times previously and presented as a pathologic

induration upon palpation that affected the full

thickness of the lip.

Under local anesthesia, a pentagonal resection of the

lesion was performed with 0.5-cm lateral margins

and extending in depth as far as the submucosa. The

upper margin of the excision coincided with the ala

nasi and the lower margin with the vermilion. The

first defect of skin and muscle was geometric,

measured 3 by 4 cm, and involved nearly one entire

side of the upper lip (Figure 1). After the first stage

of Mohs surgery, a positive margin was observed in

contact with submucosa of the bed, which meant

that a small en bloc excision had to be performed.

The patient requested a single-stage procedure for

the repair. How would you reconstruct this upper lip

defect?

Figure 1. Defect after Mohs excision with the planned flap marked.

*Department of Dermatology, University Clinic of Navarra, Pamplona, Spain

2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc. ISSN: 1076-0512 Dermatol Surg 2014;40:576579 DOI: 10.1111/dsu.12393

576

Reconstruction Options

The principles of an ideal upper lip reconstruction

include restoration of dynamic motion, sensation,

oral sphincter competence, and minimization of

distortion and disfigurement. The distortion or

ablation of the melolabial fold and movement of

glabrous skin into the moustache area must be

avoided.

Reconstructive techniques of the upper lip include

simple closure along relaxed skin tension lines,

V-shaped excision, full-thickness skin grafting, sec-

ondary-intention healing, and tissue rearrangement.

If the defect is less than one-third of the upper lip, it

can usually be reconstructed by removing a V-

shaped wedge from the lip and closing the lip

primarily. Several options for closure of large

defects in this area exist, including melolabial

transposition flap, cheek advancement flap, and

tunnelled subcutaneous pedicle transposition flap.

The Procedure

The island pedicle flap is an excellent option for

closure of large and deep defects on the upper

cutaneous lip.14 The reconstruction places incisions

at the junction of cosmetic units and uses an island

pedicle flap to replace resected tissue with similar

tissue, restoring the melolabial fold without

distorting surrounding functional and aesthetic

structures. This technique is cosmetically and func-

tionally successful, and the symmetry of the oral

commissure is maintained.

After tumor removal, the mobility of the surround-

ing tissue was determined. The closure lines were

planned so that they were located in the junctions of

cosmetic units without crossing the junctions. The

island pedicle flap has two lateral curvilinear inci-

sions tangential to the defect superiorly along the

melolabial fold and inferiorly along the vermilion

(Figure 1). The island flap is based on subcutaneous

fat lateral to orbicularis oris. The flap was under-

mined at the upper level of the subcutaneous fat,

mobilized and advanced medially, and gently pulled

into place with a hook.

A positive margin in contact with the submucosa of

the bed was observed after the first stage of Mohs

surgery. As a result, we decided to excise the affected

area en bloc, including it in a small V-shaped

excision 1.5 cm wide (Figure 2). Lateral margins

were removed with margin control. This procedure

has the added advantage of making closure easier by

slightly reducing the necessary displacement of the

subcutaneous island pedicle advancement-flap.

The V-shaped excision was designed in such a way

that it extended over the complete height of the lip

from the vermilion to the base of the nose. A 30

chromic stitch was used to close the upper portion of

oral mucosa. The most important stitch was the

placement of a 60 silk stitch to align the vermilion

cutaneous junction (Figure 3).

The area around the secondary defect, from which

the flap was taken, was extensively undermined to

allow for appropriate mobility of the flap.5 Once

sufficient mobility of the flap was achieved, the

anchoring stitch was placed. A small Burows

triangle superior to the lip defect was marked for

excision to enlarge the defect so that the border of

Figure 2. Final defect after V-shaped excision. The en blocexcision was performed after the island pedicle flap wasincised.

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40 :5 :MAY 2014 577

the flap coincided with the ala nasi. Enlarging the

defect to facilitate positioning the border of the

island flap along an aesthetic boundary provided

maximum scar camouflage. An absorbable 40

suture was used, avoiding vascular compromise of

the flap. Skin edges were approximated using 60

silk sutures. The flap donor site was closed in a V-Y

fashion (Figure 4). The patient was evaluated

4 months after the operation (Figure 5).

Discussion

Upper lip defects that are less than one-fourth of the

upper lip length can be closed directly. Primary

closure of larger defects often leads to asymmetry or

whistling deformity. The alar crescent advancement

flap technique has been widely used for repair of large

central (for varying-length partial- and full-thickness)

defects of the upper lip and base of the nose. This flap

can be conceptualized as a procedure that entails

removal of Burows triangles, followed by a cheek

advancement flap. Large central defects that involve

30% to 60% of the original width of the lip can be

reconstructed with transposition flaps (AbbeEst-

lander flap) involving the use of lower lip tissue.

Defects more than two-thirds of the central upper lip

are best treated with rotation advancement flaps that

recruit tissues from the lip and cheek regions.

Our patient lost the full thickness of the lip,

including the skin and muscle over almost half the

length of the lip. Vertical side-to-side closure or

wedge resection was not chosen owing to the length

of the defect, although a minimum V-shaped resec-

tion, which was necessary given local involvement,

aided final closure. Melolabial subcutaneous tissue

island pedicle advancement flaps have an excellent

blood supply, maintain the anatomy of the melola-

Figure 3. Suture of V-shaped excision and aligning thevermilion junction.

Figure 4. Immediate postoperative result. The island pedi-cle flap sutured in place after advancement.

Figure 5. The lip 4 months after surgery. Good aestheticand functional resultd. Only the median vertical scar of theupper lip is still visible.

DEFECT OF THE UPPER LIP

DERMATOLOGIC SURGERY578

bial fold, and do not disrupt follicular integrity,

allowing men to retain growth of moustache hair.4

One potential complication of island pedicle flap is

trapdoor deformity. In this case, because we used the

flap for a deep defect that extended to the orbicularis

muscle, no thinning of the flap was necessary, and

this side effect was avoided. In the case of defects

that do not encompass the greater part of the upper

lip, surrounding tissue may be removed to the edges

of this cosmetic subunit to hide scars in the

melolabial crease and vermilion.

Conundrum Keys

Several goals must be considered in the reconstruc-

tive surgery of the upper lip:

(1) Try to hide the scars in the natural creases and

cosmetic units, particularly in the melolabial

groove and vermilion.

(2) Reconstruction with advancement island pedicle

flap preserves cosmetic boundaries and uses

similar, nonglabrous skin to preserve facial

hair in men.

(3) The key to achieving this degree of mobility is

extensive undermining in the subdermal plane in

the tissue surrounding the flap. The underlying

central vascular pedicle must be at least one-

third of the total surface area of the flap for the

overlying flap to remain viable.

(4) This simple and straightforward technique is a

single-stage procedure and provides good func-

tional and aesthetic results.

References

1. Li JH, Xing X, Liu HY, Li P, et al. Subcutaneous island pedicle

flap: variations and versatility for facial reconstruction. Ann Plast

Surg 2006;57:2559.

2. Tomich JM, Wentzell JM, Grande DJ. Subcutaneous island pedicle

laps. Arch Dermatol 1987;123:5148.

3. Dzubow LM. Subcutaneous island pedicle flaps. J Dermatol Surg

Oncol 1986;12:5916.

4. Ray TL, Weinberger CH, Lee PK. Closure of large defects on the

cutaneous upper lip using an island pedicle flap. Dermatol Surg

2010;36:9314.

5. Chan STS. A technique of undermining a V-Y subcutaneous island

flap to maximize advancement. Br J Plast Surg 1988;41:627.

Address correspondence and reprint requests to: PedroRedondo, MD, PhD, Department of Dermatology,University Clinic of Navarra, 31080 Pamplona, Spain, ore-mail: predondo@unav.es

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