RECONSTRUCTIVE CONUNDRUM

Combined Vestibular Mucosal Advancement and Island

Pedicle Flaps for the Repair of a Defect Involving the
Cutaneous and Vermilion Upper Lip
AVANTE ROBERTS, BS,* LAUREL LEITHAUSER, MD,

AND HUGH M. GLOSTER, JR, MD

The authors have indicated no signicant interest with commercial supporters.

A
n 82-year-old woman presented with a biopsy-
conrmed primary micronodular basal cell
carcinoma on the left upper lip. Physical examina-
tion revealed an ill-dened, 0.8- by 0.8-cm hypo-
pigmented indurated papule on the left cutaneous
upper lip extending through the vermilion border.
Excision of the lesion required two stages of Mohs
micrographic surgery and produced a 1.8- by 1.2-cm
partial-thickness defect involving the cutane-
ous upper and vermilion lip (Figure 1).
How would you repair this defect?
*University of Cincinnati College of Medicine, Cincinnati, Ohio;

Department of Dermatology, University of
Cincinnati, Cincinnati, Ohio
Figure 1. The 1.8- by 1.2-cm surgical defect remaining after Mohs micrographic surgery.
2014 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.
ISSN: 1076-0512 Dermatol Surg 2014;40:580583 DOI: 10.1111/dsu.12453
580
Resolution
The lip plays a vital role in the production of speech
and sound and allows for oral competence in eating
and drinking. Aesthetically, the lip consists of
several cosmetic subunits and unique landmarks.
Thus, when considering options for repair, a recon-
structive technique that reconstitutes normal func-
tion and preserves cosmetic appearance is of critical
importance.
1
Alignment of the vermilion border is
an important part in all lip procedures, because
misalignments as small as 1 mm are noticeable at a
conversational distance.
1
The reconstruction of this
defect was challenging because it involved the
cutaneous upper lip, vermillion border, and
vermilion lip.
Several reconstructive options were considered
before the repair of this defect. Second-intention
healing is simple and cost-effective and may be a
good option for lateral, supercial defects.
1
In 2002,
Gloster reported a series of 13 patients with
partial-thickness defects of the vermilion, mucosa,
or both that were allowed to heal by second
intention with good to excellent results in terms of
preserving cosmetic appearance and maintaining
functionality, but unlike our patient, these patients
did not have signicant involvement of the cutane-
ous lip. When a defect of the vermilion or mucosa
extends more than 2 mm into the cutaneous lip and
is allowed to heal by second intention, there is
greater risk of scarring that may disrupt the vermil-
ion border, distort the natural pucker lines, and
focus unwanted attention on this area.
2
A full-thickness lip wedge repair is another option
that could be used for this defect, but a lip wedge
repair is more appropriate for the repair of full-
thickness or deep partial-thickness defects involving
up to one-third of the vermilion length of the lower
lip and up to one-fourth of the upper lip. Our
patients defect was not deep enough to warrant a lip
wedge repair. In addition, the width of the defect
involved more than one-fourth of the upper lip.
Thus, lip wedge repair could have resulted in
reduction of the size of the oral aperture and
signicant distortion of lip anatomy, especially the
philtrum, due to excess tension upon closure of the
wedge. Finally, lip wedge repair carries signicant
risk of bleeding due to transection of the labial
artery and is time consuming because it requires
precise realignment of the vermilion border and each
layer of the lip.
2,3
A transposition ap or advancement ap using tissue
reservoirs of the medial cheek would likely blunt the
melolabial fold and compromise facial symmetry. In
addition, an advancement ap could distort the
vermilion border because of secondary movement,
and a transposition ap from cheek to lip might also
pincushion (i.e., trapdoor). Advancement aps
may distort the philtrum and lead to an
asymmetrical appearance.
Vermilion aps are useful for larger vermilion
defects. They replace the vermilion with other
vermilion tissue and typically heal well. Vermilion
advancements are useful for more-central defects
and are based on the labial arteries.
1,4
Vermilion
switch aps are interpolation aps that may be
useful for lateral defects,
1
although these are staged
aps that require pedicle division approximately
10 days after surgery, and delay of pedicle division
may make tailoring of the ap difcult.
1
Island
pedicle aps are ideal for repairs involving consid-
erable loss of the cutaneous upper lip, because
incision lines can be placed in the vermilion crease
inferiorly and in existing rhytides of the upper lip
and melolabial fold superiorly.
5
After considering these options, our solution was to
combine two techniques to repair each cosmetic
subunit (cutaneous and vermilion lip) and thus
recreate the vermilion border and not violate the
melolabial fold. The rst technique used to repair
the vermilion lip was a vestibular mucosal
advancement ap, which allowed preservation of
normal vermillion taper and facilitated healing with
the use of healthy vermillion tissue. The second
technique used to restore the cutaneous portion of
ROBERTS ET AL
40: 5: MAY 2014 581
the defect was a superiorly based island pedicle ap.
These techniques together preserved the normal
anatomic and functional relationship of the cutane-
ous and vermilion lip and minimized the risk of the
complications outlined above associated with sec-
ond-intention healing, lip wedge repair, advance-
ment aps, and transposition aps.
Surgical Technique
Preoperatively, the clinical extent of the tumor and
the vermilion border on either side of the defect was
marked using a surgical pen. Under local anesthesia
with 1% lidocaine with epinephrine, the tumor was
removed in two stages of Mohs micrographic surgery.
For the vestibular mucosal advancement portion of
the repair, Burows triangles of vermilion lip were
removed, and the mucosa was undermined at the
submucosal level (see ap design in Figure 2). For the
island pedicle portion of the repair (also see ap
design in Figure 2), a triangular incision was made
superiorly, extending intothe cutaneous upper lip and
forming an apex at the alar groove. A small central
subcutaneous pedicle was meticulously dissected
beneath the ap. Because of the abundant vascularity
of the perioral tissue, a small central pedicle provides
adequate blood supply and permits maximum
mobility of the ap. The skin surrounding the ap was
then undermined in the subcutaneous plane. After
obtaining meticulous hemostasis, the secondary
defect superior to the ap was closed using 50
polyglactin subcuticular sutures, which pushed the
ap inferiorly toward the mucosal ap. The island
pedicle ap was then sutured to the vestibular
mucosal advancement ap to close the primary
defect. The junction of the two aps and closure of the
Figure 2. A combined island pedicle and vestibular mucosal
advancement ap were designed.
Figure 3. Immediate postoperative photograph showing
the incision lines with preservation of the vermilion border
and cosmetic units.
Figure 4. One-month follow-up photograph showing only
minimal distortion of the vermilion border and incision lines
blending well with upper lip rhytides.
Figure 5. Eight-month follow-up photograph showing nea-
rly undetectable distortion of the vermilion border and
blending of incision lines with upper lip rhytides.
COMBI NED FLAPS FOR UPPER LI P DEFECT REPAI R
DERMATOLOGI C SURGERY 582
Burows triangles of the mucosal ap recreated the
vermilion border (Figure 3). The repair was com-
pleted by the placement of multiple 6.0 nylon simple
interrupted epidermal sutures (Figure 3).
The patients 1- (Figure 4) and 8-month (Figure 5)
follow-up photographs show preservation of the
aesthetic appearance of the upper lip with only
minimal distortion of the vermilion border. The
incision lines resulting from the island pedicle ap
blend well with the patients upper lip rhytides and
in the alar groove.
Conundrum Keys
Combine multiple aps to restore a complex defect
involving distinct cosmetic subunits resulting in
preservation of normal anatomic and functional
relationships.
Alignment of the vermilion is an essential part of
lip procedures.
Preserve cosmetic units.
Incision lines should be placed to allow blending
with normal facial folds and rhytides.
References
1. Boutros S. Reconstruction of the lips. In: Thorne CH, Bartlett SP,
Beasley RW, Aston SJ, Gurtner GC, Spear SL, editors. Grabb and
Smiths plastic surgery. Philadelphia: Lippincott Williams &
Wilkins, 2006. pp. 36774.
2. Gloster HM Jr. The use of second intention healing for partial-
thickness Mohs defects involving the vermillion and/or mucosal
surfaces of the lip. J Am Acad Dermatol 2002;47:8937.
3. Spinowitz AL, Stegman SJ. Partial-thickness wedge and
advancement ap for upper lip repair. J Dermatol Surg Oncol
1991;17:5816.
4. Vaienti L. Central upper lip reconstruction by two vermilion aps
and a rotational skin ap. Dermatology 2012;224(2):1303.
5. Salmon P. Reconstruction of the upper lip. Dermatol Surg 2013;39
(5):789.
Address correspondence and reprint requests to: Hugh M.
Gloster, Jr., MD, 4460 Red Bank Road, Suite 130,
Cincinnati, Ohio 45227, or e-mail: hgloster@yahoo.com
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40: 5: MAY 2014 583