Lip reconstruction

March 7, 2009

San Francisco - Most operative wounds of the upper lip can be repaired linearly with an island pedicle flap or an advancement flap. About 10 percent of wounds, however, will need something more inventive, an expert says.

San Francisco

- Most operative wounds of the upper lip can be repaired linearly with an island pedicle flap or an advancement flap. About 10 percent of wounds, however, will need something more inventive, an expert says.

"When someone has a fairly substantial wound from a skin cancer, island pedicle flaps and advancement flaps are the ‘workhorse’ procedures that we rely on in the vast majority of cases," says Dr. Glenn D. Goldman, M.D., associate professor and chief of dermatology, the University of Vermont College of Medicine, Burlington, Vt.

"There are times, however, when we employ more nuanced repairs that enable us to maintain the nasolabial fold or hide the incision by making the primary arc of a repair run the nasolabial fold," Dr. Goldman says.

Linear repairs and lip wedge reconstructions offer highly aesthetic outcomes, according to Dr. Goldman, who says that these techniques often produce an almost invisible line on the lip.

Dr. Goldman says that physicians should not be afraid to extend linear repairs through the vermillion border, something that was avoided historically.

The most common advancement flap is a modified Webster cheek advancement, which uses the laxity of the cheek to repair wounds on the lip.

"Wounds up to the size of a quarter or even a half dollar can be repaired with straight-forward advancement flaps from the cheek," Dr. Goldman says.

The disadvantage of these flaps is that they tend to blunt the nasolabial fold and can, therefore, make the face somewhat asymmetric.

Transpositional flaps have historically been used from cheek to lip to repair fairly substantive operative wound. More recently, a modified technique has been undertaken in which the surgeon creates a pedicle from the cheek to the lip and then divides and contours the flap at a later date.

"Pedicled transposition flaps are elevated, thinned carefully, sutured and left for three weeks and then divided," says Dr. Goldman, who uses this technique for "substantial sized wounds that present a challenge to reconstruction."

Rotation flaps are a ‘niche’ repair, and are mainly used for defects of the apical triangle, Dr. Goldman says.

The advantage is that they require only two curvilinear lines, rather the three resulting from an island pedicle flap, and they tend not to pincushion.

The Abbe flap, which is a lower-to-upper-lip, staged transposition flap, is used mainly for full thickness wounds on the upper lip.

"I probably only use this technique once a year or even less," Dr. Goldman, tells Dermatology Times.

"It requires significant postoperative care and a separate take-down procedure; however, if a transumural defect of the upper lip is more than about a third of the size of the lip, we will usually opt for the Abbe flap," he says. DT