Dermatologic Surgery

Repair of a Through-and-Through Defect on the Upper Cutaneous Lip

Authors

  • Hari Nadiminti MD,

    1. Summit Medical Group, Berkeley Heights, New Jersey
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  • John A. Carucci MD, PhD

    Corresponding author
    1. Section of Dermatologic Surgery, New York University Langone Medical Center, New York, New York
    • Address correspondence and reprint requests to: John A. Carucci, Section of Dermatologic Surgery, New York University Langone Medical Center, 240 East 38th Street, 12th Floor, New York, New York 10016, or e-mail: john.carucci@nyumc.org

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  • The authors have indicated no significant interest with commercial supporters.

A 65-year-old man was referred for treatment of a biopsy-proven long-standing invasive basal cell carcinoma of the upper lip. The original lesion measured 2.0 by 1.7 cm and was removed after multiple stages of Mohs surgery, resulting in a through-and-through defect that measured 5.5 by 4.9 cm and included the majority of the right upper portion of the orbicularis oris (Figure 1). How would you reconstruct this defect?

Figure 1.

Defect after removal of cancer.

Resolution

Large upper lip wounds must be repaired to restore function and achieve cosmesis. Failure to restore function of the upper lip may result in impaired speech, eating, and expression.[1] The lip also plays a critical role in facial aesthetics. As such, deformities of the lip area are readily noticeable.[1]

Large full-thickness defects of the lip may require complex reconstruction to restore function and cosmesis. Wedge resection with primary closure is a good option for many wounds, but in a wound exceeding one-third of the lip, microstomia may develop.[1] Medial cheek advancement and nasolabial transposition flaps may be used to resurface large cutaneous wounds, but both repairs ablate the nasolabial fold,[2] and neither is a suitable repair for disrupted oral mucosa.

Karapandzic flaps are single-stage neurovascular myocutaneous flaps that replace lost tissue with similar adjacent tissue.[3] Although excellent for lower lip reconstructions, the size and location of the present defect made this a less-than-ideal reconstruction. After consideration of all other options, the decision was made to perform a cross-lip transposition flap (Abbe flap) in combination with a V-to-Y advancement flap. Abbe flaps are well-perfused axial flaps based on the circumoral labial arcade from the inferior and superior labial arteries. Good functional and cosmetic outcomes are obtained with this reconstruction.[4, 5]

Surgical Technique

First, an Abbe flap was designed to transpose the ipsilateral right lower lip to fill the medial part of the right upper lip defect. Second, a V-to-Y advancement flap was used to repair the lateral portion of the upper lip and inferolateral cheek defect. This combination allowed restoration of a functional upper lip and creation of a new symmetric melolabial fold. This reconstruction is a staged procedure allowing opposite-lip tissue transfer with division at 3 weeks.

First Stage: Abbe Flap and V-to-Y Advancement Flap

A full-thickness flap was designed on the lower lip approximately half the size of the upper cutaneous lip defect to distribute the defect evenly between the two halves. It is important to design a large-enough flap to allow it to be placed without tension. A full-thickness incision was made down to the medial portion of the mucosal lip down to the mental crease and three-fourths up the lateral side (Figure 2). The pedicle was then transposed 180° to the upper lip (Figure 3). The flap is usually based medially to avoid stretching of the labial artery.[4] The newly created defect of the lower lip was closed using 4–0 glycomer 631 monofilament deep sutures and 6–0 nylon superficial sutures. The Abbe flap was then sutured in place medially along the cutaneous upper lip using 4–0 glycomer 631 monofilament deep sutures, 6–0 nylon superficial sutures, and 5–0 silk along the mucosal surface. A V-to-Y advancement flap was then developed and sutured to the lateral aspect of the Abbe flap. This was sutured using 4–0 glycomer 631 monofilament buried sutures and 6–0 nylon superficial sutures (Figure 4). The superficial sutures were removed 5 days postoperatively.

Figure 2.

The Abbe flap includes skin, subcutaneous tissue, muscle, and mucosa and is based on the labial artery.

Figure 3.

The Abbe flap transposed to the upper lip.

Figure 4.

The Abbe and V-to-Y flaps are sutured into place at completion of the first stage of repair.

Second Stage: Division of the Abbe Flap

Division of the pedicle is usually performed 2 to 3 weeks after surgery, although it has been shown to be possible to divide the flap as soon as 6 days after the initial procedure.[4] We preferred to ensure the safety of the flap and divided the pedicle at 3 weeks.[4] After injecting local anesthesia, the flap was divided to recreate a functional upper and lower lip. The upper lip flap was reapproximated to recreate the vermillion border and mucosal lip using 5–0 glycomer 631 monofilament deep sutures and 6–0 nylon superficial sutures. Sutures were removed 7 days after pedicle division. At 1-month follow-up, the patient had complete functional restoration and acceptable cosmetic results. A small depression of the lower lip was noted at 6-month follow-up, and a Z-plasty was performed to correct this. His 1-year follow-up is shown in Figure 5. Abbe flaps have return of motor and sensory function by 1 month.[4] Electromyographic studies have demonstrated reinnervation of the muscle and return of tactile sensation, painful stimuli sensation, and sweating.[4, 5] At 48-month follow-up, the patient continued to have full function of the lip and remained cancer free.

Figure 5.

Follow-up 12 months after pedicle flap division.

Conundrum Keys

  • Tumor-free margins must be obtained before considering reconstruction.
  • The Abbe flap provides functional and aesthetic repair of large defects of the upper cutaneous and mucosal lip.
  • The Abbe flap can be used in combination with an island pedicle flap to recreate the melolabial fold.

Ancillary