2007 O To Z Reconstruction of Central Upper Lip Defect

RECONSTRUCTIVE CONUNDRUM
O to Z Reconstruction of Central Upper Lip Defect

KOSTANTIN VASYUKEVICH, MD, AND MARC S. ZIMBLER, MD, FACSy
A 27-year-old woman was referred for recon-

struction of a central upper lip (philtrum)
defect following Mohs micrographic resection of
situated in the upper portion of the philtrum
and extended into the left philtral column (Figure 1).
There was no involvement of the columella or
a basal cell cancer. Physical examination revealed vermilion border. How would you reconstruct
1.0 1.1-cm circumferential defect. The defect was this defect?
Figure 1. Central upper lip defect and the outline of the incisions.
Department of Otorhinolaryngology, Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medi-
cine, New York;yDepartment of Otolaryngology-Head and Neck Surgery, Beth Israel Medical Center, New York, New York
& 2007 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing
ISSN: 1076-0512 Dermatol Surg 2007;33:85–89 DOI: 10.1111/j.1524-4725.2007.33014.x
85
O TO Z RECONSTRUCTION OF CENTRAL UPPER LIP DEFECT
Resolution plasty), bilateral advancement flap closure with re-

moval of Burow’s triangles, or an island pedicle flap
Reconstruction of Mohs defects of the central upper were considered for reconstruction of the defect de-
lip can present a significant challenge to the surgeon picted in Figure 1. All these methods can be suc-
and requires careful consideration of all available cessfully employed in the reconstruction of upper lip
options. Healing by secondary intention, primary defects. None of these commonly used techniques,
closure, skin grafts, and a variety of local flaps are however, could adequately recreate the outline of the
commonly employed in facial reconstruction. Many missing philtral column and therefore would create a
of these options, however, would produce cosmetic- compromised aesthetic outcome. We elected to util-
ally unacceptable results in reconstruction of the ize an O–Z plasty advancement flap to reconstruct
upper lip. For example, healing by secondary inten- this defect of central upper lip that involved the
tion would result in scar contracture and thus distort philtral column.
the vermilion border and columella. Skin grafts are
also limited in their use in this particular location The anatomic subunits were marked out with a fine-
because of both color and texture discrepancies. tip marking pen and the soft tissues of the lip were
Moreover, skin grafts typically heal with either hyper infiltrated with 1% lidocaine with 1:100,000
or hypopigmentation, which would further com- epinephrine. Two incisions were made along the left
promise the postoperative scar. Local tissue re- vermilion border and along the right nasal-alar
arrangement provides the best color and texture crease as shown in Figure 1. Both flaps were widely
match for reconstruction of the defects in the labial undermined in the subcutaneous plane and rotated
region. When closing the defect with local tissue, into place in a Z-type fashion causing minimal
preservation of the aesthetic subunits such as the distortion to the lip. The wound was closed in layers
philtrum, vermilion border, cupid’s bow, and alar- with 5-0 inverted interrupted Monocryl and
labial crease is essential. Several options including 6-0 interrupted nylon (Figure 2A). A pressure
primary advancement flap closure (such as an O–T dressing was applied.
Figure 2. (A) Immediate postoperative appearance. (B) Patient at 30-day follow-up.
86 D E R M AT O L O G I C S U R G E RY
VA S Y U K E V I C H A N D Z I M B L E R
The sutures were removed on Postoperative Day 7. Conundrum Keys

The incision appeared well healed with a discrete O to Z advancement flap is a viable option in re-
scar in a Z-configuration. The horizontal limbs construction of central upper lip defects.
of the incision appeared well hidden at the border of
the vermilion and under the columella. In contrast, In reconstruction of the upper lip defects, careful
the vertical limb of the incision produced a visible attention should be paid to the final scar config-
line that runs along the border of the philtrum and uration and location. Placement of the flap
served to recreate the outline of the excised left incisions at the vermilion border and along the
philtral column (Figure 2B). nasal-alar crease is important in achieving good
cosmetic results.
Overall, we felt that O to Z closure of the upper Thorough preoperative planning and knowledge of
philtrum defect produced good cosmetic result and reconstructive options are essential in reconstruc-
should be considered among other options in re- tion of the defect that crosses the borders of the
construction of upper lip defects that involve philtral aesthetic subunit. O to Z closure was specifically
column. Application of this closure can also be ex- designed to reconstruct the philtrum and recreate
tended to reconstruction of facial defects in other the outline of the missing philtral column and
locations, as long as there is sufficient amount of soft therefore produced the most optimal result in
tissue available for flap advancement. This technique closure of this defect.
is limited to the areas of the face where horizontal
incisions can be placed at the borders of the aesthetic
subunits. Mental crease and lower vermilion border
or the eyebrow and deep forehead rhytids can be Address correspondence and reprint requests to: Marc S.
Zimbler, MD, FACS, Director of Facial Plastic &
used to camouflage the resulting scars in recon-
Reconstructive Surgery, Beth Israel Medical Center,
struction of the lower lip and forehead defects, 10 Union Square East, Suite 4J, New York, New York
respectively. 10003, or e-mail: [email protected].
COMMENTARY
Certainly this result is acceptable, even laudable, for this lovely young lady, but several elements of this
case and closure are bothersome. It seems the procedure was performed under general anesthesia, a
significant variation from the practice of virtually all dermatologic surgeons, Mohs disciples or not. The
increased risk to any patient of such would be unacceptable to most of my ilk, but I understand the
differences in certain specialty approaches. Even if the patient insisted, GA should be reserved for cases of
such magnitude that repair is virtually impossible without that depth of anesthesia.1 It is up to the surgeon
to protect the patients, even from themselves.
Now, the defect is slightly left-of-center and, but not all, of the philtrum. (This commentator tried to delay
writing until more time had passed to better judge the final scar, but that delay was not possible.)
Hair positioning is not an important consideration in technique here, but might be of great import in a
male patient.
The design depicted and then incised does not precisely follow the juncture plane between nose and lip
nor, apparently, of the mucosal lip and cutaneous upper lip. The most exacting attention to such
incision placement is imperative in camouflaging our operative lines. In an asymmetric defect, it is possible
3 3 : 1 : J A N U A RY 2 0 0 7 87
O TO Z RECONSTRUCTION OF CENTRAL UPPER LIP DEFECT
Figure 1. Defect of upper lip.
Figure 2. 12 months after repair with full-thickness skin

graft.
to advance one segment more than the other, using suturing techniques to fix the moving tissue to where
one desires the final scar line to be.2 The authors, rather than using the approach detailed below, chose to
accentuate the entire curvature of the medial left philtrum column and then slant obliquely laterally,
beginning in the supra-Cupid’s bow concavity on the left. In my opinion, there was a failure to adequately
free the moving flap(s) with sufficient tension-relieving techniques, resulting in an erythematous hyper-
trophic scar. This section of lip skin is thin, lies over subcutaneous tissue and then orbicularis oris muscle,
and dissects freely only with difficulty. Along the upper vermilion-skin border, two paramedian elevations
of the vermilion form Cupid’s bow. Similarly, dual elevated vertical columns of tissue form a midline
depression, located between the two paramedian elevations of the vermilion and the columella above.3
Using unilateral (on the side with the greatest movement necessary) or bilateral (if required) perioral
crescentic excisions, additional movement of the upper lip skin toward an infranasal V–Y anastomosis
becomes easier. By slanting the surgical anastomosis obliquely downward along the desired line of the
medial elevation on the left, the entire incision above the vermilion lip can be avoided, as can involving the
more delicate Cupid’s bow area as well. If necessary, it is possible to sculpt a slightly angled hemicolumn
of soft tissue beneath the skin (or even partially beneath an existing defect) and evolve a facsimile of a
raised column or use suture techniques to gather soft tissue together and raise a convex pseudocolumn. A
more extensive dissection to free the integument (perhaps even to the nasolabial fold in such a young
person), a more fixative periphiltrum suturing technique with column formation, and of course, post-
operative intralesional dilute steroids and/or V beam laser application might well be appropriate. The
healing process here easily reflects tension, and that is clearly in evidence. More adequate measures to
relieve that tension are hereby suggested, including a change in design to a V–Y closure along the medial
column elevation border, assisted by unilateral or bilateral perialar excisions and advancement to an
obliquely angled final closure line.4 This design would be applicable to both male and female patients.
88 D E R M AT O L O G I C S U R G E RY
VA S Y U K E V I C H A N D Z I M B L E R
The authors are quick to dismiss full-thickness grafting in upper lip repair situations. On the contrary,
there are many situations where preauricular, postauricular, and infraauricular grafts are better options
than extensive and deforming flap procedures (Figures 1 and 2). This seems too frequently a matter of
surgeon’s preference and skills, rather than the patient’s informed choice. In the undersigned’s half-century
experience, there are many patients who prefer full-thickness grafting techniques to single or multiple flap
techniques with/without revisions. Grafts can be harvested in some areas with thicker edges, or thicker
focal areas, thereby allowing the appearance of greater thickness. The ends of grafts can also be sutured to
effect a semirolled appearance, again allowing simulation of that desired elevated lateral philtrum effect.
Pigmentary disturbance, if significant, is easily camouflaged. Careful donor site choice with shaping grafts
to match cosmetic units or junctures does much to dissipate the unattractive old-style execution of round
grafts into round surgical defects, an ancient but still-too-often-utilized method of quick closure without
individualized aesthetic design and execution.
References
1. Field L. Against general anesthesia in ear reconstruction. Ann Plast Surg 1986;16:86.
2. Field L. Make your incisions where you want your final scar line to be: a surgical philosophy. J Dermatol Surg and Oncol 1990;16:1062–63.
3. Babak J, Blackwell K. Lips and perioral regional anatomy.

eMedicine [serial on the Internet]. 2005 Oct 17. Available from: http://www.emedicine.com/ent/topic7.htm
4. Field L. The lower eyelid curved V-to-T plasty. J Dermatol Surg Oncol l985;1:378–81.
LAWRENCE M. FIELD, MD, FIACS

Foster City, CA
3 3 : 1 : J A N U A RY 2 0 0 7 89

2007 O To Z Reconstruction of Central Upper Lip Defect

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RECONSTRUCTIVE CONUNDRUM

O to Z Reconstruction of Central Upper Lip Defect

A 27-year-old woman was referred for recon-

Resolution plasty), bilateral advancement flap closure with re-

Figure 2. (A) Immediate postoperative appearance. (B) Patient at 30-day follow-up.

The sutures were removed on Postoperative Day 7. Conundrum Keys

Figure 1. Defect of upper lip.

Figure 2. 12 months after repair with full-thickness skin

3. Babak J, Blackwell K. Lips and perioral regional anatomy.

LAWRENCE M. FIELD, MD, FIACS

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