Outcomes following V-Y advancement flap reconstruction of large upper lip defects

Abstract

Objective

To characterize revision surgery following V-Y subcutaneous tissue pedicle advancement flap repair of large upper lip skin defects.

Methods

Retrospective review of upper lip skin defects ≥3.0 cm² that were reconstructed with a V-Y subcutaneous tissue pedicle advancement flap at an academic tertiary care center. Depth and area of the defect, as well as involvement of the vermilion and nasal ala, were recorded as independent variables. Revision techniques were analyzed to identify patterns.

Results

Thirty patients were identified with upper lip skin defects ranging from 3.0 to 14.0 cm2 (mean 7.0 cm2, median 6.25 cm2). The defect involved the nasal ala in four cases and the vermilion in three cases. At least one revision surgery was performed in 14/30 (47%) patients. Alar or vermilion involvement was a significant factor in revision by chi-square analysis (p=0.026). Larger defect size did not predict a need for revision, even among cases where the defect did not involve the ala or vermilion (p=0.68).

Conclusion

Reconstruction of large upper lip skin defects with a V-Y subcutaneous tissue pedicle advancement flap is associated with a 47% revision rate, and when the defect involves the ala or vermilion, the revision rate is increased. Defect size alone cannot be used to predict the need for revision surgery. Revision techniques are demonstrated.

INTRODUCTION

The upper lip is a functionally and aesthetically important region of the face. Broadly, it comprises cutaneous and vermilion components that are separated by the vermiliocutaneous (VC) junction. The cutaneous portion is further divided into two paired lateral subunits bounded by the nasal base and melolabial folds, and separated by the midline philtrum. The intersection of the philtrum with the red lip creates the delicate “cupid’s bow.”¹

The upper lip is also a relatively frequent site of cutaneous malignancy. Surgical excision is the treatment of choice for most skin cancers of the lip. The technique used to reconstruct the resulting surgical defect depends on location, size, depth and adjacent subunit involvement. Reconstruction of small (<1 cm) cutaneous defects of the upper lip can be achieved with lip advancement (primary) closure if located in the mid- to lower- lip, but this might require excising a standing cutaneous deformity of red lip. Full-thickness skin grafting can always be utilized for repair of superficial skin defects of the upper lip, regardless of size. This can result in poor color match between the graft and adjacent lip skin, or a contour depression. Larger cutaneous defects can be converted to full-thickness and repaired with lip advancement if perfectly midline, or full-thickness lip switch flaps from the lower lip. However, the latter is a complex surgical option requiring creation of scars in the lower lip and interval pedicle detachment requiring another surgical procedure. The local flaps that can be used in the upper lip are limited because they often distort the nose, vermiliocutaneous junction, melolabial crease or philtral columns.

A V-Y advancement flap of laterally-based adjacent upper lip skin based on a subcutaneous tissue pedicle is an excellent technique for reconstructing lateral, skin only upper lip defects larger than 1 cm². This method places scars along aesthetic borders, and advances skin of similar characteristics into the upper lip. Further, this method maintains oral sphincter competence and facial nerve function. Given the robust subcutaneous pedicle, this flap is a reliable option for upper lip reconstruction in most patients including smokers. Subcutaneous undermining of portions of the flap allows advancement of a skin flap of similar thickness and contour into the upper lip. Mobilizing the island flap solely on the subcutaneous fat adjacent to the modiolus enables advancement of the flap up to and slightly beyond the philtrum allowing reconstruction of skin defects as large as one-half of the upper lip.

In 1998, we published our technique and the largest series of V-Y subcutaneous tissue pedicle advancement flaps used for upper lip reconstruction in the literature to date.² In that report, 35% of defects ≥ 4 cm² required flap contouring (“debulking”), though this statistic included defects with a significant cheek component. The purpose of this study was to further analyze larger upper lip skin defects repaired with this method in an effort to identify defect characteristics that might predict the need for revision surgery. The aesthetic or functional abnormalities that prompted revision surgery and the specific techniques used to correct them were explored as well.

METHODS

Patients with upper lip skin defects >3.0 cm² reconstructed with V-Y subcutaneous tissue pedicle advancement flaps were identified from the senior surgeon’s (SRB) prospective skin cancer reconstruction database. Inclusion criteria were at least 2 months of follow-up and cutaneous neoplasm as the etiology of the defect. Defects with >5 mm extension onto the cheek aesthetic unit (lateral to the melolabial fold) were excluded. All patients provided appropriate consent for pre-, intra- and post-operative photography and this study received Institutional Review Board approval. Variables extracted from patients’ medical records included etiology of the defect, sex, age, size of defect, and depth of defect (divided into skin, subcutaneous tissue, or involving orbicularis oris muscle). Post-operative queries included presence or absence of flap necrosis, wound infection, wound dehiscence, and need for secondary procedures. Defects were measured after resection of the primary lesion and freshening of any post-Mohs wound margins, and before undermining, in all cases.

Surgical Technique

After confirmation of tumor free margins, reconstruction was performed in the operating room under intravenous sedation and local anesthesia in all patients. The defect was measured and vertical and horizontal dimensions were recorded. The V-Y subcutaneous tissue pedicle advancement flap was then marked out with a surgical marker. The width of the flap was equal to the greatest height of the lip defect. The flap was designed so it was at least twice the length of the width of the flap and tapered into the labiomandibular sulcus. For most defects with a diameter >2cm, the remainder of the lip subunit lateral to the medial border of the defect is excised. For very large defects, we find it helpful to excise a crescent of skin around the alar-facial sulcus and replace it with a portion of the flap. This allows the superior aspect of the melolabial scar line to lay in a natural position just lateral to the ala. This flap design prevents a transverse scar across the base of the peninsula of skin composing the alar-facial sulcus, and prevents the abrupt termination of the melolabial fold at the alar base (Figure 1).

Figure 1.

Comparison of two similar defects closed with slightly different techniques. A) Patient A (74 years old) with 2x2 cm defect closed after removing the rest of the right lip subunit. B) Patient B (68 years old) with 2.5x3.5 cm defect closed after removing the subunit and a perialar crescent. C and D) Patient A before and after reconstruction. Notice how the melolabial fold is quite asymmetric. E and F) Patient B before and after reconstruction. There is no noticeable asymmetry of the melolabial creases.

The skin and subcutaneous tissues were then infiltrated with a mixture of either 1% lidocaine with 1:100,000 dilution of epinephrine (small to moderate sized flaps) or a 1:1 mixture of 0.5% lidocaine and 0.25% marcaine with 1:200,000 dilution of epinephrine for large flaps to avoid local anesthetic toxicity. The face was then prepped and draped in the usual sterile fashion. All flap incisions were then made through the dermis. The distal flap was then undermined in the subcutaneous plane while the medial border of the flap was sharply dissected from the orbicularis oris muscle fibers. The proximal third of the flap was similarly elevated in the subcutaneous plane. Most importantly, the middle third of the flap must remain pedicled to the richly perfused subcutaneous tissue. The adjacent subcutaneous cheek tissue can be freed from the pedicle by dissecting deeply perpendicular to the skin along the lateral border of the cheek incision. Deep dissection stops at the zygomaticus major fascia to avoid injuring the facial nerve fibers entering the deep aspect of the facial muscles. The flap mobility is periodically evaluated by advancing the flap toward the defect until the necessary reach is achieved. Once tension free advancement is possible the flap is secured to the medial aspect of the defect. The flap is conservatively trimmed as needed. Excised skin can potentially be used for full thickness skin grafting as needed for adjacent defects. The incisions are then closed in two layers, and a compression dressing is applied to prevent hematoma formation beneath the flap (Figure 2).

Figure 2.

Surgical technique. A) 38 year old woman with 3.0 x 1.7 cm defect of the right upper lip with a significant vermilion component. B) Planned flap marked out as well as removal of the remainder of the right lip subunit inclusive of a perialar crescent. C) Flap raised, demonstrating subcutaneous tissue pedicle based on the middle third of the flap. D) Flap inset. E) 2 months after flap inset. F) 8 months after two revisions that included contouring, scar revision, and z-plasty.

RESULTS

Between 1994 and the present, 30 patients were identified fitting the inclusion criteria, with upper lip defects ranging from 3.0 to 14.0 cm² (mean 7.0 cm², median 6.25 cm²). Eighteen subjects were female (60%). Age at the time of reconstruction ranged from 34–86. The malignancy was basal cell carcinoma (BCCA) in 16 cases, while the rest were atypical junctional melanocytic hyperplasia (AJMH) or melanoma in situ. There were no instances of wound dehiscence, or partial flap loss. One patient received a course of oral antibiotics for skin erythema and presumed cellulitis that resolved without any adverse consequences. The defect involved the nasal ala in 4 cases and the vermilion in 3 cases. At least one revision surgery was performed in 14 (47%) patients. Four of these patients underwent a second revision (13%), and one of these required a third revision (3%). During these 19 revision surgeries, flap contouring (11 times) and z-plasty (9 times) were the most commonly used techniques. Vermilionectomy, scar revision, and removal of a standing cutaneous deformity were each used 6 times. Vermilion advancement and skin excision were rarely used (twice each).

Logistic regression analysis was used to model defect depth (skin, into subcutaneous tissue, into muscle), size (cm²), vermilion involvement, and alar involvement in relation to revision surgery. Backward variable selection identified vermilion involvement as the only predictor of undergoing revision surgery. Since the R2 (a measure of statistical power) for this model was only 0.2, regression was under-powered to detect whether or not vermilion involvement was a significant predictor of needing revision surgery. A two-tailed t-test to explore the hypothesis that increasing defect size would be a predictor of revision surgery showed that this was not the case (p=0.55). Individual chi-square analysis was then performed for each categorical independent defect variable (depth, alar involvement, vermilion involvement). Vermilion involvement showed a trend towards significance (p=0.09), while the other individual variables were clearly not significant. Fisher’s exact test was used instead of chi-square for analysis of alar and vermilion involvement because of small sample sizes. Defect involvement of the nasal ala or vermilion was found to increase the likelihood of undergoing revision surgery (p=0.026). We then performed a two-tailed t-test for just the subset of cases without alar or vermilion involvement, and defect size remained non-significant (n=23, 30% revision rate, p=0.68).

DISCUSSION

V-Y subcutaneous tissue pedicle advancement flap reconstruction has been previously described in upper lip reconstruction. To our knowledge, Zook et al. in 1980 were the first to report using the V-Y island advancement flap for upper lip reconstruction following trauma or oncologic resection.³ In their version, the flap was not formally undermined, but was gently “stretched” along its periphery to increase movement. This would limit the flap to smaller defects, and would increase the chance of requiring flap contouring at a second stage. In 1990, Skouge presented an excellent discussion of the anatomy of the upper lip and reported four upper lip defects closed with V-Y subcutaneous tissue pedicle advancement flaps.⁴ That same year, Hurwitz et al described a technique that advanced both upper lip skin and vermillion to close defects involving the red lip.⁵ Carvahlo et al. later described modifications allowing reconstruction of full-thickness upper lip defects using V-Y flaps.⁶

The V-Y subcutaneous tissue pedicle advancement flap is our preferred technique for closing most upper lip skin defects >1 cm diameter that are not midline, full-thickness, or centered on the red lip. In a prior publication from our group, large upper lip and medial cheek defects were associated with a 35% revision rate. The purpose of this report was to further investigate this statistic.

We found a 47% revision rate in this updated series. Alar or vermilion involvement by the defect had a statistically significant association with revision surgery. The depth of the defect was not found to be important. Defect size alone, either including or excluding subjects with alar or vermilion involvement, was also not a significant factor (p>0.5). Thus, our results suggest that even very large upper lip defects without alar/vermilion involvement can be reconstructed with good results in just one stage. This makes sense because V-Y subcutaneous tissue pedicle advancement flaps can resurface the entire hemi-lip. However, once a natural aesthetic boundary is crossed (onto the nose or lip), the likelihood of needing further refinement surgery increases. It should be emphasized that the island advancement flap is not used to reconstruct an adjacent alar defect. These are either left to heal by secondary intention if minimal, skin-grafted if appropriate, or reconstructed with a different flap. We typically close adjacent vermilion defects with a separate vermilion advancement flap, but the Hurwitz modification⁵ could be used as well.

In our series, 7 different revision techniques were necessary: flap contouring (debulking), z-plasty, vermilionectomy, scar revision, removal of standing cutaneous deformity, vermilion advancement and skin excision. Further analysis revealed certain patterns. With large lip defects, the medial flap border is often placed on significant wound closure tension, and as a consequence, the scar along the medial aspect of the flap frequently widens or thickens over time. Also, the red lip can became elevated from scar contracture at its junction with the flap’s medial border. A common and effective solution to this problem is to perform a multiple z-plasty along the vertical axis of the scar, and excision of the vermilion that has been elevated by scar contracture (Figure 3).

Figure 3.

Typical causes for revision along the medial suture line. A) Widened vertical scar with shortening of the upper lip and elevation of the vermilion. B) Planned multiple z-plasty, scar excision and vermilionectomy. C) Immediately post revision. D) 6 months later.

A second common problem area is along the lateral half of the vermiliocutaneous (VC) border. The distance between the melolabial crease and the red lip decreases as the crease descends from the nose toward the lateral commissure. When utilizing V-Y subcutaneous tissue pedicle advancement flaps for large lip defects, tissue can accumulate above and medial to the commissure, causing fullness and a depressed vermilion. This redundant tissue represents a standing cutaneous deformity that develops as the flap is advanced and to some degree pivoted towards the defect. We typically perform a skin excision from the inferior border of the flap along the VC border and debulk the area of fullness through this opening before closing the skin. Sometimes vermilion advancement is required in addition to skin excision from the flap in order to optimize the VC junction (Figure 4).

Figure 4.

Typical causes for revision along the inferior suture line and trailing edge of the flap. A) Patient B from Figure 1 eleven months following reconstruction. B) Planned excision of hypertrophic medial and melolabial scars, removal of excess skin along the lateral vermilion, and excision of a standing cutaneous deformity along the trailing edge of the flap on the chin. C) Immediately following excision. D) 10 months after revision.

Lastly, a standing cutaneous deformity often forms along the flap’s trailing edge, where the “Y” is formed upon closure of the donor site. This problem is solved by excising a small ellipse of skin oriented along the axis of the relaxed skin tension lines (Figure 4).

To our knowledge this is the first in-depth analysis of large upper lip defects closed with a V-Y subcutaneous tissue pedicle advancement flap. Reports such as this can help to counsel patients preoperatively about the likelihood of needing revision surgery. Large upper lip defects are relatively rare, and this information can serve as a resource when planning initial or revision surgery using this technique. Perhaps most importantly, by identifying the areas that most commonly require refinement, we hope to develop modifications of the initial procedure that can reduce the need for revision surgery.

CONCLUSION

Partial thickness defects of the upper lip ≥ 3.0 cm² reconstructed with a V-Y subcutaneous tissue pedicle advancement flap had a 47% revision rate. Alar or vermilion involvement by the defect was associated with an increased rate of revision surgery. The areas that will require revision are predictable, and there are straightforward techniques to optimize the final result. Recognizing common problem areas might allow the surgeon to modify the primary surgery, thus reducing the revision rate.