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Outcomes Following V-Y Advancement Flap Reconstruction of Large Upper Lip Defects

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Outcomes Following V-Y Advancement Flap Reconstruction of Large Upper Lip Defects ORIGINAL ARTICLE Outcomes Following V-Y Advancement Flap Reconstruction of Large Upper Lip Defects Garrett R. Griffin, MD; Stephen Weber, MD, PhD; Shan R. Baker, MD Objective: To characterize revision surgery following nasal ala in 4 cases and the vermilion in 3 cases. At least V-Y subcutaneous tissue pedicle advancement flap re- 1 revision surgery was performed in 14 patients (47%). pair of large upper lip skin defects. Alar or vermilion involvement was a significant factor in revision by ␹2 analysis (P=.03). Larger defect size did not Methods: Retrospective review of upper lip skin predict a need for revision, even among cases where the defects at least 3.0 cm2 in area that were reconstructed defect did not involve the ala or vermilion (P=.68). with a V-Y subcutaneous tissue pedicle advancement flap at an academic tertiary care center. Depth and Conclusions: Reconstruction of large upper lip skin de- area of the defect, as well as involvement of the ver- fects with a V-Y subcutaneous tissue pedicle advance- milion and nasal ala, were recorded as independent ment flap is associated with a 47% revision rate, and when variables. Revision techniques were analyzed to iden- the defect involves the ala or vermilion, the revision rate tify patterns. is increased. Defect size alone cannot be used to predict the need for revision surgery. Revision techniques are Results: Thirty patients were identified as having up- demonstrated. per lip skin defects with a mean (range) area of 7.0 (3.0- 14.0) cm2 (median, 6.25 cm2). The defect involved the Arch Facial Plast Surg. 2012;14(3):193-197 HE UPPER LIP IS A FUNCTION- fects can be converted to full thickness and ally and aesthetically im- repaired with lip advancement if per- portant region of the face. fectly midline or with full-thickness lip Broadly, it comprises cuta- switch flaps from the lower lip. However, neous and vermilion com- the latter is a complex surgical option re- Tponents that are separated by the vermil- quiring creation of scars in the lower lip iocutaneous junction. The cutaneous and interval pedicle detachment requir- portion is further divided into 2 paired lat- ing another surgical procedure. The local eral subunits bounded by the nasal base flaps that can be used in the upper lip are and melolabial folds and separated by the limited because they often distort the nose, midline philtrum. The intersection of the vermiliocutaneous junction, melolabial philtrum with the red lip creates the deli- crease, or philtral columns. cate “cupid’s bow.”1 A V-Y advancement flap of adjacent up- The upper lip is also a relatively fre- per lip skin based on a subcutaneous tis- quent site of cutaneous malignancy. Sur- sue pedicle is an excellent technique for gical excision is the treatment of choice for reconstructing lateral, skin-only upper lip most skin cancers of the lip. The tech- defects larger than 1 cm2. This method nique used to reconstruct the resulting sur- places scars along aesthetic borders and ad- gical defect depends on location, size, vances skin of similar characteristics into depth, and adjacent subunit involve- the upper lip. Furthermore, this method ment. Reconstruction of small (Ͻ1 cm) cu- maintains oral sphincter competence and taneous defects of the upper lip can be facial nerve function. Given the robust sub- achieved with lip advancement (pri- cutaneous pedicle, this flap is a reliable op- mary) closure if located in the middle to tion for upper lip reconstruction in most Author Affiliations: lower lip, but this might require excising patients, including smokers. Subcutane- Department of a standing cutaneous deformity of the red ous undermining of portions of the flap Otolaryngology–Head and Neck lip. Full-thickness skin grafting can al- allows advancement of a skin flap of simi- Surgery, University of Michigan Health System, Ann Arbor ways be used for repair of superficial skin lar thickness and contour into the upper (Drs Griffin and Baker); and defects of the upper lip, regardless of size. lip. Mobilizing the island flap solely on the Lone Tree Facial Plastic & This can result in a poor color match be- subcutaneous fat adjacent to the modio- Cosmetic Surgery Center, Lone tween the graft and adjacent lip skin or in lus enables advancement of the flap up to Tree, Colorado (Dr Weber). a contour depression. Larger cutaneous de- and slightly beyond the philtrum, allow- ARCH FACIAL PLAST SURG/ VOL 14 (NO. 3), MAY/JUNE 2012 WWW.ARCHFACIAL.COM 193 ©2012 American Medical Association. All rights reserved. Downloaded From: http://archfaci.jamanetwork.com/ by a University of Michigan User on 04/06/2014 ing reconstruction of skin defects as large as one-half of dissected from the orbicularis oris muscle fibers. The proxi- the upper lip. mal third of the flap was similarly elevated in the subcutane- In 1998, our group published our technique and the ous plane. Most important, the middle third of the flap must largest series of V-Y subcutaneous tissue pedicle advance- remain pedicled to the richly perfused subcutaneous tissue. The ment flaps used for upper lip reconstruction in the lit- adjacent subcutaneous cheek tissue can be freed from the pedicle by dissecting deeply perpendicular to the skin along the lat- erature to date.2 In that report, 35% of defects at least 4 2 eral border of the cheek incision. Deep dissection stops at the cm in area required flap contouring (“debulking”), al- zygomaticus major fascia to avoid injuring the facial nerve fi- though this statistic included defects with a significant bers entering the deep aspect of the facial muscles. The flap mo- cheek component. The purpose of this study was to fur- bility is periodically evaluated by advancing the flap toward the ther analyze larger upper lip skin defects repaired with defect until the necessary reach is achieved. Once tension-free this method in an effort to identify defect characteristics advancement is possible, the flap is secured to the medial as- that might predict the need for revision surgery. The aes- pect of the defect. The flap is conservatively trimmed as needed. thetic or functional abnormalities that prompted revi- Excised skin can potentially be used for full-thickness skin graft- sion surgery and the specific techniques used to correct ing as needed for adjacent defects. The incisions are then closed them were explored as well. in 2 layers, and a compression dressing is applied to prevent hematoma formation beneath the flap (Figure 2). METHODS RESULTS Patients with upper lip skin defects at least 3.0 cm2 in area that From January 1, 1994, through December 31, 2011, we were reconstructed with V-Y subcutaneous tissue pedicle ad- identified 30 patients fitting the inclusion criteria, with vancement flaps were identified from the senior surgeon’s upper lip defects with a mean (range) area of 7.0 (3.0- (S.R.B.) prospective skin cancer reconstruction database. In- 14.0) cm2 (median, 6.25 cm2). Eighteen patients (60%) clusion criteria were at least 2 months of follow-up and cuta- were women. Age at the time of reconstruction ranged neous neoplasm as the cause of the defect. Defects with greater from 34 to 86 years. The malignancy was basal cell car- than 5-mm extension onto the cheek aesthetic unit (lateral to cinoma in 16 cases, whereas the rest were atypical junc- the melolabial fold) were excluded. All patients provided ap- tional melanocytic hyperplasia or melanoma in situ. There propriate consent for preoperative, intraoperative, and post- operative photography, and this study received institutional re- were no instances of wound dehiscence or partial flap view board approval from the University of Michigan. Variables loss. One patient received a course of oral antibiotics for extracted from patients’ medical records included cause of the skin erythema and presumed cellulitis that resolved with- defect, sex, age, size of the defect, and depth of the defect (di- out any adverse consequences. The defect involved the vided into skin, subcutaneous tissue, or involving the orbicu- nasal ala in 4 cases and the vermilion in 3 cases. At least laris oris muscle). Postoperative queries included presence or 1 revision surgery was performed in 14 of the 30 pa- absence of flap necrosis, wound infection, wound dehiscence, tients (47%). Four of these patients (13%) underwent a and need for secondary procedures. Defects were measured af- second revision, and 1 of these (3%) required a third re- ter resection of the primary lesion and freshening of any post- vision. During these 19 revision surgical procedures, flap Mohs wound margins, and before undermining, in all cases. contouring (11 times) and Z-plasty (9 times) were the Our surgical technique is as follows. After confirmation of tumor-free margins, reconstruction was performed in the op- most commonly used techniques. Vermilionectomy, scar erating room under intravenous sedation and local anesthesia revision, and removal of a standing cutaneous defor- in all patients. The defect was measured and vertical and hori- mity were each used 6 times. Vermilion advancement and zontal dimensions were recorded. The V-Y subcutaneous tis- skin excision were rarely used (twice each). sue pedicle advancement flap was then outlined with a surgi- Logistic regression analysis was used to model defect cal marker. The width of the flap was equal to the greatest height depth (skin, into subcutaneous tissue, or into muscle), of the lip defect. The flap was designed so it was at least twice size (in square centimeters), vermilion involvement, the length of the width of the flap and tapered into the labio- and alar involvement in relation to revision surgery. mandibular sulcus. For most defects with a diameter greater Backward variable selection identified vermilion than 2 cm, the remainder of the lip subunit lateral to the me- involvement as the only predictor of undergoing revi- dial border of the defect is excised.
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