Case 8 Lip Reconstruction
8.1 Description
Partial thickness central upper lip defect involving roughly 1/4 of the upper lip
Several tissues are involved: vermilion, white roll, and cutaneous lip
Multiple key anatomic structures affected: Cupid’s bow, philtral dimple, and left philtral column
Orbicularis oris muscle appears intact
8.2 Work-Up
8.2.1 History
Sun exposure history
Personal and family history of skin cancer
Genetic conditions: Xeroderma pigmentosum, Gorlin’s (nevoid basal cell) syndrome, albinism, and vitiligo
8.2.2 Physical Examination
Detailed examination of lips and oral cavity to assess the lesion or defect
Characterize findings associated with skin lesion (if present): Size, color, shape of lesion, skin irregularity,ulceration and hyperkeratosis
Lymph node examination to assess for signs of metastatic disease
8.2.3 Diagnostic Studies
If patient presents with a lesion prior to a resection, a biopsy should be performed at the time of evaluation to establish a diagnosis
Full-thickness incisional versus excisional biopsies may be performed.
Avoid shave biopsies as they may lead to incomplete assessment of the lesion, particularly in melanoma, where the depth of a tumor is critical to prognosis.
8.3 Patient Counseling
Patients must understand that the size of the final defect cannot be anticipated in skin cancer until resection has been completed.
While flap reconstructions may yield the most aesthetic results, it is reasonable for some patients (e.g., medically complicated, elderly) to opt for simpler skin graft reconstructions or even no reconstruction at all.
8.4 Treatment
Consider Mohs surgery referral, if available
Allows examination of ~100% of surgical margins, resulting in highest cure rates
Board examiner may require that you excise the lesion yourself
8.4.1 Excision
(See Chapter 7, Table 7.2)
Basal cell carcinoma
2–5 mm margin standard
7 mm for more aggressive subtypes
Squamous cell carcinoma
Most common skin cancer of lip, >90% occur on lower lip
4 mm margin if <2 cm lesion, well-differentiated, not invasive
6 mm margin if >2 cm, invasive into fat, or in high-risk location (central face, ears, scalp, hands, feet, and genitalia)
Melanoma: Margins determined by Breslow thickness
In situ: 5 mm margins
<1 mm: 1 cm margin
1–2 mm: 1 cm
>2.1 mm: 2 cm
Final margins
Following excision, additional margins may be sent as fresh specimens to confirm absence of residual disease. However, fresh frozen pathologic evaluation is notoriously unreliable and cannot ensure negative margins.
Most reliable method of confirming negative margins is with permanent sections. Unfortunately, these sections may take several days for final results.
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