Reconstructive surgery in advanced perioral non-melanoma skin cancer. Results in elderly patients

Abstract

Background: Nonmelanoma skin cancer (NMSC) of the perioral region is not uncommon. Basal cell carcinoma is predominant in the upper lip area and squamous cell carcinoma in the lower lip area. While smaller lesions can be treated by excision followed by primary closure larger defects after tumor surgery can be challenging.

Objectives: Analysis of outcome after complete surgical excision with micrographical control of excision margins (delayed Mohs surgery) of large NMSC's of the perioral region (lips and chin).

Patients and methods: This is a retrospective, single-center analysis of patients with defects after delayed Mohs surgery of ≥ 3 cm of the perioral region. The study included a total of 25 patients (4 women and 21 men) with a mean age of 83.7 years. Twenty patients were diagnosed with squamous cell carcinoma and five had basal cell carcinoma. The lower lip was affected in 19 patients, the upper lip in 4 patients and the chin in 2 patients. Tumor stage was either T1N0M0 or T2N0M0. The most common procedure for lower lip defect closure was staircase or modified staircase technique. Cheek advancement flaps were used for upper lip defect closure. Inferiorly based nasolabial rotational flap, cheek rotational flap and modified Webster flap were also employed. In one patient Webster flap and unilateral staircase technique were combined.

Results: In all patients the tumor was removed completely with preservation of function and aesthetics. No local recurrence was observed after a median follow-up of 4.9 years.

Conclusion: Perioral reconstruction after removal of large NMSC is a complex issue. The age group of over 70 years, frequently with comorbidities, requires a robust surgical technique with short operation times and tailored approaches for defect closure.

Keywords: advancement flaps; defect closure; perioral region; rotational flaps; skin cancer.

Figure 1

SCC of the lower lip (A). Defect closure and lip reconstruction by staircase technique (B).

Figure 2

SCC of the lower lip. (A) Clinical presentation of a large ulcerated tumor. (B) Resulting defect after Mohs surgery. (C) Closure by an inferiorly based nasolabial flap. (D) Six days post-surgery.

Figure 3

Large SCC of the lower lip (A). This patient underwent surgery six years ago for an SCC of the contralateral side of the lower lip limiting the current procedures. Primary excision was performed but closure by W-Y flap failed and a secondary defect closure was necessary. (B) Modified Webster flap with Burows triangle placed along the nasolabial fold and inferior incision along the labiomental crease. The muscular commissure remained uncut but fibers were separated in the vertical direction using a blunt scissor. The oral mucosa was advance and the defect was sutured in 3 layers (C) Ten days after surgery with minor whistle deformity at the site of notching.

Figure 4

Large SCC of the lower lip: (A) with closedmouth, (B) with protruded lower lip. After surgery and defect closure by a combined flap, i.e. cheek advancement and staircase. (C) Closed mouth and (D) opened mouth (6 days later).

Figure 5

BCC of the upper lip. (A) Defect after excision. An arrow marks the arteria labialis superior which should be preserved during flap design. (B) Transposition flap with excised Burow triangle in the marionette line.

Figure 6

BCC of the upper lip. (A) Sclerodermic BCC. (B) Excision with halfmoon-like Burow triangle in the marionette line. (C) Defect closure by advancement flap.

Figure 7

Large BCC of the chin. (A) Defect after Mohs surgery. (B) Flap preparation. (C) Defect closure by a rotational flap with back cuts.