bilateral reverse yu flap for upper lip reconstruction after oncologic resection
TRANSCRIPT
RECONSTRUCTIVE CONUNDRUM
Bilateral Reverse Yu Flap for Upper Lip Reconstruction AfterOncologic Resection
JOS�E ANTONIO GARC�IA DE MARCOS, MD, PHD,* IGNACIO HERAS RINC �ON, MD,* CONSTANTINO
GONZ�ALEZ C �ORCOLES, MD,* MAR�IA SEBASTI�AN ALFARO, MD,* ENRIQUE POBLET MART�INEZ, MD, PHD,†
AND SUSANA ARROYO RODR�IGUEZ, MD, DDS*
The authors have indicated no significant interest with commercial supporters.
A 79-year-old man was referred to our
department for surgical treatment of a
biopsy-proven Merkel cell carcinoma on his upper
lip. Wide tumor excision was performed. The
resulting full-thickness inverted heart-shaped
defect measured 4 cm in the transverse axis
and involved almost two-thirds of the upper
lip (Figure 1).
How Would You Reconstruct This Defect?
*Department of Oral and Maxillofacial Surgery, Albacete University Complex, Albacete, Spain; †Department ofPathology, Reina Sof�ıa University Hospital, Murcia, Spain
Figure 1. Preoperative image: proposed excision (red line) and method of repair (blue line) drawn on the lip.
© 2013 by the American Society for Dermatologic Surgery, Inc. � Published by Wiley Periodicals, Inc. �ISSN: 1076-0512 � Dermatol Surg 2014;40:193–196 � DOI: 10.1111/dsu.12294
193
Functional competence and good aesthetic results
are the objectives of upper lip reconstruction.1–3
Many methods have been described to repair large
full-thickness defects of the upper lip, indicating that
there is no ideal procedure.4
Full-thickness defects affecting up to one-quarter of
the upper lip can usually be closed directly. For
larger resections, a more-sophisticated reconstruc-
tion technique is required to avoid significant
distortion of the lip.5
The Abb�e flap is a transposition flap that is a good
reconstructive option for defects of up to one-third
of the upper lip and achieves good aesthetic results,
especially in philtrum reconstruction.4,5 This flap
can also be used in lateral defects that include the
commissure in a single-stage procedure and is then
known as Abb�e-Estlander.5,6
A unilateral crescentic perialar advancement flap is
suitable for resections of up to one-third of the upper
lip, whereas a bilateral procedure is needed in more-
extensive reconstructions.5
A Karapandzic reverse flap can be used for defects
involving more than one-third of the lip. This is
an advancement-rotational flap that allows labial
continuity in a single surgical procedure and pre-
serves sensitivity and motor function.4,5,7,8
The reverse Gillies flap is a single-stage rotational-
advancement flap also used for large upper
lip defects. It can produce denervation, which is
usually temporary.1,4,6
All of these flaps produce some level of microstomia.
Crescentic perialar advancement, reverse
Karapandzic, and reverse Gillies flaps produce
rounded commissures, so these techniques have the
disadvantage that a second-stage commissuroplasty is
almost always necessary to ensure mouth opening.4–8
In 1989, Yu described a new flap for lower lip
reconstruction after oncologil resections. The Yu
flap is a uni- or bilateral procedure that combines the
advantages of rotation and advancement flaps for
lower lip reconstruction in which the muscle is only
partially sectioned. It achieves satisfactory func-
tional and aesthetic results in a single-stage surgery.9
Belmonte and colleagues reported the first reverse
Yu flap for upper lip reconstruction in 2010 and
described a unilateral flap for a lateral defect of
35 mm after tumor excision.4
Herein, we describe a defect of almost two-thirds of
the upper paramedian lip repaired using a bilateral
reverse Yu flap. To our knowledge, and after
performing a literature review of PubMed, this is the
first case described of a bilateral reverse Yu flap for
upper lip reconstruction.
Surgical Technique
An inverted heart- or wedge-shaped full-thickness
resection was first performed. Then skin and sub-
cutaneous tissue were horizontally incised from the
labial commissure to point B (A–B line) (Figure 1).
This incision was slightly longer than half of the
defect, which is generally recommended when a
bilateral flap is used. Later, a curved incision
including skin and subcutaneous tissue was made
along the nasolabial fold (C–D line, Figures 1 and
2A). As shown in Figure 1, the B–C line was
approximately 1.5 cm long, and the D–E inci-
sion was perpendicular to the A–B line and
approximately half of the distance from D to A. The
G point in Figure 1 was the intersection between the
incision of the resection and the margin of the upper
lip vermilion. Afterward, a skin island (A–B–G in
Figure 1) was resected to create the new vermilion
area. In the same figure, the F point is a mirror image
of the G point. Figure 1 shows that the A–F line was
slightly longer than the A–G line. The dotted line A–
F–B–C in Figure 2B is the projection of the mucosal
flap to form the lip vermilion after the resection of
the skin island A–B–G (Figure 2C). In the commis-
sure, the medial third of the orbicularis muscle was
sectioned, keeping intact the other approximately
two-thirds laterally. The medial third of the orbic-
BILATERAL REVERSE YU FLAP FOR UPPER LIP RECONSTRUCTION
DERMATOLOGIC SURGERY194
ularis muscle was bluntly separated following the
direction of the muscle fibers along the H–I line
(Figure 2A). In cases in which the defect is bigger
than half of the lip, it is recommended that the H–I
line be longer than 1 cm. The same procedure was
repeated on the other side of the lip. Afterwards, a
layered closure of the midline was performed. The
flaps were positioned suturing A with B on both
sides and repositioning the new vermilion with the
A–F–B–C mucosal flap. Finally, the lower triangular
skin and subcutaneous tissue flap were moved up to
close the cheek defect (Figures 2D and 3).
A follow-up photograph taken 7 months after sur-
gery is shown in Figure 4.
The bilateral reverse Yu flap is a versatile single-
stage procedure that is useful for reconstructing
lateral and medial upper lip defects of more than
50% of the lip length with good functional and
aesthetic results. The external two-thirds of the
orbicularis muscle are kept intact, resulting in a
functional lip able to control saliva, mastication,
and speech. In addition, the size of the stoma is
maintained, which cannot be achieved with many
other flaps. In the bilateral reverse Yu flap, the
medial scar is a vertical line running from the
vermilion to the nasal base that can simulate one of
the philtral columns. Lateral scars are disguised in
Figure 3. Six days after reconstruction with the suturepartially removed.
(A) (B)
(C) (D)
Figure 2. (A) The orbicularis muscle is cut at the medial third and then split along the line H–I, following the grain of themuscle. (B) Mucous membrane flap used to cover the upper lip right vermilion. (C) Diagram showing movement of the flapson the right side. (D) Resultant scars.
GARC�IA DE MARCOS ET AL
40 : 2 : FEBRUARY 2014 195
nasolabial folds and commissure grooves. Color
and thickness of the reconstructed skin are similar
to those of the original skin of the lip. In men this
procedure provides skin with hair, which allows the
scar to be hidden with a mustache.
Conundrum Keys
A bilateral reverse Yu flap achieves the main goals of
reconstructive surgery for extensive defects of the
upper lip:
• The method can be used in large lateral and
medial defects.
• It is a single-stage procedure.
• The function of the labial sphincter is preserved.
• The size of the stoma is not altered.
• Good estethic results are obtained.
References
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Address correspondence and reprint requests to: Jos�eAntonio Garc�ıa de Marcos, MD, PhD, C/O’donnell 44,6 º B. CP: 28009, Madrid, Spain, ore-mail: [email protected]
(A) (B)
Figure 4. Seven months after reconstruction. (A) Mouth at rest. (B) Mouth opening.
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