Case 15 (2024): Staircase flap reconstruction of the lower lip

Theresia Skytte Eriksen; Camilla Asklund

Journal of Plastic, Breast & Reconstructive Surgery·Begutachtete Open-Access-Fallberichte aus der ChirurgiePeer-Review · Open Access

Case 15 (2024): Staircase flap reconstruction of the lower lip · JPBRS

Fallbericht

Case 15 (2024): Staircase flap reconstruction of the lower lip

Theresia Skytte Eriksen¹, Camilla Asklund¹

¹Herlev University Hospital, Denmark

Veröffentlicht 15. April 2024117 Aufrufe4 Min. Lesezeit

Staircase flapBengt Johansson flapLower lip reconstruction

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Zusammenfassung

A 58-year-old man was referred to the Department of Plastic Surgery with a recurrence of squamous cell carcinoma of the lower lip. In 2007 an excision of a keratoacanthoma of the lower lip was performed and the excision margins was initially not evaluated. In the past 6 months the patient has noticed a progressing mass in the scar tissue. A wedge-shaped excision biopsy confirmed the diagnosis: rec

Wichtigste Lernpunkte

Pearls

Reconstruction of the lips can be challenging both aesthetically and functionally for any plastic surgeon. The Bengt Johansson flap can provide an aesthetically and functionally good result in relation to sensibility, motility, symmetry, and length of the lower lip and thereby minimize microstomia.
By designing the flap tilted along the mentolabial crease the scar will align with the crease and visionally be almost unnoticeable.
If perineural invasion, or poorly differentiated histology with close margins is detected, postoperative radiation therapy can be considered.

Pitfalls

There is a considerable probability that the patient will end up with microstomia. In this case the probability was especially high due to the preexisting shortening of the lower lip following two previously surgeries.
When larger reconstruction is preformed free histological margins are important. The frozen section histology gives us some indications perioperatively, but final histology is first obtained weeks postoperatively.
The probability of complications in terms of poor healing was high because of the patients long-term smoking history.
Furthermore, considerations about patient compliance regarding postop regime is important when flap reconstruction of the lip is performed.

Patient history

Examination

At the preoperative examination the tumor was described as a 10x10x10 mm mass in the current scar tissue. Because of two former excisions of the lower lip the total length of the lip was found to be approximately 60 mm. No pathological lymph nodes were found by palpation of the head and neck.

Pre-operative considerations

Different treatment options were considered including surgery and radiation therapy. The patient was examined by a radiation oncologist and a plastic surgeon and thereby thoroughly informed on the different options. Surgical considerations included the length of the lip, obtaining free margins before reconstruction, type of reconstruction and postoperative precautions. The operative solution was chosen and surgery with frozen section histology and reconstruction with staircase flap (also known as Bengt Johansson flap) was planned. His anticoagulant treatment with Clopidogrel was paused 5 days preoperatively and he was urged to stop smoking.

Schritt 1 — Excision of tumor

Excision was performed with 10 mm margin after sending frozen section to histology. Perioperatively 2 g cloxacillin was given intravenously.

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Case 15 (2024): Staircase flap reconstruction of the lower lip

Zusammenfassung

Wichtigste Lernpunkte

Patient history

Examination

Pre-operative considerations

Schritt 1 — Excision of tumor

Schritt 2 — Design of the staircase flap (aka Bengt Johansson flap)

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Schritt 3 — Reconstruction

Schritt 4 — Removal of stiches

Schritt 5 — Follow-up

Post-operative plan

Pearls

Pitfalls