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Theresia Skytte Eriksen, Camilla Asklund. Case 15 (2024): Staircase flap reconstruction of the lower lip. Journal of Plastic, Breast & Reconstructive Surgery. 2024.
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Theresia Skytte Eriksen1, Camilla Asklund1
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
BeforeAfterA 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: recurrence of squamous cell carcinoma. He was a long-time smoker and in treatment with anticoagulant medicine.
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.
1
Excision was performed with 10 mm margin after sending frozen section to histology. Perioperatively 2 g cloxacillin was given intravenously.
2
Because of a paramedian defect the flap was designed so that the tissue needed to close the defect was unequally added from each side of the mentolabial crease. The total length of the defect (marked red) needs to be equal to the total length of the tissue added from the two sides combined (the two blue lines). The stairs ‘steps’ and ending triangle are tiled in such a manner that the scar will follow the mentolabial crease and the stair formation thereby will be minimized or non-existing. The optimal dimensions of the ‘steps’ is 10 x 8 mm. The blue lines are incised through the muscle leaving only the mucosa intact for maximum movement of the flap. The green retangles and triangles are incised through the dermis and removed.
3
After the frozen sections was cleared by the pathologist the flap was raised along the perioperative drawings and approximated to close the defect. The tissue was sutured in multiple layers. For muscle closure 4-0 PDS was used. Mucosa was closed with 5-0 Novosyn rapid uncolored suture. A few dermal stiches with 4-0 Novosyn was applied and afterwards the skin was closed with 5-0 nylon single sutures.
4The stiches were removed 10 days postoperative. The patient has healed nicely and without any complications. Final histology showed well-differentiated squamous cell carcinoma with free margins. No perineural or vascular invasion was detected. 3 weeks after surgery the patient reported no discomfort or pain in relation to the lower lip or chin.
The first 24 hours the patient was only allowed to intake cold liquid diet. Afterwards his diet contained of liquid to soft progressing towards normal diet after 10 days. After intake of food and drinks, the patient was instructed to rinse his mouth with sparkling water. Furthermore, he was informed to minimize physical activities, talking and facial expressions the first 10 days. He continued antibiotic treatment 3 days postoperative. The patient has a follow-up consultation 3 months postoperative (incl. UL of the head and neck).
