SAN FRANCISCO Respect the nasolabial folds, vermilion border, and mental crease to get the most natural-looking results from reconstructive surgery around the mouth.
Put linear surgical scars into those linesnot across themto avoid a noticeable asymmetry that "gets very exaggerated during movement" of the mouth, Dr. Ken K. Lee said at the annual meeting of the Pacific Dermatologic Association. Even respecting the lines of current or future rhytids can help hide a scar.
Surgeons commonly used to use a transition flap from the cheek to repair surgical defects on the upper cutaneous lip, but this would blunt the entire nasolabial fold. "If the crease is completely gone, it looks unnatural," so surgeons today shy away from that technique, said Dr. Lee, director of dermatologic and laser surgery at Oregon Health and Science University, Portland.
Perioral surgical defects on the upper lip tend to leave indented scars unless the surgeon hypereverts the incision. "The natural tendencythe reason we get wrinkles in this areais it wants to invert. So you really have to do an exaggerated eversion to prevent this type of indented scar," he said. The creation of a little ridge when a defect is closed helps produce a nearly invisible scar instead of an indented one.
Closing in a linear fashion may not suffice for larger defects, but the surgeon still should respect the cosmetic lines when using other techniques for closure. Aligning the closure of a rotation flap with the nasolabial fold, rhytids, mental crease, or vermilion border will help hide a scar.
For larger defects, the island pedicle flap becomes the surgeon's work horse, in all its variations. "It allows me to bring skin in from outside the lip unit to fill in larger defects in the lip," Dr. Lee said.
He used a pedicle flap from outside the nasolabial fold to help close a complex defect in the upper cutaneous lip, nose, and cheek in one patient, closing along the nasolabial fold and advancing the cheek. "Recreating all the cosmetic borders is important," he said.
For a young woman in her 30s with little extra skin compared with older patients, it is difficult to repair a defect that takes up a large portion of the upper cutaneous lip just by using the skin inside of the nasolabial fold. It's okay to tap the reservoir of cheek skin for an island pedicle flap to repair this, but "the important thing is that when you zip up the island pediclethe defect behind itthat line needs to follow the nasolabial fold," he said.
The downside of island pedicle flaps is potential "pincushioning," he added, but if the incision has been adequately undermined and the edges everted, resulting in a good-looking scar, pincushioning will go away in time.
'The natural tendencythe reason we get wrinkles in this areais it wants to invert.' DR. LEE
An island pedicle flap can utilize skin from outside the perioral borders to fill a defect in the upper lip, with closure along the nasolabial fold for a good cosmetic result as demonstrated in the patient above. The patient is shown before and after surgery (left and middle, respectively), and after the wound had healed (right). Photos courtesy Dr. Ken K. Lee
