RECONSTRUCTIVE CONUNDRUM

O to Z Reconstruction of Central Upper Lip Defect

KOSTANTIN VASYUKEVICH, MD, AND MARC S. ZIMBLER, MD, FACSy

A 27-year-old woman was referred for recon-

struction of a central upper lip (philtrum)
defect following Mohs micrographic resection of
a basal cell cancer. Physical examination revealed
1.0
1.1-cm circumferential defect. The defect was
situated in the upper portion of the philtrum
and extended into the left philtral column (Figure 1).
There was no involvement of the columella or
vermilion border. How would you reconstruct
this defect?

Figure 1. Central upper lip defect and the outline of the incisions.

Department of Otorhinolaryngology, Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medi-
cine, New York;yDepartment of Otolaryngology-Head and Neck Surgery, Beth Israel Medical Center, New York, New York

& 2007 by the American Society for Dermatologic Surgery, Inc.  Published by Blackwell Publishing 
ISSN: 1076-0512  Dermatol Surg 2007;33:85–89  DOI: 10.1111/j.1524-4725.2007.33014.x

85
 O TO Z RECONSTRUCTION OF CENTRAL UPPER LIP DEFECT
Resolution
Reconstruction of Mohs defects of the central upper
lip can present a significant challenge to the surgeon
and requires careful consideration of all available
options. Healing by secondary intention, primary
closure, skin grafts, and a variety of local flaps are
commonly employed in facial reconstruction. Many
of these options, however, would produce cosmetic-
ally unacceptable results in reconstruction of the
upper lip. For example, healing by secondary inten-
tion would result in scar contracture and thus distort
the vermilion border and columella. Skin grafts are
also limited in their use in this particular location
because of both color and texture discrepancies.
Moreover, skin grafts typically heal with either hyper
or hypopigmentation, which would further com-
promise the postoperative scar. Local tissue re-
arrangement provides the best color and texture
match for reconstruction of the defects in the labial
region. When closing the defect with local tissue,
preservation of the aesthetic subunits such as the
philtrum, vermilion border, cupid’s bow, and alar-
labial crease is essential. Several options including
primary advancement flap closure (such as an O–T
Figure 2. (A) Immediate postoperative appearance. (B) Patient at 30-day follow-up.
86 D E R M AT O L O G I C S U R G E RY
plasty), bilateral advancement flap closure with re-
moval of Burow’s triangles, or an island pedicle flap
were considered for reconstruction of the defect de-
picted in Figure 1. All these methods can be suc-
cessfully employed in the reconstruction of upper lip
defects. None of these commonly used techniques,
however, could adequately recreate the outline of the
missing philtral column and therefore would create a
compromised aesthetic outcome. We elected to util-
ize an O–Z plasty advancement flap to reconstruct
this defect of central upper lip that involved the
philtral column.
The anatomic subunits were marked out with a fine-
tip marking pen and the soft tissues of the lip were
infiltrated with 1% lidocaine with 1:100,000
epinephrine. Two incisions were made along the left
vermilion border and along the right nasal-alar
crease as shown in Figure 1. Both flaps were widely
undermined in the subcutaneous plane and rotated
into place in a Z-type fashion causing minimal
distortion to the lip. The wound was closed in layers
with 5-0 inverted interrupted Monocryl and
6-0 interrupted nylon (Figure 2A). A pressure
dressing was applied.
 VA S Y U K E V I C H A N D Z I M B L E R

The sutures were removed on Postoperative Day 7. Conundrum Keys

The incision appeared well healed with a discrete
scar in a Z-configuration. The horizontal limbs
of the incision appeared well hidden at the border of
the vermilion and under the columella. In contrast,
the vertical limb of the incision produced a visible
line that runs along the border of the philtrum and
served to recreate the outline of the excised left
philtral column (Figure 2B).
Overall, we felt that O to Z closure of the upper
philtrum defect produced good cosmetic result and
should be considered among other options in re-
construction of upper lip defects that involve philtral
column. Application of this closure can also be ex-
tended to reconstruction of facial defects in other
locations, as long as there is sufficient amount of soft
tissue available for flap advancement. This technique
is limited to the areas of the face where horizontal
incisions can be placed at the borders of the aesthetic
subunits. Mental crease and lower vermilion border
or the eyebrow and deep forehead rhytids can be
used to camouflage the resulting scars in recon-
struction of the lower lip and forehead defects,
respectively.
 O to Z advancement flap is a viable option in re-
construction of central upper lip defects.
 In reconstruction of the upper lip defects, careful
attention should be paid to the final scar config-
uration and location. Placement of the flap
incisions at the vermilion border and along the
nasal-alar crease is important in achieving good
cosmetic results.
 Thorough preoperative planning and knowledge of
reconstructive options are essential in reconstruc-
tion of the defect that crosses the borders of the
aesthetic subunit. O to Z closure was specifically
designed to reconstruct the philtrum and recreate
the outline of the missing philtral column and
therefore produced the most optimal result in
closure of this defect.
Address correspondence and reprint requests to: Marc S.
Zimbler, MD, FACS, Director of Facial Plastic &
Reconstructive Surgery, Beth Israel Medical Center,
10 Union Square East, Suite 4J, New York, New York
10003, or e-mail: MZimbler@chpnet.org.

COMMENTARY

Certainly this result is acceptable, even laudable, for this lovely young lady, but several elements of this
case and closure are bothersome. It seems the procedure was performed under general anesthesia, a
significant variation from the practice of virtually all dermatologic surgeons, Mohs disciples or not. The
increased risk to any patient of such would be unacceptable to most of my ilk, but I understand the
differences in certain specialty approaches. Even if the patient insisted, GA should be reserved for cases of
such magnitude that repair is virtually impossible without that depth of anesthesia.1 It is up to the surgeon
to protect the patients, even from themselves.

Now, the defect is slightly left-of-center and, but not all, of the philtrum. (This commentator tried to delay
writing until more time had passed to better judge the final scar, but that delay was not possible.)
Hair positioning is not an important consideration in technique here, but might be of great import in a
male patient.
The design depicted and then incised does not precisely follow the juncture plane between nose and lip
nor, apparently, of the mucosal lip and cutaneous upper lip. The most exacting attention to such
incision placement is imperative in camouflaging our operative lines. In an asymmetric defect, it is possible

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 O TO Z RECONSTRUCTION OF CENTRAL UPPER LIP DEFECT

Figure 1. Defect of upper lip.

Figure 2. 12 months after repair with full-thickness skin

graft.

to advance one segment more than the other, using suturing techniques to fix the moving tissue to where
one desires the final scar line to be.2 The authors, rather than using the approach detailed below, chose to
accentuate the entire curvature of the medial left philtrum column and then slant obliquely laterally,
beginning in the supra-Cupid’s bow concavity on the left. In my opinion, there was a failure to adequately
free the moving flap(s) with sufficient tension-relieving techniques, resulting in an erythematous hyper-
trophic scar. This section of lip skin is thin, lies over subcutaneous tissue and then orbicularis oris muscle,
and dissects freely only with difficulty. Along the upper vermilion-skin border, two paramedian elevations
of the vermilion form Cupid’s bow. Similarly, dual elevated vertical columns of tissue form a midline
depression, located between the two paramedian elevations of the vermilion and the columella above.3
Using unilateral (on the side with the greatest movement necessary) or bilateral (if required) perioral
crescentic excisions, additional movement of the upper lip skin toward an infranasal V–Y anastomosis
becomes easier. By slanting the surgical anastomosis obliquely downward along the desired line of the
medial elevation on the left, the entire incision above the vermilion lip can be avoided, as can involving the
more delicate Cupid’s bow area as well. If necessary, it is possible to sculpt a slightly angled hemicolumn
of soft tissue beneath the skin (or even partially beneath an existing defect) and evolve a facsimile of a
raised column or use suture techniques to gather soft tissue together and raise a convex pseudocolumn. A
more extensive dissection to free the integument (perhaps even to the nasolabial fold in such a young
person), a more fixative periphiltrum suturing technique with column formation, and of course, post-
operative intralesional dilute steroids and/or V beam laser application might well be appropriate. The
healing process here easily reflects tension, and that is clearly in evidence. More adequate measures to
relieve that tension are hereby suggested, including a change in design to a V–Y closure along the medial
column elevation border, assisted by unilateral or bilateral perialar excisions and advancement to an
obliquely angled final closure line.4 This design would be applicable to both male and female patients.

88 D E R M AT O L O G I C S U R G E RY
 VA S Y U K E V I C H A N D Z I M B L E R

The authors are quick to dismiss full-thickness grafting in upper lip repair situations. On the contrary,
there are many situations where preauricular, postauricular, and infraauricular grafts are better options
than extensive and deforming flap procedures (Figures 1 and 2). This seems too frequently a matter of
surgeon’s preference and skills, rather than the patient’s informed choice. In the undersigned’s half-century
experience, there are many patients who prefer full-thickness grafting techniques to single or multiple flap
techniques with/without revisions. Grafts can be harvested in some areas with thicker edges, or thicker
focal areas, thereby allowing the appearance of greater thickness. The ends of grafts can also be sutured to
effect a semirolled appearance, again allowing simulation of that desired elevated lateral philtrum effect.
Pigmentary disturbance, if significant, is easily camouflaged. Careful donor site choice with shaping grafts
to match cosmetic units or junctures does much to dissipate the unattractive old-style execution of round
grafts into round surgical defects, an ancient but still-too-often-utilized method of quick closure without
individualized aesthetic design and execution.

References
1. Field L. Against general anesthesia in ear reconstruction. Ann Plast Surg 1986;16:86.

2. Field L. Make your incisions where you want your final scar line to be: a surgical philosophy. J Dermatol Surg and Oncol 1990;16:1062–63.

3. Babak J, Blackwell K. Lips and perioral regional anatomy.

eMedicine [serial on the Internet]. 2005 Oct 17. Available from: http://www.emedicine.com/ent/topic7.htm

4. Field L. The lower eyelid curved V-to-T plasty. J Dermatol Surg Oncol l985;1:378–81.

LAWRENCE M. FIELD, MD, FIACS

Foster City, CA

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