Upper Lip Lift Excision Used as Full-Thickness Skin Graft for Mohs Reconstruction of the Philtrum: A Case Report

Plastic surgeons are often tasked with treating soft tissue defects of the face, and they are judged not only by the successful reconstruction of the defect but by the final aesthetic appearance of the reconstruction. Many reconstructive techniques have their advantages and flaws, with wide variations in donor site morbidity. Previously described aesthetic boundaries of the upper lip limit the utility of local flap reconstruction in certain areas because of evident scarring and vermilion distortion.¹

Multiple techniques have been described for upper lip reconstruction, including secondary intention, excision and primary closure, full-thickness skin grafts, and local flaps or a combination of these.^2,3 Full thickness skin grafts have been popularized especially in reconstruction of philtral defects, as long as they do not cross the philtrum. A key principle in reconstructive surgery is to replace defects with like tissue. Usually, the best color matches for upper lip reconstruction are preauricular skin, forehead skin, or other portions of the lip.²

The lip lift was first described by Austin⁴ in 1986 as a “wavy ellipse on the upper lip skin following the contours of the base of the nose”, leading to a lifted, more pronounced, and fuller appearing upper lip. Since that time, there have been multiple modifications and advancements described.^5-7 This paper presents a case of upper lip reconstruction after Mohs resection of cutaneous malignancy using the excised skin from an upper lip lift as a full-thickness skin graft. To our knowledge, this technique has not yet been described in the literature.

Two female patients presented to the senior author's clinic post Mohs micrographic surgery resection of cutaneous malignancies involving the upper lip philtral column.

Patient 1

The first patient was a 42-year-old woman presenting with a 1-cm² defect involving the philtrum as well as a portion of the white roll and vermillion border after Mohs resection of a cutaneous squamous cell carcinoma. A full-thickness skin graft measuring 0.8 x 2 cm was harvested from the upper lip along the nasal sill, trimmed, and inset to the defect. The upper lip lift donor site was closed in 2 layers. At 3-week follow-up, the patient was instructed to start scar massage, and at 7-week follow-up, 0.1 mL of Kenalog was injected into the scar. She underwent lip tattooing at 5 months postoperative to restore the red appearance of her dry vermillion.

Patient 2

The second patient was a 36-year-old woman presenting with a 1-cm² defect of the lower philtral dimple after Mohs resection of a basal cell carcinoma. A full-thickness skin graft was then harvested in a 1-cm² ellipse from the right upper ergotrid at the base of the ala, trimmed, and inset into the defect. To match the lip lift on the donor side, the same patterned ellipse was also made at the contralateral alar base. The donor sites were closed primarily in 2 layers. The patient was seen at 1 and 3 weeks postoperative without complication and with annual follow-up thereafter.

Patient 1

At 1-week follow-up, there was a small area of skin graft loss near the vermilion, which created a furnace in her scar that was improved with Kenalog injection and tattooing. At 6-month postoperative, her surgical scars are nearly unnoticeable and vermillion border is well defined (Figure 1).

Patient 2

At 1½ years postoperative, the patient has a very well-defined vermilion border, unnoticeable surgical scars, and a fuller appearing upper lip (Figure 2).

Defects of the upper lip can prove to be challenging for the reconstructive surgeon. Depending on the location, various techniques can be used, including secondary intention, resection and primary closure, full-thickness skin grafts, and local flaps.^2,3 Many of these techniques lead to aesthetically unpleasing donor sites and possible distortion of local tissues. In an area that is in the center of the face, millimeters of distortion can be visually apparent.

With a recent increase in focus on visual appearance and vast use of social media, many patients—especially younger to middle-aged women—desire a fuller, more pronounced appearance of their upper lip. This technique uses the donor site to its advantage and may lead to a result aesthetically superior to even the preoperative appearance. With the scar from the upper lip lift excision being hidden at the base of the nose, it is often unnoticeable. Combining the absence of obvious scarring and the additional fullness added to the upper lip, this technique should be considered in all younger to middle-aged women with philtral defects.

In the cases presented above, narrow lip lift excisions were performed providing very modest, if any, additional lip fullness. Therefore, this technique can be applicable to anyone with a philtral defect, no matter their desire for additional fullness.

For defects involving the vermillion border, tattooing can be employed months postoperative to restore the lost pigment. Due to the contraction and typical darkening of the skin graft, adjuncts such as local steroid injection or dermabrasion can be effective at further improving the final appearance of the recipient site.

Affiliations: ¹Mississippi Center for Plastic Surgery, Ridgeland, MS; ²University of Mississippi Medical Center Division of Plastic and Reconstructive Surgery, Jackson, MS

Correspondence: David Steckler, MD; dsteckler@gmail.com

Disclosures: The authors disclose no relevant financial or nonfinancial interests.