One‐stage reconstruction of large upper lip oncologic defects using vermilion border rotation‐advancement flap

The upper lip consists of complex aesthetic units that contribute to both function and appearance. Therefore, the management of upper lip tumors requires a balance between radical excision, functional preservation (speech, mastication), and aesthetic restoration (contour, symmetry). Conventional flap techniques often compromise these units, potentially affecting both function and quality of life.1 For simple upper lip defects, established repair techniques include island flaps, V-Y advancement flaps, and free flaps.2-4 For more complex defects involving both the upper lip and the alar/nasal sill, surgeons have developed a technique that combines a double Z-plasty within a V-Y advancement flap to reconstruct the upper cutaneous lip and nasal sill.5 Although current surgical approaches can reduce scarring and improve aesthetic outcomes, they frequently alter the natural contour of the vermilion border, leading to distortion and deformity in clinical practice. Additionally, postoperative scar contracture may occur, potentially leading to complications such as upper lip shortening and asymmetry of the oral commissures. Therefore, we propose a modified vermilion border rotation-advancement flap for the reconstruction of upper cutaneous lip and nasal sill defects, which has demonstrated satisfactory clinical outcomes. Precise incision placement: The incision follows natural facial creases (nasolabial fold, nasal sill, philtral ridge), thereby minimizing scar visibility and preserving the natural contour of the vermilion border. Nasal deformity prevention: A triangular extension on the alar side of the flap incorporated redundant "dog-ear" tissue to facilitate nasal sill reconstruction, effectively restoring the structural integrity of the ipsilateral nostril (supplementary online Figure S1). Functional philtral ridge reconstruction: Following the principles of cleft lip repair,6 a reverse incision was made on the medial lip, extending from the white roll to the philtral dimple. A 2.5 mm equilateral micro-triangular flap was then designed on the lateral aspect of the lower edge of the defect and inset into the reverse incision to prevent philtral ridge shortening (supplementary online Figure S2). The wound was closed using the modified buried vertical mattress suture (MBVMS) technique (supplementary online Figure S3). A 5-0 absorbable suture (VICRYL, ETHICON) was placed in the subcutaneous and dermal layers, with the epidermis approximated using a 6-0 nylon suture (ETHICON). After healing, silicone-based therapy was started for scar prevention. At the 2-month postoperative follow-up, the patient demonstrated well-concealed incisions and a satisfactory restoration of upper lip contour and symmetry (Figure 2). The deficiency of reconstructive resources and the close adjacency to critical aesthetic subunits (nasal sill, philtral ridge, Cupid's bow and lip tubercle) make current repair techniques for paramedian (philtral ridge and its lateral region) defects unable to achieve precise reconstruction, leading to unsatisfactory repair outcomes. To achieve both functional and aesthetic outcomes, reconstruction should follow these principles: (1) maintain symmetry of the nasolabial fold and the upper lip; (2) protect or precisely reconstruct the Cupid's bow and philtral ridge to prevent displacement; (3) avoid wrinkling at the skin–vermilion junction; (4) prevent vermilion ectropion or superior retraction; and (5) design incision lines strategically to conceal scars within natural folds, thereby reducing the "patch effect" associated with horizontal scars.2 Guided by these principles, we used a vermilion border rotation-advancement flap inspired by the hatchet flap concept of Tomás-Velázquez.7 However, the paramedian defect involved multiple aesthetic subunits, requiring fundamental modifications in flap design and technique. During flap transfer, redundant "dog-ear" tissue on the alar side was used to reconstruct the nasal sill, minimizing the need for additional donor tissue. The philtral ridge was rebuilt following cleft lip repair principles to restore midline contour. Excess vermilion tissue was trimmed to preserve the lip tubercle's natural projection. This modified approach not only satisfies the dual requirements of functional and aesthetic reconstruction but also achieves harmonious restoration of facial subunits through precise anatomical reconstruction, yielding ideal clinical results. In this case, the reconstructed area showed no color or texture mismatch and demonstrated satisfactory symmetry both at rest and during smiling, resulting in excellent functional and cosmetic outcomes. Given the complexity of deep defects involving the upper cutaneous lip and nasal sill, this flap should be considered a reliable option for similar reconstructions. None. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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