Upper lip basal cell carcinoma: surgical treatment and reconstruction with transposition flap

Data de submissão: 30/07/2011
Approved on: 10/09/2011

This study was carried out at the
Dermatology Clinic of the Hospital Getúlio
Vargas (UFPI ) – Teresina (PI), Brazil.

Conflicts of interests: none
Financial support: none

Abstract

Basal cell carcinoma is the most common human malignant tumor, and is most frequently located on the face. The excision of lesions greater than 2 cm from the upper lip requires a complex and difficult reconstruction. The authors describe the case of a 74-year-old female patient who had a nodular basal cell carcinoma of approximately 2 cm on the upper lip, which crossed the vermillion border. The lesion was excised and the reconstruction carried out using a nasolabial transposition flap with an inferior base. Histologic analysis showed there was a complete resection, with a satisfactory aesthetic result after one year.

Keywords: CARCINOMA, BASAL CELL, LIP, RECONSTRUCTIVE SURGICAL PROCEDURES

INTRODUCTION

Basal cell carcinomas (BCCs) are the most common malig- nant tumor in humans, occurring most frequently in the face. They have unique clinical and histological features, grow slow- ly and have several clinical and histopathologic variants. They rarely result in metastases and the causes of its occurring in mucous membranes are unclear. Most BCCs appear without an apparent cause, however there are several predisponent factors, such as fair skin and prolonged exposure to the sun. It is esti- mated that 40% of patients who develop one lesion will have one or more BCC within the following 10 years. 1,2

BCCs appear in several different shapes; the nodular shape is one of the most prevalent. In general nodular BCCs begin as a red or skin-colored pearly papule. They grow slowly and develop telangiectasia on the surface. As they grow, the central portion frequently becomes ulcerated, developing into the nod- ule-ulcerative form. Sometimes they develop without ulcerat- ing, as was observed in the present case.

CASE REPORT

A 74-year-old patient originally from Teresina, state of Piaui, Brazil, was referred to the dermatologic clinic of Hospital Getúlio Vargas – UFPI, in Teresina. The patient presented with a tumoration in the upper lip, which had been slowly developing for several years. A pearly and apparently solid tumorous lesion with a hyperchromic base and approximately a 2-cm diameter was observed in the left half of the upper lip. The tumoration partially crossed into the vermilion area (Figures 1 and 2). Significant hirsutism could also be observed. The histopatho- logic examination of the punch biopsy indicated the presence of a solid-pattern BCC (Figure 3). The lesion was excised with 5- mm safety margins, and a naso-labial crease transposition flap was used in the reconstruction with an inferior pedicle (Figures 4and 5) from the apex of the nasal crease. There were no com- plications in the immediate post-operative period. The patient presented very satisfactory aesthetic results (Figures 6 and 7) and no signs of recurrence during the 18-month follow-up period.

DISCUSSION

According to data from the Instituto Nacional do Câncer – INCA (Brazilian National Institute of Cancer), BCCs account for roughly 25% of all cancer cases and 70% of the cutaneous cancers reported in Brazil. 3 In spite of their high prevalence, these tumors are unlikely to metastasize and are usually curable with a single surgical treatment. 1 When they are located in the upper lip, the reconstruction requires increased care to preserve the functional and aesthetic aspects of this sensitive area. 2 Particularly important are the positioning of the lip''''''''s border with the vermilion, maintaining the original position of the philtrum, and the maintenance of the bilateral symmetry and height of the nasolabial creases. Among the several excision and reconstruction techniques that can be used to meet those objec- tives, a nasolabial flap 4-7 is the best option, especially in elderly patients who frequently have excess skin in that area. 4 Due to the dimensions of the area to be rebuilt in this case, the flap was extended up to the nasal crease, where the suture was positioned in order to hide the scar. An additional important detail was that the excision had to be extended and the undermining of the lip line towards the right half of the lip had to be carried out in order to facilitate the closure in the flap''''''''s extremity to prevent high tension in the suture line, which could lead to the necro- sis of the flap''''''''s tip.

In the present case, in addition to the difficulty imposed by the location in the upper lip, the tumor had a large diameter (± 2 cm) and had partially invaded the vermilion. Thus the incision had to extend into the lip''''''''s mucus membrane due to the safety margin. The reconstruction with a nasolabial flap was chosen due to the availability of donor skin and the donor area''''''''s simi- larity and proximity to the receiving area. The procedure involved the complete removal of the tumor with a good aes- thetic result. The patient has been periodically followed up, with no signs of recurrence as of the last consultation in July 2011.

References

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