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22 Parapharyngeal Space Tumour Excision
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Part IX
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Lip Surgery
Lip Shave (Vermilionectomy)
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MarekJ.Ogledzki andCarlosA.Ramirez
23
23.1 Introduction
Actinic cheilitis (AC) is considered a premalignant involvement of the entire lower lip as a result of chronic sun exposure; it can progress to squamous cell carcinoma, with
transformation rates of 10–30% [1, 2]. It is characterized by
lower lip atrophy, loss of vermilion border, loss of elasticity,
dry keratotic plaques with ssures, and supercial ulcers
(Fig. 23.1). AC is found predominantly in fair-skinned,
middle- aged men with extensive lifetime sun exposure [1].
Vermilionectomy is a well-established method of management of AC.This method involves complete excision of
the lower lip epithelium from the vermilion border to the
wet-dry line, with various methods of reconstruction. It was
initially thought that the method was introduced by Bernhard
von Langenbeck and Friedrich von Esmarch, but Victor von
Bruns was performing this procedure for management of
lower lip tumours several years prior to von Langenbeck’s
original report in 1855 [3]. Since then, the procedure application became focused on the treatment of AC, and a number
of modications have been described.
Additional ablative treatments for AC that have been
described include the use of 5-FU, imiquimod, cryosurgery,
electrodesiccation, photodynamic therapy, chemical peels,
and CO2 laser. Vermilionectomy and CO2 laser ablation are
among the most efcacious, with the lowest long-term AC
recurrence rates [4, 5]. The CO2 laser provides precise control of the depth and borders of the ablation and has been
associated with less post-treatment scarring and paresthesias
than surgical vermilionectomy, but vermilionectomy is the
only treatment modality that allows histologic examination
of the specimen, providing margin analysis and identication of invasive disease. In addition, it can be easily com-
M. J. Ogledzki · C. A. Ramirez (*)
Department of Oral/Maxillofacial Surgery, Ascension St. John
Hospital, Warren, MI, USA
e-mail: Marek.Ogledzki@Ascension.org;
carlos.ramirez@ascension.org
bined with a wedge excision if any invasive component is
identied [4, 6, 7].
Vermilionectomy has remained mostly unchanged over
the years. In 1967, Burket [8] explained a modication technique to excise a wedge of orbicularis oris muscle to facilitate closure. However, this technique leads to increased
post-operative discomfort, increased risk of bleeding due to
increased vascularity, added loss of lip bulk, and is not necessary for closure [4, 9]. The modied vermilionectomy may
be useful in some situations, in which dysplastic changes
may extend to a greater depth [2]. Field [10] suggested that
extending the vermilionectomy beyond the commissure and
onto the inferolateral aspect of the upper lip would reduce
discomfort and cicatricial nodules at the commissure of the
lip, but this technique has not been widely employed in practice; most surgeons employ the standard excision technique.
The entire vermilion should be excised, as AC often diffusely
involves the labial surface and aesthetic results are superior
with resurfacing of the entire lip subunit (Fig.23.2) [4].
Multiple modications to the closure technique have been
proposed in hopes of improving aesthetic appearance and
minimizing post-operative sequelae. Von Bruns published an
illustration of the mucosal advancement ap in 1857; this has
remained the mainstay of the reconstruction [3]. Fernandez
Vozmediano etal. [11] proposed a W-plasty technique aimed
at breaking up a straight scar line at the new vermilion border,
similar to cutaneous scar revision. Despite elevation of a
mucosal ap, the lower lip tends to retract, resulting in a
decreased anterior-posterior dimension. To offset this retraction, Lustig etal. [12] proposed using a bipedicled myomucosal axial ap, and Ay and Aytekin [13] suggested meshing the
mucosal ap, similar to a skin graft. Some authors advocate
primary closure of the defect without undermining, reporting
a similar cosmetic result and a signicant decrease in paresthesia, pain, and lip incontinence with primary closure [14].
Sand et al. [15] estimated that primary closure results in a
one-third width reduction, but found their cohort to have similar recovery proles. They concluded that primary closure is
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_23
217
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Fig. 23.1 Actinic cheilitis
M. J. Ogledzki and C. A. Ramirez
Fig. 23.2 Markings for vermilionectomy
best tted for elderly or anticoagulated patients, to decrease
operative time and bleeding risk [15]. Another known discomfort in some patients is the “prickly sensation” from
advanced mucosa overlapping cutaneous hair follicles. Field
[16] reasoned that this results from excess tension of the
mucosal ap after closure and recommended extending the
submucosal dissection of the advancement ap to the level of
the retrobuccal sulcus or the oral vestibule. We employ this
technique in our practice to achieve closure with the least tension possible, to prevent dehiscence and the disappearance of
the lower lip. In our experience, careful submucosal dissection spares the emerging mental nerves, and paresthesias are
usually related to neovascularization of the advanced mucosa,
which usually resolves after several months.
23.2 Pre-operative Checklist,
Considerations, andAnaesthesia
Prior to proceeding with the vermilionectomy, a thorough
history and physical must be completed. Use of antiplatelet
or anticoagulation signicantly increases the risk of hema-
toma formation resulting in possible mucosal ap failure.
Any medication adjustment should be made in conjunction
with the patient’s primary care physician, and meticulous
haemostasis must be maintained during surgery. A thorough
discussion regarding the expected esthetic outcome of the
procedure, possible complications, and post-operative
course should be had with all patients. The patient should be
alerted of diet adjustments at home. If the patient has a history of herpes labialis or “cold sores,” pre-operative course
of antivirals is recommended to prevent an outbreak. Preoperative biopsy of ulcerations should be completed in order
to identify invasive lesion requiring a wedge resection
(Fig.23.3).
Pre-operative evaluation of the lesion and adjacent structures must be completed. Lower labial mucosa should be
examined for any previous surgical incisions, lesions, or
scarring. Any scarring in the area will make submucosal dissection signicantly more difcult, compromise vascularity
of the submucosal ap, and increase the overall potential risk
of complications. Signicant scarring of the labial mucosa
should preclude use of an advancement ap, and primary
closure should be performed.
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Fig. 23.3 Partial vermilionectomy with wedge excision
219
The vermilionectomy can be performed under local or
general anaesthesia. Nasal intubation is recommended to
provide adequate access and prevent distortion, to allow for
symmetric reconstruction. It is the author’s preference to
perform this delicate procedure in a controlled setting under
general anaesthesia as an outpatient.
The patient must be informed of the possible risks and
expected postsurgical aesthetic changes. Elevation of mucosal ap is associated with an increased risk of hematoma formation, which may lead to infection and ap necrosis [4]. In
addition, short-term lower lip paresthesia may occur, owing
to dissection into the mandibular vestibule near the mental
nerve [14]. Long-term discomfort and “prickly sensation”
have been reported [16]. Mucocele formation has been
reported from disruption of labial minor salivary glands [17].
In rare cases, short-term lip incontinence may result [14].
Any disruption in normal healing may result in lower lip
asymmetry requiring revision surgery. The patient should
expect posterior migration of the vermilion border, resulting
in decreased fullness of the lower lip [14].
23.3 Indications
Actinic cheilitis (AC) is considered a premalignant condition
of the labial skin, with malignant transformation ranging
from 10 to 30% [1]. Simple vermilionectomy is performed
for management of AC in the absence of malignant features.
Diagnosis of AC is based on clinical ndings and can be conrmed with biopsy. In the presence of a focal malignant
lesion, wedge resection in addition to vermilionectomy is
performed.
The reconstruction modality is based on patient factors. We prefer to use a labial mucosa advancement ap to
minimize tension at the suture line. For patients with signicant comorbidities requiring anticoagulation or antiplatelet agents, however, simple closure of the
vermilionectomy defect is preferred, to minimize the risk
of hematoma formation and shorten the duration of general anaesthesia.
23.4 Surgical Technique
23.4.1 Vermilionectomy
The patient is placed in supine position and prepped and
draped in standard surgical fashion. Marking of vermilionectomy incision is performed rst, using a ne-tip marking
pen. Incision is marked along the white roll of the lower lip,
or 1–2mm from the vermilion border to include a small cuff
of skin and ensure adequate resection margins. Commissures
constitute the lateral extent and the wet-dry line is the posterior extent of the resection (Figs.23.4 and 23.5). Anaesthetic
may be used only after incision marking.
Size #15 blade is used to create an incision along the anterior marking, extending into the commissures, through skin
and into the subcutaneous tissue, beveling away from the
resection specimen. The posterior incision is then performed
through mucosa to the level of the muscle. The specimen is
then grasped with Adson toothed forceps, and tenotomy scissors are used to undermine in the submucosal plane along the
orbicularis oris muscle (Figs. 23.6, 23.7, and 23.8). The
author prefers to make the incision with a Bovie electrocautery set on 15 cut and then proceed with the bipolar forceps
set to 12 to elevate the specimen. The specimen is removed,
orientated with silk suture, and passed over for histopathology (Fig.23.9).
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Fig. 23.4 Supercially invasive squamous cell carcinoma
M. J. Ogledzki and C. A. Ramirez
Fig. 23.5 Markings for vermilionectomy
Fig. 23.6 Excision through mucosa and submucosa
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Fig. 23.7 Visualization of underlying musculature
221
Fig. 23.8 Residual defect
Fig. 23.9 Resected specimen with silk suture markings for orientation
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M. J. Ogledzki and C. A. Ramirez
23.4.2 Vermilionectomy andWedge Resection
The patient is placed in supine position and prepped and
draped in standard surgical fashion. Marking of the vermilionectomy incision is performed rst, using a ne-tip marking pen. Incision is marked along the white roll of the lower
lip or 1–2mm from vermilion border to include a small cuff
of skin and ensure adequate resection margins. Commissures
constitute the lateral extent and the wet-dry line is the posterior extent of the resection (Fig.23.10). Next, wedge resection marking is performed. Anaesthetic may be used only
after incision marking.
Size 15 blade is used to create an incision along the anterior marking, beveling away from the specimen and stopping
at the lateral borders of the outlined wedge resection marking.
Posterior incision is completed in same fashion and con-
nected to the anterior incision at the commissures. Next, the
mucosa is undermined using tenotomy scissors in the supramuscular plane from lateral to medial, until the resection
marking of the wedge resection is reached. Next, the wedge
resection is completed, removing the entire specimen en bloc
(Fig.23.11).
23.4.3 Mucosal Advancement Flap
Following resection, meticulous haemostasis must be
obtained. Bipolar electrocautery allows excellent haemostasis with minimal tissue damage. The lower lip is everted out
of the mouth, and tenotomy scissors are used to undermine in
the submucosal plane to the depth of the mandibular vestibule. Bilateral 1-cm releasing incisions of the mucosal ap
Fig. 23.10 Markings for vermilionectomy with wedge excision
Fig. 23.11 Resected wedge resection specimen
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Fig. 23.12 Mucosal advancement
223
Fig. 23.13 Completed mucosal advancement
are made at the commissures adjacent to the defect to allow
advancement without distortion of the commissures. The
mucosal ap is then sutured to the skin using 5-0 Prolene
interrupted simple sutures (Figs.23.12 and 23.13).
23.5 Post-operative Care
Post-operative multimodality pain medication should be prescribed, including anti-inammatories. Ice may be applied
for 24–48 h to reduce swelling, after which heat may be
applied. Because of oral contamination, the author prescribes
a 5–7-day course of antibiotics to cover oral ora. The patient
is prescribed a full liquid diet for 72h, followed by a mechanical soft diet for an additional 4–7 days. The patient is
instructed to apply a very thin layer of antibiotic ointment
daily. Sutures are removed after 7–10 days. The patient is
seen weekly for the rst 3weeks (Figs.23.14, 23.15, 23.16,
23.17, and 23.18).
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Fig. 23.14 Appearance 3months after partial vermilionectomy with wedge excision
M. J. Ogledzki and C. A. Ramirez
Fig. 23.15 Pre-operative supercially invasive squamous cell carcinoma
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