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Lip reconstruction following resection for an unusual basal-cell carcinoma
Lip reconstruction following resection for an unusual basal-cell carcinoma David E. Kelly, D.D.X.,* Kenneth Al. Klein, M.D., a?ld William P. Harriga,n, M.D., D.D.S., New York, N. Y. DEPARTMENTS
OF ORAL
SURGERY
AND
PATHOLOGY,
BELLEVUE
HOSPITAL
Basal-cell carcinoma most commonly occurs in men in the fifth to seventh decades of life. The area of the lesion is usually one that has frequent exposure to the sun: the middle third of the face and upper lip. An unusual case of basal-cell carcinoma occurring on the lower lip and involving the commissure in a 2l-year-old woman is presented. The surgical procedures for resection of the tumor and reconstruction of the commissure are described.
B
asal-cell carcinoma is the most frequently encountered form of skin cancer.l The most common locations are the periorbital region and the upper lip,l areas which one would expect to be most exposed to sunlight, one of the major implicated etiologic agents. The patients are usually of advanced age, and there is a predominance of males. The case being reported here is unusual because of the patient’s youth, her lack of exposure to any of the supposed carcinogenic factors, and the lesion’s unusual location. CASE
REPORT
In
late March, 1974, a Zl-year-old Puerto Rican woman was seen in the oral surgery clinic at Bellevue Hospital, complaining of an ulcer of the lower lip. The patient stated that the lesion had been present 1 year, having started as an indurated area on the mucous membrane at the junction of the oral mucosa and the vermilion border. The lesion at first was not greatly visible and had been present 6 months before she sought treatment in the dermatology clinic at another hospital. She had received a B-month course of Neosporin topical powder and parenteral penicillin without resolution of the lesion. Her past medical history and family history as well as the review of systems were noncontributory. The patient was a city dweller, without excessive exposure to the sun, and she was a nonsmoker. Physical examination showed the patient to be a well-developed, well-nourished, lightskinned young woman. She had no skin lesions or nevi other than the lesion of the lower lip. *Present address: Carolina, Chapel Hill,
Department N. C.
of Oral
Surgery,
School
of Dentistry,
University
of North
19
20
Kelly,
Klek,
OK11 slug. July, 1975
Fig.
Fig.
1. Preoperative
8. Excision
of tumor
photograph
and E&lander
of tumor.
flap
closure.
Fig. 3. Estlander Z%g. 4. Estlander
flap closure flap closure
immediately postoperatively. 3 weeks postoperatively.
This lesion was located primarily on the vermilion border of the right lateral third of the lower lip, involving the commissure (Fig. 1). Approximately 1 mm. of skin was involved in the ulcer. The edges of the ulcer were indurated and rolled. Induration was also present on the mucosal and skin surfaces of the lower lip for about 1 cm. inferiorly to the vermilion border. NO lymph nodes were palpated in the suprahyoid or submandibular areas. she was sedated and an incisional biopsy Because the patient was very apprehensive, The histologic diagnosis was basosquamous-cell was performed with local anesthesia. carcinoma. Six days later the patient returned for admission and definitive treatment. On admission, the patient’s chest radiograph, electrocardiogram, complete blood count, electrolytes, and liver function were all within normal limits. The VDRL response was nonreactive. Radiographs of the jams showed no evidence of keratocysts. Because of the nature of this type of tumor and the patient’s age, consideration had to be given to obtaining the best possible cosmetic result as well as to elimination of the tumor. It was necessary to sacrifice the commissure of the lip; therefore, we decided that two separate procedures-the Estlander flap2 and Gilles vermilion pedicle procedurese--offered the best way to accomplish a cosmetic result. On April 5, 1974, the patient was taken to the operating room, and, after induction of general anesthesia and nasotracheal intubation, the lines of incisions for excision of the tumor and for elevation of the Estlander flap were marked with methylene blue dye (Fig. 2, a). Point a must be 3 mm. from the vermilion border to preserve the superior labial artery, and the width of the Estlander flap (a to c) should be one half the midth of the defect left after excision of the tumor (c to f). The wedge resection of the tumor was accomplished, with the incision in the upper lip (c to d) made on a bias to match the width of the vermilion border of the lower lip (f to g) (Fig. 2, R). The full-thickness Estlander flap was then elevated and rotated down, so that point II was sutured to point e, point c was sutured to point f, and point d was sutured to point g (Fig. 2, C). The mucosal surface was closed first with 4-O interrupted silk sutures, followed by closure of the muscular layer with 3-O plain gut sutures. The skin was closed finally with
22
Kelly,
Fig.
Kleirt,
5. Gilles
awl
vermilion
Oral July,
Harrigm
pedicle
procedure
for
reconstruction
Surg. 1975
of the commissure.
5-O nylon interrupted sutures (Fig. 3). The patient tolerated the procedure well and was discharged the following day. Three weeks following resection of the tumor, the patient was readmitted. Healing of the foreshortened, rounded lip at this time was normal (Fig. 4). The patient was again taken to the operating room, and, following induction of general anesthesia, a Gilles vermilion pedicle procedures was performed to reconstruct the right commissure of the lip. For this procedure a vermilion mucosal pedicle flap was created from the rounded portion of the lip. This flap should equalize the length of the upper lip (Fig. 5, B and B). A triangle of skin was removed to restore the commissure to its natural length (Fig. 5, B). Following removal of the skin an incision was made through the underlying muscle and mucosa (Fig. 5, C). The vermilion pedicle flap was then sutured to the upper portion of the lip (Fig. 5, 11)
Volume Number
Lip
40 1
FQ. 6. Final procedurca.
result
after
reconstruction
and a mucosal advancement flap from the and commissure (Fig. 5, E and P). Healing defect (Fig. 6). The patient is now one year Pathology
recomvhdion
of the commissure
follouti~~g resectim
with
a Gilles
vermilion
23
pedicle
lower lip was used to resurface the lower lip occurred without complication or gross cosmetic post-surgery without evidence of recurrence.
report
The specimen was received in formalin and consisted of a segment of lower lip in continuity with the right commissure and a portion of the upper lip. The entire specimen measured 2.0 by 2.0 by 2.5 cm. along its skin and mucosal surfaces and 1.5 cm. at its greatest depth. An ulcerated lesion was noted 0.3 cm. medial to the mucosal side. The lesion measured 0.5 cm. in its greatest (anteroposterior) diameter. The epithelial border immediately surrounding the lesion was slightly raised and hyperkeratotic. Microscopically, the mucocutaneous junction was ulcerated, with the ulcer base consisting of necrotic debris and an underlying, infiltrating tumor which extended into the uppermost portion of striated muscle. The tumor comprised mainly cords and nests of relatively uniform, medium-sized cells with oval to round nuclei (Fig. 7). No mitotic figures were noted. The cells at the periphery of the cords and nests were arranged in an orderly manner with their long axes perpendicular to the basement membrane (Fig. 8). In areas, groups of the tumor cells were noted to be squamoid in appearance and, focally, were producing keratin. Adjacent to these areas, the squamoid cells were gathered around larger, cystlike spaces containing laminated keratin-like material (Fig. 9). Occasional foci of the tumor cells had a sebaceous appearance with clear cytoplasm and faint stippling (Fig. 10). The stroma surrounding the tumor nests and cords was chronically inflamed but showed no mucoid or amyloid-like change. The epithelium overlying the margins of the lesion, on both the mucous membrane and skin sides, was hyperplastic and displayed moderate orthokeratosis. No obvious actinic change was noted in the dermal connective tissue.
DISCUSSION
When this lesion was first seen, diagnosis of chancre was considered. However, the duration of the lesion as well as its failure to respond to antibiotic therapy suggested a diagnosis of carcinoma, even though it is admittedly rare
24
Kelly,
Klei)l,
totd IInwigtr?l
Fig. 7. Overview of ulcerating tumor infiltrating (Hematoxylin and eosin stain. Magnification, x30.) Fig. 8. Characteristic nest of basal-cell carcinoma palisading. (Hematoxylin and eosin stain. Magnification,
into
the
cells showing x150.)
underlying tendency
connective toward
tissue. peripheral
at this age and in this location. .A negative VDRL response further reinforced this opinion. Basal-cell carcinoma, like squamous-cell carcinoma of the skin and mucous membranes, is usually seen in an older age group. When present in childhood or in young adults, it is most frequently multiple, arising in the skin, and is as-
Fig. 9. Portion of tumor nests recapitulating the formation eosin stain. Magnification, x150.) Fig. 10. Other nests of tumor attempting to differentiate (Hematoxylin and eosin stain. Magnification, x150.)
of hair
follicles.
(Hemntoxylin
and
torvnrd
sel~nceous
rlements.
sociated with squamous-cell-lined inclusion cysts of the jaws (“basal-cell ncvus syndrome”). Careful clinical and radiographic examination of this patient failed to reveal any other tumors, either of the skin or of the mucous membrane of the mouth, or the presence of any cysts in the facial bones. IVc can thus safely conclude that the lesion did not belong to this group. The usual factors implicated in the pathogenesis of basal-cell carcinoma are excessive exposure to sunlight, x-irradiation, or the parenteral or topical use of arsenic compounds. This patient, a city dweller with an office occupation, has been exposed to none of these factors. SUMMARY
An unusual case of basal-cell carcinoma of the lower lip has been presented. As it was necessary to sacrifice the commissure of the lip in removing the tumor, two surgical procedures were planned to, first, remove the tumor and, later, allow reconstruction of the commissure of t,he lip for the best possible cosmetic result. The tumor itself, although not particularly aggressive, is interesting because it occurred in a young patient with no apparent predisposing factors. REFERENCES
1. Lever, W. F.: Histopathology Company, p. 579.
of
the
Skin,
ed.
4, Philadelphia,
1967,
J.
13. Lippincott
J. A.: Methode tl’autoplastie tlr 2. E&lander, emprunte a l’autre levre, Rev. Mens. Med. Chir. 3. Gilles, H. D., and Miller, I). R., Jr.: Principles Littlr, Brown & Company, vol. 11, p. 508. Baprint requests to: Dr. David E. Kelly lkpartment of Oral Surgery School of Dentistry Iyniversity of North (hrolina (‘impel Hill, N.C. 27514
la jaw ou tl’une lwro par 1: 344, 1877. and Art of Plastic Surgery,
uw Boston,
I:w~t~e:tu 1957,
OF ORAL
SURGERY
AND
PATHOLOGY,
BELLEVUE
HOSPITAL
Basal-cell carcinoma most commonly occurs in men in the fifth to seventh decades of life. The area of the lesion is usually one that has frequent exposure to the sun: the middle third of the face and upper lip. An unusual case of basal-cell carcinoma occurring on the lower lip and involving the commissure in a 2l-year-old woman is presented. The surgical procedures for resection of the tumor and reconstruction of the commissure are described.
B
asal-cell carcinoma is the most frequently encountered form of skin cancer.l The most common locations are the periorbital region and the upper lip,l areas which one would expect to be most exposed to sunlight, one of the major implicated etiologic agents. The patients are usually of advanced age, and there is a predominance of males. The case being reported here is unusual because of the patient’s youth, her lack of exposure to any of the supposed carcinogenic factors, and the lesion’s unusual location. CASE
REPORT
In
late March, 1974, a Zl-year-old Puerto Rican woman was seen in the oral surgery clinic at Bellevue Hospital, complaining of an ulcer of the lower lip. The patient stated that the lesion had been present 1 year, having started as an indurated area on the mucous membrane at the junction of the oral mucosa and the vermilion border. The lesion at first was not greatly visible and had been present 6 months before she sought treatment in the dermatology clinic at another hospital. She had received a B-month course of Neosporin topical powder and parenteral penicillin without resolution of the lesion. Her past medical history and family history as well as the review of systems were noncontributory. The patient was a city dweller, without excessive exposure to the sun, and she was a nonsmoker. Physical examination showed the patient to be a well-developed, well-nourished, lightskinned young woman. She had no skin lesions or nevi other than the lesion of the lower lip. *Present address: Carolina, Chapel Hill,
Department N. C.
of Oral
Surgery,
School
of Dentistry,
University
of North
19
20
Kelly,
Klek,
OK11 slug. July, 1975
Fig.
Fig.
1. Preoperative
8. Excision
of tumor
photograph
and E&lander
of tumor.
flap
closure.
Fig. 3. Estlander Z%g. 4. Estlander
flap closure flap closure
immediately postoperatively. 3 weeks postoperatively.
This lesion was located primarily on the vermilion border of the right lateral third of the lower lip, involving the commissure (Fig. 1). Approximately 1 mm. of skin was involved in the ulcer. The edges of the ulcer were indurated and rolled. Induration was also present on the mucosal and skin surfaces of the lower lip for about 1 cm. inferiorly to the vermilion border. NO lymph nodes were palpated in the suprahyoid or submandibular areas. she was sedated and an incisional biopsy Because the patient was very apprehensive, The histologic diagnosis was basosquamous-cell was performed with local anesthesia. carcinoma. Six days later the patient returned for admission and definitive treatment. On admission, the patient’s chest radiograph, electrocardiogram, complete blood count, electrolytes, and liver function were all within normal limits. The VDRL response was nonreactive. Radiographs of the jams showed no evidence of keratocysts. Because of the nature of this type of tumor and the patient’s age, consideration had to be given to obtaining the best possible cosmetic result as well as to elimination of the tumor. It was necessary to sacrifice the commissure of the lip; therefore, we decided that two separate procedures-the Estlander flap2 and Gilles vermilion pedicle procedurese--offered the best way to accomplish a cosmetic result. On April 5, 1974, the patient was taken to the operating room, and, after induction of general anesthesia and nasotracheal intubation, the lines of incisions for excision of the tumor and for elevation of the Estlander flap were marked with methylene blue dye (Fig. 2, a). Point a must be 3 mm. from the vermilion border to preserve the superior labial artery, and the width of the Estlander flap (a to c) should be one half the midth of the defect left after excision of the tumor (c to f). The wedge resection of the tumor was accomplished, with the incision in the upper lip (c to d) made on a bias to match the width of the vermilion border of the lower lip (f to g) (Fig. 2, R). The full-thickness Estlander flap was then elevated and rotated down, so that point II was sutured to point e, point c was sutured to point f, and point d was sutured to point g (Fig. 2, C). The mucosal surface was closed first with 4-O interrupted silk sutures, followed by closure of the muscular layer with 3-O plain gut sutures. The skin was closed finally with
22
Kelly,
Fig.
Kleirt,
5. Gilles
awl
vermilion
Oral July,
Harrigm
pedicle
procedure
for
reconstruction
Surg. 1975
of the commissure.
5-O nylon interrupted sutures (Fig. 3). The patient tolerated the procedure well and was discharged the following day. Three weeks following resection of the tumor, the patient was readmitted. Healing of the foreshortened, rounded lip at this time was normal (Fig. 4). The patient was again taken to the operating room, and, following induction of general anesthesia, a Gilles vermilion pedicle procedures was performed to reconstruct the right commissure of the lip. For this procedure a vermilion mucosal pedicle flap was created from the rounded portion of the lip. This flap should equalize the length of the upper lip (Fig. 5, B and B). A triangle of skin was removed to restore the commissure to its natural length (Fig. 5, B). Following removal of the skin an incision was made through the underlying muscle and mucosa (Fig. 5, C). The vermilion pedicle flap was then sutured to the upper portion of the lip (Fig. 5, 11)
Volume Number
Lip
40 1
FQ. 6. Final procedurca.
result
after
reconstruction
and a mucosal advancement flap from the and commissure (Fig. 5, E and P). Healing defect (Fig. 6). The patient is now one year Pathology
recomvhdion
of the commissure
follouti~~g resectim
with
a Gilles
vermilion
23
pedicle
lower lip was used to resurface the lower lip occurred without complication or gross cosmetic post-surgery without evidence of recurrence.
report
The specimen was received in formalin and consisted of a segment of lower lip in continuity with the right commissure and a portion of the upper lip. The entire specimen measured 2.0 by 2.0 by 2.5 cm. along its skin and mucosal surfaces and 1.5 cm. at its greatest depth. An ulcerated lesion was noted 0.3 cm. medial to the mucosal side. The lesion measured 0.5 cm. in its greatest (anteroposterior) diameter. The epithelial border immediately surrounding the lesion was slightly raised and hyperkeratotic. Microscopically, the mucocutaneous junction was ulcerated, with the ulcer base consisting of necrotic debris and an underlying, infiltrating tumor which extended into the uppermost portion of striated muscle. The tumor comprised mainly cords and nests of relatively uniform, medium-sized cells with oval to round nuclei (Fig. 7). No mitotic figures were noted. The cells at the periphery of the cords and nests were arranged in an orderly manner with their long axes perpendicular to the basement membrane (Fig. 8). In areas, groups of the tumor cells were noted to be squamoid in appearance and, focally, were producing keratin. Adjacent to these areas, the squamoid cells were gathered around larger, cystlike spaces containing laminated keratin-like material (Fig. 9). Occasional foci of the tumor cells had a sebaceous appearance with clear cytoplasm and faint stippling (Fig. 10). The stroma surrounding the tumor nests and cords was chronically inflamed but showed no mucoid or amyloid-like change. The epithelium overlying the margins of the lesion, on both the mucous membrane and skin sides, was hyperplastic and displayed moderate orthokeratosis. No obvious actinic change was noted in the dermal connective tissue.
DISCUSSION
When this lesion was first seen, diagnosis of chancre was considered. However, the duration of the lesion as well as its failure to respond to antibiotic therapy suggested a diagnosis of carcinoma, even though it is admittedly rare
24
Kelly,
Klei)l,
totd IInwigtr?l
Fig. 7. Overview of ulcerating tumor infiltrating (Hematoxylin and eosin stain. Magnification, x30.) Fig. 8. Characteristic nest of basal-cell carcinoma palisading. (Hematoxylin and eosin stain. Magnification,
into
the
cells showing x150.)
underlying tendency
connective toward
tissue. peripheral
at this age and in this location. .A negative VDRL response further reinforced this opinion. Basal-cell carcinoma, like squamous-cell carcinoma of the skin and mucous membranes, is usually seen in an older age group. When present in childhood or in young adults, it is most frequently multiple, arising in the skin, and is as-
Fig. 9. Portion of tumor nests recapitulating the formation eosin stain. Magnification, x150.) Fig. 10. Other nests of tumor attempting to differentiate (Hematoxylin and eosin stain. Magnification, x150.)
of hair
follicles.
(Hemntoxylin
and
torvnrd
sel~nceous
rlements.
sociated with squamous-cell-lined inclusion cysts of the jaws (“basal-cell ncvus syndrome”). Careful clinical and radiographic examination of this patient failed to reveal any other tumors, either of the skin or of the mucous membrane of the mouth, or the presence of any cysts in the facial bones. IVc can thus safely conclude that the lesion did not belong to this group. The usual factors implicated in the pathogenesis of basal-cell carcinoma are excessive exposure to sunlight, x-irradiation, or the parenteral or topical use of arsenic compounds. This patient, a city dweller with an office occupation, has been exposed to none of these factors. SUMMARY
An unusual case of basal-cell carcinoma of the lower lip has been presented. As it was necessary to sacrifice the commissure of the lip in removing the tumor, two surgical procedures were planned to, first, remove the tumor and, later, allow reconstruction of the commissure of t,he lip for the best possible cosmetic result. The tumor itself, although not particularly aggressive, is interesting because it occurred in a young patient with no apparent predisposing factors. REFERENCES
1. Lever, W. F.: Histopathology Company, p. 579.
of
the
Skin,
ed.
4, Philadelphia,
1967,
J.
13. Lippincott
J. A.: Methode tl’autoplastie tlr 2. E&lander, emprunte a l’autre levre, Rev. Mens. Med. Chir. 3. Gilles, H. D., and Miller, I). R., Jr.: Principles Littlr, Brown & Company, vol. 11, p. 508. Baprint requests to: Dr. David E. Kelly lkpartment of Oral Surgery School of Dentistry Iyniversity of North (hrolina (‘impel Hill, N.C. 27514
la jaw ou tl’une lwro par 1: 344, 1877. and Art of Plastic Surgery,
uw Boston,
I:w~t~e:tu 1957,