Island Flap for Upper-Lip Reconstruction: Analysis of Key Aspects and a Case Series

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Caso 4. (a) Carcinoma basocelular en el labio superior. (b) Delimitación del tumor con margen para escisión con cirugía de Mohs y adaptación del defecto, de modo que llegue al surco naso-labial y a la línea de unión de la piel del labio superior con el bermellón. (c) Defecto final tras extirpación con bordes libres y escisión de tejido sano superior e inferior. Diseño del colgajo siguiendo el pliegue del surco nasolabial y la línea de unión de la piel del labio superior con el bermellón, acabando ambas líneas en el ángulo de arrugas naturales de la comisura labial. (d) y (e). Colgajo suturado con puntos simples de seda de 6/0. Las cicatrices superior e inferior se esconden en líneas naturales y la cicatriz medial es vertical y paralela a las arrugas. (f) Aspecto al acudir para la retirada de puntos 7 días tras la intervención. Caso 6. (g) Carcinoma basocelular en el labio superior (derecho). (h) Imagen del colgajo que, tras ser labrado en el plano subcutáneo manteniendo un pedículo subcutáneo central que garantice la vascularización, avanza hacia el defecto. Previamente se había extirpado la lesión con cirugía de Mohs. (i) Resultado 6 meses tras la intervención." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Tomás-Velázquez, P. Redondo" "autores" => array:2 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Tomás-Velázquez" ] 1 => array:2 [ "nombre" => "P." 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Tomás-Velázquez, P. Redondo" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Tomás-Velázquez" "email" => array:1 [ 0 => "atomasv@unav.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Redondo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Dermatología, Clínica Universidad de Navarra, Pamplona y Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colgajo en isla del labio superior: claves fundamentales y serie de casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1545 "Ancho" => 2163 "Tamanyo" => 394592 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Design, surgical technique, and outcome based on 2 representative cases. Case 4. A, Basal cell carcinoma on the upper lip. B, Definition of the tumor with a margin to be excised using Mohs surgery and adaptation of the defect so that it reaches the nasolabial fold and the line where the skin of the upper lip meets the vermillion border. C, Final defect after removal with free borders and excision of the upper and lower healthy skin. Design of the flap following the nasolabial fold and the line where the skin of the upper lip meets the vermillion border, with both lines finishing at the angle of the natural wrinkles in the oral commissure. D and E, Sutured flap with simple stitches (silk 6/0). The upper and lower scars are hidden in natural lines and the medial scar is vertical, parallel to the wrinkles. F, Appearance at removal of the stitches 7 days after surgery. Case 6. G, Basal cell carcinoma on the right upper lip. H, Image of the flap, which, after being worked in the subcutaneous plane by maintaining a central subcutaneous pedicle that guarantees the blood supply, advances toward the defect. The lesion had previously been removed using Mohs surgery. I, Outcome 6 months after the procedure." ] ] ] "textoCompleto" => "IntroductionThe upper lip is a common site for skin cancer. Reconstruction of the upper lip may be hampered by the limited availability of adjacent tissue and the by the functional and cosmetic importance of this anatomic unit. Options for reconstructive surgery depend on the size, location, and depth of the lesion.Preservation of the function and appearance of the upper lip during reconstruction surgery must take into account the following: (1) Maintenance of symmetry in the nasolabial fold and the upper lip; (2) Sparing or reconstruction of the philtrum and Cupid’s bow without displacement; (3) Avoidance of creases at the line where the skin meets the vermillion border; (4) Avoidance of eclabium or upward traction on the vermillion border; and (5) Avoidance of horizontal scars by hiding incisions in natural folds or following relaxed tension lines or wrinkles.In our experience, the subcutaneous island pedicle flap on the upper lip fulfills these norms and enables successful reconstruction of most defects at this site.The objective of the present study was to review a series of patients who underwent reconstructive surgery in the upper lip based on an island flap and to describe and illustrate the surgical technique, taking into account basic practical considerations.MethodsPatientsWe reviewed the clinical history and imaging data available for patients who underwent reconstruction surgery based on an island flap in the Dermatology Department of Clínica Universidad de Navarra, Pamplona, Spain between 2015 and 2019. Cosmetic and functional outcomes were evaluated independently by 2 dermatologists, and patients were asked about their satisfaction with the outcome. The study was approved by the Ethics Committee of Universidad de Navarra, and the patients provided their informed consent.We selected 15 patients (7 men and 8 women, with a mean age of 65.6 years [range, 40-78 years]). The patients had had different types of skin cancer affecting the upper lip (basal cell carcinoma, 10 cases; melanoma, 2 cases; squamous cell carcinoma, 3 cases) that were treated with Mohs micrographic surgery (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Each half of the upper lip (left and right) was divided into 3 parts (medial, central, and lateral) in order to describe the location of the defects (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).Surgical TechniqueAll of the patients had undergone Mohs micrographic surgery under local anesthetic (bupivacaine 0.5%), with resulting defects measuring from 3 to 7.6 cm2 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).The steps for making the flap and reconstruction were as follows (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1Reconstruction started with adaptation of the final defect. It is essential for this to extend beyond the nasolabial fold and below the line where the skin meets the vermillion border. When this is not the case, a surgical skin marker can be used to draw the areas of healthy skin to be removed in order to adapt the defect and remove it. This first step makes it possible to achieve a more favorable cosmetic outcome, since it enables scars to be hidden in natural folds or lines, thus avoiding horizontal scars.</li><li class="elsevierStyleListItem" id="lsti0010">2The island flap is designed. Using a surgical skin marker, a triangular flap is drawn; the medial part of the flap contains the defect. The upper part lies in the nasolabial fold and the lower part where the skin meets the vermillion border, in such a way that both lines converge on the natural wrinkles in the oral commissure. The size of the flap depends on the lines that delimit it. However, when the defect is larger, the upper side of the triangle can be extended with a line parallel to the nasolabial fold on the cheek.</li><li class="elsevierStyleListItem" id="lsti0015">3The incisions are then made with a cold scalpel by marking out the design. The flap is cut and worked at the level of the subcutaneous tissue above the orbicular muscle. A subcutaneous pedicle must be maintained. This should be sufficiently thick to enable adequate vascularization of the flap and, at the same time, mobile in order to facilitate the advancement of the tissue.</li><li class="elsevierStyleListItem" id="lsti0020">4Once adequate hemostasis has been achieved, the flap is advanced, and the wound is closed. The medial sutures are placed (normally first with an anchor at a reference point in the center of the medial side), followed by the remaining sutures. Subcutaneous stitches are placed first (Novosyn 4/0), followed by tension-free stitches (silk 6/0).</li><li class="elsevierStyleListItem" id="lsti0025">5The secondary defect is closed directly using a V-Y technique.</li><li class="elsevierStyleListItem" id="lsti0030">6A slightly compressive dressing is placed.</li></ul><elsevierMultimedia ident="fig0005"></elsevierMultimedia>In 3 cases, the reconstruction involved variations owing to the larger size and/or location of the lesion. A bilateral island pedicle flap was placed in 2 cases (one by combining an advancement flap from the cheek and the other by combining the unilateral flap with a paramedian forehead flap to reconstruct the nasal ala).ResultsAll of the flaps progressed satisfactorily without acute complications such as bleeding, infection, or necrosis and without the need for correction of scars. Postoperative follow-up was from 6 to 34 months.The functional and cosmetic outcomes were satisfactory, both for the dermatologist and for the patient in all cases. Slight eversion of the upper lip was recorded in 1 case. In functional terms, mouth opening and upper lip mobility remained intact, and paresthesia was reported in the area in 4 cases during the days after the procedure, although this resolved after a few weeks. In cosmetic terms, the scars were hidden in natural lines, as follows: upper scar, in the nasolabial fold; lower scar, at the line where the skin meets the vermillion border; closure of the V-Y advancement flap, wrinkles of the oral commissure; and medial border, in a vertical scar hidden among the vertical wrinkles on the upper lip.DiscussionLarge defects following Mohs surgery on the upper lip make reconstruction challenging because of the cosmetic and functional importance of this area. Local flaps are the main option for defects where direct closure is not possible. In most cases, we believe that the subcutaneous island pedicle flap of the upper lip is the reconstructive option of choice, taking into account a few basic considerations.As commented on above, a key consideration is that of adapting the defect. It is not uncommon to find designs in which this flap has horizontal scars in the middle of the upper lip. This occurs when the area of healthy tissue between the defect and the nasolabial fold (above) and/or between the defect and the vermillion border (below) is not sacrificed. Whenever possible, horizontal scars on the upper lip should be avoided, since they run contrary to the wrinkles and relaxed tension lines, resulting in a very poor cosmetic appearance. The simple maneuver of removing a small amount of neighboring healthy tissue makes it possible to hide curved scars in the nasolabial fold and the vermillion border and enables the scar to run into the natural wrinkles of the oral commissure. The medial scar, on the other hand, is vertical and runs parallel to the philtrum and wrinkles. In addition, this flap enables reconstruction with skin of the same characteristics as that removed; this is essential in men, as it ensures that hairy skin and, therefore, the appearance of the moustache, are maintained.The flap used here is an advancement-rotation flap, which is easily designed and performed and enables the expression and appearance of the upper lip to be maintained and large defects to be closed.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Similarly, the versatility of island flaps means that dermatological surgeons are generally comfortable performing them, since the design is useful in other areas of the face. Li et al.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> used the traditional island flap or variants thereof (e.g., the transposition island flap) in 80 patients with relatively large and deep defects on the nose, lip, and cheek, achieving favorable results in more than 90% of cases. Kimyai-Asadi and Goldberg<a class="elsevierStyleCrossRef" href="#bib0015">3</a> review key aspects of the anatomy and vascularization of this flap and propose additional variants, also at other sites, such as tunneling, which we do not feel is a suitable option for the upper lip, since it can result in a marked trapdoor effect. However, various authors<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> present images showing that in the case of the upper lip, not extending the defect towards the natural lines mentioned above can lead to horizontal scars in the middle of this anatomical subunit. The subtle difference observed by sacrificing adjacent healthy tissue in order to reach the borders of the upper lip, which is particularly easy in large defects,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> is fundamental.Other options for reconstruction include the melolabial transposition flap, the cheek advancement flap, the subcutaneous tunneled pedicle flap, or transposition-advancement flaps from another area of the upper lip.<a class="elsevierStyleCrossRefs" href="#bib0035">7–9</a> These options are second choice owing to the distortion or loss of symmetry in the nasolabial fold, the fact that they do not spare aesthetic units, alteration of the moustache (men), or resulting trapdoor effect. However, they may be considered in large defects including the upper lip adjacent to the commissure when a subcutaneous island pedicle flap is impossible. Grafts should generally not be used at this site, since in addition to the unsatisfactory cosmetic effect, they carry a high risk of retraction that may hamper functionality in the area. Finally, in defects that, besides the upper lip, involve neighboring anatomical areas, the subcutaneous island pedicle flap can be combined with other flaps. Furthermore, the advancement-rotation flap can be designed from both sides (bilateral) in the case of large centrally located defects including the philtrum and the nasal vestibule.ConclusionThe subcutaneous island pedicle flap enables simple reconstruction of many surgical defects affecting the upper lip where direct closure is not possible. Its functional and cosmetic outcomes are satisfactory, with preservation of the orbicular muscle. In addition, scars can be hidden in natural folds, with maintenance of symmetry in the nasolabial fold, philtrum, and lip.Conflicts ofinterestThe authors declare that they have no conflicts of interest." 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We describe a series of 15 patients (7 men and 8 women; mean age, 65.6 years) with skin cancer on the upper lip treated with Mohs surgery: 10 basal cell carcinomas, 2 melanomas, and 3 squamous cell carcinomas. The resulting defects measured between 3 and 7.6 cm. We used island flaps to reconstruct the defects in all cases, hiding the incisions in the nasolabial fold, at the line where the skin meets the vermillion border of the lip, and in the relaxed skin tension lines. We explain key aspects of the surgeries and design of the reconstructions, with emphasis on the importance of occasionally sacrificing small areas of healthy skin. Cosmetic and functional outcomes were satisfactory in all patients, and there were no postsurgical complications." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La reconstrucción del labio superior tras la cirugía de Mohs supone, en ocasiones, un reto para el cirujano dermatológico. Presentamos una serie de 15 pacientes (7 hombres y 8 mujeres; edad media 65,6 años) con cáncer cutáneo (10 carcinomas basocelulares, 2 melanomas y 3 carcinomas escamosos) localizados en el labio superior intervenidos mediante cirugía de Mohs con defectos resultantes de 3-7.6 cm. Para la reconstrucción se empleó un colgajo en isla del labio superior diseñado escondiendo las incisiones en el pliegue nasolabial, en la línea de unión del bermellón con la piel y en las líneas de tensión de la piel relajada. Se explican las claves del diseño y la cirugía, enfatizando en la importancia de sacrificar en ocasiones pequeñas zonas de tejido sano. Se alcanzaron resultados satisfactorios cosméticos y funcionales, sin complicaciones postquirúrgicas en todos los pacientes." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Tomás-Velázquez A, Redondo P. Colgajo en isla del labio superior: claves fundamentales y serie de casos. Actas Dermosifiliogr. 2021;112:171–175." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1545 "Ancho" => 2163 "Tamanyo" => 394592 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Design, surgical technique, and outcome based on 2 representative cases. Case 4. A, Basal cell carcinoma on the upper lip. B, Definition of the tumor with a margin to be excised using Mohs surgery and adaptation of the defect so that it reaches the nasolabial fold and the line where the skin of the upper lip meets the vermillion border. C, Final defect after removal with free borders and excision of the upper and lower healthy skin. Design of the flap following the nasolabial fold and the line where the skin of the upper lip meets the vermillion border, with both lines finishing at the angle of the natural wrinkles in the oral commissure. D and E, Sutured flap with simple stitches (silk 6/0). The upper and lower scars are hidden in natural lines and the medial scar is vertical, parallel to the wrinkles. F, Appearance at removal of the stitches 7 days after surgery. Case 6. G, Basal cell carcinoma on the right upper lip. H, Image of the flap, which, after being worked in the subcutaneous plane by maintaining a central subcutaneous pedicle that guarantees the blood supply, advances toward the defect. The lesion had previously been removed using Mohs surgery. I, Outcome 6 months after the procedure." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "All defects were reconstructed using a subcutaneous island pedicle flap on the upper lip.Abbreviations: BCC, basal cell carcinoma; F, female; M, male; SCC, squamous cell carcinoma." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Patient Case/Age/Sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Neoplasm \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Size of Defect, cm \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><elsevierMultimedia ident="202102100800020671"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 / 60 / M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 × 1.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 / 73 / F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.5 × 2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 / 40 / M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 × 2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 / 59 / F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.6 × 2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 / 75/ M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Center-medial right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.5 × 2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 / 68 / F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Center-medial left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 × 2.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 / 76 / F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.3 × 2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 / 58 / F<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Center-medial left  + nasal ala \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 × 2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 / 70 / F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 × 2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 / 52 / F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Central left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 × 1.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 / 63 / M<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medial bilateral + columella \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 × 2.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 / 78 / M<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medial bilateral + tip of the nose and columella + cheek \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.3 × 2.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 / 73 / F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SCC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medial left \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.8 × 1.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 / 70 / M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Melanoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Center-medial right \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 × 1.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; 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Liu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.sap.0000221639.76906.3a" "Revista" => array:7 [ "tituloSerie" => "Ann Plast Surg" "fecha" => "2006" "volumen" => "57" "paginaInicial" => "255" "paginaFinal" => "259" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16929189" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109709027570" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Island pedicle flap" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Kimyai-Asadi" 1 => "L.H. Goldberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.det.2004.07.001" "Revista" => array:6 [ "tituloSerie" => "Dermatol Clin" "fecha" => "2005" "volumen" => "23" "paginaInicial" => "113" "paginaFinal" => "127" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15620623" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A regional approach to reconstruction of the upper lip" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J.A. Zitelli" 1 => "D.G. Brodland" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1524-4725.1991.tb01607.x" "Revista" => array:7 [ "tituloSerie" => "J Dermatol Surg Oncol" "fecha" => "1991" "volumen" => "17" "paginaInicial" => "143" "paginaFinal" => "148" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2002159" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0735109717370870" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lip reconstruction after Mohs cancer excision: lessons learned from 615 consecutive cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Sanniec" 1 => "M. Harirah" 2 => "J.F. Thornton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PRS.0000000000006509" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2020" "volumen" => "145" "paginaInicial" => "533" "paginaFinal" => "542" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31985654" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Closure of large surgical defects on the cutaneous upper lip using an island pedicle flap" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.L. Ray" 1 => "C.H. Weinberger" 2 => "P.K. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1524-4725.2010.01570.x" "Revista" => array:7 [ "tituloSerie" => "Dermatol Surg" "fecha" => "2010" "volumen" => "36" "paginaInicial" => "931" "paginaFinal" => "934" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20482734" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S073510971636421X" "estado" => "S300" "issn" => "07351097" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reconstruction of perioral defects post-Mohs micrographic surgery: a dermatological surgeon’s approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Hafiji" 1 => "W. Hussain" 2 => "P. 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Zide" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PRS.0000000000005279" "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "2019" "volumen" => "143" "paginaInicial" => "572" "paginaFinal" => "582" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30688905" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The transposition advancement flap for repair of postsurgical defects on the upper lip" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.M. 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Island Flap for Upper-Lip Reconstruction: Analysis of Key Aspects and a Case Series

Colgajo en isla del labio superior: claves fundamentales y serie de casos

A. Tomás-Velázquez

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atomasv@unav.es

Corresponding author.

, P. Redondo

Departamento de Dermatología, Clínica Universidad de Navarra, Pamplona y Madrid, Spain

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    "titulo" => "Island Flap for Upper-Lip Reconstruction&#58; Analysis of Key Aspects and a Case Series"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Design&#44; surgical technique&#44; and outcome based on 2 representative cases&#46; <span class="elsevierStyleItalic">Case 4</span>&#46; A&#44; Basal cell carcinoma on the upper lip&#46; B&#44; Definition of the tumor with a margin to be excised using Mohs surgery and adaptation of the defect so that it reaches the nasolabial fold and the line where the skin of the upper lip meets the vermillion border&#46; C&#44; Final defect after removal with free borders and excision of the upper and lower healthy skin&#46; Design of the flap following the nasolabial fold and the line where the skin of the upper lip meets the vermillion border&#44; with both lines finishing at the angle of the natural wrinkles in the oral commissure&#46; D and E&#44; Sutured flap with simple stitches &#40;silk 6&#47;0&#41;&#46; The upper and lower scars are hidden in natural lines and the medial scar is vertical&#44; parallel to the wrinkles&#46; F&#44; Appearance at removal of the stitches 7 days after surgery&#46; <span class="elsevierStyleItalic">Case 6</span>&#46; G&#44; Basal cell carcinoma on the right upper lip&#46; H&#44; Image of the flap&#44; which&#44; after being worked in the subcutaneous plane by maintaining a central subcutaneous pedicle that guarantees the blood supply&#44; advances toward the defect&#46; The lesion had previously been removed using Mohs surgery&#46; I&#44; Outcome 6 months after the procedure&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The upper lip is a common site for skin cancer&#46; Reconstruction of the upper lip may be hampered by the limited availability of adjacent tissue and the by the functional and cosmetic importance of this anatomic unit&#46; Options for reconstructive surgery depend on the size&#44; location&#44; and depth of the lesion&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Preservation of the function and appearance of the upper lip during reconstruction surgery must take into account the following&#58; &#40;<span class="elsevierStyleItalic">1</span>&#41; Maintenance of symmetry in the nasolabial fold and the upper lip&#59; &#40;<span class="elsevierStyleItalic">2</span>&#41; Sparing or reconstruction of the philtrum and Cupid&#8217;s bow without displacement&#59; &#40;<span class="elsevierStyleItalic">3</span>&#41; Avoidance of creases at the line where the skin meets the vermillion border&#59; &#40;<span class="elsevierStyleItalic">4</span>&#41; Avoidance of eclabium or upward traction on the vermillion border&#59; and &#40;<span class="elsevierStyleItalic">5</span>&#41; Avoidance of horizontal scars by hiding incisions in natural folds or following relaxed tension lines or wrinkles&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In our experience&#44; the subcutaneous island pedicle flap on the upper lip fulfills these norms and enables successful reconstruction of most defects at this site&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of the present study was to review a series of patients who underwent reconstructive surgery in the upper lip based on an island flap and to describe and illustrate the surgical technique&#44; taking into account basic practical considerations&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">We reviewed the clinical history and imaging data available for patients who underwent reconstruction surgery based on an island flap in the Dermatology Department of Cl&#237;nica Universidad de Navarra&#44; Pamplona&#44; Spain between 2015 and 2019&#46; Cosmetic and functional outcomes were evaluated independently by 2 dermatologists&#44; and patients were asked about their satisfaction with the outcome&#46; The study was approved by the Ethics Committee of Universidad de Navarra&#44; and the patients provided their informed consent&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We selected 15 patients &#40;7 men and 8 women&#44; with a mean age of 65&#46;6 years &#91;range&#44; 40-78 years&#93;&#41;&#46; The patients had had different types of skin cancer affecting the upper lip &#40;basal cell carcinoma&#44; 10 cases&#59; melanoma&#44; 2 cases&#59; squamous cell carcinoma&#44; 3 cases&#41; that were treated with Mohs micrographic surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Each half of the upper lip &#40;left and right&#41; was divided into 3 parts &#40;medial&#44; central&#44; and lateral&#41; in order to describe the location of the defects &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Surgical Technique</span><p id="par0040" class="elsevierStylePara elsevierViewall">All of the patients had undergone Mohs micrographic surgery under local anesthetic &#40;bupivacaine 0&#46;5&#37;&#41;&#44; with resulting defects measuring from 3 to 7&#46;6&#8239;cm<span class="elsevierStyleSup">2</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The steps for making the flap and reconstruction were as follows &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0050" class="elsevierStylePara elsevierViewall">Reconstruction started with adaptation of the final defect&#46; It is essential for this to extend beyond the nasolabial fold and below the line where the skin meets the vermillion border&#46; When this is not the case&#44; a surgical skin marker can be used to draw the areas of healthy skin to be removed in order to adapt the defect and remove it&#46; This first step makes it possible to achieve a more favorable cosmetic outcome&#44; since it enables scars to be hidden in natural folds or lines&#44; thus avoiding horizontal scars&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0055" class="elsevierStylePara elsevierViewall">The island flap is designed&#46; Using a surgical skin marker&#44; a triangular flap is drawn&#59; the medial part of the flap contains the defect&#46; The upper part lies in the nasolabial fold and the lower part where the skin meets the vermillion border&#44; in such a way that both lines converge on the natural wrinkles in the oral commissure&#46; The size of the flap depends on the lines that delimit it&#46; However&#44; when the defect is larger&#44; the upper side of the triangle can be extended with a line parallel to the nasolabial fold on the cheek&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0060" class="elsevierStylePara elsevierViewall">The incisions are then made with a cold scalpel by marking out the design&#46; The flap is cut and worked at the level of the subcutaneous tissue above the orbicular muscle&#46; A subcutaneous pedicle must be maintained&#46; This should be sufficiently thick to enable adequate vascularization of the flap and&#44; at the same time&#44; mobile in order to facilitate the advancement of the tissue&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0065" class="elsevierStylePara elsevierViewall">Once adequate hemostasis has been achieved&#44; the flap is advanced&#44; and the wound is closed&#46; The medial sutures are placed &#40;normally first with an anchor at a reference point in the center of the medial side&#41;&#44; followed by the remaining sutures&#46; Subcutaneous stitches are placed first &#40;Novosyn 4&#47;0&#41;&#44; followed by tension-free stitches &#40;silk 6&#47;0&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0070" class="elsevierStylePara elsevierViewall">The secondary defect is closed directly using a V-Y technique&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0075" class="elsevierStylePara elsevierViewall">A slightly compressive dressing is placed&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In 3 cases&#44; the reconstruction involved variations owing to the larger size and&#47;or location of the lesion&#46; A bilateral island pedicle flap was placed in 2 cases &#40;one by combining an advancement flap from the cheek and the other by combining the unilateral flap with a paramedian forehead flap to reconstruct the nasal ala&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">All of the flaps progressed satisfactorily without acute complications such as bleeding&#44; infection&#44; or necrosis and without the need for correction of scars&#46; Postoperative follow-up was from 6 to 34 months&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The functional and cosmetic outcomes were satisfactory&#44; both for the dermatologist and for the patient in all cases&#46; Slight eversion of the upper lip was recorded in 1 case&#46; In functional terms&#44; mouth opening and upper lip mobility remained intact&#44; and paresthesia was reported in the area in 4 cases during the days after the procedure&#44; although this resolved after a few weeks&#46; In cosmetic terms&#44; the scars were hidden in natural lines&#44; as follows&#58; upper scar&#44; in the nasolabial fold&#59; lower scar&#44; at the line where the skin meets the vermillion border&#59; closure of the V-Y advancement flap&#44; wrinkles of the oral commissure&#59; and medial border&#44; in a vertical scar hidden among the vertical wrinkles on the upper lip&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Large defects following Mohs surgery on the upper lip make reconstruction challenging because of the cosmetic and functional importance of this area&#46; Local flaps are the main option for defects where direct closure is not possible&#46; In most cases&#44; we believe that the subcutaneous island pedicle flap of the upper lip is the reconstructive option of choice&#44; taking into account a few basic considerations&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">As commented on above&#44; a key consideration is that of adapting the defect&#46; It is not uncommon to find designs in which this flap has horizontal scars in the middle of the upper lip&#46; This occurs when the area of healthy tissue between the defect and the nasolabial fold &#40;above&#41; and&#47;or between the defect and the vermillion border &#40;below&#41; is not sacrificed&#46; Whenever possible&#44; horizontal scars on the upper lip should be avoided&#44; since they run contrary to the wrinkles and relaxed tension lines&#44; resulting in a very poor cosmetic appearance&#46; The simple maneuver of removing a small amount of neighboring healthy tissue makes it possible to hide curved scars in the nasolabial fold and the vermillion border and enables the scar to run into the natural wrinkles of the oral commissure&#46; The medial scar&#44; on the other hand&#44; is vertical and runs parallel to the philtrum and wrinkles&#46; In addition&#44; this flap enables reconstruction with skin of the same characteristics as that removed&#59; this is essential in men&#44; as it ensures that hairy skin and&#44; therefore&#44; the appearance of the moustache&#44; are maintained&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The flap used here is an advancement-rotation flap&#44; which is easily designed and performed and enables the expression and appearance of the upper lip to be maintained and large defects to be closed&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Similarly&#44; the versatility of island flaps means that dermatological surgeons are generally comfortable performing them&#44; since the design is useful in other areas of the face&#46; Li et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> used the traditional island flap or variants thereof &#40;e&#46;g&#46;&#44; the transposition island flap&#41; in 80 patients with relatively large and deep defects on the nose&#44; lip&#44; and cheek&#44; achieving favorable results in more than 90&#37; of cases&#46; Kimyai-Asadi and Goldberg<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> review key aspects of the anatomy and vascularization of this flap and propose additional variants&#44; also at other sites&#44; such as tunneling&#44; which we do not feel is a suitable option for the upper lip&#44; since it can result in a marked trapdoor effect&#46; However&#44; various authors<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> present images showing that in the case of the upper lip&#44; not extending the defect towards the natural lines mentioned above can lead to horizontal scars in the middle of this anatomical subunit&#46; The subtle difference observed by sacrificing adjacent healthy tissue in order to reach the borders of the upper lip&#44; which is particularly easy in large defects&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> is fundamental&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Other options for reconstruction include the melolabial transposition flap&#44; the cheek advancement flap&#44; the subcutaneous tunneled pedicle flap&#44; or transposition-advancement flaps from another area of the upper lip&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a> These options are second choice owing to the distortion or loss of symmetry in the nasolabial fold&#44; the fact that they do not spare aesthetic units&#44; alteration of the moustache &#40;men&#41;&#44; or resulting trapdoor effect&#46; However&#44; they may be considered in large defects including the upper lip adjacent to the commissure when a subcutaneous island pedicle flap is impossible&#46; Grafts should generally not be used at this site&#44; since in addition to the unsatisfactory cosmetic effect&#44; they carry a high risk of retraction that may hamper functionality in the area&#46; Finally&#44; in defects that&#44; besides the upper lip&#44; involve neighboring anatomical areas&#44; the subcutaneous island pedicle flap can be combined with other flaps&#46; Furthermore&#44; the advancement-rotation flap can be designed from both sides &#40;bilateral&#41; in the case of large centrally located defects including the philtrum and the nasal vestibule&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The subcutaneous island pedicle flap enables simple reconstruction of many surgical defects affecting the upper lip where direct closure is not possible&#46; Its functional and cosmetic outcomes are satisfactory&#44; with preservation of the orbicular muscle&#46; In addition&#44; scars can be hidden in natural folds&#44; with maintenance of symmetry in the nasolabial fold&#44; philtrum&#44; and lip&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts ofinterest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1332881"
          "palabras" => array:6 [
            0 => "Labio superior"
            1 => "Colgajo en isla"
            2 => "Colgajo de ped&#237;culo subcut&#225;neo"
            3 => "C&#225;ncer cut&#225;neo"
            4 => "Cirug&#237;a"
            5 => "Reconstrucci&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Upper-lip reconstruction after Mohs micrographic surgery is challenging for dermatologic surgeons&#46; We describe a series of 15 patients &#40;7 men and 8 women&#59; mean age&#44; 65&#46;6 years&#41; with skin cancer on the upper lip treated with Mohs surgery&#58; 10 basal cell carcinomas&#44; 2 melanomas&#44; and 3 squamous cell carcinomas&#46; The resulting defects measured between 3 and 7&#46;6&#8239;cm&#46; We used island flaps to reconstruct the defects in all cases&#44; hiding the incisions in the nasolabial fold&#44; at the line where the skin meets the vermillion border of the lip&#44; and in the relaxed skin tension lines&#46; We explain key aspects of the surgeries and design of the reconstructions&#44; with emphasis on the importance of occasionally sacrificing small areas of healthy skin&#46; Cosmetic and functional outcomes were satisfactory in all patients&#44; and there were no postsurgical complications&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La reconstrucci&#243;n del labio superior tras la cirug&#237;a de Mohs supone&#44; en ocasiones&#44; un reto para el cirujano dermatol&#243;gico&#46; Presentamos una serie de 15 pacientes &#40;7 hombres y 8 mujeres&#59; edad media 65&#44;6 a&#241;os&#41; con c&#225;ncer cut&#225;neo &#40;10 carcinomas basocelulares&#44; 2 melanomas y 3 carcinomas escamosos&#41; localizados en el labio superior intervenidos mediante cirug&#237;a de Mohs con defectos resultantes de 3-7&#46;6&#8239;cm&#46; Para la reconstrucci&#243;n se emple&#243; un colgajo en isla del labio superior dise&#241;ado escondiendo las incisiones en el pliegue nasolabial&#44; en la l&#237;nea de uni&#243;n del bermell&#243;n con la piel y en las l&#237;neas de tensi&#243;n de la piel relajada&#46; Se explican las claves del dise&#241;o y la cirug&#237;a&#44; enfatizando en la importancia de sacrificar en ocasiones peque&#241;as zonas de tejido sano&#46; Se alcanzaron resultados satisfactorios cosm&#233;ticos y funcionales&#44; sin complicaciones postquir&#250;rgicas en todos los pacientes&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Tom&#225;s-Vel&#225;zquez A&#44; Redondo P&#46; Colgajo en isla del labio superior&#58; claves fundamentales y serie de casos&#46; Actas Dermosifiliogr&#46; 2021&#59;112&#58;171&#8211;175&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1545
            "Ancho" => 2163
            "Tamanyo" => 394592
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Design&#44; surgical technique&#44; and outcome based on 2 representative cases&#46; <span class="elsevierStyleItalic">Case 4</span>&#46; A&#44; Basal cell carcinoma on the upper lip&#46; B&#44; Definition of the tumor with a margin to be excised using Mohs surgery and adaptation of the defect so that it reaches the nasolabial fold and the line where the skin of the upper lip meets the vermillion border&#46; C&#44; Final defect after removal with free borders and excision of the upper and lower healthy skin&#46; Design of the flap following the nasolabial fold and the line where the skin of the upper lip meets the vermillion border&#44; with both lines finishing at the angle of the natural wrinkles in the oral commissure&#46; D and E&#44; Sutured flap with simple stitches &#40;silk 6&#47;0&#41;&#46; The upper and lower scars are hidden in natural lines and the medial scar is vertical&#44; parallel to the wrinkles&#46; F&#44; Appearance at removal of the stitches 7 days after surgery&#46; <span class="elsevierStyleItalic">Case 6</span>&#46; G&#44; Basal cell carcinoma on the right upper lip&#46; H&#44; Image of the flap&#44; which&#44; after being worked in the subcutaneous plane by maintaining a central subcutaneous pedicle that guarantees the blood supply&#44; advances toward the defect&#46; The lesion had previously been removed using Mohs surgery&#46; I&#44; Outcome 6 months after the procedure&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">All defects were reconstructed using a subcutaneous island pedicle flap on the upper lip&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; BCC&#44; basal cell carcinoma&#59; F&#44; female&#59; M&#44; male&#59; SCC&#44; squamous cell carcinoma&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Patient Case&#47;Age&#47;Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Neoplasm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Size of Defect&#44; cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><elsevierMultimedia ident="202102100800020671"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#47; 60 &#47; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#8239;&#215;&#8239;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#47; 73 &#47; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;5&#8239;&#215;&#8239;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#47; 40 &#47; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8239;&#215;&#8239;2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#47; 59 &#47; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;6&#8239;&#215;&#8239;2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#47; 75&#47; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Center-medial right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;5&#8239;&#215;&#8239;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#47; 68 &#47; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Center-medial left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;7&#8239;&#215;&#8239;2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#47; 76 &#47; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;3&#8239;&#215;&#8239;2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#47; 58 &#47; F<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Center-medial left &#8239;&#43;&#8239;nasal ala&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8239;&#215;&#8239;2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#47; 70 &#47; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&#8239;&#215;&#8239;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#47; 52 &#47; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#8239;&#215;&#8239;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#47; 63 &#47; M<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Medial bilateral&#8239;&#43;&#8239;columella&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8239;&#215;&#8239;2&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#47; 78 &#47; M<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Medial bilateral&#8239;&#43;&#8239;tip of the nose and columella&#8239;&#43;&#8239;cheek&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;3&#8239;&#215;&#8239;2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#47; 73 &#47; F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Medial left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;8&#8239;&#215;&#8239;1&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#47; 70 &#47; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Melanoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Center-medial right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#8239;&#215;&#8239;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#47; 70 &#47; M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Center-medial right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;8&#8239;&#215;&#8239;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Información del artículo

ISSN: 15782190
Idioma original: Inglés

DOI:10.1016/j.adengl.2020.12.017

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