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Presentation

Panel Discussion on Reconstructive Flap Techniques for Lip and Facial Defects

Description

The panel session on reconstructive flap techniques focused on lip and facial defects after Mohs surgery and melanoma excision, emphasizing how preserving the orbicularis oris and restoring oral lining are key to function. For a large full-thickness lip defect, multiple options were discussed, including Carapanzic, S-Lander, bilobed, bilateral rotation, and Burrows advancement-type approaches, with panelists stressing that direct closure or even second-intention healing can sometimes work if the muscle is preserved and the defect is primarily mucosal. The presenter’s actual reconstruction used a bilobed flap to borrow laxity from the jawline and resurface the defect after advancing muscle and mucosa, with good functional and cosmetic outcomes. In a second case involving a lateral upper-lip melanoma defect, the team considered commissuroplasty, buccal mucosal grafts, anteriorly based mucosal flaps, combined local flaps, and second intention; the final approach was to leave the mucosal defect to heal while preserving function, resulting in an excellent long-term result after immunotherapy. The discussion then shifted to a forehead defect, where the panel compared bilobed flaps, A-to-T bilateral advancement, rotation, interpolation flaps, and partial second-intention healing. Throughout, the speakers highlighted how transposition flaps work through Z-plasty-like tissue lengthening, making them useful for redirecting tension and avoiding distortion of free margins such as the brow, nose, and lip.

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Conclusions

The presentation concludes that lip defects are best reconstructed by first restoring the internal functional unit—mucosa and orbicularis oris muscle—before resurfacing the skin with a local flap.
For large or complex lip defects, several approaches can work, including Karapandzic, Estlander, bilobed, bilateral rotation, commissuroplasty, and buccal mucosal graft-based techniques, with choice driven by defect location and available laxity.
The lip is highly forgiving and often can be closed more conservatively than expected, sometimes even allowing second-intention healing when the muscle is preserved.
Preserving the orbicularis oris is central to maintaining lip function and often makes reconstruction easier and outcomes better.
Open or horizontally wide facial defects can sometimes be managed effectively by transposition or advancement patterns that use nearby laxity, such as jawline, cheek, forehead, or scalp donor tissue.
The bilobed flap can be a useful option for some lip and facial defects, but only when the internal defect is properly closed and the flap is used to resurface the area without distorting key margins.
For ill-defined lentigo maligna or other facial melanoma-type defects, Mohs surgery with MART-1 immunostaining can help define margins accurately and permit tissue-sparing reconstruction.
When a defect is too large or strategically located, staged reconstruction such as interpolation flaps can provide reliable coverage and acceptable healing.
A-to-T advancement and other bilateral advancement patterns are effective for broad forehead or scalp defects because they distribute tension and heal well.
Z-plasty is presented as the core geometric mechanism underlying many transposition flaps, because it reorients tissue and lengthens the central axis of the defect.
Bilobed and trilobed flaps are essentially combinations of multiple Z-plasties, explaining how they achieve lengthening while minimizing distortion of free margins.
Understanding the mechanism of transposition flaps helps surgeons choose and design reconstructions that preserve function, reduce distortion, and improve cosmetic outcomes.

Rohrer TE, Kaufman AJ. How Would You Reconstruct It: Masters Panel.
Brodland D. How would you reconstruct this wound?
Rhombic Flaps Work Thanks to the Beauty of the Z-Plasty.
A Bilobe Transposition Flap has 3 Z-plastys.