Lip Reconstruction (Melanoma In Situ)

Lip Reconstruction (Melanoma In Situ) — Surgical Case Study

Overview

This case describes the surgical management of a melanoma in situ (lentigo maligna subtype) of the upper lip in a fit and well man in his 70s. The lesion involved the vermilion-cutaneous junction — a functionally and anatomically critical boundary — and its management required balancing the oncological priority of complete excision against the reconstructive priority of preserving a competent and mobile upper lip. The lesion presented as a variegated pigmented patch of the left upper lip extending across the vermilion-cutaneous junction. Diagnostic biopsy confirmed melanoma in situ, lentigo maligna type. The patient was otherwise fit and well, with no features to suggest invasive disease or regional spread, and the treatment goal was complete excision of the in situ melanoma with a single-stage reconstruction planned around smile symmetry and oral competence.

Preoperative assessment & clinical findings

Detailed clinical and histopathological evaluation identified the following features:

The lesion

• Variegated pigmented lesion of the left upper lip, with irregular pigmentation characteristic of lentigo maligna
• Extension across the vermilion-cutaneous junction, involving both cutaneous and vermilion components of the upper lip
• Diagnostic biopsy confirming melanoma in situ, lentigo maligna subtype, with no evidence of dermal invasion

Functional & reconstructive considerations

• The lesion occupied a subunit of the upper lip such that adequate excision would encompass approximately one third of the upper lip width
• Involvement of the vermilion-cutaneous junction, where precise realignment is required for an acceptable result
• Requirement to preserve orbicularis oris continuity, oral competence, and symmetric smile function
• Otherwise fit and well, with no comorbidity precluding single-stage excision and flap reconstruction under the planned anaesthetic

Regional assessment

• No clinically palpable cervical or facial lymphadenopathy
• No clinical or histological features suggesting invasive melanoma requiring sentinel lymph node biopsy or wider oncological staging

Operative plan & surgical decision-making

The surgical plan was designed to achieve complete excision of the melanoma in situ while restoring a functional upper lip in a single operative episode. Two decisions defined the plan: the extent of excision, and the method of reconstruction. Excision was planned as a full-thickness wedge of the upper lip, encompassing the lesion and its vermilion-cutaneous component with a defined 7 mm peripheral surgical margin. The wedge involved approximately one third of the upper lip. This margin was chosen deliberately, and is directly supported by the evidence base for head and neck lentigo maligna. In a retrospective case series of 379 patients with head and neck lentigo maligna from Melanoma Institute Australia, a surgical margin of ≥6.5 mm (corresponding to a pathological margin of ≥3 mm) was associated with a local recurrence rate of 2.6%, compared with 27% where the margin was <6.5 mm (pathological margin <3 mm) (Crouch et al., 2021, European Journal of Surgical Oncology). My preference is for a 7 mm surgical margin, which reliably achieves a histological margin of ≥3 mm. In the anatomically constrained lip, this defined margin achieves reliable oncological clearance while avoiding an unnecessarily wide excision that would increase the reconstructive burden without demonstrated benefit. Reconstruction was planned as a Karapandzic flap — a neurovascular, musculocutaneous rotation-advancement flap that recruits the remaining orbicularis oris to reconstitute a continuous, innervated, and competent oral sphincter. To support the functional result, the plan incorporated cranial orbicularis resuspension and a caudal Z-plasty at the vermilion border.

Procedure performed

Wedge excision of the upper lip

A full-thickness wedge excision of the left upper lip was performed, removing the pigmented lesion together with its vermilion-cutaneous component. The excision was taken with a 7 mm margin and encompassed approximately one third of the upper lip. Margins were oriented and marked for histopathological assessment to confirm complete excision of the in situ melanoma.

Karapandzic flap reconstruction

The defect was reconstructed with a Karapandzic flap. Circumoral incisions were designed to preserve the neurovascular pedicles supplying and innervating the orbicularis oris, allowing the residual muscle to be mobilised and rotated into the defect as a functional, sensate unit. This reconstitutes a continuous oral sphincter rather than simply closing the skin, which is central to maintaining oral competence and dynamic smile function.

Orbicularis resuspension — cranial

Cranial resuspension of the orbicularis oris was performed to re-establish the vertical support of the reconstructed lip, counteracting the downward vector of the rotated flap and preserving upper lip height and philtral balance.

Z-plasty — caudal

A Z-plasty was performed caudally at the vermilion border to break up the vertical scar line, realign the vermilion-cutaneous junction precisely, and prevent notching or a straight-line contracture across this critical boundary.

Margin confirmation

Histopathological examination confirmed that excision of the melanoma in situ was complete, with clear margins. No invasive component was identified.

Results — 3 months postoperative

At three months postoperatively, the reconstructed upper lip had healed satisfactorily, with the following features noted:

• Complete oncological clearance — histology confirmed complete excision of the melanoma in situ, with clear margins
• Oral competence maintained — the reconstructed orbicularis sphincter provided a competent seal without drooling or incompetence
• Preserved smile function — dynamic function of the lip was preserved, with no significant asymmetry at rest or in animation
• Preserved lip height and contour — cranial orbicularis resuspension maintained upper lip vertical height and philtral balance
• Well-aligned vermilion border — the caudal Z-plasty realigned the vermilion-cutaneous junction with no notching or step-off
• Scar maturation progressing — circumoral scars settled along anatomical boundaries and continued to mature

The combination of a defined, function-preserving excision margin and a neurovascular flap reconstruction achieved the dual goals of oncological completeness and functional lip preservation in a single operation.

Photographic comparison

Standardised clinical photography: immediately preoperative, immediately postoperative, and 3 months postoperative.

IMMEDIATELY PREOPERATIVE

IMMEDIATELY POSTOPERATIVE

3 MONTHS POSTOPERATIVE

Frontal view shown. Additional views available on request.

Surgical technique summary

Evidence base & references

The margin chosen for this excision is grounded in the largest contemporary series addressing surgical margins for head and neck lentigo maligna (melanoma in situ). In a retrospective case series of 379 patients from Melanoma Institute Australia, a surgical margin of ≥6.5 mm — corresponding to a pathological (histological) margin of ≥3 mm — was associated with a local recurrence rate of 2.6%, compared with 27% where the surgical margin was <6.5 mm (pathological margin <3 mm). On this basis, my preference for lentigo maligna of the lip is a 7 mm surgical margin, which reliably delivers a histological margin of ≥3 mm while remaining as tissue-sparing as the oncology allows in this functionally critical region. References: Crouch G, Sinha S, Lo S, Saw RPM, Lee KK, Stretch J, Shannon K, Guitera P, Scolyer RA, Thompson JF, Ch’ng S. Clinical outcomes following surgical treatment of lentigo maligna of the head and neck. Eur J Surg Oncol. 2021 May;47(5):1145–1151. doi:10.1016/j.ejso.2020.09.028. PMID: 33023795. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J Plast Surg. 1974;27(1):93–97 — the original description of the neurovascular circumoral flap employed in this reconstruction.

AHPRA Compliance Notice: This case study is intended for general information purposes only. Individual outcomes vary, as the result experienced by one person does not necessarily reflect the result another person may experience. All surgical procedures carry risks and require a recovery period. Results shown are specific to this patient and cannot be guaranteed for others. Surgery should only be considered after thorough consultation with an appropriately qualified Specialist Plastic Surgeon, and a second opinion is encouraged. Full information on the risks of surgery and recovery is available on our risks of surgery page. This content does not constitute medical advice.

Dr David Sparks — Specialist Plastic Surgeon | FRACS (Plast.) | MED0001863770 | The Coastal Clinic, Southport QLD | Fraser-Kirk Plastic Surgery, Sunshine Coast QLD