Case Competition 2024 – All submitted cases Case 15 Staircase flap reconstruction of the lower lip
Keywords: Staircase flap, Bengt Johansson flap, Lower lip reconstruction
Authors: Theresia Skytte Eriksen (MD) and Camilla Asklund (MD). Herlev University Hospital, Denmark
A 58-year-old man was referred to the Department of Plastic Surgery with a recurrence of squamous cell carcinoma of the lower lip. In 2007 an excision of a keratoacanthoma of the lower lip was performed and the excision margins was initially not evaluated. In the past 6 months the patient has noticed a progressing mass in the scar tissue. A wedge-shaped excision biopsy confirmed the diagnosis: recurrence of squamous cell carcinoma. He was a long-time smoker and in treatment with anticoagulant medicine.
Before and after
Patient examination
At the preoperative examination the tumor was described as a 10x10x10 mm mass in the current scar tissue. Because of two former excisions of the lower lip the total length of the lip was found to be approximately 60 mm. No pathological lymph nodes were found by palpation of the head and neck.
Pre-Operative Considerations
Different treatment options were considered including surgery and radiation therapy. The patient was examined by a radiation oncologist and a plastic surgeon and thereby thoroughly informed on the different options. Surgical considerations included the length of the lip, obtaining free margins before reconstruction, type of reconstruction and postoperative precautions. The operative solution was chosen and surgery with frozen section histology and reconstruction with staircase flap (also known as Bengt Johansson flap) was planned. His anticoagulant treatment with Clopidogrel was paused 5 days preoperatively and he was urged to stop smoking.
Step 1: Excision of tumor
Excision was performed with 10 mm margin after sending frozen section to histology. Perioperatively 2 g cloxacillin was given intravenously.
Step 2: Design of the staircase flap (aka Bengt Johansson flap)
Because of a paramedian defect the flap was designed so that the tissue needed to close the defect was unequally added from each side of the mentolabial crease. The total length of the defect (marked red) needs to be equal to the total length of the tissue added from the two sides combined (the two blue lines). The stairs ‘steps’ and ending triangle are tiled in such a manner that the scar will follow the mentolabial crease and the stair formation thereby will be minimized or non-existing. The optimal dimensions of the ‘steps’ is 10 x 8 mm. The blue lines are incised through the muscle leaving only the mucosa intact for maximum movement of the flap. The green retangles and triangles are incised through the dermis and removed.
Step 3: Reconstruction
After the frozen sections was cleared by the pathologist the flap was raised along the perioperative drawings and approximated to close the defect. The tissue was sutured in multiple layers. For muscle closure 4-0 PDS was used. Mucosa was closed with 5-0 Novosyn rapid uncolored suture. A few dermal stiches with 4-0 Novosyn was applied and afterwards the skin was closed with 5-0 nylon single sutures.
Step 4: Removal of stiches
The stiches were removed 10 days postoperative. The patient has healed nicely and without any complications. Final histology showed well-differentiated squamous cell carcinoma with free margins. No perineural or vascular invasion was detected. 3 weeks after surgery the patient reported no discomfort or pain in relation to the lower lip or chin.
Post-Operative Plan
The first 24 hours the patient was only allowed to intake cold liquid diet. Afterwards his diet contained of liquid to soft progressing towards normal diet after 10 days. After intake of food and drinks, the patient was instructed to rinse his mouth with sparkling water. Furthermore, he was informed to minimize physical activities, talking and facial expressions the first 10 days. He continued antibiotic treatment 3 days postoperative. The patient has a follow-up consultation 3 months postoperative (incl. UL of the head and neck).
- Reconstruction of the lips can be challenging both aesthetically and functionally for any plastic surgeon. The Bengt Johansson flap can provide an aesthetically and functionally good result in relation to sensibility, motility, symmetry, and length of the lower lip and thereby minimize microstomia.
- By designing the flap tilted along the mentolabial crease the scar will align with the crease and visionally be almost unnoticeable.
- If perineural invasion, or poorly differentiated histology with close margins is detected, postoperative radiation therapy can be considered.
- There is a considerable probability that the patient will end up with microstomia. In this case the probability was especially high due to the preexisting shortening of the lower lip following two previously surgeries.
- When larger reconstruction is preformed free histological margins are important. The frozen section histology gives us some indications perioperatively, but final histology is first obtained weeks postoperatively.
- The probability of complications in terms of poor healing was high because of the patients long-term smoking history.
- Furthermore, considerations about patient compliance regarding postop regime is important when flap reconstruction of the lip is performed.
