A modified Goldstein flap for leishmaniasis sequelae of the upper lip

Introduction

The red lip, also named vermilion, is an area that is distinguished by its morphology and unique texture compared to the rest of the body, which limits the possibilities of its repair. In order to meet the principle of aesthetic repair “using an area with similar characteristics and close to the defect”, the lower lip is commonly used as a donor site area. However, this results in a narrowing of the mouth, or microstomy, which is the major drawback of this surgical procedure [1]. On the other hand, some vermilion defects seem to be closed using simple sutures by stretching the edges of the wound, but it causes a flattening of the lip and a reduction or even disappearance of its furrows, which for some, are a mark of beauty.

Objective

This article aims to describe a novel technique to repair a vermillion sequela of leishmaniasis, inspired by the Goldstein flap offering a less invasive procedure without involving the vestibular mucosa.

Clinical case

A 27-year-old female patient consulted us to repair a scar on her upper lip that was even more visible with labial mobility. The scar, due to cutaneous leishmaniasis, left a depressed surface of the vermilion limited on one side by an overlay of the mucosa and disrupting the cutaneo-mucous line (figs. 1, 2). Given the extent of the scar, its excision resulted in a defect which, when repaired by stretching and suturing, would result in a loss of tissue thickness and projection as well as an erasure of the furrows. Our surgical option was inspired by the Goldstein flap and based on the superficial vascular network, as follows.
The surgical repair was carried out under general anaesthesia. The design of the flaps was outlined with a marker pen (fig. 3). The scalpel then passed along the mucocutaneous border of the lip, and the junction of the wet and dry mucosa of the vermillion border after contouring the medial edge of the flap. The depth of the incisions through the skin and the junction of dry and wet mucosa reached a level that involved a split-thickness of the orbicularis muscle without including the wet mucosa. Thus, the labial mucosa on the posterior edge of the lip was not included in the flap. The harvest of the arterialized vermillion flap by splitting the orbicularis muscle was performed while preserving branches of the superior labial artery in the flap. The partial thickness defect following scar excision was thus repaired by the medial translation of two opposite vermillion split-thickness flaps. The orbicularis ring was naturally restored and the dry mucosal texture and grooves were also naturally restored. Otherwise, no postoperative complication had occurred such as retention cyst formation or muscular necrosis. Both, aesthetic and functional results were very satisfying (fig. 4).

Discussion

Cutaneous leishmaniasis is an infectious disease involving various species of leishmania parasites vectored by sandflies. It is considered a serious health problem in the Mediterranean region because it causes scarring on exposed areas of the body, particularly on the face, which can be mutilating and disfiguring with a significant psychological and social impact. Mucocutaneous involvement is rare notably regarding nasal and lip mucosa [2]. The lip area is a pivotal feature of the lower face, particularly the vermilion area, which draws the most attention. This anatomical region reflects the three-dimensional projection of the mouth at rest and in any range of motion. The enhancement of the vermillion adds tremendous beauty to the lips. Therefore, reconstruction should be meticulous taking into consideration its proportionality and specificity, namely its height, thickness, colour and specific furrows [3]. This work intends to provide a new option through the use of a modified vermillion elastic flap, implying a split-thickness of the orbicular muscle without displacing the wet mucosa unlike what was performed by both Goldstein and Sawada [4]. This novel technical repair technique is more suitable for partial thickness defect which avoids intraoral sutures, and thus further specific care, feeding disorder and less infectious risk.
The elastic arterialized vermillion flap described by Goldstein ensures the repair of full-thickness of approximately one-half of the vermillion defect [5]. This flap includes a composite tissue sandwich consisting of orbicularis oris muscle and labial mucosa on the posterior aspect and orbicularis and labial skin on the anterior aspect. However, we harvested a split-thickness flap including a composite tissue of dry vermilion mucosa and only a superficial layer of the orbicularis muscle running above the musculo-mucosal vascular network. This harvesting way is a safe procedure without a risk of tissue necrosis. Indeed, the vascular pattern of the vermillion includes a superficial subcutaneous network involving superficial ascending branches of the superior labial artery and branches of the inferior alar artery and a deep submucosal network supplied by deep ascending branches of the superior labial artery and labial branches of the infraorbital artery. The blood supply of the orbicularis muscle is ensured by small vertical branches from the subcutaneous and submucosal vascular networks. It was described that the superior labial artery runs above the vermilion border on the lateral half of the upper lip, then close to the vermilion border, and enters the muscle along the medial half of the lip. Additionally, radiological research supported by micro-computed tomography exploration showed that the vascular network is based on arteriovenous anastomosis of capillaries in the vermillion area [6]. This vascular pattern enabled the harvest of a split-thickness superficial muscular layer close to the dry mucosa of the vermilion without any vascular impairment. Nevertheless, injury of the superior labial artery should be avoided, mainly when cutting the vermillion border.

Conclusions

The split-thickness vermillion flap is a good alternative for small or large partial-thickness defects of the vermillion based on the superficial layer of the vascular network of the lip. It preserves the particular texture while preserving natural grooves, and avoids its shortening causing microstomia or flattening resulting in projection impairment. Our proposal technique is simple and reliable and provides successful aesthetic and functional results.

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The author declares no conflict of interest.

References