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Background Failure to perform Mohs micrographic surgery (MMS) meticulously on the nose and lips can lead to larger defects and tumor recurrence, which can have aesthetic and functional repercussions for patients. Objective To review pre-, intra-, and postoperative techniques and pearls for performing MMS on the nose and lips to optimize outcomes. Materials and methods Technical nuances and pearls cultured from the authors' own practice, those acquired from mentors and colleagues, and information identified from the literature are discussed to provide a logical approach to performing effective MMS on the nose and lips. Results When performing MMS on the nose and lips, sound preoperative preparation, precise surgical technique, and particular attention to reducing false-positives and false-negatives while harvesting Mohs layers enhances the fidelity of the MMS procedure, minimizing defect sizes and reducing tumor recurrence. Conclusion Refining Mohs technique on the nose and lips allows more effective performance of tumor extirpation, improved microscopic evaluation, and more conservative reconstruction, leading to better patient outcomes.

BACKGROUND The lips are a common location for skin cancer and thus for Mohs micrographic surgery (MMS). There are few studies looking at second intention healing of Mohs defects of the lips, and none have used a scar assessment scale. OBJECTIVE To evaluate the acceptability of second intention healing of the vermilion lips following MMS using a patient questionnaire and the Patient and Observer Assessment Scale (POSAS). METHODS Eligible patients were found through chart review. A patient questionnaire and the patient scale of the POSAS were performed over the phone. For patients who were able to come to clinic, the observer scale of the POSAS was performed. RESULTS Forty-seven phone interviews and 21 clinic assessments were performed. Overall, patients noted excellent functional outcomes, and good to excellent cosmetic outcomes, and were satisfied with healing time. There was not a significant difference between the patient and observer total scores (p = .63) or overall scores (p = .59). CONCLUSION Second intention healing can have satisfactory functional and cosmetic outcomes and healing times with few complications and should be considered for surgical defects on the vermilion lips as large as 2.8 cm even when there is involvement of the cutaneous lip and muscular layer.

Background The lip is an anatomic junction for 2 disparate groups of cancer. Cutaneous squamous cell carcinoma (cSCC) is a common malignancy with a favorable prognosis, whereas oral-mucosal squamous cell carcinoma (omSCC) is associated with significantly higher rates of nodal disease and worse outcomes. The squamous cell carcinoma of the lip (lip SCC) is more aggressive than cSCC but less aggressive than omSCC. However, work-up and treatment vary between specialties. Objectives The authors sought to review and compare the risk factors and clinical behavior of cSCC, omSCC, and lip SCC, review tumor biology of squamous cell carcinoma, and compare work-up and treatment algorithms for lip SCC. Methods A comprehensive PubMed and MEDLINE database search was performed with comparison of primary literature on cSCC, omSCC, and lip SCC. Results Lip SCC exhibits rates of nodal metastasis and death that are intermediate between cSCC and omSCC, and shares many similar biologic mechanisms. There are variations in the treatment guidelines between dermatology and otolaryngology for lip SCC. Conclusion Lip SCC is an overlapping entity that poses many challenges to clinicians. Specialists should be aware of current staging modalities as well as imaging and treatment recommendations to optimize patient outcomes.

Background Large full-thickness wounds of the upper lip are often referred to operating room–based surgeons for repair given the perceived difficulties in restoring upper lip form and function with simpler operative techniques. Objective To illustrate the functional, aesthetic, and cost differences between two techniques used to repair full-thickness wounds of the upper lip. Materials and Methods Two patients with difficult full-thickness wounds of the majority of the upper lip were reviewed. One patient underwent reconstruction with a composite free flap in an operating room, and one underwent repair using local tissue rearrangement using bilateral modified nasolabial flaps in an outpatient setting. Results Both patients were adequately reconstructed, but the patient repaired using local tissue rearrangement had a better aesthetic outcome and superior preservation of oral competency. In addition, the costs of this patient's reconstructive care were less than 2.4% of the costs of the care of the patient repaired using a free flap. Conclusion When possible, large, full-thickness wounds of the upper lip should be repaired with local tissue rearrangement in an outpatient setting to offer patients potential improvements in functional and aesthetic outcomes while minimizing treatment costs.

BACKGROUND Post-vermilionectomy defect closure by a mucosal advancement flap is a well-established method, although moderate morbidity may accompany the procedure, especially in elderly patients. The objective of the present study was to compare a simple primary closure (PC) for reconstruction after complete resection of the vermilion (vermilionectomy) with closure using a mucosal advancement flap (MAF). METHODS After margin-controlled vermilionectomy, 18 patients with actinic cheilitis (n=5) or squamous cell carcinoma in situ (n=13) of the lower lip were included in the present study. Patients were randomized into one group receiving PC (n=8) and a second group receiving MAF closure (n=10) for reconstruction of the surgical defect on the lower lip. All complications, esthetic outcomes (EOs), and cut–suture times were documented. RESULTS In the MAF group, patients' mean EO score on a 10-point scale was 8.4, and the surgeons' mean EO rate was 7.8. In the PC group the patients' mean EO score was 7.5 and the surgeons' mean EO rate was 6.4 for the reconstruction achieved. The rate of side effects was significantly higher in the MAF group than in the PC group (p

BACKGROUND Carcinoma of the lower lip is a common cancer of the head and neck region. The accepted standard of care is surgical resection and reconstruction. The delicate location poses a challenge to surgeons because they have to aim for conflicting goals: complete oncological resection and functional and aesthetic restoration. For over a century, this challenge led to the development of more than 100 different reconstructive procedures. OBJECTIVE To develop a standardized surgical approach to simplify selection of an adequate reconstructive procedure. MATERIALS AND METHODS We performed a review of the literature and a retrospective analysis of 59 patients treated according to a standardized surgical approach over the past 5 years. RESULTS By taking into account the anatomic location, the width of the defect, and the amount of tissue loss, three flowcharts have been developed to guide the physician to a selection of suitable reconstructive procedures for each case. CONCLUSION This surgical approach facilitated the successful reconstruction of all encountered defects, and over a mean period of 31 months, no recurrences or major complications were seen.

Actinic cheilitis (AC) is a common premalignant condition of the lips resulting from chronic or excessive ultraviolet exposure. Many different treatment modalities have been reviewed in the literature. Current methods include topical 5-fluorouracil, imiquimod, photodynamic therapy, chemical peels, cryosurgery, electrodesiccation and curettage, carbon dioxide laser, and vermilionectomy with or without mucosal advancement.

BACKGROUND. Desmoplastic trichilemmoma is a rare pseudomalignant variant of trichilemmoma. It generally presents as a small papule on the face and is often clinically misdiagnosed as a basal cell carcinoma or verruca vulgaris. It is histologically similar to a trichilemmoma, but has a central area of desmoplasia that can mimic an invasive carcinoma. OBJECTIVE. The objective was to report a case of desmoplastic trichilemmoma of the lower lip that was treated with Mohs micrographic surgery. METHODS. A case is reported and the literature is reviewed. RESULTS.The patient underwent Mohs micrographic surgery for removal of the neoplasm. Six months after the procedure, the patient remained tumor free. CONCLUSIONS. Although desmoplastic trichilemmoma is a benign neoplasm, it is often histologically confused with basal cell carcinoma and malignant trichilemmoma. Desmoplastic trichilemmoma is also most frequently located on the face. Considering these factors, Mohs micrographic surgery appears to represent an excellent choice for removal of these tumors to achieve clear margins and a good cosmetic result.

Background. Aesthetic facial reconstruction requires understanding regional anatomy and tissue movement and the ability to use innovatively the tissue adjacent to the defect to create a reconstruction that preserves the function of the area and the cosmetic facial units. Objective. Facial reconstruction after Mohs micrographic resection of nonmelanoma skin cancer confined to one cosmetic unit was compared with reconstruction of two or more units using techniques to place scars at the junction of cosmetic units with combinations of local flaps and grafts. Acute complications, function, and final appearance of the reconstruction were evaluated. Methods. During a 10-year period, 500 cases acquired prospectively had facial surgical defects repaired. Tissue was removed to place the closure line at the junction of cosmetic units and was mobilized from within one cosmetic unit with primary closure or local advancement, rotation, or transposition flaps. When the defect bridged cosmetic units, segmental repair was performed with combinations of flaps and grafts placing scars at the junction of cosmetic units. Segmental repair often combined advancement flaps to restore contours with full-thickness skin grafts to prevent distortion in areas with minimal loss of contour. Scars were more often unfavorably placed with single flap repair within a cosmetic unit. There was more flap loss with single flap repair of a single unit than with segmental facial repair using a combination of flaps and/or grafts. Conclusion. Segmenting the wound into smaller units reflecting the underlying cosmetic units of the face was useful to develop a reconstruction plan to replace tissue with similar tissue and to provide consistently satisfying aesthetic results. Facial contours were restored without distorting surrounding structures.

Background. Trichoblastoma is a benign neoplasm with primitive hair follicle differentiation. The tumor is characterized by nests and cords of epithelial cells in an organized relationship with stroma. Some of the epithelial cells resemble follicular germ and other cells show follicular sheath differentiation. The neoplasm is symmetrical and well circumscribed. In addition, cytologic examination shows no atypia. Concept of its malignant counterpart is poorly understood. Objective. We report two trichoblastic neoplasms that show histologic features of malignancy. Methods. Skin biopsies from the lip region of a 53-year-old female and a 74-year-old male who had presented with the neoplasms in that location for several years were reviewed. Excised specimens measured 2 × 1 × 1 cm and 1.6 × 0.7 × 0.8 cm respectively. Results. The histologic sections revealed locally aggressive neoplasms showing prominent differentiation towards hair germ and follicular sheath with formation of papillary mesenchymal bodies, follicular bulb-like structures, small keratin cysts and rare malformed hair shaft. The neoplasm showed asymmetry of architecture and massive subcutaneous and muscular infiltration. Conclusion. With demonstration of these two cases and references of few other reported cases we raise the possibility of existence of trichoblastic carcinoma that is distinct from basal cell carcinoma.