The Karapandzic flap in recurrent melanoma of the lip.

The lip is the most common site of malignancy in the oral cavity. The lower lip is involved more often than is the upper lip; perioral skin is often involved, as well. The most common malignancies are cutaneous, including squamous cell carcinoma, basal cell carcinoma and, occasionally, malignant melanoma. Once oncologic resection is completed, reconstruction is based on the size, depth, and location of the defect.

Many flaps have been used to correct such defects. In 1974, Karapandzic first described the use of a myocutaneous flap to close defects that involve more than half the lip surface area. We review the usefulness of the Karapandzic flap as an option for patients with previously compromised lip function who experience a recurrence or a second primary tumor.

A 42-year-old white man presented with a history of a recurrent malignant melanoma on his right lower lip; 1 year earlier, a plastic surgeon had performed a wedge resection with primary closure. On examination, the patient had a 2 x 1.5-cm ulcerative lesion on the right lower lip (figure 1). He also had a firm, fixed, nontender, 3 x 3-cm mass that involved the right submandibular triangle but was distinct from the submandibular gland; computed tomography corroborated this finding. No other lymphadenopathy was seen.

[FIGURE 1 OMITTED]

The patient underwent successful resection of the lip melanoma with oncologic margins and a right supraomohyoid neck dissection, followed by reconstruction with a Karapandzic flap. Postoperatively, he completed a course of radiotherapy, and at the 2.5-year follow-up, he had no evidence of recurrence.

In general, the choice of options for lip reconstruction is based on the size, depth, and location of the defect. Full-thickness defects less than half the surface area of the lip are usually closed primarily. Defects that span between half and two-thirds the surface area of either lip are commonly closed via the classic two-stage Abbe-Estlander flap technique or a modification thereof, depending on involvement of the oral commissure. These "lip-switch" flaps result in progressive microstomia and decreased oral competence because of the loss of neuronal stimulation with the advancement of the flap.

The Karapandzic technique involves the creation of circumoral incisions involving the nasolabial and mental creases (figure 2). The incisions are taken down to, but not through, the intraoral mucosa. The orbicularis oris is gradually freed from the other perioral muscles (muscles of facial expression) in order to maximize advancement of the flap. Care is taken to locate and preserve the superior and inferior labial arteries, as well as the branches of the facial nerve that enter the orbicularis oris peripherally and deep to the muscle. Once mobilization is complete, a meticulous tension-free, three-layered closure is performed, and care is taken to reapproximate the vermilion (figure 3). Complete and immediate function may be restored because the neurovascular pedicle is preserved.

[FIGURES 2-3 OMITTED]

Although the Karapandzic flap is no more beneficial than other flaps in terms of microstomia, it does offer several advantages:

* It allows surgeons to fill a lip defect with tissue that is similar to that of a nascent lip.

* Circumoral scars may be cosmetically acceptable because they are located in the nasolabial and mental creases. Cosmetic appeal may be limited in patients with large defects. Crescentic perialar incisions may be used to decrease the tissue irregularities that occur at the nose.

* The Karapandzic flap results in better oral competence because it preserves motor and sensory innervation. The labial arteries and the facial nerve branches along the periphery of the orbicularis oris are skeletonized and preserved, which allows for the maintenance of their function.

* The flap can be created in a single stage.

Suggested reading

Karapandzic M. Reconstruction of lip detects by local arterial flaps. Br J Plast Surg 1974;27:93-7.

Panje WR. Lip reconstruction. Otolaryngol Clin North Am 1982;15: 169 78.

Polly AD, Tan EP. Lower lip reconstruction. Br J Plast Surg 1981;34: 83-6.

From the Department of Otolaryngology, Charles R. Drew University of Medicine and Science, Los Angeles,