RECONSTRUCTIVE CONUNDRUM

Bilateral Reverse Yu Flap for Upper Lip Reconstruction AfterOncologic Resection

JOS�E ANTONIO GARC�IA DE MARCOS, MD, PHD,* IGNACIO HERAS RINC �ON, MD,* CONSTANTINO

GONZ�ALEZ C �ORCOLES, MD,* MAR�IA SEBASTI�AN ALFARO, MD,* ENRIQUE POBLET MART�INEZ, MD, PHD,†

AND SUSANA ARROYO RODR�IGUEZ, MD, DDS*

The authors have indicated no significant interest with commercial supporters.

A 79-year-old man was referred to our

department for surgical treatment of a

biopsy-proven Merkel cell carcinoma on his upper

lip. Wide tumor excision was performed. The

resulting full-thickness inverted heart-shaped

defect measured 4 cm in the transverse axis

and involved almost two-thirds of the upper

lip (Figure 1).

How Would You Reconstruct This Defect?

*Department of Oral and Maxillofacial Surgery, Albacete University Complex, Albacete, Spain; †Department ofPathology, Reina Sof�ıa University Hospital, Murcia, Spain

Figure 1. Preoperative image: proposed excision (red line) and method of repair (blue line) drawn on the lip.

© 2013 by the American Society for Dermatologic Surgery, Inc. � Published by Wiley Periodicals, Inc. �ISSN: 1076-0512 � Dermatol Surg 2014;40:193–196 � DOI: 10.1111/dsu.12294

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Functional competence and good aesthetic results

are the objectives of upper lip reconstruction.1–3

Many methods have been described to repair large

full-thickness defects of the upper lip, indicating that

there is no ideal procedure.4

Full-thickness defects affecting up to one-quarter of

the upper lip can usually be closed directly. For

larger resections, a more-sophisticated reconstruc-

tion technique is required to avoid significant

distortion of the lip.5

The Abb�e flap is a transposition flap that is a good

reconstructive option for defects of up to one-third

of the upper lip and achieves good aesthetic results,

especially in philtrum reconstruction.4,5 This flap

can also be used in lateral defects that include the

commissure in a single-stage procedure and is then

known as Abb�e-Estlander.5,6

A unilateral crescentic perialar advancement flap is

suitable for resections of up to one-third of the upper

lip, whereas a bilateral procedure is needed in more-

extensive reconstructions.5

A Karapandzic reverse flap can be used for defects

involving more than one-third of the lip. This is

an advancement-rotational flap that allows labial

continuity in a single surgical procedure and pre-

serves sensitivity and motor function.4,5,7,8

The reverse Gillies flap is a single-stage rotational-

advancement flap also used for large upper

lip defects. It can produce denervation, which is

usually temporary.1,4,6

All of these flaps produce some level of microstomia.

Crescentic perialar advancement, reverse

Karapandzic, and reverse Gillies flaps produce

rounded commissures, so these techniques have the

disadvantage that a second-stage commissuroplasty is

almost always necessary to ensure mouth opening.4–8

In 1989, Yu described a new flap for lower lip

reconstruction after oncologil resections. The Yu

flap is a uni- or bilateral procedure that combines the

advantages of rotation and advancement flaps for

lower lip reconstruction in which the muscle is only

partially sectioned. It achieves satisfactory func-

tional and aesthetic results in a single-stage surgery.9

Belmonte and colleagues reported the first reverse

Yu flap for upper lip reconstruction in 2010 and

described a unilateral flap for a lateral defect of

35 mm after tumor excision.4

Herein, we describe a defect of almost two-thirds of

the upper paramedian lip repaired using a bilateral

reverse Yu flap. To our knowledge, and after

performing a literature review of PubMed, this is the

first case described of a bilateral reverse Yu flap for

upper lip reconstruction.

Surgical Technique

An inverted heart- or wedge-shaped full-thickness

resection was first performed. Then skin and sub-

cutaneous tissue were horizontally incised from the

labial commissure to point B (A–B line) (Figure 1).

This incision was slightly longer than half of the

defect, which is generally recommended when a

bilateral flap is used. Later, a curved incision

including skin and subcutaneous tissue was made

along the nasolabial fold (C–D line, Figures 1 and

2A). As shown in Figure 1, the B–C line was

approximately 1.5 cm long, and the D–E inci-

sion was perpendicular to the A–B line and

approximately half of the distance from D to A. The

G point in Figure 1 was the intersection between the

incision of the resection and the margin of the upper

lip vermilion. Afterward, a skin island (A–B–G in

Figure 1) was resected to create the new vermilion

area. In the same figure, the F point is a mirror image

of the G point. Figure 1 shows that the A–F line was

slightly longer than the A–G line. The dotted line A–

F–B–C in Figure 2B is the projection of the mucosal

flap to form the lip vermilion after the resection of

the skin island A–B–G (Figure 2C). In the commis-

sure, the medial third of the orbicularis muscle was

sectioned, keeping intact the other approximately

two-thirds laterally. The medial third of the orbic-

BILATERAL REVERSE YU FLAP FOR UPPER LIP RECONSTRUCTION

DERMATOLOGIC SURGERY194

ularis muscle was bluntly separated following the

direction of the muscle fibers along the H–I line

(Figure 2A). In cases in which the defect is bigger

than half of the lip, it is recommended that the H–I

line be longer than 1 cm. The same procedure was

repeated on the other side of the lip. Afterwards, a

layered closure of the midline was performed. The

flaps were positioned suturing A with B on both

sides and repositioning the new vermilion with the

A–F–B–C mucosal flap. Finally, the lower triangular

skin and subcutaneous tissue flap were moved up to

close the cheek defect (Figures 2D and 3).

A follow-up photograph taken 7 months after sur-

gery is shown in Figure 4.

The bilateral reverse Yu flap is a versatile single-

stage procedure that is useful for reconstructing

lateral and medial upper lip defects of more than

50% of the lip length with good functional and

aesthetic results. The external two-thirds of the

orbicularis muscle are kept intact, resulting in a

functional lip able to control saliva, mastication,

and speech. In addition, the size of the stoma is

maintained, which cannot be achieved with many

other flaps. In the bilateral reverse Yu flap, the

medial scar is a vertical line running from the

vermilion to the nasal base that can simulate one of

the philtral columns. Lateral scars are disguised in

Figure 3. Six days after reconstruction with the suturepartially removed.

(A) (B)

(C) (D)

Figure 2. (A) The orbicularis muscle is cut at the medial third and then split along the line H–I, following the grain of themuscle. (B) Mucous membrane flap used to cover the upper lip right vermilion. (C) Diagram showing movement of the flapson the right side. (D) Resultant scars.

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40 : 2 : FEBRUARY 2014 195

nasolabial folds and commissure grooves. Color

and thickness of the reconstructed skin are similar

to those of the original skin of the lip. In men this

procedure provides skin with hair, which allows the

scar to be hidden with a mustache.

Conundrum Keys

A bilateral reverse Yu flap achieves the main goals of

reconstructive surgery for extensive defects of the

upper lip:

• The method can be used in large lateral and

medial defects.

• It is a single-stage procedure.

• The function of the labial sphincter is preserved.

• The size of the stoma is not altered.

• Good estethic results are obtained.

References

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North Am 2005;13:301–14.

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reconstruction: a survey-based analysis. Dermatol Surg

2008;34:1652–8.

3. Lopiccolo MC, Kouba DJ. Bilateral peri-alar advancement flap

to close a midline upper lip defect. Dermatol Surg

2011;37:1159–62.

4. Belmonte-Caro R, Infante-Cossio P, Garcia-Perla-Garcia A,

Torres-Carranza E. Reverse Yu’s flap for upper lip reconstruction.

J Plast Reconstr Aesthet Surg 2010;63:e148–50.

5. Jackson IT, editor. Lip reconstruction. In: Local flaps in head and

neck reconstruction (2nd ed). St. Louis: Quality Medical

Publishing Inc; 2007. pp. 429–532.

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Reconstrucci�on labial. In: Burgue~no Garc�ıa M, G�omez Garc�ıa E,

editors. Atlas de colgajos locales en la reconstrucci�on de cabeza y

cuello. Madrid: Elsevier Espa~na, S.A.; 2007. pp. 291–326.

7. Dean Ferrer A, Alamillos Granados F, V�elez Garc�ıa-Nieto A.

Reconstrucci�on del labio inferior mediante colgajo de Yu: aspectos

funcionales. Piel 2000;15:288–91.

8. Renner GJ. Reconstruction of the lip. In: Baker SR, Swanson NA,

editors. Local flaps in facial reconstruction. St. Louis, Missouri:

Mosby, Inc.; 1995. pp. 345–96.

9. Yu JM. A new method for reconstruction of the lower lip after

tumor resection. Eur J Plast Surg 1989;12:155–9.

Address correspondence and reprint requests to: Jos�eAntonio Garc�ıa de Marcos, MD, PhD, C/O’donnell 44,6 º B. CP: 28009, Madrid, Spain, ore-mail: pepio2@hotmail.com

(A) (B)

Figure 4. Seven months after reconstruction. (A) Mouth at rest. (B) Mouth opening.

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