Direct primary closure without undermining in the repair of vermilionectomy defects of the lower lip

Optimizing outcomes following tumour extirpation of the lip provides a unique challenge for the reconstructive surgeon. In addition to considering the aesthetic consequences of any chosen repair, the surgeon must also ensure oral sphincter size, function and control are maintained. The challenge presented when repairing this particular central facial site is clearly evident given that, to date, over 100 separate repair techniques have been promulgated to optimize outcomes in lip reconstructive surgery. Mohs micrographic surgery is undoubtedly the gold-standard surgical treatment for nonmelanoma skin cancer involving the lips and perioral tissues, allowing the creation of small, shallow surgical defects. Here, just like the eyelid and alar rim, tissue preservation is crucial. Every millimetre of sacrificed tissue not only impacts upon the reconstructive options available to the surgeon but also determines the complexity of the surgery necessary to achieve a desirable functional and aesthetic outcome. Reflecting, auditing and critically appraising any surgical technique or practice is vital to promote the highest standards in the art of reconstructive surgery. Questioning why we do things the way we do, and challenging conventional perceived dogma will ensure our patients continue to receive the very best care. One such example is the use of tie-over bolster dressings after full-thickness skin grafting, which has generally been perceived as a necessary requirement to ensure graft survival. We know that for smaller grafts, however, this is certainly not the case. In this issue, Barry and colleagues present an elegant retrospective review of their experience of primary closure without undermining in the repair of superficial Mohs surgical defects of the lower lip. The authors challenge the conventional wisdom that undermining of the mucosa to the level of the gingival sulcus is necessary to achieve good results in lower lip repair. Rather than elaborating upon or modifying a complex reconstructive technique, the authors go ‘back-to-basics’ and, in doing so, reduce the risk of complications (bleeding, swelling, postoperative dysaesthesia) without compromising results. Indeed, the simplicity of a primary closure without undermining, which they describe, is arguably within the capability of all dermatologists, irrespective of their level of surgical expertise. For the ‘Mohs purists’, the removal of tissue unaffected by tumour to create a total vermilionectomy defect may be unappealing. However, this is one situation where ‘more is less’ – as the removal of tissue under such circumstances enables a simpler repair with a low complication rate to be performed. Furthermore, as the authors state, the surrounding skin of the lower lip affected by a skin cancer frequently displays actinic changes and thus its removal may indeed be beneficial for the patient, beyond its role in facilitating the surgical repair. Highlighting this simple reconstructive technique within the dermatology literature is to be commended.