A middle-aged man with an upper lip rapidly growing deeply infiltrating well-differentiated squamous cell carcinoma. Discussion was held regarding whether this could be a variant of keratoacanthoma. Although clear margins were achieved with Mohs excision, radiation therapy was considered. However, the location, the upper lip, poses significant morbidity with radiation. Upper lips develop significant mucositis, edema, and interfere with the function of speech and eating making the treatment course difficult. Also, the youth of this patient and long term carcinogenic effects of radiation is another factor weighing against radiation. Discussion was held regarding utility of CT PET scan to determine the potential lymphatic spread in this deeply invasive carcinoma. CT PET scan must be delayed approximately 12 weeks after surgical intervention to allow the inflammatory and hypermetabolic postoperative processes to subside. Otherwise false positive findings are at risk with the CT PET scan. Discussion was held regarding the depth of invasion and risk of metastasis and need for postoperative radiation. No direct evidence exists to support the depth of cutaneous invasion with the risk of metastasis as it does for melanoma. Squamous cell carcinoma has been studied in mucosal and intraoral lesions where a correlation was found between depth of invasion and cervical metastasis. Applying this observation to cutaneous squamous cell carcinomas is an area of controversy.
Reconstruction of deep central upper lip defects, large central lip defects is challenging. In this particular case, a nasolabial island fascia cutaneous flap was utilized. This is a flap based on deep perforators originating from angular artery. Its base is lateral to the nasal ala. It is transposed through a subcutaneous tunnel into the central lip defect. This flap causes relatively unpredictable blood supply to its distal tip. As such it should be used with some trepidation and caution.