Click on image to enlarge advance with cursor over border

return to: Melanoma (Evaluation and Management)

see also: Case Example Lip Reconstruction Peri-alar Crescentic Advancement Flap

Modified Operative Note

PreOp DX: Lower lip melanoma

Postop Dx: Same

Procedure: Wide excision of right lower lip melanoma with 1.0 to 1.5 cm margins about pre-existing scar (3.5 x 3.0 cm W-plasty resection)

Complex multi-layered closure of 3.5 cm lip defect (mucosa/muscle/skin)

Right level IA sentinel lymph node biopsy.

Right level IB sentinel lymph node biopsy.

Findings: see photos, facial nerve stimulator used to identify and preserve the marginal mandibular nerve confirmed intact at end of procedure

Procedure Details:

After written consent was obtained and the history reviewed and updated, the patient was brought to main OR #24. After being properly identified, general anesthesia was induced and the patient was intubated transnasally without difficulty. A brief time-out was performed.

The lower lip was injected with 4 cc of 1% lidocaine with 1:100,000 dilution of epinephrine. Following placement of a throat pack, intraoral (dilute betadine) and external (solo prep with betadine gel) preps were performed with draping place to widely expose the face and neck.  

A W-plasty incision was designed and oriented with suture placement followed by photographic documentation to widely encompass the visible and palpable lower lip scar with 1 cm margins in a through-and-through fashion through the lip to include underlying intraoral mucosa. The back edge of the scalpel blade scored the anterior skin-mucosal junction at the sites of incision to direct reapproximation following resection.  Initial incision was made with a 15 blade followed by 11 blade for through-and-through incision.

Eversion of anterior lip mucosa was effected with initial placement of 5-0 nylon and the previously scored muco-cutaneous junction. Following placement of nylon sutures to re-approximate the vermillion border, interrupted 3-0 Vicryl sutures were placed in the deep muscle layer of the lip and mucosal closure after interrupted 5-0 and 6-0 nylon sutures has been placed on the skin and on the visible wet lip.

The sentinel lymph node dissection was done following use of the gamma probe counter to initially provide readings through the skin of the two sentinel lymph nodes identified on lymphoscintigraphy. We then made a submental incision approximately 6 cm wide to provide access to both nodes and carried the incision through the platysma. We used the gamma probe to direct our dissection and we identified one node in level 1A, which was dissected, with an appropriate fall in the gamma counter readings. We then dissected more posteriorly in level 1B and identified the marginal mandibular nerve with the nerve stimulator and we avoided the nerve during the case, keeping it intact. We took out a larger lymph node in right level 1B with an appropriate fall in the gamma counter measurements. We then closed the neck wound with interrupted 3-0 Vicryl sutures, and the skin was closed with interrupted 5-0 nylon sutures