Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Letter to the Editor - Study Letter
doi: 10.4103/ijdvl.IJDVL_1003_18
PMID: 31571610

Application of a “fish mouth flap” combined with an orbicularis oculi myocutaneous flap after surgical removal of basal cell carcinoma in the facial buccal region

Siqi Fu1 , Adriana C Panayi2 , Qianjin Lu1 , Hai Long1
1 Department of Dermatology, Medical Cosmetic Center, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
2 Department of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA

Correspondence Address:
Hai Long
Department of Dermatology, Medical Cosmetic Center, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011
How to cite this article:
Fu S, Panayi AC, Lu Q, Long H. Application of a “fish mouth flap” combined with an orbicularis oculi myocutaneous flap after surgical removal of basal cell carcinoma in the facial buccal region. Indian J Dermatol Venereol Leprol 2019;85:649-652
Copyright: (C)2019 Indian Journal of Dermatology, Venereology, and Leprology


Basal cell carcinoma (BCC) is a slow-growing, locally invasive malignant skin tumor mostly seen in the facial buccal area consistent with the embryological median line. Surgical excision of the tumor is the mainstay of treatment. We propose a modified “fish mouth flap” combined with the orbicularis oculi myocutaneous flap for cosmetic restoration after surgical removal of buccal BCC.

From July 2013 to October 2017, 25 patients (13 males and 12 females) presenting with a BCC in the facial buccal region in close proximity to the nose and lower eyelid were treated. The mean age was 67 years (44–82 years), and the average size of the tumor was 2.24 × 1.55 cm, ranging from 1.0 × 0.8 cm to 3.5 × 1.55 cm. The course of the disease ranged from 2 to 20 years. All patients were diagnosed with BCC by pathological examination and treated with extended resection under local anesthesia. The indolent-growth subtypes (nodular and superficial) and smaller tumors (<2 cm) were treated with extended 0.3–0.5 cm resections, while the aggressive-growth subtypes (morpheaform, infiltrative, micronodular and basosquamous) and larger tumors (>2 cm) were treated with extended 0.5–1.0 cm resections.[1] All patients underwent Mohs surgery to make sure that the lesional tissues were completely cleared [Figure - 1]a, [Figure - 1]b, [Figure - 1]c.

Figure 1:

The flap was marked on the skin at the lower border and on both sides of the defect. The lower flap corresponded to the “fish body,” while the two sides were “the upper and lower lip of the fish mouth” [Figure - 2]a and [Figure - 2]b. The length of the flap was approximately twice the length of the defect. The tip of the upper and lower lip did not need to be too sharp [Figure - 1]b. The skin and subcutaneous tissue were dissected above the deep fascia surface and the upper lip contained the orbicularis oculi muscle to ensure maximum blood supply. The “fish body” was then stretched to allow advancement and the upper and lower lip flaps of the “fish mouth” were rotated and promoted to cover the wound. The process was similar to the closure of the upper and lower lips, just as the term “fish mouth flap” describes it [Figure - 1]d. Subcutaneous tension and interrupted suturing of the skin was then performed. Finally, Vaseline gauze and a cotton pad were used to dress the surgical area [Figure - 1]e.

Figure 2:

All 25 flaps survived with primary healing. The patients were followed up from 6 months to 4 years. No deformation of the lower eyelid and nose was observed and scarring was minimal. The flaps showed adequate matching with the recipient site, in terms of both color and texture. All patients were satisfied with the surgical results [Figure - 1]f.

The occurrence of a BCC is more common in middle-aged and elderly people, with the predilection site at the head-and-neck region. The treatment method varies with factors that can potentially influence the prognosis, such as the tumor size, location and histological type.[2] The lower eyelid and paranasal region are high-risk areas of this tumor. Apart from complete removal of the lesion, attention should be paid to cosmetic satisfaction and the function of the eyelid and nose. Flap transfer is a method that allows for adequate cosmetic and functional restoration.

The “fish mouth flap” described in this study is a type of modified V-Y flap, a combination of the advancement flap and rotation flap.[3] Ellabban and Bremner used fish mouth flap to repair the postexcision defect of a squamous cell carcinoma on the back of the thigh with good results.[4] When using it on the facial buccal region, one should pay attention to the following technical aspects: (1) detaching in the nasolabial groove area should avoid injuring the perforating branch of facial vessels; (2) to maintain adequate blood supply to the flap lip, the orbicularis oculi muscle with multisource blood supply should be included in the upper lip of the fish mouth flap;[5] ( 3) the excision line should be marked on the margin of an aesthetic unit to prevent the trap-door deformity which is more likely to occur in younger patients.

A limitation of our reported technique is that it is not suitable for tumors involving the nasal dorsum or nasal root. Moreover, it is not suitable when the tumor involves the lower palpebral margin. Nevertheless, for a tumor located in the buccal region near the lower eyelid and paranasal area, our method provides a simple, yet effective technique for the cosmetic restoration of a postexcision skin defect.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This work was supported in part by the National Natural Science Foundation of China (81773334), Natural Science Foundation of Hunan Province (2018JJ3756), Hu-Xiang Talents Program of Science-Technology Department of Hunan Province (2018RS3031), and Outstanding Innovation Talents Program of Changsha Science-Technology Bureau (kq1802002).

Conflicts of interest

There are no conflicts of interest.

Trakatelli M, Morton C, Nagore E, Ulrich C, Del Marmol V, Peris K, et al. Update of the European guidelines for basal cell carcinoma management. Eur J Dermatol 2014;24:312-29.
[Google Scholar]
Marzuka AG, Book SE. Basal cell carcinoma: Pathogenesis, epidemiology, clinical features, diagnosis, histopathology, and management. Yale J Biol Med 2015;88:167-79.
[Google Scholar]
Niranjan NS, Price RD, Govilkar P. Fascial feeder and perforator-based V-Y advancement flaps in the reconstruction of lower limb defects. Br J Plast Surg 2000;53:679-89.
[Google Scholar]
Ellabban MG, Bremner N. 'Fish mouth' modification for enhancing the advancement of V-Y flap. J Plast Reconstr Aesthet Surg 2007;60:213-5.
[Google Scholar]
Li XQ, Wang JQ. Orbicularis oculi myocutaneous flap for upper cicatricial ectropion. J Craniofac Surg 2016;27:70-3.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections