Repair of Apical Triangle Defects Using Melolabial

Rotation Flaps
Maideh Orangi,* Mary E. Dyson, BS,* Leonard H. Goldberg, MD,*†‡ and
Arash Kimyai-Asadi, MD*†‡

BACKGROUND The apical triangle of the upper cutaneous lip, also known as the alar-facial sulcus, is an
anatomical structure bound medially by the nasal ala, laterally by the medial cheek, and inferiorly by the
remainder of the upper cutaneous lip. During reconstruction, retaining the central concavity and the convex
lateral and medial outlines of this location is required to maintain midfacial symmetry.

OBJECTIVE This is a retrospective study of our use of the melolabial rotation flap for reconstruction of
surgical defects of the apical triangle.

METHODS AND MATERIALS Eighty-six surgical defects involving the apical triangle that were repaired with
melolabial rotation flaps were included. All tumors were treated with Mohs micrographic surgery before
reconstruction. Preoperative, intraoperative, and postoperative details of each case were analyzed.

RESULTS Of the 86 defects included in the study, 68 (79%) were evaluated postoperatively. The apical tri-
angle was preserved in all cases. Clinical asymmetry was noted in 3 patients (3.4%). No major complications
were noted, and no patient required surgical revision.

CONCLUSION Melolabial rotation flaps may be considered for single-stage reconstruction of surgical defects
involving the apical triangle.

The authors have indicated no significant interest with commercial supporters.

rotation flap for reconstruction of surgical defects in

T he apical triangle of the upper cutaneous lip,
also known as the alar-facial sulcus, is a
midfacial topographical anatomical structure
this anatomical location.

bound medially by the lateral portion of the nasal

ala, laterally by the medial portion of the cheek
along the melolabial fold, and inferiorly by the
remainder of the upper cutaneous lip (Figure 1).
Proper attention to restoration of the apical triangle
during reconstructive surgery is critical to
maintaining midfacial symmetry. Obliteration of
the sulcus results in the medial cheek skin appearing
draped over the lateral portion of the nasal ala
without any intervening concavity. Reconstruction
using linear repairs and flaps involving cheek
advancement and transposition are particularly
prone to distorting the apical triangle. The authors
report their experience with the use of the melolabial
Methods
The inclusion criteria for this study were a surgical
defect from Mohs micrographic surgery involving the
apical triangle (Figure 2A) that was repaired using a
melolabial rotation flap. The study period ranged from
November 2006 to June 2017. The study protocol
conformed to the ethical guidelines of the 1975 Dec-
laration of Helsinki. Informed consent was obtained
from all patients for the use of clinical photographs for
research, education, and publication purposes. Surgi-
cal and postoperative records were obtained retro-
spectively and compiled in a Microsoft Excel database.
Statistical findings were expressed as mean 6 one SD,

*DermSurgery Associates, Houston, Texas; †Department of Medicine, Houston Methodist Hospital, Houston,
Texas; ‡Department of Dermatology, Weill Cornell Medical College, New York, New York

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· ·
ISSN: 1076-0512 Dermatol Surg 2019;45:358–362 DOI: 10.1097/DSS.0000000000001633

358

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 ORANGI ET AL

and in appropriate cases, ranges (minimum to maxi-

mum) were recorded.

Each repair was performed by initially making an

Figure 1. The apical triangle is bound medially by the
nasal ala, laterally by the medial cheek and melolabial
crease, and inferiorly by the remainder of the upper
cutaneous lip.
inferolateral incision directly into the melolabial crease
(Figure 2B). The length of the incision was determined
intraoperatively based on tissue mobility; the shortest
incision that would allow the tip of the flap to be posi-
tioned at the superior vertex of the apical triangle was
typically used. Dissection of the flap would be performed
in an inferomedial direction in a subcuticular plane
beneath any adnexal structures but above the orbicularis
oris muscle (Figure 2C). A single cuticular tacking suture
would often be placed at the tip of the flap for proper
positioning of the leading edge of the flap into the apex of
the apical triangle (Figure 2D). The tacking suture is
ideally placed inferolaterally to superomedially, placing
the tension vector along the melolabial fold to avoid

Figure 2. (A) Surgical defect (1.2 · 0.9 cm) involving the apical triangle. (B) Incision placed in melolabial crease. (C) Removal
of dogear along the nasal sill and flap dissection in a subcutaneous plane above the orbicularis oris muscle. (D) Placement
of a cuticular tacking suture for proper positioning of the tip of the flap. (E) Placement of subcuticular absorbable sutures.
“Rule of halves” allows for resolution of any mismatch between the medial and lateral borders of the melolabial fold. (F)
Removal of tacking suture and placement of running cuticular suture.

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 APICAL TRIANGLE ROTATION FLAP

Figure 3. (A) Basal cell carcinoma (1.1 · 0.9 cm) involving the apical triangle. (B) Mohs micrographic surgery layer and
resulting final surgical defect (1.5 · 1.4 cm). (C) Melolabial rotation flap using inferior standing cone placed vertically into
the upper cutaneous lip. Note that edema may make it appear that the patient is developing eclabium, but from experience,
this resolves completely as the edema subsides. (D) Three-month postoperative results demonstrating preserved symmetry
in the height, width, and depth of the apical triangle without any eclabium.

eclabium that may result from a more vertically placed (Figure 2E). Typically, transfer of the flap would result
suture. The cuticular suture would be readily replaced if in mild insetting of the tip of the flap because of pivotal
the resulting tension vector raised concern for the restraint, obviating any need for further deliberate
development of eclabium. insetting to create a more pronounced sulcus.

In most cases, the length mismatch between the lateral
and medial aspects of the melolabial fold incision would
be resolved through suturing using the “rule of halves”
when placing the subcuticular absorbable sutures (Fig-
ure 2E). In some instances, further lengthening of the
incision would be performed to minimize the relative
length discrepancy and avoid a prominent standing
cutaneous cone in the inferomedial cheek.
A standing cone excision would then be performed
inferomedial to the surgical defect, either in a more
vertical fashion into the upper cutaneous lip directly
below the defect perpendicular to the free margin of
the vermilion border, ideally along the relaxed skin
tension lines (Figure 3B), or in a more horizontal
crescenteric fashion directly below the nasal sill to
place the incision in the inferior portion of the alar
crease along its border with the upper cutaneous lip
Suturing was performed using 4-0 poliglecaprone-25
absorbable buried sutures (Figure 1E), followed by 5-0
nylon cuticular sutures (Figure 2F). A combination of
simple interrupted and running sutures was used as
deemed appropriate in each case. The initial tacking
suture would typically be removed to prevent surface
scarring due to tension (Figure 2F).
The surgical sites were bandaged using a compression
dressing that would be left overnight. Patients were
instructed to wash the surgical site and apply petro-
latum and a light dressing daily until suture removal.
Male patients were advised to avoid shaving the area.
Suture removal was planned at 1 week. Patients with
significant travel times were free to have suture
removal with their referring physicians if no compli-
cations were noted. Perioperative antibiotics were not
used; patients were advised not to withhold any

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 ORANGI ET AL

Figure 4. (A) Basal cell carcinoma (0.8 · 0.6 cm) involving the apical triangle. (B) Surgical defect after 5 stages of Mohs
micrographic surgery (3.0 · 2.3 cm). (C) Melolabial rotation flap using inferomedial standing cone. Note marked edema
causing pseudoeclabium. (D) Three-year postoperative results demonstrating preserved symmetry in the height, width,
and depth of the apical triangle without eclabium.

anticoagulants; and patients were not advised to alter
smoking habits. Patients were advised to follow-up if
any short-term or long-term complications were to
develop, if they were displeased with the final aesthetic
result, or as indicated for management of future
unrelated cutaneous malignancies.
Results
Over the eleven-year study period, 86 apical triangle defects
met the inclusion criteria. The patients included 46 men
(53.5%) and 40 women (46.5%). The mean age was 67.3
6 11.9 years (range 32.6–92.5 years). The tumors included
78 basal cell carcinomas (90.7%), 5 invasive squamous cell
carcinomas (5.8%), and 3 in situ squamous cell carcinomas
(3.5%), all of which were treated with Mohs micrographic
surgery before reconstruction. The mean defect size was 1.3
6 0.6 cm (range 0.5–3.8 cm) · 1.0 6 0.5 cm (range 0.5–
2.6 cm). The mean length of the melolabial crease incision
was 3.0 6 1.0 cm (range 1.0–5.5 cm).
Sixty-eight patients (79%) were evaluated post-
operatively; many of the later visits were for evaluation of
subsequent skin tumors. Average duration of follow-up
was 2.7 years (range 6 days to 10.1 years). There were no
reported cases of infection, hemorrhage requiring medi-
cal attention, flap necrosis, wound dehiscence, hyper-
trophic scarring, or eclabium. One patient developed a
2-mm pustule 3 months postoperatively along the
melolabial crease; this was attributed to an ingrown hair
reaction and drainage resulted in resolution of the prob-
lem. One patient was seen 2 years postoperatively for
asymmetry of the medial cheeks with excess laxity on the
side where the flap was performed; examination and
comparison with preoperative photographs were con-
sistent with preoperative asymmetry of the medial cheeks;

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 APICAL TRIANGLE ROTATION FLAP

and no distortion of the apical triangle or increase in the
asymmetry was noted. Clinical asymmetry was noted in 3
cases (3.4%), in each case due to inferior displacement of
the apex of the apical triangle. No patient required or
requested surgical revision.
Conclusions
and colleagues in a series of 37 patients. Of these, 35 were
found to have maintained facial symmetry after recon-
struction. This study demonstrates the utility of melolabial
rotation in recreating the topography and contours of the
apical triangle. Of note, many of the defects in this study
involved multiple other anatomical subunits (medial
cheek, nasal ala, nasal sidewall, upper cutaneous lip, etc.).5

The importance of subunit-based reconstruction of the

Limitations of our study include its retrospective
nasal area has been recognized in the past 3 decades.1 It
nature and the lack of a uniform long-term follow-up
has also been recognized that certain nasal repairs, par-
protocol. Strengths of this study include the relatively
ticularly cheek-based advancement and transposition
large number of cases and the relative uniformity of
flaps, can distort the apical triangle.2 Similarly, vertically
defects in terms of anatomical location, demonstrating
oriented linear repairs of apical triangle defects would
reproducibility of the repair. Furthermore, a signifi-
result in obliteration of the sulcus by suturing the medial
cant number of patients, including those with rela-
cheek to the nasal ala with loss of the natural intervening
tively large surgical defects (Figure 4), had multiyear
sulcus. Conversely, horizontal repairs would generally be
follow-up with minimal long-term problems.
avoided in this area because of concern about eclabium.

In our experience, advantages of this repair include its

Despite these realities, there is a paucity of literature
relatively simple design and execution, single-stage
addressing exactly how to reconstruct this anatomical
reconstruction, rapid postoperative recovery, and
area. Some articles have concentrated on how to address
reliable functional and aesthetic results even in larger
an apical triangle that has been distorted by previous
surgical defects. Furthermore, the incision lines are
reconstructive surgery, for example, by using compound
well-camouflaged by the melolabial fold and in some
z-plasties to obliterate the melolabial fold followed by a
cases by the inferior border of the nasal sill. As such,
delayed linear incision to recreate a new crease combined
The authors recommend consideration of melolabial
with a plastic bolster to create a concave sulcus.3 Although
rotation flaps as a first-line, single-stage modality for
this type of repair does recreate the apical triangle, it is best
reconstruction of surgical defects of the apical triangle.
used for cases where previous reconstruction has obliter-
ated the sulcus, not as a primary reconstructive technique
Acknowledgments Patients provided written consent
for defects in this area, particularly given the 2 to 3 staged
for the use of their images.
reconstructive procedures required.
References
The use of cheek-advancement flaps using buried
1. Burget GC, Menick FJ. The subunit principle in nasal reconstruction.
tension-bearing sutures anchoring the cheek-based Plast Reconstr Surg 1985;76:239–47.
flap to the fascia and periosteum of the nasal notch of 2. Baker SR, Johnson TM, Nelson BR. The importance of maintaining the
the maxilla has been reported in a series of 40 patients alar-facial sulcus in nasal reconstruction. Arch Otolaryngol Head Neck
Surg 1995;121:617–22.
for reconstruction of the apical triangle.4 Although a
3. Reddy R, Mobley SR. The apical triangle: an overlooked aesthetic facial
reproducible and single-staged repair that may be subunit. Dermatol Surg 2011;37:1–5.
appropriate in select patients, this procedure may
4. Robinson JK. Placement of the tension-bearing suture in repairing the
result in medial displacement of the melolabial fold alar facial junction. J Am Acad Dermatol 1997;36:440–3.

and ensuing asymmetry of the apical triangle.
The use of melolabial rotation flaps (referred to as “lip
rotation flaps”) or modified reconstructions adding
melolabial rotation to cheek-advancement flaps to
reconstruct the apical triangle was reported by Jahangir
5. Jahangir HJ, Stevenson M, Ratner D. Modified flap design for symmetric
reconstruction of the apical triangle of the upper lip. Dermatol Surg
2012;38:905–11.
Address correspondence and reprint requests to: Arash
Kimyai-Asadi, MD, 7515 Main Street, Suite 240, Houston,
TX 77030, or e-mail: akimyai@yahoo.com

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