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Received: 21 November 2018 Revised: 29 August 2019 Accepted: 6 November 2019
DOI: 10.1111/vsu.13359

SHORT CASE SERIES

Lip-to-nose flap for reconstruction of the nasal planum

after curative intent excision of squamous cell carcinoma in
cats: Description of technique and outcome in seven cases

Federico Massari DVM, DECVS1 | Lavinia E. Chiti DVM2 |

1 1
Marta L. P. Lisi DVM, PhD | Dario Drudi DVM |
Vincenzo Montinaro DVM, MSc1 | Paolo Sommaruga DVM1

1
Clinica Veterinaria Nervianese,
Nerviano, Milan, Italy
2
Dipartimento di Medicina Veterinaria,
Università degli Studi di Milano, Milan,
Italy
Correspondence
Lavinia E. Chiti, Dipartimento di
Medicina Veterinaria, Università degli
Studi di Milano, Via Celoria 10, 20122
Milan, Italy.
Email: lavinia.chiti@gmail.com
Abstract
Objective: To describe the surgical technique for nasal planum reconstruction
with a lip-to-nose flap after curative intent surgical excision of squamous cell
carcinoma (SCC) in cats and to report the surgical outcomes.
Study design: Short case series.
Animals: Seven cats with SCC of the lateral (n = 6) or dorsal (n = 1) aspect of
the nasal planum.
Methods: After tumor excision, a mucocutaneous lip-to-nose flap was
harvested from the upper lip and transposed to reconstruct the nasal planum.
Variables recorded included surgical time, surgical complications, healing com-
plications, flap success rate, and cosmetic and long-term functional outcomes.
Results: Median surgical time was 67.5 minutes (range 49-80), and no
intraoperative complications occurred. Postoperatively, six cats developed self-
limiting edema of the muzzle, and one cat had nasal discharge for 2 days. No
major complications occurred during the healing process, and all cats went on
to achieve successful healing of their flap. A small area of partial-thickness
necrosis developed at the cranial edge of the flap in three cats and healed spon-
taneously in all cases within a few days. According to owner satisfaction and
periodic clinical assessment, cosmetic and long-term functional of outcomes
were considered good in all cats.
Conclusion: The lip-to-nose flap allowed for aesthetic and functional reconstruc-
tion of the nasal planum after curative intent surgical excision of feline SCC.
Clinical significance: The lip-to-nose flap is an option for a single-stage
reconstruction of the nasal planum following partial nasal planectomy in cats.

1 | INTRODUCTION carcinoma frequently arises on sparsely haired, non-

pigmented areas such as the nasal planum due to chronic
Squamous cell carcinoma (SCC) accounts for 15% of cuta- exposure to ultraviolet light.1,2 Although cutaneous SCC
neous tumors in cats and is the most common malig- is locally invasive, distant metastases are extremely rare,
nancy of the feline nasal planum.1,2 Squamous cell and local control of the disease is thus the cornerstone of

Veterinary Surgery. 2020;49:339–346. wileyonlinelibrary.com/journal/vsu © 2019 The American College of Veterinary Surgeons 339

340
oncological management of this tumor.1,2 According to
the World Health Organization staging system for feline
skin tumors,3 classification of cutaneous SCC is based on
the depth of invasion and size of the tumor, with Tis and
T1 defined as small (<2 cm in diameter) and superficial
lesions, T2 defined as small (2-5 cm in diameter) lesions
showing minimal invasion of deeper tissues, and T3-T4
defined as larger tumors (>5 cm in diameter) invading
the subcutis and deeper tissues. Several treatment
options, including cryosurgery, photodynamic therapy,
strontium-90 plesiotherapy, curettage and diathermy,
and intralesional chemotherapy, are suitable for the
treatment of early-stage, noninvasive tumors (Tis, T1, T2)
and have shown limited morbidity and a low rate of
long-term recurrence.2,4-8 However, for extensive and/or
invasive SCC of the nasal planum, more aggressive local
therapies such as surgical excision and/or teletherapy are
warranted to achieve long-term control of the local
disease.2,4,6,9
Surgical excision, when feasible, is an effective treat-
ment option for advanced lesions of the nasal planum.
Indeed, complete excision of the tumor with histologi-
cally free margins is very often curative,2,6 with one arti-
cle reporting no local recurrences in cats with completely
excised SCC.10
To achieve tumor-free margins, it is recommended
that the lesion be removed with a minimum lateral mar-
gin of 4 to 5 mm and one fascial plane deep; thus, partial
or total nasal planectomy is often required, and the aes-
thetic result associated with these procedures is a signifi-
cant concern.2,6,11 Although quality of life of the animal
is usually improved after tumor removal, the cosmetic
outcome of partial/total nasal planectomy is considered
poor and represents a major limitation to surgery because
owners may not accept the altered appearance of the
cat.2,6,11 Furthermore, the direct apposition of skin with
nasal mucosa may result in poor functional outcome due
to nasal stenosis, while external exposure of the nasal
mucosa to the environment may cause chronic rhinitis
and sneezing.2,12
A local advancement flap from the dorsal muzzle has
been proposed to overcome such limitations. Although
the cosmetic outcome with this technique has been
improved, the flap allows for reconstruction of the phil-
trum only, leaving the nasal conchae exposed and, poten-
tially, leading to chronic inflammation of the nasal
mucosa and a suboptimal cosmetic outcome.12
The lip-to-nose flap is a mucocutaneous flap based on
the upper lip skin and labial mucosa that has previously
been used successfully for reconstruction of a dorsal nasal
defect in a dog.13 By allowing direct mucosal apposition
without tension, this technique resulted in primary
healing of the nasal wound with minimal scar tissue
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MASSARI ET AL.
formation, thus providing a good functional and cosmetic
outcome.13 Preliminary results with use of the same tech-
nique for reconstruction of the nasal planum in one cat
have been presented as a poster at an international
meeting.14
The objective of the present study was to add to the
knowledge based on the promising results previously
reported by describing the use of the lip-to-nose flap for
cosmetic reconstruction of the nasal planum in cats
after curative intent surgical excision of SCC and to
report the surgical outcomes associated with this
technique.
2 | MATERIALS AND METHODS
2.1 | Case selection and preoperative
findings
Clinical records of cats that underwent curative intent
surgical excision of SCC of the nasal planum and recon-
struction with the lip-to-nose flap between April 2015
and January 2018 were reviewed. Squamous cell carci-
noma of the nasal planum had to be confirmed either his-
tologically or cytologically for cats to be eligible for
inclusion.
Data retrieved from the clinical records included sig-
nalment, clinical signs, and results of physical examina-
tion and hematological analysis. Characteristics of the
primary tumor were also reported: location (right nostril,
left nostril, philtrum), presentation (first vs recurrence),
and tumor size at its longest diameter. Before admission
to surgery, all cats underwent a complete oncological
staging, including fine-needle aspiration of regional
lymph nodes, thoracic radiographs, and abdominal
ultrasound.
2.2 | Preparation and anesthesia
All cats were premedicated with methadone (0.2 mg/kg
IM, Semfortan; Eurovet Animal Health BV, Bladel, the
Netherlands) and medetomidine (10 μg/kg IM, Sedastart;
Esteve Spa, Milan, Italy). General anesthesia was induced
with propofol (2-4 mg/kg IV, Proposure; Merial Italia
Spa, Milan, Italy) and maintained with isoflurane
(Isoflurane Vet; Merial Italia Spa, Milan, Italy) in oxygen
after orotracheal intubation. In all cases, local block of
the infraorbital nerve with 0.5 mL of bupivacaine 0.5%
(Marcaine; Aspen Pharma Trading, Dublin, Ireland) was
performed just after anesthesia induction. During sur-
gery, saline solution 0.9% was administered IV at a rate
of 5 to 10 mL/kg/hour.
 1532950x, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13359 by UNIVERSITY FEDERAL DA FRONTEIRA SUL, Wiley Online Library on [11/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MASSARI ET AL. 341

2.3 | Surgical technique
All cats were positioned in sternal recumbency, with the
whole muzzle clipped from hair and aseptically prepared
for surgery. After curative intent SCC excision, the
resulting defect was reconstructed with a mucocutaneous
lip-to-nose flap based on the subdermal plexus. For all
the procedures, surgical gloves and instruments were
changed after SCC excision before raising the flap. The
flap was harvested from the ipsilateral upper lip, as previ-
ously described by Chiti et al13 in the dog. Two full-
thickness incisions were made on the upper lip, starting
just ventral to the lower eyelid and reaching the lip mar-
gin. The incisions were outlined so that the flap would
make an angle of approximately 90 from a line drawn
between the medial canthi of each eye, and they were
divergent so that the base of the flap would be wider than
the tip to preserve the vascular supply from the subder-
mal plexus. The cranial edge of the flap started just
caudal-lateral to the philtrum, and the distance between
the cranial and caudal edges was decided in each case on
the basis of the width of the nasal planum defect to be
reconstructed. At the tip of the flap, the buccal mucosa
was divided from the gingival mucosa, preserving 1 to
3 mm of the buccal mucosa; dorsally, the flap was ele-
vated by undermining under the platysma muscle. A
bridging incision was made just caudolateral to the
defect, and the mucocutaneous flap was then transposed
to cover the nasal planum defect. At the cranial edge of
the flap, the buccal mucosa was sutured to the remaining
nasal mucosa in a simple continuous pattern with poly-
glactin 910 USP 4-0 (Figures 1, 2). The lateral edges of
the flap were then sutured in a monolayer simple contin-
uous pattern, and the defect at the donor site was
reconstructed in two layers in a simple continuous pat-
tern with the same suturing material. All excised tumors
were submitted for histopathology.
2.4 | Postoperative care and outcomes
Cefazolin (25 mg/kg IV, Cefazolina TEVA; Teva Italia Srl,
Milan, Italy) was administered during surgery and peri-
operatively in all cats and then discontinued. Pain was
managed with buprenorphine (15 μg/kg IV twice daily,
Buprenodale; Dechra Veterinary Products Srl, Turin,
Italy) until discharge. Meloxicam (0.05-0.1 mg/kg orally
once daily, Metacam; Boehringer Ingelheim Div Veter,
Milan, Italy) was administered for 5 days after surgery to
reduce inflammation and edema related to the surgical
procedure. Cats had an Elizabethan collar placed postop-
eratively until complete wound healing to prevent self-
trauma and flap damage; no specific recommendations
about feeding were made.
Cats were routinely rechecked 7 and 15 days postoper-
atively to assess flap viability; additional clinical examina-
tions were scheduled, if required, from the day of surgery
until complete healing of the flap. Periodic rechecks were
then scheduled every 2 months for the first year and every
6 months for the second year. Thereafter, follow-ups were
collected by telephone contact with the owner and/or
referring veterinarian. Surgical time, intraoperative com-
plications, perioperative complications (<24 hours after
surgery), postoperative complications (>24 hours after

F I G U R E 1 Reconstruction
of a lateral nasal planum defect
with the lip-to-nose flap. A, The
tumor involves the right nostril,
while the contralateral alar
cartilage and the whole philtrum
are free from disease. B, After
excision of the tumor, the lip-to-
nose flap is harvested from the
ipsilateral upper lip, preserving
part of the labial mucosa
(arrow). Note the bridging
incision (asterisk) that enabled a
wider caudal margin to be
obtained. C, The lip-to-nose flap
has been transposed to cover the
nasal defect and has been
sutured to the recipient site in a
simple continuous pattern. The
donor site was reconstructed in
a routine fashion

342
surgery), and hospitalization time were recorded for each
case. Postoperative complications of the flap healing pro-
cess were defined as minor when they were self-limiting
and defined as major when they required a surgical revi-
sion.15 Owners were asked about their satisfaction with
the aesthetic appearance and functional results of their
cats’ nose during the clinical recheck 2 months after sur-
gery. Follow-up time was reported.
3 | R E SUL T S
3.1 | Animals
Seven cats were included in the study. All cats were
domestic shorthairs; five were neutered females, and
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MASSARI ET AL.
F I G U R E 2 Reconstruction of a
dorsal defect with the lip-to-nose
flap. A, Aspect of the defect after
tumor excision; note that the lateral
part of both alar cartilages (black
asterisks) and the ventral part of the
philtrum (white asterisk) have been
spared. B, Creation of the
mucocutaneous flap; the whole
labial mucosa has been harvested
with the flap (blue asterisk). C, A
bridging incision (arrow) has been
created to allow transposition of the
flap. D, The mucosal border of the
flap is sutured to the caudal margin
of the nasal defect. E, Finally, the
mucosal border is loosely sutured to
the ventral part of the philtrum. F,
Aspect of the nasal planum
immediately after reconstruction
two were castrated males. Median age at presentation
was 10 years (range, 8-13), and median weight was 4 kg
(range, 3.9-4.6). At physical examination, two cats had
an ulcerative lesion involving the right nostril, four had
a lesion of the left nostril, and one had a lesion involv-
ing the dorsal aspect of the nasal planum. Median
tumor diameter was 3.5 mm (range, 2-4). In all cats
with a lateralized lesion, the ventral part of the phil-
trum and the contralateral alar cartilage were macro-
scopically free from disease, while both the alar
cartilages and the ventral part of the philtrum were
tumor free in the cat with a dorsal lesion. Other clinical
signs at presentation included sneezing in three cats
and anorexia in one cat.
The diagnosis of SCC was confirmed preoperatively
by histology in five cats and cytology in two cats. All

MASSARI ET AL.
tumors were staged as infiltrative lesions (T3) on the
basis of histopathology or visual assessment and were
considered good candidates for surgical excision. This
was the first presentation of the tumor in six cats, while
one had a local recurrence of Tis that had been treated
with photodynamic therapy 1 year previously and had
evolved to become an infiltrative tumor shortly after
recurrence. The oncological staging was negative for dis-
tant metastasis in all cats. Hematological analyses were
performed in all cats and revealed a mild non-
regenerative anemia in one cat and creatinine values
above the normal range in two. Viral diseases (feline
immunodeficiency virus and feline leukemia virus) were
excluded in all cats.
3.2 | Surgical outcomes
To achieve curative intent surgical excision, a partial
nosectomy was performed in all cats, leaving 4 to 5 mm
of macroscopically clean margin around the tumor. In
the two cats with a lesion involving the right nostril, the
right alar, dorsal lateral, and ventral lateral cartilages
were excised, while the contralateral alar cartilages and
ventral part of the philtrum were preserved. In the four
cats with involvement of the left nostril, the tumor was
resected sparing the right alar cartilage and ventral part
of the philtrum (Figure 1B). In the cat with a dorsal
lesion, the lateral part of both alar cartilages and the
ventral part of the philtrum were preserved (Figure 2A).
For reconstruction of the dorsal defect, the buccal
mucosa was sutured to the remaining parts of the alar
cartilages bilaterally and to the ventral part of the
philtrum ventrally (Figure 2); great care was taken to
FIGURE 3 Moderate edema of the muzzle in a cat 24 hours after surgery. A, Front view. B, lateral view
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343
preserve the subdermal plexus. Use of a labial advance-
ment flap to reconstruct the donor site was not required
in any of the cats.
Median surgical time was 67.5 minutes (range, 49-80),
and no intraoperative complications occurred. Periopera-
tive complications occurred in six of seven (86%) cases
and were self-limiting in all cats. Six cats developed mild
to moderate edema of the muzzle that resolved spontane-
ously during the first 48 to 72 hours after surgery
(Figure 3); cat 2 had a perioperative serosanguinous nasal
discharge that underwent spontaneous remission within
2 days. No further perioperative complications were
recorded. All cats were discharged 2 days after surgery
without functional abnormalities or signs of discomfort.
No major postoperative complications were reported, and
all cats went on to achieve successful healing of their
flap. Minor postoperative complications were observed in
three of seven (43%) cats. In cat 1, an area of partial-
thickness necrosis was noted at the cranial apex of the
flap 5 days after surgery; the necrotic area involved 10%
of the flap but spared the mucosal margin. The eschar
was easily removed during the clinical examination
15 days postsurgery without the requirement for further
anesthetic episodes, and the resulting wound healed by
second intention within 2 weeks without compromising
the functional or cosmetic outcome of the flap. In cats
2 and 6, a small eschar of 2 × 2 mm and 2 × 3 mm,
respectively, developed at the cranial edge of the flap, but
the flap had completely healed in both cats by 15 days
postsurgery. The lip-to-nose flap healed completely with-
out complications in the remaining four cats.
According to owners’ answers and clinical assess-
ment, cosmetic outcome was considered satisfactory in
all cases because the lip-to-nose flap allowed for an

344
aesthetic reconstruction of the nasal planum with resto-
ration of an acceptable appearance (Figure 4). Long-term
functional outcome was good in all cats, and chronic rhi-
nitis, sneezing, or stenosis of the nostril did not occur in
any of the cats during the follow-up period. Histopatho-
logical examination of the excised tumors confirmed the
presence of invasive SCC in all cats, and the tumors were
completely excised with tumor-free margins in all cases.
Median duration of follow-up was 485 days (range,
274-1275). At the end of the study, all cats were alive
without signs of recurrence.
4 | DISCUSSION
Curative intent surgical excision is the cornerstone of
treatment of invasive SCC of the nasal planum in cats,
and nasal planectomy is often required to achieve com-
plete excision of the tumor with a 4 to 5 mm macroscopi-
cally clean margin.1,2 However, because the nasal
planum is a highly specialized structure that contributes
to the aesthetic appearance of the cat, the possibility of a
suboptimal cosmetic outcome, which is unacceptable for
some owners, is a major concern when performing nasal
planectomy.2,6,11 In addition, direct skin apposition and
external exposure of the nasal mucosa after nosectomy
may result in long-term complications such as stenosis of
the nostrils and chronic rhinitis.2,12
The lip-to-nose flap is a mucocutaneous flap that can
be easily harvested from the upper lip skin and the
attached labial mucosa and allows for a single-stage
reconstruction of the nasal planum. It has been previ-
ously employed for the cosmetic reconstruction of a dor-
sal defect of the nasal planum of unknown origin in a
dog.13 As previously discussed, preliminary results with
the same technique in a single cat have been presented at
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MASSARI ET AL.
F I G U R E 4 Cosmetic outcome
1 month after reconstruction of a
lateral (A) defect and a dorsal
(B) defect
an international meeting.14 In the study presented here,
the lip-to-nose flap was successfully used to reconstruct
lateral and dorsal defects of the nasal planum in seven
cats after partial nasal planectomy, with a good cosmetic
and functional outcome. Indeed, with the great amount
of free local tissue offered by the upper lip, the lip-to-nose
flap is feasible for reconstruction of both lateral and dor-
sal defects. Furthermore, because the flap is harvested
from the craniolateral portion of the lip, more tissue at
the caudal part of the nasal planum can be excised during
tumor removal, thus increasing the opportunity for a
wider surgical margin while not compromising the over-
all result of the reconstruction.
Incorporation of the buccal mucosa and its apposition
with the remaining nasal mucosa allows for primary
wound healing with reduced inflammatory response and
scar tissue formation, thus reducing the risk of postopera-
tive stenosis of the nostrils. Furthermore, use of this
mucocutaneous flap to reconstruct the nasal planum per-
mits the creation of an interface between the nasal
mucosa and the environment. This may prevent chronic
inflammation of the nasal mucosa while allowing for a
more aesthetic reconstruction of the nose compared to
what is achieved with traditional nosectomy. The cos-
metic result is further improved by incorporation of the
nonhaired lip margin, yielding a result that resembles the
original appearance of the nose.
A skin advancement flap from the dorsal muzzle has
previously been described to improve cosmetic appear-
ance and reduce mucosal irritation secondary to exposure
after nasal planectomy.12 This technique, however,
involves mobilization of local tissue at the dorsal caudal
muzzle, which may not be available if the surgical re-
section extends caudally; it is thus feasible only in cases
in which the caudal part of the nasal planum can be pre-
served. Furthermore, the aesthetic and functional results

MASSARI ET AL.
with this technique are inferior to those achieved with
the lip-to-nose flap described here. In fact, although the
advancement flap allows for reconstruction of the phil-
trum, the nasal conchae are left exposed, thus
compromising the cosmetic result; moreover, direct appo-
sition of the skin flap to the nasal mucosa may result in
narrowing of the nostrils during the healing process. In
the present case series, stenosis of the nostril or signs
associated with chronic inflammation of the nasal
mucosa were not recorded, and the appearance of the
reconstructed nose was acceptable in all cats.
Thanks to the limited extension of the tumors on the
nasal planum, we were able to pursue a curative intent
surgical excision while sparing at least one alar cartilage
and the ventral part of the philtrum in all cats, and total
planectomy was not required in any of our cases. How-
ever, even in the presence of tumors involving both
nostrils and/or the whole philtrum, which require total
nasal planectomy, use of the lip-to-nose flap may allow
for a cosmetic improvement compared with traditional
techniques.
The lip-to-nose flap healed completely in all of the
cats that we treated, and no major complications arose
during the healing process. The upper lip is a highly vas-
cularized structure and, assuming that blood supply is
preserved, a high success rate can be expected. Further-
more, although the blood supply of this flap is primarily
based on the subdermal plexus, a possible vascular con-
tribution from the infraorbital and nasal arteries may
result in a higher success rate, as has been hypothesized
in the dog.13 However, this assumption remains purely
hypothetical, and additional studies are warranted to
determine the exact vascular contributions to the flap.
Minor complications occurred in 43% of the cats.
However, the fact that in three cats a superficial necro-
sis of a small area (<10% of the flap) occurred at the
cranial margin of the flap did not compromise the over-
all outcome of the lip-to-nose flap because the resulting
wound healed rapidly by second intention in all cases
without the requirement for additional treatments or
additional costs for owners. Self-limiting edema
occurred in six cats between 2 and 3 days after surgery.
Edema and partial-thickness necrosis are common
complications of the healing process of local flaps
because the subdermal plexus can be easily damaged
during flap harvesting, even when all principles of deli-
cate tissue handling are respected. Such complications
must be expected after reconstruction with the lip-to-
nose flap and usually do not compromise the viability
of the flap.
Results of the present study provide evidence
that the lip-to-nose flap is feasible for single-stage
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345
reconstruction of the nasal planum in cats after partial
nasal planectomy for excision of small tumors, with a
good cosmetic and long-term functional outcome. How-
ever, additional studies are warranted to better delin-
eate the success rate of the flap and to assess whether
this technique may be used to reconstruct wider defects
resulting from total nosectomies and/or traumatic inju-
ries of the muzzle.
CONFLICT OF INTEREST
The authors declare no conflicts of interest related to this
report.
ORCID
Lavinia E. Chiti https://orcid.org/0000-0003-2658-5660
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MASSARI ET AL.
How to cite this article: Massari F, Chiti LE,
Lisi MLP, Drudi D, Montinaro V, Sommaruga P.
Lip-to-nose flap for reconstruction of the nasal
planum after curative intent excision of squamous
cell carcinoma in cats: Description of technique
and outcome in seven cases. Veterinary Surgery.
2020;49:339–346. https://doi.org/10.1111/vsu.13359