Lower Lip Squamous Cell Carcinoma: Surgical Management and Reconstruction Using Bilateral Bernard-Webster Flap

Nikita Chandak^1*, Hemkant Verma², Sparsh Sharma¹, Akhilesh Dalal²

1. Department of General Surgery

2. Department of Surgical Oncology

*Correspondence to: Dr. Nikita Chandak, Email: niki.nikichandak@gmail.com

Copyright.

© 2026 Dr Nikita Chandak, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 05 December 2025

Published: 01 February 2026

DOI: https://doi.org/10.5281/zenodo.18385082

Abstract

Squamous cell carcinoma (SCC) of the lower lip is a common oral malignancy, strongly linked to environmental and lifestyle factors such as ultraviolet radiation and tobacco use. Early diagnosis and surgical excision remain the cornerstone of management. Reconstruction after wide excision is crucial to restore aesthetics and function. The Bernard- Webster flap provides a reliable single-stage solution for large central lower lip defects.

A 61-year-old Nepalese female presented with a painless, progressive ulcer on the lower lip for five months. She had no history of tobacco use or significant sun exposure. Biopsy confirmed squamous cell carcinoma. Contrast-enhanced CT revealed a 2.2 × 1.4 × 1.8 cm lesion without deep invasion or significant nodal involvement, staged as T2N0M0. The patient underwent wide local excision with right modified radical neck dissection (MRND type III). The resulting defect was reconstructed using a bilateral Bernard-Webster flap.

Postoperative recovery was uneventful. The patient resumed oral intake on day one, and the surgical site healed without infection, hematoma, or wound dehiscence. She was discharged on postoperative day three. Sutures were removed on day 14, with healthy scar formation and no gaping. At one-month follow-up, the patient demonstrated good lip competence, intact oral continence, and clear speech. By the third postoperative month, scar maturation was satisfactory, cosmetic appearance was acceptable, and functional outcomes including mastication, swallowing, and articulation were preserved. No local recurrence, nodal disease, or distant metastasis were detected during this follow-up period.

This case demonstrates that wide excision with MRND and bilateral Bernard-Webster flap reconstruction is an effective approach for lower lip SCC, offering oncological safety, functional restoration, and satisfactory aesthetics. Long-term follow-up remains essential.

Introduction

Lip carcinoma represents a distinct subset of oral cavity cancers, with squamous cell carcinoma (SCC) being the predominant histological type. SCCs occur more frequently in elderly white men (male-to-female ratio, 28.5:4.3), has a peak incidence in the sixth and seventh decades, and is more common in the lower lip (>95% of cases).Over 95% of lip cancers occur on the lower lip, with a peak incidence in the sixth to seventh decade of life and a male predominance [1]. Recognized risk factors include prolonged sun exposure, tobacco use, alcohol consumption, and infection with oncogenic strains of human papillomavirus (HPV) [2].India bears a high burden of lip and oral cavity cancers, accounting for more than 100,000 new cases annually [3]. According to NCCN and ESMO guidelines, surgical excision with adequate margins remains the treatment of choice for localized lip SCC [4]. Reconstruction is equally important to restore speech, oral competence, and cosmesis. Among available techniques, the Bernard-Webster flap is well-suited for extensive central lower lip defects, providing good functional and aesthetic results [5,6].This case report highlights the surgical management of a lower lip SCC with reconstruction using a bilateral Bernard-Webster flap.

Case Presentation

A 61-year-old Nepalese female presented with a non-healing ulcer on her lower lip for five months. The lesion was painless and progressively enlarged. She denied bleeding, dysphagia, or significant risk factors such as smoking or prolonged sun exposure. Her medical history was unremarkable.

Examination: A well-defined, ulcero-proliferative growth measuring 3 × 2 cm was seen on the right lower lip, extending toward the midline without commissure involvement.[figure 1] The lesion was firm, non-tender, and non-mobile. Few sub centimetric cervical lymphadenopathy was detected. Intraoral examination was otherwise normal.

Investigations: Biopsy confirmed moderately differentiated SCC. Contrast-enhanced CT of the face and neck [figure 2 -3] showed a localized iso-to-hypodense lesion (2.8 × 1.4 × 2 cm) with peripheral enhancement, extending toward the buccal mucosa without deeper invasion. Subcentimetric lymph nodes were noted in the submental and level IIa regions without necrosis. The tumor was staged as T2N0M0.

The procedure was complication-free. The patient was extubated and resumed oral intake on postoperative day one. She was discharged on day three. Sutures were removed on day 14. At 3-month follow-up, she exhibited excellent lip competence, normal speech, and good cosmesis [figure 7].

Reconstructive Considerations.

Lower lip reconstruction must preserve critical functions such as oral competence, articulation, salivary continence, mastication, and acceptable aesthetics. The technique chosen varies by size, anatomical site, and depth of the surgical defect [8-11] [Table No. 1]

The decision to perform MRND type III in this case was justified, as nodal metastasis occurs in approximately 10-15% of moderately differentiated T2 SCCs of the lower lip [6,7]. Prophylactic neck dissection in such cases improves local control and survival outcomes. Postoperative care plays an equally vital role in optimizing recovery. Maintenance of oral hygiene, antiseptic mouth rinses, early resumption of oral feeding, and dedicated physiotherapy help prevent flap contracture and maintain perioral muscle tone. Baumann and Robb also highlighted the necessity for long-term follow-up to detect local recurrences or secondary primaries, which are not uncommon in high-risk patients [8].

From an aesthetic standpoint, the Bernard-Webster flap remains one of the most dependable options for central lip reconstruction. The strategic placement of incisions along natural nasolabial creases ensures scar camouflage, while V-Y advancement of the flap helps maintain vertical lip height and vermilion contour [10,12,14]. Brinca et al. observed that the Bernard-Webster flap offers superior midline projection and symmetry compared with the Karapandzic flap, particularly in large central defects where commissures are spared [9]. Recent literature further supports this technique as a versatile and robust option for extensive lower lip defects without necessitating microvascular transfer [10]

While this case demonstrates excellent oncological and reconstructive outcomes, it represents a single clinical experience. Larger multicentric studies with standardized outcome measures are needed to further validate the long-term oncologic safety, functional success, and aesthetic satisfaction associated with this approach. The incorporation of modern tools such as three-dimensional digital imaging and flap simulation software may enhance preoperative planning and improve postoperative symmetry and contour in future reconstructions [16]. Additionally, employing validated functional assessment scales such as the Oral Function Scale and FACE-Q questionnaire would allow for more objective evaluation of patient-reported outcomes.

Conclusions

This case underscores the importance of comprehensive surgical management of lower lip SCC, combining wide local excision, appropriate neck dissection, and robust reconstruction. The bilateral Bernard-Webster flap proved effective in restoring oral competence, speech, and aesthetics. Long-term follow-up remains essential given the risk of recurrence and secondary head and neck malignancies.