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鍾經略醫生 Dr Chung King Lueh

個案研究：嘴唇脫墨／下唇脫痣（位於下唇唇紅區） Case Study: CO2 laser complete ablation of a Naevus on the vermilion body/zone of the lower lip

Clinical Discussion: Challenges in the CO₂ Laser Ablation of a Large Benign Melanocytic Nevus on the Lower Lip Vermilion Zone and the subsequent Surgical Closure of the Large Wound

Abstract

Benign melanocytic nevi of the lower lip vermilion present unique anatomical and aesthetic challenges. Because the lower lip is highly vascular and functionally mobile, simple excision or superficial laser ablation risks significant cosmetic defects, wound dehiscence, or secondary infection. Consequently, clinicians must balance complete tissue removal with precise structural repair. This report details the successful treatment of a 1.0cm x 1.5cm benign melanocytic nevus on a 50-year-old male. By combining deep CO2 laser photoevaporation in Ultrapulse mode with layered primary closure, we achieved complete lesion eradication, dynamic stability, and a near-invisible scar.

Case Presentation

Patient History

A 50-year-old male presented with a long-standing, dark pigmented lesion on his lower lip. He reported no significant past medical or family history of dermatological malignancy.

Physical Examination

During the clinical examination, we observed:

Anatomical & Technical Challenges

Removing a 1.0 cm x 1.5 cm lesion from the lower lip presents several distinct hurdles:

  1. Defect-to-Anatomy Ratio: First, removing a 1.5 cm vertical span effectively splits the lower lip vermilion into separate left and right segments. Leaving this deep defect open to heal by secondary intention severely impairs basic oral functions like eating and speaking.
  2. Vascularity & Hemostasis: Second, the labial arteries supply abundant blood to the lip. As a result, cold-knife excision without extensive cautery risks heavy intraoperative and postoperative bleeding.
  3. Infection Risk: Third, the lower lip constantly encounters saliva, food particles, and oral bacteria. Therefore, an open mucosal wound creates a high risk for localized infection.
  4. Vermilion Alignment: Finally, the lower lip vermilion border serves as a prominent facial landmark. Even a 1 mm misstep across this border creates a visible cosmetic defect. In addition, routine facial movements put continuous tension on the wound, which encourages scar widening.

Surgical Procedure & Methodology

Primary surgical excision would have required wide safety margins and produced an unnecessarily large defect. Instead, we chose a hybrid approach: high-precision CO2 laser ablation followed by primary layered suture closure.

                    [ 1.0 cm x 1.5 cm Nevus Removal ]
                                   │
              ┌────────────────────┴────────────────────┐
              ▼                                         ▼
   [ CO₂ Laser Ultrapulse ]                 [ Layered Primary Closure ]
   • Precise layer-by-layer                 • Deep buried dermal sutures
     photoevaporation                         (Absorbable, tension reduction)
   • Visual clearance of nevus roots        • Non-absorbable 5-0 nylon
   • Simultaneous hemostasis                  for fine surface alignment

1. High-Precision CO2 Laser Ablation

2. Surgical Reconstruction & Layered Closure

Even though the laser prevented immediate bleeding, leaving a 1.5 cm vertical defect open remained unsafe. Therefore, we immediately performed a primary reconstructive closure:

Postoperative Course & Clinical Outcome

Postoperative Care Protocol

Results

Clinical Takeaways

  1. Utility of CO2 Ultrapulse Laser: First, the Ultrapulse mode offers exquisite depth control on vascular mucosa. It allows complete removal of benign tissue under direct vision without damaging healthy surrounding structures.
  2. Mandatory Primary Closure: Second, clinicians must suture large mucosal defects even if laser ablation yields a dry wound bed. Deep dermal tension-reducing sutures are essential to withstand the strong forces of the orbicularis oris muscle.
  3. Extended Suture Retention: Finally, high-tension mucosal sites benefit from extended suture support. Leaving sutures in place longer allows the deep dermis to mature before full mechanical movement resumes.

臨床討論：下唇唇紅區大型良性色素痣之 CO₂ 激光氣化與手術縫合挑戰

摘要

下唇唇紅區的良性黑色素痣（Melanocytic nevi）在臨床處置上，向來具備獨特的解剖與美學挑戰。由於下唇血管極為豐富，且日常動態活動頻繁，因此若單純進行傳統切除或淺層激光氣化，極易引致顯著的面部缺陷、傷口裂開或繼發性感染。基於上述考量，臨床醫生必須在「完整清除病灶」與「精準結構修復」之間取得平衡。本文詳細記錄一例位於 50 歲男性下唇、大小為 1.0 cm×1.5 cm 的良性黑色素痣成功案例。我們特別結合了深層 CO2​ 超脈衝激光氣化（Ultrapulse mode） 與 分層一期縫合技術，進而成功實現病灶完全清除、維持動態穩定，並達到近乎無痕的理想預後。

案例呈現

病患病史

一名 50 歲男性因下唇長期存在深色色素痣前來求診。在病史方面，患者無顯著既往病史，亦無皮膚惡性腫瘤之家族病史。

理學檢查

於臨床檢查期間，我們觀察到：

解剖與技術挑戰

若要從下唇完整清除一個 1.0 cm×1.5 cm 的病灶，臨床上必然會面臨以下幾項明確的難題：

  1. 缺陷與解剖比例：首先，去除 1.5 cm 的垂直範圍，實際上會將下唇唇紅區分割成獨立的左右兩半。倘若任由這個深層缺陷以二期癒合（Secondary intention）方式自行修復，隨之而來的將是嚴重損害進食與說話等基本口腔功能。
  2. 血管分佈與止血：其次，唇動脈為嘴唇提供極為豐富的血供。因此，若採用冷鋼刀直接切除而無電灼止血，術中及術後大出血的風險極高。
  3. 感染風險：再者，下唇日常會持續接觸唾液、食物殘渣及口腔細菌。這意味著，開放性的黏膜傷口會造成極高的局部感染風險。
  4. 唇紅緣對齊：最後，下唇唇紅緣是極其重要的面部美學標誌。即使跨越該邊界僅出現 1 mm 的微小錯位，也會造成肉眼可見的缺陷。此外，日常面部表情運動會對傷口產生持續張力，進一步拉寬疤痕。

手術過程與方法

鑑於傳統的一期手術切除需要保留較寬的安全邊緣，從而會製造出不必要的大型缺陷；因此，我們選擇了複合式方案：高精準度 CO2​ 激光氣化，隨後緊接進行一期分層縫合。

                    [ 1.0 cm x 1.5 cm 墨痣清除 ]
                                   │
              ┌────────────────────┴────────────────────┐
              ▼                                         ▼
   [ CO₂ 超脈衝激光 (Ultrapulse) ]            [ 一期分層縫合重建 ]
   • 精準逐層氣化病灶                         • 深層埋線縫合 (可吸收線，減張)
   • 直觀清除黑色素痣「根部」                  • 5-0 尼龍線進行表層精細對齊
   • 同步凝血止血

1. 高精準度 CO2​ 激光氣化

2. 手術重建與分層縫合

儘管激光成功阻止了即時出血，但留下一道 1.5 cm 的垂直缺口依然極具風險。為此，我們隨即進行了一期重建縫合：

術後護理與臨床結果

術後護理方案

臨床結果

臨床要點

  1. CO2​ 超脈衝激光的應用價值：首先，超脈衝模式在富含血管的黏膜上展現了極佳的深度控制能力。這使得醫生能在直視下完全去除良性組織，同時又不傷害周圍的健康結構。
  2. 大型黏膜缺陷必須進行一期縫合：其次，即便激光氣化創造了無血的傷口床，臨床醫生仍必須對大型黏膜缺陷進行縫合。尤其深層真皮減張縫合更是抵禦口輪匝肌（Orbicularis oris muscle）強大張力的關鍵所在。
  3. 高張力部位需延長留線時間：最後，高張力與高活動度的黏膜部位確實能從延長縫線支持中獲益。適度延長留線時間，將有助於讓深層真皮在完全恢復機械運動之前，達成更為充分的成熟與癒合。