The “Frogger Flap”: A Novel Quadruple Rhomboid Flap for Complex Central Upper Lip Reconstruction

The frogger flap is a novel flap that utilizes four rhomboid flaps to reconstruct defects of the central upper lip. In our case report, a Mohs defect was created in the central lip centered on the Cupid’s bow involving the vermillion as well as cutaneous skin. The reconstructive challenge was to replace like with like, respect the subunits of the lip, re-establish the contour and shape of Cupid’s bow, and avoid distortion of the philtral columns. 

To accomplish our goals, we utilized the rhomboid flap in a way that would create the M shape of Cupid’s bow associated with the peaks of the vermillion situated at the bottom of the philtral columns. By orienting the top two rhomboid flaps along the white roll, the junction between vermillion and cutaneous skin, and then angling upward, parallel to the philtral columns, the cutaneous portion of the M is then reconstructed. Then by creating another set of rhomboid flaps running along the red line, or junction between the wet and dry mucosa, and then angling downward, the vermillion portion of the M is reconstructed to fit in perfectly along the cutaneous incision line. 

The key to setting up the design is in creating a chevron pattern involving four rhomboid flaps. One concern regarding the inferior set of rhomboid flaps is that the blood supply coming into the base of the two flaps is fairly narrow. Anywhere else in the body, the two flaps would likely result in partial flap loss due to ischemia. Due to the rich vascular supply of the face and lip region, this is not an issue. It is recommended to elevate all four flaps in the place superficial to the orbicular is muscle, to ensure a robust blood supply.