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Treatment of post-traumatic lower lip ptosis: Report of case
230
POST-TRAUMATIC
9. Biller HF, Lawson W, Som P, et al: Glomus vagale tumors. Ann Otol Rhino1 Laryngol 98:21, 1989 10. Moore G, Yarington CT, Mangham GA: Vagal body tumors: Diagnosis and treatment. Laryngoscope 96:533, 1985
LOWER
LIP
PTOSIS
11. Persson AV, Frusha JD, Dial PF: Vagal body tumor: Paraganglioma of the head and neck. Cancer 35:232, 1985 12. Pratt LW: Familial carotid body tumors. Arch Otolaryngol 97:334, 1973
J Oral Maxillofac Surg 54:230-233, 1996
Treatment of Post- trauma tic Lower Lip Ptosis: Report MOHAMMAD
HOSEIN
KALANTAR
Ptosis of the lower lip is a distressing, unesthetic facial deformity that commonly follows contraction of bum scars or skin loss in the area below the lip or mentolabial fold.’ Wound healing and contraction in the lower lip and chin may also produce a similar condition.’ Moreover, this deformity may follow maxillofacial surgical procedures and osteotomies of the chin when extensive soft-tissue reflection, degloving, and improper wound closure is used.“-7 The following report describes a patient with posttraumatic lower lip ptosis and discusses prevention and treatment of the condition. Report of Case A lo-year-old girl wasbrought to the emergencyward of the Baqiyatallah Medical Center on September 22, 1993 after suffering a fall from a staircase. She was seen by the emergency room physician who ordered computerized tomographic (CT) scans of the skull and posteroanterior and lateral jaw radiographs. Because no fractures were found and head injury was ruled out, the physician repaired the intraoral laceration present in the lower vestibule. The patient was referred to the Oral and Maxillofacial Surgery Clinic 3 days later and, on examination, extensive facial edema, eccymosis, and hematoma formation was evident bilaterally in the cheeks, submental area, and lower lip. There were no facial lacerations. The occlusion was undisturbed and no fractures could be found clinically or radiographically. However, ptosis of the lower lip was imme-
* Assistant Professor of Oral and Maxillofacial Surgery, Chairman and Head, Clinic of Oral and Maxillofacial Surgery, Baqiyatallah Medical Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. Address correspondence and reprint requests to Dr Motamedi: Africa Expway, Golestan St, Giti Blvd No. 11, Tehran, IR Iran 19667. 0 1996 American
Association
0278-2391/96/5402-0021$3.00/O
of Oral and Maxillofacial
Surgeons
of Case MOTAMEDI,
DDS*
diately evident and examination of sagittal skull CT scans revealed inferior soft-tissue positioning and extensive swelling in the submental area (Fig 1). Intraoral examination was exceedingly difficult due to lack of cooperation by the patient. However, it was noted that the anterior and anterolatera1 aspects of the vestibule were lacerated from the left premolar to the right premolar area. Some of the alveolar bone was denuded. The vestibule had been traumatically deepened and inadequately sutured at that level in one layer with 3-O silk suture. The patient’s parents deferred surgery in hope of improvement of the position of the lower lip with resolution of the edema and hematoma. However, there was no change when she was again seen 10 days later and the intraoral sutures were removed and the edema had subsided. Still in hope of future improvement, the child continued active lip exercises to decrease the interlabial gap and lip incompetence. The patient was examined again nearly 1 year after the initial trauma. Lip incompetence, loss of the buccolabial and mentolabial folds, increased interlabial gap, and scar formation in the lower vestibule were evident (Fig 2). The child’s mother complained that the child’s mouth remained open at night and that she drooled constantly. She presented a childhood photograph confirming that she had no lip incompetence prior to the trauma (Fig 3). After consenting to operation, under general anesthesia via nasoendotracheal intubation, an incision was made in the lower vestibule and the scar tissue was removed. The incision was extended posteriorly to mobilize the soft tissues in an attempt to elevate the lower lip by performing V-Y plasty (Fig 4). However, although helpful, this procedure did not completely close the excessive interlabial gap. Therefore, the mandible was degloved and the inferiorly displaced mentalis muscle was mobilized and sutured superiorly, which helped to reposition the lower lip and genial soft tissues. In addition, to restore and deepen the mentolabial fold, minor osseous contouring was performed on the chin. This procedure also aided in closing the interlabial gap. The wound was closed in layers with 3-O and 4-O vicryl sutures and an elastic bandage was placed at the end of the procedure as is done for routine genioplasty, but with greater upward traction. This was allowed to remain for 2 weeks to prevent hematoma formation and stabilize the soft tissues in their proper position. The patient was doing well 9 months postoperatively. She
MOHAMMAD
HOSEIN
KALANTAR
231
MOTAMEDI
FIGURE 3. Childhood photograph lip seal before the trauma.
FIGURE 1. Sagittal CT scan of the patient showing extensive tissue edema and hematoma in the area of the lower lip and submental area, and inferior posterior displacement of the soft tissues resulting in ptosis of the lower lip.
had nocturnal drooling, and lip competence and normal facial esthetics had been restored (Fig 5).
no longer
Discussion Lower lip ptosis is a relatively rare complication of facial trauma which has not been found to be addressed in the standard texts of oral and maxillofacial surgery. This overlooked sequel of facial trauma is a distressing and unesthetic soft tissue deformity.’ In this deformity
of the patient
showing
normal
there is an eversion of the oral mucosa causing a protrusion and ptosis of lip vermillion and mucosa.* Obliteration of the mentolabial sulcus adds to the deformity and can make the chin appear small.* Ptosis of the lower lip interferes with lip seal and may cause drooling. It can be most distressing to the patient both functionally and esthetically and its correction should have a high priority.’ Treatment of this deformity has included use of scar excision and various Z-plasty techniques, as well as split-thickness skin or mucosal grafts and nasolabial flaps when tissue has been lost.’ However, complementary procedures on the hard and soft tissues of the chin may also be required to decrease the interlabial gap and restore proper hard and soft tissue relationships, especially in long-standing cases.3-6 The best method of treatment of lip ptosis is preven-
of the patient approximately I year FIGURE 2. A, B, Appearance after the initial trauma showing ptosis of the lower lip, excessive show of lower gingiva, and lip incompetence in repose. Note the loss of buccolabial and mentolabial folds (arrows). C, Also note the scar formation in the lower anterior vestibule.
232
tion. Thus, the deformity or its potential occurrence should be recognized and correctly timed interceptive procedures should be instituted. Lacerations in the area of the vestibule and chin should always be treated primarily with closure in layers and incorporation of flaps and grafts for defects. The effects of soft tissue degloving in the area of the chin following genioplasty procedures are also well known,‘-6 and it should be understood that soft tissue degloving can also occur traumatically leading to development of the same deformity. If a secondary procedure is required, it should be appreciated that revisional surgery is always more difficult than control of the soft tissues at the time of original surgery because of scarring, fibrosis, and changes in normal anatomic relationships. Thus, secondary procedures are best used after the final soft tissue drape has been established and the residual defect has been identified.‘-5 The first step in treatment of deformities resulting from scar formation is to remove the scar. When the area of contraction is localized, advancement flaps and V-Y plasty may then be used.’ Reduction of chin height and contouring procedures also help to decrease the interlabial gap.’ Muscle repositioning must also be performed if inferior tissue positioning has occurred secondary to trauma or surgery resulting in redundant tissue in the submental region.4 Surgical technique and method of wound closure also have been shown to effect soft tissue relationships. Chin drooping may follow extensive soft tissue stripping in the area of the chin, which may be associated with shortening of the lower lip. Incorrect wound repair, vestibular scarring, extensive detachment of soft tissues from the chin, suprahyoid myotomy, improper closure of a soft tissue incision, hematoma formation, and genial contouring are all known to affect the soft tissue esthetics in the area of the chin and lower lip? Chin ptosis or “witch’s chin,” 5 an unesthetic complication secondary to degloving of the chin or lack of repositioning of the mentalis muscle at the time of surgery, may also lead to an inferior tissue position and excessinterlabial
POST-TRAUMATIC
LOWER
LIP
PTOSIS
FIGURE 5. A, Nine-month postoperative photograph of the patient showing restoration of normal lip posture in repose. B, Note the restoration of the buccolabial and mentolabial folds.
gap, lip incompetence, exposure of the lower teeth, and redundant tissue in the submental area.4 The mentalis muscle should always be repositioned and reapproximated to prevent ptosis of the chin. Tape dressings placed at the end of surgical procedures on the chin to stabilize the soft tissues and prevent hematoma formation have been advocated by many investigators, who recommend leaving them on for periods ranging from 5 to 14 days.“@ This may also be helpful in preventing lower lip ptosis. Careful attention to all genial and oral vestibular wounds also can minimize or prevent the occurrence of this distressing facial deformity and its sequelae. References
FIGURE 4. A, Outline of buccal sulcus incisions for release of contracture of the lower vestibule. B, Suture of mucosal flaps by the V-Y method, releasing the contracture lengthening and elevating the lower lip.
1. Converse JM, Wood-Smith D: Techniques for the repair of the lips and cheeks, in Converse JM: Reconstructive Plastic Surgery, Philadelphia, PA, Saunders, 1977, pp 1561. 1564 2. Feldman JJ: Facial burns, in McCarthy JG: Plastic Surgery, Philadelphia, PA, Saunders, 1990, chapter 41, pp 21872188 3. Bell WH, McBride K: Genioplasty strategies, in Bell WH (ed): Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992, chapter 64, p 2440
MOHAMMAD
HOSEIN
KALANTAR
233
MOTAMEDI
4. Betts NJ, Fonseca RJ: Soft tissue changes associated with gnathic surgery, in Bell WH (ed): Modem Practice in gnathic and Reconstructive Surgery. Philadelphia, PA, ders, 1992, chapter 62, pp 2138-2204 5. Bell WH, Brammer JA, McBride KL, et al: Reduction oplasty: Surgical techniques and soft tissue changes, Surg Oral Med Oral Path01 51:471, 1981 6. Hohl TH, Epker BN: Macrogenia: A study of treatment
orthoOrthoSaungeniOral results
with surgical recommendations. Oral Surg Oral Med Oral Pathol 41:545, 1976 7. Bell WH, McBride KL: Chin surgery, in Bell WH (ed): Surgical Correction of Dentofacial Deformities. Philadelphia, PA, Saunders, 1980, chapter 14, pp 121 l-1248 8. Spiessl B, Tschopp HM: Surgery of the jaws, in Nauman HH: Head and Neck Surgery, Stuttgart, Germany, Georg Thieme, 1980, chapter 12, p 247
POST-TRAUMATIC
9. Biller HF, Lawson W, Som P, et al: Glomus vagale tumors. Ann Otol Rhino1 Laryngol 98:21, 1989 10. Moore G, Yarington CT, Mangham GA: Vagal body tumors: Diagnosis and treatment. Laryngoscope 96:533, 1985
LOWER
LIP
PTOSIS
11. Persson AV, Frusha JD, Dial PF: Vagal body tumor: Paraganglioma of the head and neck. Cancer 35:232, 1985 12. Pratt LW: Familial carotid body tumors. Arch Otolaryngol 97:334, 1973
J Oral Maxillofac Surg 54:230-233, 1996
Treatment of Post- trauma tic Lower Lip Ptosis: Report MOHAMMAD
HOSEIN
KALANTAR
Ptosis of the lower lip is a distressing, unesthetic facial deformity that commonly follows contraction of bum scars or skin loss in the area below the lip or mentolabial fold.’ Wound healing and contraction in the lower lip and chin may also produce a similar condition.’ Moreover, this deformity may follow maxillofacial surgical procedures and osteotomies of the chin when extensive soft-tissue reflection, degloving, and improper wound closure is used.“-7 The following report describes a patient with posttraumatic lower lip ptosis and discusses prevention and treatment of the condition. Report of Case A lo-year-old girl wasbrought to the emergencyward of the Baqiyatallah Medical Center on September 22, 1993 after suffering a fall from a staircase. She was seen by the emergency room physician who ordered computerized tomographic (CT) scans of the skull and posteroanterior and lateral jaw radiographs. Because no fractures were found and head injury was ruled out, the physician repaired the intraoral laceration present in the lower vestibule. The patient was referred to the Oral and Maxillofacial Surgery Clinic 3 days later and, on examination, extensive facial edema, eccymosis, and hematoma formation was evident bilaterally in the cheeks, submental area, and lower lip. There were no facial lacerations. The occlusion was undisturbed and no fractures could be found clinically or radiographically. However, ptosis of the lower lip was imme-
* Assistant Professor of Oral and Maxillofacial Surgery, Chairman and Head, Clinic of Oral and Maxillofacial Surgery, Baqiyatallah Medical Center, Baqiyatallah University of Medical Sciences, Tehran, Iran. Address correspondence and reprint requests to Dr Motamedi: Africa Expway, Golestan St, Giti Blvd No. 11, Tehran, IR Iran 19667. 0 1996 American
Association
0278-2391/96/5402-0021$3.00/O
of Oral and Maxillofacial
Surgeons
of Case MOTAMEDI,
DDS*
diately evident and examination of sagittal skull CT scans revealed inferior soft-tissue positioning and extensive swelling in the submental area (Fig 1). Intraoral examination was exceedingly difficult due to lack of cooperation by the patient. However, it was noted that the anterior and anterolatera1 aspects of the vestibule were lacerated from the left premolar to the right premolar area. Some of the alveolar bone was denuded. The vestibule had been traumatically deepened and inadequately sutured at that level in one layer with 3-O silk suture. The patient’s parents deferred surgery in hope of improvement of the position of the lower lip with resolution of the edema and hematoma. However, there was no change when she was again seen 10 days later and the intraoral sutures were removed and the edema had subsided. Still in hope of future improvement, the child continued active lip exercises to decrease the interlabial gap and lip incompetence. The patient was examined again nearly 1 year after the initial trauma. Lip incompetence, loss of the buccolabial and mentolabial folds, increased interlabial gap, and scar formation in the lower vestibule were evident (Fig 2). The child’s mother complained that the child’s mouth remained open at night and that she drooled constantly. She presented a childhood photograph confirming that she had no lip incompetence prior to the trauma (Fig 3). After consenting to operation, under general anesthesia via nasoendotracheal intubation, an incision was made in the lower vestibule and the scar tissue was removed. The incision was extended posteriorly to mobilize the soft tissues in an attempt to elevate the lower lip by performing V-Y plasty (Fig 4). However, although helpful, this procedure did not completely close the excessive interlabial gap. Therefore, the mandible was degloved and the inferiorly displaced mentalis muscle was mobilized and sutured superiorly, which helped to reposition the lower lip and genial soft tissues. In addition, to restore and deepen the mentolabial fold, minor osseous contouring was performed on the chin. This procedure also aided in closing the interlabial gap. The wound was closed in layers with 3-O and 4-O vicryl sutures and an elastic bandage was placed at the end of the procedure as is done for routine genioplasty, but with greater upward traction. This was allowed to remain for 2 weeks to prevent hematoma formation and stabilize the soft tissues in their proper position. The patient was doing well 9 months postoperatively. She
MOHAMMAD
HOSEIN
KALANTAR
231
MOTAMEDI
FIGURE 3. Childhood photograph lip seal before the trauma.
FIGURE 1. Sagittal CT scan of the patient showing extensive tissue edema and hematoma in the area of the lower lip and submental area, and inferior posterior displacement of the soft tissues resulting in ptosis of the lower lip.
had nocturnal drooling, and lip competence and normal facial esthetics had been restored (Fig 5).
no longer
Discussion Lower lip ptosis is a relatively rare complication of facial trauma which has not been found to be addressed in the standard texts of oral and maxillofacial surgery. This overlooked sequel of facial trauma is a distressing and unesthetic soft tissue deformity.’ In this deformity
of the patient
showing
normal
there is an eversion of the oral mucosa causing a protrusion and ptosis of lip vermillion and mucosa.* Obliteration of the mentolabial sulcus adds to the deformity and can make the chin appear small.* Ptosis of the lower lip interferes with lip seal and may cause drooling. It can be most distressing to the patient both functionally and esthetically and its correction should have a high priority.’ Treatment of this deformity has included use of scar excision and various Z-plasty techniques, as well as split-thickness skin or mucosal grafts and nasolabial flaps when tissue has been lost.’ However, complementary procedures on the hard and soft tissues of the chin may also be required to decrease the interlabial gap and restore proper hard and soft tissue relationships, especially in long-standing cases.3-6 The best method of treatment of lip ptosis is preven-
of the patient approximately I year FIGURE 2. A, B, Appearance after the initial trauma showing ptosis of the lower lip, excessive show of lower gingiva, and lip incompetence in repose. Note the loss of buccolabial and mentolabial folds (arrows). C, Also note the scar formation in the lower anterior vestibule.
232
tion. Thus, the deformity or its potential occurrence should be recognized and correctly timed interceptive procedures should be instituted. Lacerations in the area of the vestibule and chin should always be treated primarily with closure in layers and incorporation of flaps and grafts for defects. The effects of soft tissue degloving in the area of the chin following genioplasty procedures are also well known,‘-6 and it should be understood that soft tissue degloving can also occur traumatically leading to development of the same deformity. If a secondary procedure is required, it should be appreciated that revisional surgery is always more difficult than control of the soft tissues at the time of original surgery because of scarring, fibrosis, and changes in normal anatomic relationships. Thus, secondary procedures are best used after the final soft tissue drape has been established and the residual defect has been identified.‘-5 The first step in treatment of deformities resulting from scar formation is to remove the scar. When the area of contraction is localized, advancement flaps and V-Y plasty may then be used.’ Reduction of chin height and contouring procedures also help to decrease the interlabial gap.’ Muscle repositioning must also be performed if inferior tissue positioning has occurred secondary to trauma or surgery resulting in redundant tissue in the submental region.4 Surgical technique and method of wound closure also have been shown to effect soft tissue relationships. Chin drooping may follow extensive soft tissue stripping in the area of the chin, which may be associated with shortening of the lower lip. Incorrect wound repair, vestibular scarring, extensive detachment of soft tissues from the chin, suprahyoid myotomy, improper closure of a soft tissue incision, hematoma formation, and genial contouring are all known to affect the soft tissue esthetics in the area of the chin and lower lip? Chin ptosis or “witch’s chin,” 5 an unesthetic complication secondary to degloving of the chin or lack of repositioning of the mentalis muscle at the time of surgery, may also lead to an inferior tissue position and excessinterlabial
POST-TRAUMATIC
LOWER
LIP
PTOSIS
FIGURE 5. A, Nine-month postoperative photograph of the patient showing restoration of normal lip posture in repose. B, Note the restoration of the buccolabial and mentolabial folds.
gap, lip incompetence, exposure of the lower teeth, and redundant tissue in the submental area.4 The mentalis muscle should always be repositioned and reapproximated to prevent ptosis of the chin. Tape dressings placed at the end of surgical procedures on the chin to stabilize the soft tissues and prevent hematoma formation have been advocated by many investigators, who recommend leaving them on for periods ranging from 5 to 14 days.“@ This may also be helpful in preventing lower lip ptosis. Careful attention to all genial and oral vestibular wounds also can minimize or prevent the occurrence of this distressing facial deformity and its sequelae. References
FIGURE 4. A, Outline of buccal sulcus incisions for release of contracture of the lower vestibule. B, Suture of mucosal flaps by the V-Y method, releasing the contracture lengthening and elevating the lower lip.
1. Converse JM, Wood-Smith D: Techniques for the repair of the lips and cheeks, in Converse JM: Reconstructive Plastic Surgery, Philadelphia, PA, Saunders, 1977, pp 1561. 1564 2. Feldman JJ: Facial burns, in McCarthy JG: Plastic Surgery, Philadelphia, PA, Saunders, 1990, chapter 41, pp 21872188 3. Bell WH, McBride K: Genioplasty strategies, in Bell WH (ed): Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992, chapter 64, p 2440
MOHAMMAD
HOSEIN
KALANTAR
233
MOTAMEDI
4. Betts NJ, Fonseca RJ: Soft tissue changes associated with gnathic surgery, in Bell WH (ed): Modem Practice in gnathic and Reconstructive Surgery. Philadelphia, PA, ders, 1992, chapter 62, pp 2138-2204 5. Bell WH, Brammer JA, McBride KL, et al: Reduction oplasty: Surgical techniques and soft tissue changes, Surg Oral Med Oral Path01 51:471, 1981 6. Hohl TH, Epker BN: Macrogenia: A study of treatment
orthoOrthoSaungeniOral results
with surgical recommendations. Oral Surg Oral Med Oral Pathol 41:545, 1976 7. Bell WH, McBride KL: Chin surgery, in Bell WH (ed): Surgical Correction of Dentofacial Deformities. Philadelphia, PA, Saunders, 1980, chapter 14, pp 121 l-1248 8. Spiessl B, Tschopp HM: Surgery of the jaws, in Nauman HH: Head and Neck Surgery, Stuttgart, Germany, Georg Thieme, 1980, chapter 12, p 247