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Reconstruction of both upper and lower lips
Reconstruction of both upper and lower lips Anil Madaree 1, Ian C. McGibbon 2, Warwick M. M. Morris 3
1Consultant and Head of Sub Department, Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital, 2Consultant Plastic Surgeon, Provincial Hospital, George, ~Consultant Sub-Department of Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital, South Africa
SUMMARY. Major defects of both the upper and lower lips occurring in the same patient are unusual and challenging problems that could confront a plastic- or maxillofacial surgeon. We have encountered two such patients and detail their presentation, reconstructive technique used and the postoperative outcome.
text of Sosruta (Hessler, 1855). In the western world, Celsus is credited with being the first to describe the closure of a lip defect in the first century A.D. (Celso, 1826). Since then a myriad of techniques have been described by various authors to reconstruct lips and these have been detailed in previous papers (Mazzola and Lupo, 1984; Bradley and Leake, 1984). These techniques include use of the remaining lip fragments, the intact lip, local flaps, pedicled flaps and free flaps. These references describe reconstruction of major defects of either the upper or lower lip. We could find only one reference that discusses reconstruction o f both upper and lower lips in the same patient (Parsons, 1978). We have encountered two such patients and would like to describe their presentations, reconstructive procedures and post operative result.
INTRODUCTION Defects of the lips are common occurrences in plastic surgery. The aetiology varies from congenital, traumatic, burns, following tumour excision, infection and post radiation. When reconstruction of such defects are planned, there are certain goals that one aims to achieve to obtain a satisfactory result. These include adequate opening of the oral aperture in both the horizontal and vertical dimensions, oral competence, maintenance of sensation, adequate support of the lower lip, creation of an adequate labial sulcus and aesthetic considerations such as lip balance, symmetry, location and direction of scars, commissure reconstruction and creation of a vermilion. The earliest reference to lip reconstruction dates back to 1000 B.C. in ancient India as reported in the sacred
B
A
Fig. ImPatient 1 : Appearance post injury (A) frontal, (B) lateral. 168
Reconstruction of both upper and lower lips
Case 1
This 10-year-old boy was referred with a history of an explosive device having exploded in his mouth (Fig. 1). No further details of the nature of the explosive device could be elucidated from the patient. He sustained a burst type of injury to the lower third of his face. He sustained loss of two thirds of the upper lip and four fifths of the lower lip with the commissures being intact. There was also loss of the anterior quarter of the tongue. The mandible was fractured in several places with loss of the parasymphyseal part. There was loss of and fractures of the dentition. Under general anaesthesia, the wounds were debrided, the remaining fragments of bone wired together and primary closure of the facial wounds
........
J
obtained. The patient was given intravenous antibiotics, mouth washes and fed via a nasogastric tube. The wounds developed sepsis and began to break down after a few days with complete breakdown at 2 weeks. Frequent wet dressings were applied until the wounds were clean again. Five weeks after the original injury, reconstruction of both upper and lower lips was planned using a Bernard type reconstruction (Bernard, 1853; Martin, 1932). The commissures were split on both sides and cheek flaps were elevated (Fig. 2). The modiolus was preserved bilaterally. The other perioral muscles were split. Care was taken to preserve the motor and sensory nerves by using a spreading type of blunt dissection rather than sharp dissection. The buccal mucosa~was split in a posterior direction to allow
........
A
B
Fig. 2--(A) Schematic design of flap elevation and advancement, (B) Flaps sutured into position.
A
169
B
Fig. 3~Patient 1 : Appearance 5 months post reconstruction, (A) frontal, (B) adequate opening of oral aperture.
170
Journal of Cranio-MaxillooFacial Surgery
anterior advancement. The flaps were advanced medially and Burows triangles of skin and subcutaneous tissue removed in the nasolabial and lateral mental regions. Vermilion was created by suturing the oral mucosa to the skin with 5.0 chromic catgut. The skin was sutured with 5.0 Vicryl and 6.0 interrupted nylon. The wounds healed with no major complications. Five months postoperation the patient had a satisfactory result with adequate opening of the oral aperture in both the horizontal and vertical dimensions (Fig. 3). Sensation was present in the reconstructed lips with good oral competence. Case 2
This 25-year-old male sustained a self-inflected gunshot injury of the lower third of the face (Fig. 4). He sustained loss of two thirds of the upper lip and three
Fig. ~-Patient 2: Appearance post injury.
A
quarters of the lower lip with the commissures intact. There was loss of the central maxillary alveolus, loss of the mandible in the parasymphyseal region and associated fractures of the remaining maxilla and mandible. There was loss of the anterior third of the floor of the mouth and the central part of the chin. The wound was debrided and the remaining fragments of bone wired together. The first stage of reconstruction involved free tissue transfer of the lateral border of scapula and a parascapular flap. The bone was used to reconstruct the defect in the mandible and the skin paddle to reconstruct the floor of the mouth and the chin defect (Fig. 5). At the second stage, reconstruction of the lips was undertaken. As in the first case a Bernard type technique was employed. The commissures were split and cheek flaps elevated with preservation of the nerves and modiolus. The flaps were advanced and Burows triangles of skin and subcutaneous tissue
Fig. 5--Patient 2: Appearance 6 weeks after free tissue transfer of lateral border of scapula and parascapular flap. The flap designs for the second stage reconstruction are outlined.
B
Fig. 6~Patient 2: Appearance 3 years following lip reconstruction, (A) frontal, (B) adequate opening of oral aperture.
Reconstruction of both upper and lower lips 171 excised in the nasolabial and lateral mental regions. Oral mucosa was stitched to skin to create a vermilion. The wounds healed uneventfully. Three years after the reconstruction the patient has a satisfactory appearance (Fig. 6). The patient had sensation in the reconstructed lips with good oral competence.
DISCUSSION Major defects of both upper and lower lips occurring in the same patient is a rather daunting and challenging situation that could face a plastic or maxillofacial surgeon. Literature pertaining to this reconstruction is virtually non existent. The primary goal of reconstruction should be restoration of function of the lips. This entails creating a sensate lip with an adequate oral aperture, ability for good lip expression and without the troublesome disability of drooling of saliva. The aesthetic appearance of the lips is the other factor to be taken into account when undertaking such reconstructive procedures. The attempt at primary closure in our first patient was obviously against traditional surgical teaching. This, being a high velocity injury, should never have been closed primarily. We were optimistic that the good vascular supply to the face would allow us the liberty of transgressing this surgical principle. The two patients that we have reconstructed have satisfactory results. They both have adequate oral opening in both the horizontal and vertical dimensions. Sensation is present in both patients and neither of them drool saliva. The aesthetic appearance was satisfactory in both cases especially if one considers the appearance immediately after injury. There are, however, still some unsolved problems,
The reconstructed lips do have a tight appearance which is most evident in profile view. The use of an oral splinting device postoperatively could perhaps solve this problem to a certain extent. The new vermilion which is cheek muccosa may be unstable initially but this improved with time in out patients. We would recommend the use of this technique in the reconstruction of major defects of the upper and lower lips. It is a relatively simple technique with a predictably satisfactory result.
References Bernard, C. : Cancer de la levre inferieure opere par un proceed
nouveau. Bull. Mem. Soc. Chir. (1853) 3 357 Bradley, C., Leake, J. E. : Compensatory reconstruction of the
lips and mouth after major tissue loss. Clin. Plast. Surg. (1984) 11 637 Celso, A. C. : De Medicina Libri VIII, Cap. IX Paris, Compete, 1826 Hessler, F.." Commentarii et annotationes in Sus Ayurvedam. Enke Erlangen 1855, p. 12 Martin, H. E. : Chelioplasty for advanced carciomas of the lip. Surg. Gynec. Obst. (1932) 54 914 Mazzola, R . f , Lupo, G. : Evolving concepts in lip reconstruction. Clin. Plast. Surg. (1984) 11 583 Parsons, R. IV. : Reconstruction of the lower face and lips. Clin. Plast. Surg. (1975) 2 551
A. Madaree
Sub Department of Plastic and ReconstructiveSurgery University of Natal Wentworth Hospital Private Bag Jacobs 4026 Durban Republic of South Africa Paper received 9 September 1992 Accepted 11 February 1993
1Consultant and Head of Sub Department, Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital, 2Consultant Plastic Surgeon, Provincial Hospital, George, ~Consultant Sub-Department of Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital, South Africa
SUMMARY. Major defects of both the upper and lower lips occurring in the same patient are unusual and challenging problems that could confront a plastic- or maxillofacial surgeon. We have encountered two such patients and detail their presentation, reconstructive technique used and the postoperative outcome.
text of Sosruta (Hessler, 1855). In the western world, Celsus is credited with being the first to describe the closure of a lip defect in the first century A.D. (Celso, 1826). Since then a myriad of techniques have been described by various authors to reconstruct lips and these have been detailed in previous papers (Mazzola and Lupo, 1984; Bradley and Leake, 1984). These techniques include use of the remaining lip fragments, the intact lip, local flaps, pedicled flaps and free flaps. These references describe reconstruction of major defects of either the upper or lower lip. We could find only one reference that discusses reconstruction o f both upper and lower lips in the same patient (Parsons, 1978). We have encountered two such patients and would like to describe their presentations, reconstructive procedures and post operative result.
INTRODUCTION Defects of the lips are common occurrences in plastic surgery. The aetiology varies from congenital, traumatic, burns, following tumour excision, infection and post radiation. When reconstruction of such defects are planned, there are certain goals that one aims to achieve to obtain a satisfactory result. These include adequate opening of the oral aperture in both the horizontal and vertical dimensions, oral competence, maintenance of sensation, adequate support of the lower lip, creation of an adequate labial sulcus and aesthetic considerations such as lip balance, symmetry, location and direction of scars, commissure reconstruction and creation of a vermilion. The earliest reference to lip reconstruction dates back to 1000 B.C. in ancient India as reported in the sacred
B
A
Fig. ImPatient 1 : Appearance post injury (A) frontal, (B) lateral. 168
Reconstruction of both upper and lower lips
Case 1
This 10-year-old boy was referred with a history of an explosive device having exploded in his mouth (Fig. 1). No further details of the nature of the explosive device could be elucidated from the patient. He sustained a burst type of injury to the lower third of his face. He sustained loss of two thirds of the upper lip and four fifths of the lower lip with the commissures being intact. There was also loss of the anterior quarter of the tongue. The mandible was fractured in several places with loss of the parasymphyseal part. There was loss of and fractures of the dentition. Under general anaesthesia, the wounds were debrided, the remaining fragments of bone wired together and primary closure of the facial wounds
........
J
obtained. The patient was given intravenous antibiotics, mouth washes and fed via a nasogastric tube. The wounds developed sepsis and began to break down after a few days with complete breakdown at 2 weeks. Frequent wet dressings were applied until the wounds were clean again. Five weeks after the original injury, reconstruction of both upper and lower lips was planned using a Bernard type reconstruction (Bernard, 1853; Martin, 1932). The commissures were split on both sides and cheek flaps were elevated (Fig. 2). The modiolus was preserved bilaterally. The other perioral muscles were split. Care was taken to preserve the motor and sensory nerves by using a spreading type of blunt dissection rather than sharp dissection. The buccal mucosa~was split in a posterior direction to allow
........
A
B
Fig. 2--(A) Schematic design of flap elevation and advancement, (B) Flaps sutured into position.
A
169
B
Fig. 3~Patient 1 : Appearance 5 months post reconstruction, (A) frontal, (B) adequate opening of oral aperture.
170
Journal of Cranio-MaxillooFacial Surgery
anterior advancement. The flaps were advanced medially and Burows triangles of skin and subcutaneous tissue removed in the nasolabial and lateral mental regions. Vermilion was created by suturing the oral mucosa to the skin with 5.0 chromic catgut. The skin was sutured with 5.0 Vicryl and 6.0 interrupted nylon. The wounds healed with no major complications. Five months postoperation the patient had a satisfactory result with adequate opening of the oral aperture in both the horizontal and vertical dimensions (Fig. 3). Sensation was present in the reconstructed lips with good oral competence. Case 2
This 25-year-old male sustained a self-inflected gunshot injury of the lower third of the face (Fig. 4). He sustained loss of two thirds of the upper lip and three
Fig. ~-Patient 2: Appearance post injury.
A
quarters of the lower lip with the commissures intact. There was loss of the central maxillary alveolus, loss of the mandible in the parasymphyseal region and associated fractures of the remaining maxilla and mandible. There was loss of the anterior third of the floor of the mouth and the central part of the chin. The wound was debrided and the remaining fragments of bone wired together. The first stage of reconstruction involved free tissue transfer of the lateral border of scapula and a parascapular flap. The bone was used to reconstruct the defect in the mandible and the skin paddle to reconstruct the floor of the mouth and the chin defect (Fig. 5). At the second stage, reconstruction of the lips was undertaken. As in the first case a Bernard type technique was employed. The commissures were split and cheek flaps elevated with preservation of the nerves and modiolus. The flaps were advanced and Burows triangles of skin and subcutaneous tissue
Fig. 5--Patient 2: Appearance 6 weeks after free tissue transfer of lateral border of scapula and parascapular flap. The flap designs for the second stage reconstruction are outlined.
B
Fig. 6~Patient 2: Appearance 3 years following lip reconstruction, (A) frontal, (B) adequate opening of oral aperture.
Reconstruction of both upper and lower lips 171 excised in the nasolabial and lateral mental regions. Oral mucosa was stitched to skin to create a vermilion. The wounds healed uneventfully. Three years after the reconstruction the patient has a satisfactory appearance (Fig. 6). The patient had sensation in the reconstructed lips with good oral competence.
DISCUSSION Major defects of both upper and lower lips occurring in the same patient is a rather daunting and challenging situation that could face a plastic or maxillofacial surgeon. Literature pertaining to this reconstruction is virtually non existent. The primary goal of reconstruction should be restoration of function of the lips. This entails creating a sensate lip with an adequate oral aperture, ability for good lip expression and without the troublesome disability of drooling of saliva. The aesthetic appearance of the lips is the other factor to be taken into account when undertaking such reconstructive procedures. The attempt at primary closure in our first patient was obviously against traditional surgical teaching. This, being a high velocity injury, should never have been closed primarily. We were optimistic that the good vascular supply to the face would allow us the liberty of transgressing this surgical principle. The two patients that we have reconstructed have satisfactory results. They both have adequate oral opening in both the horizontal and vertical dimensions. Sensation is present in both patients and neither of them drool saliva. The aesthetic appearance was satisfactory in both cases especially if one considers the appearance immediately after injury. There are, however, still some unsolved problems,
The reconstructed lips do have a tight appearance which is most evident in profile view. The use of an oral splinting device postoperatively could perhaps solve this problem to a certain extent. The new vermilion which is cheek muccosa may be unstable initially but this improved with time in out patients. We would recommend the use of this technique in the reconstruction of major defects of the upper and lower lips. It is a relatively simple technique with a predictably satisfactory result.
References Bernard, C. : Cancer de la levre inferieure opere par un proceed
nouveau. Bull. Mem. Soc. Chir. (1853) 3 357 Bradley, C., Leake, J. E. : Compensatory reconstruction of the
lips and mouth after major tissue loss. Clin. Plast. Surg. (1984) 11 637 Celso, A. C. : De Medicina Libri VIII, Cap. IX Paris, Compete, 1826 Hessler, F.." Commentarii et annotationes in Sus Ayurvedam. Enke Erlangen 1855, p. 12 Martin, H. E. : Chelioplasty for advanced carciomas of the lip. Surg. Gynec. Obst. (1932) 54 914 Mazzola, R . f , Lupo, G. : Evolving concepts in lip reconstruction. Clin. Plast. Surg. (1984) 11 583 Parsons, R. IV. : Reconstruction of the lower face and lips. Clin. Plast. Surg. (1975) 2 551
A. Madaree
Sub Department of Plastic and ReconstructiveSurgery University of Natal Wentworth Hospital Private Bag Jacobs 4026 Durban Republic of South Africa Paper received 9 September 1992 Accepted 11 February 1993