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Surgical Pearl: Removal of a large labial mucocele
PEARLS Stuart J. Salasche, MD Feature Editor
Surgical Pearl: Removal of a large labial mucocele Thao A. Tran, BA, and Harry L. Parlette III, MD Charlottesville, Virginia
A mucocele is a relatively common oral mucosal abnormality that results from the obstruction or injury of a minor salivary gland duct. It is readily diagnosed by history, appearance, and palpation. There is a small, round or oval, smooth, soft, fluctuant swelling that distorts the oral mucosal surface. Size may vary from a few millimeters to a centimeter or more in diameter.1 A superficially located mucocele will present as a variably sized bluish translucent elevation with thinning of the overlying tissue. If it is more deeply situated, the lesion has the color of the normal mucosa and the fluid-filled nature is somewhat obscured, making the diagnosis less apparent.2 There are two types of mucoceles. The first type, the mucous extravasation cyst, is not a true cyst because it lacks an epithelial lining. It arises from a partially or totally severed salivary gland duct resulting in the accumulation of saliva in the adjacent soft tissue. Here it is walled off by a fibrous connective tissue pseudocapsule.3 A second type, the mucous retention cyst, is lined by ductal epithelium. It develops from partial obstruction of a duct in the presence of continued mucous secretion from the salivary gland.3 Of the two types, the extravasation mucocele is more common and occurs most frequently on the lower lip of a young person. The retention mucocele is more apt to occur on the buccal cheek or soft palate of an older patient.2 Small and superficial mucoceles do not require treatment because they often heal after spontaneous rupture. Recurrences are frequent. Various treatments, both medical and surgical, have been
From the Department of Dermatology, University of Virginia Health System. Reprints are not available from the authors. J Am Acad Dermatol 1999;40:760-2. Copyright © 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16/74/96377
760
Fig 1. Large untreated labial mucocele.
described for large or recurrent mucoceles. Our surgical approach is described. A 25-year-old woman presented for evaluation and management of a rather large painless cystic mass causing deformity of her right lower lip (Fig 1). She reported a history of alternate enlargement and shrinkage of this mass in her right inner lower lip over the last year. The current large cystic growth had been present for a few months and measured 18 × 10 mm. Because of continued enlargement and resulting distortion of the patient’s lower lip, surgical therapy was recommended. Local anesthesia around the presumed mucocele was obtained with the application of topical 20% benzocaine on a 2 × 2-inch gauze followed within several minutes by the submucosal injection of 1% lidocaine with 1:100,000 epinephrine. The area was prepared with chlorhexadine wash. Stabilization of the large cyst to be removed was accomplished by placement of a 5-0 suture at both ends of the elliptical piece of tissue to be excised. Using these two sutures to apply countertraction, the tissue ellipse containing the cyst was held taut during the excision procedure (Fig 2). This
Journal of the American Academy of Dermatology Volume 40, Number 5, Part 1
Fig 2. Traction sutures in place. Dental rolls for absorbency.
allowed a delicate and controlled excision, skirting the mucocele itself by a narrow margin and avoiding rupture of the cystic mass. Care was taken not to rupture the cyst to increase the likelihood of total removal and to make the remaining dissection easier. The incisions creating the ellipse were carried down to the orbicularis oris muscle to ensure removal of the entire offending salivary apparatus (gland and duct). More superficial removal is apt to lead to recurrences.4 Before excision, the likely course of the inferior labial artery was noted. In our patient this was superior to the position of the cyst. The inferior labial artery is a branch of the facial artery and runs under the mucosa and on the posterior surface of the orbicularis oris muscle approximately one fourth inch down from the edge of the lip. It is a tortuous vessel that receives blood flow from the facial artery on both sides. Should it be damaged, ligation on both sides of the rupture is required. After the ellipse containing the mucocele and offending salivary unit (gland and duct) was delivered, the resultant wound was closed with two layers of 5-0 absorbable chromic suture. A deep layer was placed to approximate the deep tissues just above the orbicularis oris muscle. The more superficial layer was placed just below the mucosal surface to coapt the mucosal edges. The knots on the more superficial layer were buried to enhance the patient’s comfort (Fig 3). Suturing the wound in this fashion not only results in maximum patient comfort but precludes the need for suture removal. The patient was advised to rinse with salt water every 3 to 4 hours while awake for the first several
Pearls 761
Fig 3. Sutured wound immediately after operation.
Fig 4. Healed wound 4 days after surgery.
days. Spicy, acidic, or salty foods were to be avoided, and a soft diet was recommended. The patient was seen on postoperative day 4 with the suture line already almost imperceptible (Fig 4). Follow-up at 6 months revealed no recurrence of the lesion. The keys to this surgical approach are several. First, the use of tension sutures to stabilize the ellipse of tissue being excised enhances easy dissection and excellent visibility. Second, the buried resorbable sutures used for closure of the mucosa not only give an excellent cosmetic result but maximize the patient’s comfort and convenience in that no sutures have to be removed. Third, by carrying the excision down to the orbicularis oris below the minor salivary glands and their ducts, the likelihood of any recurrence is effectively eliminated. Fourth, tissue is available for histopathologic confirmation of the clinical diagnosis.
Journal of the American Academy of Dermatology May 1999
762 Pearls REFERENCES 1. Eveson JW. Superficial mucoceles: pitfall in clinical and microscopic diagnosis. Oral Surg Oral Med Oral Pathol 1988;66:318-22. 2. Bodner L, Tal H. Salivary gland cysts of the oral cavity: clinical observation and surgical management. Compendium 1991;12(3):150-6.
3. Tal H, Altini M, Lemmer J. Multiple mucous retention cysts of the oral mucosa. Oral Surg 1984;58:692-5. 4. Laskin DM. Surgery of the oral cavity. In: Epstein E, Epstein E Jr, editors. Skin surgery. 6th ed. Philadelphia: WB Saunders; 1987. p. 505.
IOTADERMA #64 Name 3 syndromes associated with silvery hair in infants. Jeffrey D. Bernhard, MD Answer will appear in the June issue of the Journal.
APRIL IOTADERMA (#63) What anatomic feature of the ear is named after Charles Darwin, and whom did Darwin himself name it after? Answer: Darwin’s tubercle (tuberculum auriculare) is a small inward-pointing projection sometimes found on the edge of the helix. The poet and sculptor Thomas Woolner first called Darwin’s attention to it. In a letter to Woolner, Darwin called it the “Woolnerian tip” and, in jest, the “Angulus Woolnerianus.” REFERENCE Millard Dr, Pickard RE. Darwin’s tubercle belongs to Woolner. Arch Otolaryngol 1970; 91:334-5.
Surgical Pearl: Removal of a large labial mucocele Thao A. Tran, BA, and Harry L. Parlette III, MD Charlottesville, Virginia
A mucocele is a relatively common oral mucosal abnormality that results from the obstruction or injury of a minor salivary gland duct. It is readily diagnosed by history, appearance, and palpation. There is a small, round or oval, smooth, soft, fluctuant swelling that distorts the oral mucosal surface. Size may vary from a few millimeters to a centimeter or more in diameter.1 A superficially located mucocele will present as a variably sized bluish translucent elevation with thinning of the overlying tissue. If it is more deeply situated, the lesion has the color of the normal mucosa and the fluid-filled nature is somewhat obscured, making the diagnosis less apparent.2 There are two types of mucoceles. The first type, the mucous extravasation cyst, is not a true cyst because it lacks an epithelial lining. It arises from a partially or totally severed salivary gland duct resulting in the accumulation of saliva in the adjacent soft tissue. Here it is walled off by a fibrous connective tissue pseudocapsule.3 A second type, the mucous retention cyst, is lined by ductal epithelium. It develops from partial obstruction of a duct in the presence of continued mucous secretion from the salivary gland.3 Of the two types, the extravasation mucocele is more common and occurs most frequently on the lower lip of a young person. The retention mucocele is more apt to occur on the buccal cheek or soft palate of an older patient.2 Small and superficial mucoceles do not require treatment because they often heal after spontaneous rupture. Recurrences are frequent. Various treatments, both medical and surgical, have been
From the Department of Dermatology, University of Virginia Health System. Reprints are not available from the authors. J Am Acad Dermatol 1999;40:760-2. Copyright © 1999 by the American Academy of Dermatology, Inc. 0190-9622/99/$8.00 + 0 16/74/96377
760
Fig 1. Large untreated labial mucocele.
described for large or recurrent mucoceles. Our surgical approach is described. A 25-year-old woman presented for evaluation and management of a rather large painless cystic mass causing deformity of her right lower lip (Fig 1). She reported a history of alternate enlargement and shrinkage of this mass in her right inner lower lip over the last year. The current large cystic growth had been present for a few months and measured 18 × 10 mm. Because of continued enlargement and resulting distortion of the patient’s lower lip, surgical therapy was recommended. Local anesthesia around the presumed mucocele was obtained with the application of topical 20% benzocaine on a 2 × 2-inch gauze followed within several minutes by the submucosal injection of 1% lidocaine with 1:100,000 epinephrine. The area was prepared with chlorhexadine wash. Stabilization of the large cyst to be removed was accomplished by placement of a 5-0 suture at both ends of the elliptical piece of tissue to be excised. Using these two sutures to apply countertraction, the tissue ellipse containing the cyst was held taut during the excision procedure (Fig 2). This
Journal of the American Academy of Dermatology Volume 40, Number 5, Part 1
Fig 2. Traction sutures in place. Dental rolls for absorbency.
allowed a delicate and controlled excision, skirting the mucocele itself by a narrow margin and avoiding rupture of the cystic mass. Care was taken not to rupture the cyst to increase the likelihood of total removal and to make the remaining dissection easier. The incisions creating the ellipse were carried down to the orbicularis oris muscle to ensure removal of the entire offending salivary apparatus (gland and duct). More superficial removal is apt to lead to recurrences.4 Before excision, the likely course of the inferior labial artery was noted. In our patient this was superior to the position of the cyst. The inferior labial artery is a branch of the facial artery and runs under the mucosa and on the posterior surface of the orbicularis oris muscle approximately one fourth inch down from the edge of the lip. It is a tortuous vessel that receives blood flow from the facial artery on both sides. Should it be damaged, ligation on both sides of the rupture is required. After the ellipse containing the mucocele and offending salivary unit (gland and duct) was delivered, the resultant wound was closed with two layers of 5-0 absorbable chromic suture. A deep layer was placed to approximate the deep tissues just above the orbicularis oris muscle. The more superficial layer was placed just below the mucosal surface to coapt the mucosal edges. The knots on the more superficial layer were buried to enhance the patient’s comfort (Fig 3). Suturing the wound in this fashion not only results in maximum patient comfort but precludes the need for suture removal. The patient was advised to rinse with salt water every 3 to 4 hours while awake for the first several
Pearls 761
Fig 3. Sutured wound immediately after operation.
Fig 4. Healed wound 4 days after surgery.
days. Spicy, acidic, or salty foods were to be avoided, and a soft diet was recommended. The patient was seen on postoperative day 4 with the suture line already almost imperceptible (Fig 4). Follow-up at 6 months revealed no recurrence of the lesion. The keys to this surgical approach are several. First, the use of tension sutures to stabilize the ellipse of tissue being excised enhances easy dissection and excellent visibility. Second, the buried resorbable sutures used for closure of the mucosa not only give an excellent cosmetic result but maximize the patient’s comfort and convenience in that no sutures have to be removed. Third, by carrying the excision down to the orbicularis oris below the minor salivary glands and their ducts, the likelihood of any recurrence is effectively eliminated. Fourth, tissue is available for histopathologic confirmation of the clinical diagnosis.
Journal of the American Academy of Dermatology May 1999
762 Pearls REFERENCES 1. Eveson JW. Superficial mucoceles: pitfall in clinical and microscopic diagnosis. Oral Surg Oral Med Oral Pathol 1988;66:318-22. 2. Bodner L, Tal H. Salivary gland cysts of the oral cavity: clinical observation and surgical management. Compendium 1991;12(3):150-6.
3. Tal H, Altini M, Lemmer J. Multiple mucous retention cysts of the oral mucosa. Oral Surg 1984;58:692-5. 4. Laskin DM. Surgery of the oral cavity. In: Epstein E, Epstein E Jr, editors. Skin surgery. 6th ed. Philadelphia: WB Saunders; 1987. p. 505.
IOTADERMA #64 Name 3 syndromes associated with silvery hair in infants. Jeffrey D. Bernhard, MD Answer will appear in the June issue of the Journal.
APRIL IOTADERMA (#63) What anatomic feature of the ear is named after Charles Darwin, and whom did Darwin himself name it after? Answer: Darwin’s tubercle (tuberculum auriculare) is a small inward-pointing projection sometimes found on the edge of the helix. The poet and sculptor Thomas Woolner first called Darwin’s attention to it. In a letter to Woolner, Darwin called it the “Woolnerian tip” and, in jest, the “Angulus Woolnerianus.” REFERENCE Millard Dr, Pickard RE. Darwin’s tubercle belongs to Woolner. Arch Otolaryngol 1970; 91:334-5.