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British Journal of Oral and Maxillofacial Surgery 47 (2009) 102–105
Treatment of chronic lip fissures with carbon dioxide laser James Combes a,∗ , Timothy K. Mellor b,1 a b
Maxillofacial Unit, St George’s Hospital, Blackshaw Road, London, SW17 0QT, United Kingdom Maxillofacial Unit, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY, United Kingdom
Accepted 2 June 2008 Available online 28 August 2008
Abstract Resurfacing of cutaneous tissue with carbon dioxide laser increases the amount and quality of collagen and elastin subepithelially. We used this technique to ablate 12 chronic lip fissures in one woman and 10 men. Five patients’ fissures had persisted for durations ranging from several months to seven years; the other six had fissures that split between one and five times annually, and took weeks or months to heal. Ten fissures had re-epithelialised completely six weeks postoperatively, while in two cases the treatment was repeated. At mean long-term follow-up of 70 months (range 44–93) of 11 cases, eight had had no recurrence. One patient, whose fissure had healed at three months was lost to follow-up; one fissure had not improved; one had recurred less severely; and one had split only once, then healed quickly and not recur. Only one patient had postoperative discomfort that required analgesia, and one had a mildly raised scar. This small series shows that this is a successful, safe technique with low morbidity, however, the technology is not always readily available. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Lip fissure; Carbon dioxide laser; Laser resurfacing
Introduction Chronic lip fissures are linear ulcers that usually occur in the sagittal plane of the vermillion on either the upper or lower lips (Fig. 1). They have a reported prevalence of 0.6%, and are commoner in men than women by a ratio of almost 4:1, and of roughly equal incidence on the upper and lower lip.1–3 There seems to be no correlation between excessive outdoor exposure or smoking and the development of such fissures.1 As they are often painful, unsightly, and tend to recur if they heal at all, patients may seek professional advice. Unfortunately not all cases respond to conservative forms of treatment, and while excision and cryotherapy are effective, both have drawbacks. We used resurfacing with carbon dioxide laser to ablate 12 chronic lip fissures in 11 patients. Six weeks postoperatively 10 had re-epithelialised, and the ∗
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treatment was repeated in two. At mean long-term follow up of 70 months (range 44–93) eight had not recurred; one that had healed at three months was lost to follow up; one had recurred less severely; one had split once only to heal quickly and not recur; and one had not improved. This small series shows that this is a successful, safe technique with low morbidity, however, the technology is not always readily available.
Patients, material, and method We used a SharplanTM carbon dioxide laser with SilkTouchTM flashscanning microprocessor to ablate the fissures. Eleven operations were done under local anaesthesia and one under general anaesthesia so that a third molar could be removed at the same time. The laser was set to a power of 18 watts with a pulse of 0.2 seconds, and a spot width of 3 mm. The Figures show an operative series of a single lower lip midline fissure (Fig. 1) that had been present for 7 years and had never healed completely.
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.06.013
J. Combes, T.K. Mellor / British Journal of Oral and Maxillofacial Surgery 47 (2009) 102–105
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Fig. 1. A median lower lip fissure.
Fig. 4. Scrubbing of the wound to remove the debris from photothermolysis.
Fig. 2. First stage of treatment of the median lip fissure with a series of separate laser scans 3 mm in diameter.
Fig. 5. The wound after 2 passes of the laser over the whole area; the deep part of the fissure is still obvious.
It is first treated with a single line of separate laser pulses 3 mm wide (Fig. 2) followed by similar passes on either side of the initial line with as little overlap as possible (Fig. 3). The wound is then scrubbed with damp gauze to remove debris from the photothermolysis and allow the laser to be applied directly to vital tissue on the next pass (Fig. 4). The process is then repeated, leaving the deep part of the fissure obvious (Fig. 5). A third pass is then made down the line of the fissure, which is scrubbed (Fig. 6) before one more pass is completed over the whole wound. The fissure itself has therefore had 4 passes of the laser, and the adjacent tissue 3 passes. The wound is not scrubbed at the end, but is dressed with soft paraffin (Fig. 7).
Fig. 3. Similar laser passes on either side of the initial wound.
Fig. 6. A third laser pass down the line of the initial fissure.
Fig. 7. The end of the procedure showing the wound after 4 central and 3 lateral passes.
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J. Combes, T.K. Mellor / British Journal of Oral and Maxillofacial Surgery 47 (2009) 102–105
Fig. 8. The lip completely healed with no evidence of the fissure 6 weeks postoperatively.
Patients are prescribed paracetamol and codeine for analgesia, and chloramphenicol 1% eye ointment as a wound dressing. Fig. 8 shows healing six weeks after treatment.
Results Twelve chronic lip fissures were treated in 11 patients; nine fissures were in the midline, seven of which were on the lower lip and two on the upper; the other three were to the left of centre, with two on the upper and one on the lower lip. The distribution and the male predilection agrees with Axéll and Skoglund.1 Five patients had had fissures constantly for between several months and seven years’ duration since initial presentation, while the other six had fissures that split between one and five times a year, and took between two weeks and several months to heal. Four patients smoked cigarettes and six spent much time outdoors. Most had used petroleum jelly or lip salve, while two had used sodium fusidate 2% ointment (Fucidin), and three miconazole cream, but with no discernable effect. One patient found that playing the trombone caused his lip to split and it would not heal unless he did not play for a prolonged period. None of the patients had a family history of lip fissures. The short-term results of the laser treatment were encouraging. Patients were reviewed as close as possible to two weeks and six weeks postoperatively. Ten fissures had reepithelialised completely by six weeks, while two did not heal. Of those whose fissures had healed there was no evidence of thickening or scarring of the lip at this stage. Only one patient had postoperative discomfort and required analgesia. Of the two fissures that had not healed at six weeks, one was an upper midline lesion on the lip of a 16-year-old boy, which seemed to have been eliminated completely with three central and two lateral passes, unlike the case described. He was offered further laser treatment, excision, or no further treatment. He opted for laser treatment again, the second course of which was successful. The other patient was a 24year-old man with a lower midline fissure that he had had intermittently for seven years; it occurred twice a year and took months to heal. He had the treatment twice, after which
it healed initially, but it recurred sometime over the next six years and returned to its preoperative state. As some lesions might have healed by the six-week follow-up without intervention, long-term follow-up was necessary to assess the efficacy of this treatment accurately. Patients were contacted by telephone, but one patient who had been reviewed at three months could not be traced. Follow-up times for the rest ranged from 44 to 93 months (mean 70). Two further patients in addition to the 24-year-old man described above had had a recurrent fissure after initial healing; the first was a 21-year-old man whose lower midline fissure had recurred when he was contacted 84 months after the initial treatment. He could not recall exactly when the lip had started to split again, but he had not sought further treatment as the fissure had been much less severe and had healed in a ‘week or two’ rather than taking months as before. The second patient was a 20-year-old man who had had a lower midline fissure continuously for between 2 and 4 years before treatment. It had recurred once for a short period several months after initial healing, but had healed with no intervention, and had not recurred again during follow-up of 80 months. The only female patient, who was also the only diabetic patient, developed a slightly hypertrophic scar after her upper lip fissure was treated, but this caused her no concern. No other patients in whom the fissures healed had any cosmetic irregularity when followed up.
Discussion The aetiology of lip fissures is not clear. It has been suggested that they may be related to a hereditary predisposition for weakness in first branchial arch fusion and could even represent a discreet manifestation of a Tessier number 30 facial cleft of the lower lip.1–3 In support of this Axéll and Skoglund1 suggest that most fissures on the upper lip occur slightly lateral to the midline while most on the lower lip occur in the midline. Malaligned anterior teeth, possibly in conjunction with a parafunctional habit, have also been associated with upper lip fissures.4 The prevalence of lip fissures is reported to be higher in patients with orofacial granulomatosis, Crohn’s disease and Downs syndrome.5 Histologically, excised fissures have a discontinuity of the epithelium with hyperplastic areas at the margins, and there is often a chronic heavy inflammatory infiltrate in the surrounding connective tissue.1 Staphylococcus aureus has been found and the persistent nature of fissures has been attributed to this bacterium.6,7 Candidal hyphae are rare, and we could find no reports of dysplasia, although reactive epithelial atypia has been reported in one case.1,2,8 There is a single reported case of a 29-year-old man who had a squamous cell carcinoma that arose from a non-healing chronic lower median lip fissure that he had had since birth.9 Several methods of invasive treatment have been advocated, as these lesions do not always heal with conservative management. Maisels10 described excision and Z-plasty
J. Combes, T.K. Mellor / British Journal of Oral and Maxillofacial Surgery 47 (2009) 102–105
closure in 1969. Several authors have championed this method, or that of simple excision, with excellent results,1–3,8 although there is often postoperative swelling particularly with Z-plasty.2 Ball and Barnard11 suggested that this type of treatment is too severe for what seems to be a minor problem and recommended cryosurgery on the basis of five cases treated. They reported that this produced good aesthetic results with less hardness or immobility of the lip than excision, and was easier and less time consuming than excision. However, it could cause postoperative swelling and pain. Cutaneous resurfacing with carbon dioxide laser is effective in the elimination of facial rhytids. Histological studies show an increase in collagen with greater compaction, and an increase in elastin fibres after treatment, making this technique potentially suitable for the treatment of lip fissures.12,13 Use of a scanning or pulsed carbon dioxide laser allows accurate control of tissue photothermolysis and enables the operator to ablate tissue at a precise depth and breadth. Only one case of 12 we studied was a failure. This fissure was as extensive, if not more so, than the others treated, and we wonder whether its failure to heal was because it had not been ablated completely as in the other case that did not heal initially. We wonder whether treatment in cases like these would be more successful when the lesion is quiescent. Treatment of lip fissures with carbon dioxide laser is quicker and simpler than excision alone, or excision with Z-plasty, it involves no suturing, and there is little or no postoperative pain or swelling.
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