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Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 334 - файл
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Fig. 11.5 Superiorly based nasolabial ap. (a) Markings for excision and ap, (b) Excision defect
and ap raised, (c) Flap transposed into defect, (d) Final closure
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Fig. 11.6 Inferiorly based nasolabial ap. (a) Markings for excision and ap, (b) Excision dfect
and ap raised, (c) Mobilisation of ap into defect, (d) Final closure
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Inferiorly Based Nasolabial Flap
This is a random pattern ap, though it overlies the course of the facial vessels.
Indications: Medium-sized defect of a variety of shapes.
Technique: The ap is raised along the nasolabial fold, with one of its margins
also forming the margin of the defect. A trial transfer and template can help determine the size of the ap. The overall length of the ap is planned to be longer to
accommodate any loss of effective length, and the tip triangulated to help primary
closure. The base of the ap is designed to be wider than the tip to maintain vascularity. The ap is raised in the subcutaneous plane. The wound margins are undermined in the subcutaneous plane, and the wound is closed in layers (Fig.11.6a–d).
Tips: There is a tendency for “pin cushioning” with circular defects, and it also
makes it difcult to place the scars along RSTL (see superiorly based nasolabial
ap—Fig. 11.5a–d). Consideration should be given to modifying the defect to include
parallel margins and extending it to make the nal scar lie along aesthetic boundaries
and RSTL. The medial dog ear can be excised along the mentolabial crease. The
width of the ap should be adequate to prevent displacement of the vermillion.
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Mucosa Only
Primary Closure
Indications: Small defects.
Technique: The defect is converted to a vertical ellipse, and the wound margins
minimally undermined and the defect closed in layers.
Tips: Try and avoid “horizontal” incisions to minimise damage to the sensory
nerve supply of the lips and distortion of the vermillion border.
Mucosal Advancement Flap
Indication: Large mucosal defects, whole lower lip mucosal defect (lip shave).
Technique: The margins of the mucosal defect are modied if necessary, to
leave even/straight wound edges. The mucosa of the inner surface of the lip is raised
as a ap with its base at the labial sulcus. The ap is raised on the surface of the
muscle, deep to the plane of the minor salivary glands This is best done by alternate
blunt and sharp dissection, in a vertical direction to create channels, prior to division. Care is taken not to “button hole” the ap. Frequent attempts are made to
assess the mobility and adequacy of the ap and if possible, the “intervening” tissue
is retained between the channels to preserve some sensation. Once adequate mobility is obtained, the ap is sutured accurately to create a new vermillion border
(Fig.11.7a–e, f–k).
Tips: There is a tendency for scar contracture to result in a decrease in vermillion
exposure. This can be partly accommodated by placing the new vermillion border at
a more anterior location. The lateral margins of the defect are frequently narrow,
and it is therefore not necessary to dissect widely in this area, which can prevent
additional damage to the mental nerves.
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Fig. 11.7 Mucosal advancement ap. (a) Markings for excision, (b) Excision defect, (c) Mucosal
ap raised, (d) Initial closure, (e) Final closure, (f) Lesion lower lip, (g) Markings for excision, (h)
Mucosal excision, (i) Excision defect, (j) Mucosa raised, (k) Final closure
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e
f
g
Fig. 11.7 (continued)
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Full-thickness Defects
Primary Closure (Shield Rather Than Simple “V” Excision)
Indication: Small defects up to 1/3rd of the lip.
Technique: The lesion is marked with adequate margins, and the excision is
planned to leave a “shield” shaped defect, with parallel wound edges superiorly and
triangulated margins inferiorly to facilitate primary closure. The axis of the excision
is made along the perioral rhytids. The wound is closed in three layers (mucosa,
muscle and skin), taking care to accurately align the vermillion border
(Fig.11.8a–c, d–i).
Tips: A simple “wedge/V” excision should be avoided, as this leads to maximum
wound tension at the superior margin and a longer scar to accommodate the “V”,
without compromising the excision margins. A “shield” excision allows the tension
to be evenly distributed across a larger area. Getting an assistant to squeeze the lips,
during the resection aids control of the labial arteries for haemostasis.
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Fig. 11.8 Shield excision and primary closure. (a) Markings for excision, (b) Excision defect, (c)
Final closure, (d) Markings for excision, (e) Markings for excision - open mouth, (f) Excision
defect, (g) Excision defect - open mouth, (h) Final closure, (i) Final closure - open mouth
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g
h
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Fig. 11.8 (continued)
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“W” Excision
Indication: Small lesions, up to 1/3rd of the lip.
Technique: The lesion is marked with adequate margins, and the excision is
planned to leave a defect with parallel wound edges superiorly and “W” margins
inferiorly to facilitate primary closure. The axis of the excision is made along the
perioral rhytids. The wound is closed in three layers (mucosa, muscle and skin),
taking care to accurately align the vermillion border (Fig.11.9a–c, d–g).
Tips: A simple “wedge/V” excision should be avoided, as this leads to maximum
wound tension at the superior margin and a longer scar to accommodate the “V”,
without compromising the excision margins. A “W” excision allows the tension to
be evenly distributed across a larger area and importantly the overall length of the
scar to be reduced, so that it does not transgress the adjacent aesthetic boundaries.
Getting an assistant to squeeze the lips, during the resection aids control of the labial
arteries for haemostasis.
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