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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_688_Библиотеки_им_академика_М_И_Перельмана
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404
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11 Lips/Chin
Bilateral Advancement Flap
Indications: Large defects.
Technique: The defect is modied to obtain parallel sides. An incision is made
from the superior edge of the defect, curving upwards past the nasolabial fold and
the inferior edge along the mentolabial fold. This incision is made only through skin
and deeper tissues mobilised by blunt dissection. Corresponding incisions are made
in the mucosa, to obtain the necessary mobilisation. The aps edges are mobilised,
and the wound is closed in layers (Fig.11.14a–d).
Tips: The dog ears created are excised along the nasolabial and mentolabial
folds. Care should be taken to prevent danaage to the mental nerves. Additional
release of tissue from their mandibular attachements may be required. The advanced
buccal mucosa can be used to resurface the lips, but a tongue ap may be necessary
to obtain the necessary bulk.
b
Lower Lip
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a
c d
405
Fig. 11.14 Bilateral advamcement aps. (a) Markings for excision and ap, (b) Excision defect
and aps raised, (c) Myocutaneous/mucosal aps mobilsed into defect, (d) Final closure
406
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11 Lips/Chin
Bilateral Commissurotomy andAdvancement ofSkin, Muscle,
andMucosal Flaps
Indications: Large lower lip defects.
Technique: The planned composite excision is carried out, ideally as a rectangle
with parallel lateral edges. Horizontal skin incisions are made from the base of the
defect to a distance approximately twice that of the defect, and bilateral Burrow’s
ap is elevated in the subcutaneous plane.
Bilateral mucosal commissurotomy incisions are then made and extended to
same distance bilaterally. The mucosal ap is elevated to the lower labial sulcus.
Supra-periosteal mobilisation of the depressor labii inferioris and depressor
anguli oris is carried out. The risorius is bluntly mobilised, along with mobilisation
of the levator labii superioris, levator labii superioris alaeque nasi, zygomaticus
major and minor muscle groups. These careful mobilisations would allow advancement of the remaining orbicularis oris muscle without compromising the motor
innervation. This whole process is repeated on the contralateral side and skin/muscle/mucosa unit mobilised bilaterally. A round bodied 4/0 pds suture is used to
repair the muscle bilaterally. The skin aps are advanced towards the midline and
closed in layers.
The new commissure is created by suturing the skin to the advanced muscle, with
the same preoperative commissure dimension. The advanced mucosal aps are
sutured to the newly created commissure bilaterally.
The vestibular mucosa is advanced to create new vermillion border matching the
remaining vermillion (Fig.11.15a–d, e–i, j–m).
Tips and benets: Adequate blunt mobilisation of the muscle group will provide
the necessary lip volume. The commissurotomy only involves the orbicularis oris
musculature. The mobilised muscle group based on the risorius will be sutured to
the cut ends of orbicularis oris musculature, thus re-creating the new orbicularis oris
aperture with intact motor innervation. Blunt dissection aids preservation of the
motor and sensory innervations in addition to the vascularity of the mobilised tissue.
As “additional” tissue is brought into the defect, it reduces the risk of microstomia
associated with “redistribution” aps. Round bodied needles are preferably used for
suturing the muscle layer.
ba
Lower Lip
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407
c
d
e
f
Fig. 11.15 Bilateral commisurotomyand advancement of skin, muscle and mucosal aps. (a)
Markings for excision and aps, (b) Excision defect and ap incisions, (c) Mobilisation of myocutaneous and mucosal aps into defect, (d) Final closure, (e) Large lesion lower lip, (f) Excision
defect and ap incisions, (g) Final closure, (h) Post operative appearance - rest, (i) Post operative
apperance - smiling, (j) Markings for excision and ap, (k) Excision defect and ap markings, (l)
Fianl closure, (m) Early post operative appearance
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11 Lips/Chin
g
i
h
j
kl
m
Fig. 11.15 (continued)
Lower Lip
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409
Karapandzic+Abbe Flap
Indications: Large defects.
Technique: (See Abbe (Fig.11.1a–d) and karapandzic aps (Fig.11.13a–d) for
additional details). The defect is modied to obtain parallel margins. An abbe ap
based laterally and a karapandzic ap predominantly based on the contral lateral
side are raised, taking particular care not to compromise the vascularity of the Abbe
ap. The wounds are closed in layers (Fig.11.16a–d). The Abbe ap is divided in
3–4weeks time, and any revision of the vermillion border carried out at this stage
(Fig.11.16e).
Tips: (See Figs.11.11a–d, 11.13a–d) This combination allows the donor sites to
be more equally distributed between the upper and lower lip. A decrease in the size
of the oral aperture is inevitable, as it is still a “lip redistribution” ap, which does
not bring additional tissue to reconstruct the defect.
410
b
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11 Lips/Chin
a
d
c
e
Fig. 11.16 Karapandzic and Abbe ap. (a) Markings for excision and ap, (b) Excision defect
and ap raised, (c) Flaps mobilised into defect, (d) Final closure at rst stage, (e) Final closure
after second stage
Lower Lip
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411
Bilateral Fan Flap
Indications: Total lower lip defect.
Technique: The margins of the defect are modied to obtain parallel edges. The
rectangular fan ap is marked out immediately lateral to the defect, with the width
of the rectangle equal to the size of the hemi lip defect. The length (height) of the
rectangle is twice the width and based along the nasolabial fold. The medial back
cut is marked to stop short of the upper lip vermillion, to preserve the superior labial
vessels and acts as a pivot point for the ap rotation. A full-thickness incision is
made along the inferior, lateral and upper medial margins, and the ap mobilised
into the defect. The wound is closed in layers. The vermillion is reconstructed with
a tongue ap (Fig.11.17a–d).
Tips: The fan ap imports “new” cheek tissue into the defect, and the reduction
in size of the oral aperture is minimised. The motor and sensory nerve supply is
divided (unlike a karapandzic ap) though partial ingrowth occurs over a period of
time. The corners of the rectangle can be rounded to facilitate rotation and wound
closure. The position of the commissure is often preserved. The defect margins are
of different length and should be accommodated by differential suturing. It is often
possible to place the nal suture line along the nasolabial and mentolabial folds.
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11 Lips/Chin
a
b
Fig. 11.17 Bilateral fan aps. (a) Markings for excision and aps, (b) Excision defect and aps
raised, (c) Flaps mobilised into defect, (d) Final closure
Upper Lip (Philtrum/Lateral)
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413
Upper Lip (Philtrum/Lateral)
Skin Only (Consider Converting toFull Thickness)
Primary Closure
Indications: Small defects.
Technique: The defect is converted into an ellipse to orient the scar along the
perioral rhytids. The wound margins are undermined in the sub-cuatneous plane and
closed in layers (Fig.11.18a, b).
Tips: Closure of elliptical defects leads to increase in length of the scar and can
cause distortion of the vermillion border. This can be overcome by utilising an alternate method of reconstruction or extending the wound into the mucosa and accurately approximating the vermillion border. Consideration should be given to
converting the defect into a full-thickness defect to aid closure.
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