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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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11 Lips/Chin
Island Advancement Flap
Indications: Medium-/large-sized defects.
Technique: The defect is modied to obtain parallel lateral margins and extended
superiorly and inferiorly to the base of nose and vermillion border, if necessary, to
best camouage the scars. Curvilinear incisions are made from the superior and
inferior margins of the defect, to delineate a triangular skin island, at least two to
three times the length of the defect. The ap is oriented along the melolabial fold.
The incision is deepened only through the skin along the entire outline of the ap.
The central subcutaneous tissue, beneath the ap is preserved to provide the vascularity. The ap subcutaneous tissue closest and furthest from the defect is released
incrementally to obtain the necessary mobility. The ap is mobilised into the defect,
and wound is closed in layers (Fig.11.23a–c, d–h, i–o).
Tips: The defect can be enlarged to occupy the whole subunit for best position-
ing of the scars. Maintain adequate width of the ap to avoid distortion of the vermillion border and nasal base. The size of the skin pedicle will also determine the
extent of safe subcutaneous dissection. It is mandatory to retain an adequate subcutaneous island pedicle, the size of which needs to take into account additional tissue
release that might be required to obtain the necessary mobility.
b
Upper Lip (Philtrum/Lateral)
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a
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c
Fig. 11.23 Island advancement ap. (a) Markings for excision and ap, (b) Excision defect and
ap raised, (c) Final closure, (d) Markings for excision, (e) Markings for excision and ap, (f)
Excision defect, (g) Flap mobilised into defect, (h) Final closure, (i) Markings for excision, (j)
Markings for excision and ap, (k) Excision defect, (l) Flap incisions, (m) Subcutaneous pedicle,
(n) Flap mobilised into defect, (o) Final closure
d
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11 Lips/Chin
e
f
gh
Fig. 11.23 (continued)
Upper Lip (Philtrum/Lateral)
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i
j
kl
Fig. 11.23 (continued)
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11 Lips/Chin
m
o
n
Fig. 11.23 (continued)
Upper Lip (Philtrum/Lateral)
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429
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 defect is modied to obtain parallel lateral wound edges and
extended inferiorly and superiorly to the vermillion border and nasal base. 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, the ap is mobilised into
the defect, and the wound is closed in layers (Fig.11.24a–d, e–i).
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). The width of the ap should be adequate to prevent displacement of the vermillion and nasal base.
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ab
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11 Lips/Chin
c
d
e
Fig. 11.24 Inferiorly based nasolabial ap. (a) Markings for excision and ap, (b) Excision
defect and ap raised, (c) Flap mobilised into defect, (d) Final closure, (e) Lesion upper lip, (f)
Markings for excision and ap, (g) Excision dfect and ap raised, (h) Fianl closure, (i) Early post
operative appearance
f
gh
Upper Lip (Philtrum/Lateral)
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i
431
Fig. 11.24 (continued)
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11 Lips/Chin
Full-Thickness Defects
Philtrum/Lateral 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 edge inferiorly and
triangulated margins superiorly 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.11.25a–c).
Tips: A “shield” excision rather than a “V” allows the tension to be evenly dis-
tributed across a larger area. Getting an assistant to squeeze the lips, during the
resection aids control of the labial arteries for haemostasis.
Full-Thickness Defects
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a
b
c
Fig. 11.25 Excision and primary closure. (a) Markings for excision, (b) Excision defect, (c)
Final closure
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