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7 Injuries oftheCheek
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Injuries oftheLips
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8
8.1 Anatomy
The labial (lip) region includes an upper and a
lower eshy (musculoskeletal) fold, which converges at lateral commissures, circumscribes the
buccal orice, and, when closed, forms the anterior wall of the oral cavity.
The external surface of the lip has three distinct regions: the skin, the vermilion, and the oral
mucosa. The vermilion, found only in mucosa, is
a non-cornied layer of stratied epithelium. Its
epithelial cells contain a compound called eleidin, which makes it translucent (Brown et al.
2007). The translucency allows the underlying
vascular papillae to give the lips their pink color.
The skin meets the vermilion at the vermilion
border, which is further separated into the red
line and the white line. The vermilion joins the
alveolar oral mucosa at the “wet-dry” border. The
labial mucosa meets the alveolar mucosa vestibular fold, which meets the gingiva.
The upper lip has a median vertical groove—
the philtrum—widening below to end opposite
the labial tubercle, a projection on the free edge
of the lip which is prominent in children and
responsible for the characteristic curve of the oral
ssure (Cupid’s bow). Muscle bers of the orbicularis oris muscle bilaterally approach the midline to decussate and insert into skin
contralaterally, thereby raising philtral ridges.
The levator labii superioris muscle inserts at the
vermilion border, which is displaced upwards by
a lifting action to form Cupid’s bow (Latham and
Deaton 1976). Namnoum et al. (1997) more
recently postulated that philtral ridges are formed
by thickened dermis and dermal appendages.
The essential muscle of the lip is the orbicularis
oris, which is disposed in an elliptical manner
about the buccal aperture, the extremities of its
upper and lower portions meeting at the lip commissures (Fig.8.1). The facial muscles bilaterally
converge and are attached to the orbicularis oris.
These muscles, physiologically, are dilators of the
orice. The integrity of the orbicularis oris is essential for many crucial functions such as speech,
facial expressions, and retaining oral secretions.
A rich blood supply to the lips is provided by
the labial branches of the external maxillary
(facial) artery, which have a coronary distribution
deep to the orbicularis muscle and are therefore
nearer to the mucous membrane than to the skin
(Anson and McVay 1971). The veins lie to the
outer side of the muscle (Fig.8.2).
The anatomic marks (vermilion border, philtrum, Cupid’s bow) are extremely important during a cosmetic repair of an injured lip. Furthermore,
because the lips lack bony support, the healing of
a severe injury, with consequent contracture of
muscle and scar tissue, may result in mouth deformity and even serious distortion of neighboring
structures. On the other hand, the rich vascularity
of the lips and their freedom from bony attachment partly account for the quick and successful
healing of most of the injuries.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
C. A. Ioannidis, Soft Tissue Injuries of the Head and Neck,
https://doi.org/10.1007/978-3-031-14915-3_8
77
78
Orbicularis
mand. vei
n
Fig. 8.1 Schematic
representation of the
muscles of the lower lip.
The orbicularis oris can
be easily identied
8 Injuries oftheLips
oris
Depressor
labii. inf.
Risorius
Superfic.
temp. vein
Retro
n
Fig. 8.2 Schematic representation of the labial veins
Ang. vein
Facial vei
8.2 Lacerations
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8.2 Lacerations
There are two main classications of lip injuries:
lacerations and avulsions. Simple lacerations can
frequently be managed in the emergency department (Fig.8.3).
Lacerations involving the vermillion border
frequently produce a V-type deformity
(Figs. 8.4, 8.5, and 8.6). The most important
step in closing them is to keep both sides of the
vermilion border exact and even. If the two sides
Fig. 8.3 (a) Female
patient with simple
laceration to the right
upper lip, which was
managed in the
emergency department
by approximation and
xation with steristrips.
(b) The same patient
1month later. The scar
is hardly visible
ab
are aligned properly, the wound heals with
acceptable cosmetic results. Uneven approximation leads to a step or a bulge in the vermilion
border and a lip deformity. Once the vermilion
border has been aligned correctly, the rest of the
wound can be closed easily. A technique of
using needle marks left by the local anesthesia
needle has been described for nonspecialists
(James 1998). The author prefers to use regional
anesthesia or sedation for children. Regional
anesthesia of the lower lip can best be attained
Fig. 8.4 (a and b) Male
patient with recently
repaired left upper lip
laceration involving the
vermilion border; a
V-type deformity can be
noticed. The patient
refused re-repair of the
deformity
Fig. 8.5 (a and b)
Female patient with
previously repaired
injury to the right upper
lip with involvement of
the vermilion border.
The V-type deformity is
clearly noticeable
ab
ab
80
8 Injuries oftheLips
Fig. 8.6. (a) Child with
poorly repaired dog bite
injury of the right upper
and lower lip involving
the vermilion border. (b)
After proper alignment
of the vermilion border
and re-repair. (c and d)
The same child 1year
after repair.
a
cd
by performing a mental nerve block (inltration
of anesthetic into the buccal sulcus between the
apices of the rst and the second premolars) on
the side of the injury. The upper lip is anesthetized using an infraorbital nerve block (inltration of anesthetic solution into the infraorbital
foramen 1cm lateral to the nasal ala and 1cm
caudal to the infraorbital rim). After anesthesia,
irrigation, and inspection for foreign bodies,
focus must be placed on the exact alignment of
the aforementioned borders. The rst suture (6.0
problems) is placed on either side of the border
reapproximating exactly its red line and white
line. The rest of the wound usually falls into
alignment to set up the rest of the closure. In
more complex wounds, and if multiple interruptions of the vermilion border are present, multiple sutures are used to restore continuity of the
border. The rest of the wound, if merely supercial, can be closed with the remaining Prolene.
Deep wounds and/or full-thickness wounds
(through the entire lip) are closed using a threelayer technique. The approximation of the orbicularis oris is rst performed using absorbable
material (usually undyed Vicryl 4.0). Then the
mucosa is closed with the same suture material.
Finally, the skin is closed with interrupted
sutures using nonabsorbable material (usually
b
Prolene 5.0 or 6.0). Some authors use tissue
adhesive for skin closure. The advantages are
less time and less pain with equal cosmetic
results (Brown etal. 2007). However, Smith and
Maconochie (2003) in a literature review of
studies comparing tissue adhesives and sutures
in pediatric lacerations found that all of them,
except for one case report, excluded lip
lacerations.
Intraoral lacerations heal quicker when a few
absorbable mucosal sutures are placed. If the
orbicularis oris muscle has been injured, it should
be approximated rst with an absorbable 3.0 or
4.0 polyglycolic acid sutures. Lacerations at the
vestibular fold and at the border of the gingival
and the intraoral mucosa can also be repaired
with absorbable sutures. Some authors propose
placement of a small drain to facilitate wound
closure and prevent uid accumulation and possible subsequent infection in the space created by
the contaminated laceration (Brown etal. 2007).
Avulsions of the tissue overlying the mandibular
or maxillary ridge can be cumbersome because
of the thin tissue and the lack of underlying
anchoring tissue. If possible, the gingival ap is
sutured to neighboring tissue; otherwise, a suture
is brought circumferentially around the teeth to
anchor the repair.
8.3 Avulsions
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81
8.3 Avulsions
Large lip avulsions that involve signicant tissue
loss of the vermilion and other local landmarks
can pose a surgical dilemma for the reconstructive surgeon (Figs.8.7 and 8.8). Several authors
trying to avoid extensive scarring and further permanent distortion of the local anatomy, which is
frequently associated with immediate repair with
local aps and adjacent tissue transfer, have
treated patients conservatively (Zackowski etal.
1986; Miller 1987; Rhee et al. 2004). Patients
Fig. 8.7 Male patient with large avulsion of the lower lip
and chin
Fig. 8.8 Male patient with large avulsion of the upper
and lower lip
with extensive traumatic tissue loss to the lip vermilion and other landmarks were left to heal by
secondary intention with good functional and
cosmetic results. Minor surgical revisions were
necessary in less than half of the patients (ca
40%) 1year post-treatment in order to improve
the outcome (Zackowski etal. 1986; Rhee etal.
2004). Although it is unusual for a partial lip
avulsion to require medicinal leeches, there have
been reports of cases where arterial inow was
adequate, whereas venous outow was inadequate (Frodel Jr et al. 2004). In such cases,
medicinal leeches may play a very important role
in salvaging the congested lip segment.
Traumatic amputation of the lip is a rare yet
devastating event causing serious functional and
aesthetic problems. Microsurgical replantation is a
reasonable option offering functional and aesthetic
benets; however, it has risks of blood transfusion
and a lengthy operative time and hospital stay.
Walton etal. (1998) in a multi- institutional study
reviewed 13 lip replantations from 12 institutions.
Lip replantation was successful in all 13 patients.
Partial ap loss occurred in one patient owing to
iatrogenic injury. Injuries in two patients were the
result of a human bite; the remaining injuries
resulted from dog bites. Average hospital stay was
11.9days. Ten patients suffered amputations of the
upper lip, and three suffered amputations of the
lower lip. Average defect size was 10.6 cm2.
Operative time ranged from 2.5 to 12h (median
5.7h). Ischemia time averaged 2.9h. All patients
had an arterial anastomosis, whereas no vein was
available in 7/13 patients. Anticoagulant therapy
was administered in the majority of patients (heparin in 10/13, low- molecular- weight dextran 7/13,
aspirin 7/13). Leech therapy was employed in
11/13 patients. Blood transfusion was necessary in
12/13 patients (average of 6.2units of packed red
blood cells). Postoperatively, one patient suffered
vein thrombosis, requiring anastomotic revision.
Nearly one-third of patients (4/13) suffered prolonged edema lasting longer than 4months. Color
match of the lip segment was rated excellent in all
cases. Hypertrophic scarring occurred in 6/13
patients. A total of 12 revision procedures were
performed in six patients. Ten patients demonstrated active orbicularis muscle contraction in the
82
8 Injuries oftheLips
replanted lip segment. Stomal continence was
present in all lips. Sensibility was rated quite good
with 12/13 patients demonstrating at least protective moving two-point sensibility (>or=10mm).
Partial replant necrosis in one patient resulted in
signicant scar and contraction that compromised
the aesthetic appearance. Overall, however, all
patients were uniformly pleased with the nal
result (Walton etal. 1998). The fact that reestablishment of venous outow is the most problematic technical challenge has been experienced by
other authors also (Jeng etal. 1992; Duroure etal.
2004). By incorporating the adjuncts of anticoagu-
lation, leech therapy, and antispasmodics, a successful outcome can be expected despite the
paucity of vessels (Walton et al. 1998; Frodel Jr
etal. 2004).
8.4 Reconstruction
Soft-tissue defects of the lips are reconstructed
with local aps and/or free tissue transfer depending on the size of the defect. Small-to-moderate
defects can be adequately reconstructed with
local aps, whereas massive defects, usually secondary to gunshot injuries, require free tissue
transfer (Kaufman et al. 2009; Fernandes and
Clemow 2012). Occasionally, a combination of
microvascular and local ap techniques may be
necessary for the repair of severe defects.
Advances in microvascular technique have
established free ap transfer as the gold standard
in the reconstruction of severe facial trauma
(Long etal. 2002; McLean etal. 2005; Fernandes
and Clemow 2012). Various free aps have been
used by surgeons to reconstruct near-total or total
lip defects. A composite forearm-palmaris longus
was described by Jeng etal. (2004) for total lip
reconstruction. The skin ap for the reconstruction of the intraoral lining and the skin defect was
folded over the palmaris longus tendon. Both
ends of the vascularized tendon were laid through
the bilateral modiolus and anchored with adequate tension to the intact orbicularis muscle of
the upper lip. All patients had good oral continence at rest and had achieved sufcient oral
competence when eating 1year after the opera-
tions. Most patients were able to resume a regular
diet, and 15% of the patients could eat a soft diet.
All patients regained a near-normal speech and
had an acceptable appearance. Fernandes and
Clemow (2012) also used the radial forearm ap
with the palmaris longus tendon in the majority
of their patients with lip defects. The authors
used an anterolateral thigh ap with fascia to suspend the lip in one patient. The anterolateral
thigh ap (ATF) was reported to be the most
commonly applied free ap in the practice of
Kaufman etal. 2009, due to the ability to harvest
it simultaneously with the facial procedures by a
second team, its long pedicle, and primary donorsite closure (Kaufman et al. 2009). The radial
forearm ap, however, shares the same features
with the ATF except for the donor-site closure.
Gurunluoglu etal. (2012) described a functional
lower lip reconstruction with an innervated gracilis muscle ap. Lip lining was reconstructed with
the skin paddle of a bular ap, used for mandibular defect reconstruction. The external surface of the gracilis muscle was skin- grafted. An
electromyographic study at 1 year postoperatively demonstrated successful reinnervation of
the gracilis muscle. Starting about 10weeks postoperatively, patients exhibited voluntary lip
movements and oral competence. In addition, all
patients achieved near-normal speech, evidence
of recovered protective sensitivity, and satisfactory appearance (mean follow- up 16.1 months)
(Gurunluoglu etal. 2012).
As mentioned before, a combination of microsurgical techniques and local aps optimizes the
aesthetic outcome. Haddock etal. (2012) recently
reported on revision surgery after free tissue
transfer of a circumex scapular variant or supercial interior epigastric ap in 24 cases of facial
burns and trauma. Revision renement was indicated in all cases (6 months postoperatively).
Flap revision involved liposuction, debulking, reelevation, and release of tethering, followed by
tissue rearrangement by means of advancement,
rotation, transposition, and/or turnover aps of
subcutaneous tissues from the previous free ap.
Severe lip deciencies were addressed with local
aps. The authors also used autologous fat injection to the lip to improve the tissue contour.
References
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83
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Saunders, Philadelphia, 1971, p 172.
Brown DJ, Jaffe JE, Henson JK.Advanced laceration man-
agement. Emerg Med Clin North Am. 2007;25:83–99.
Duroure F, Simon E, Fadhul S, et al. Microsurgical lip
replantation: evaluation of functional and aesthetic
results of three cases. Microsurgery. 2004;24:265–9.
Fernandes R, Clemow J.Outcomes of total or near-total
lip reconstruction with microvascular tissue transfer. J
Oral Maxillofac Surg. 2012;70:2899–906.
Frodel JL Jr, Barth P, Wagner J. Salvage of partial
facial soft tissue avulsions with medicinal leeches.
Otolaryngol Head Neck Surg. 2004;131:934–9.
Gurunluoglu R, Glasgow M, Williams SA, etal. Functional
reconstruction of total lower lip defects using innervated gracilis ap in the setting of high-energy ballistic injury to the lower face: preliminary report. J Plast
Reconstr Aesthet Surg. 2012;65:1335–42.
Haddock NT, Saadeh PB, Siebert JW.Achieving aesthetic
results in facial reconstructive microsurgery: planning
and executing secondary renements. Plast Reconstr
Surg. 2012;130:1236–45.
James D.Reliable method for closing lacerations across
the vermilion border of the lip. Can Fam Physician.
1998;44:47–8.
Jeng SF, Wei FC, Noordhoff MS. Successful replanta-
tion of a bitten-off vermilion of the lower lip by
microvascular anastomosis: case report. J Trauma.
1992;93:914–6.
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struction with a composite radial forearm-palmaris
longus tendon ap: a clinical series. Plast Reconstr
Surg. 2004;113:19–23.
Kaufman Y, Cole P, Hollier LH Jr. Facial gunshot wounds:
trends in management. Craniomaxillofac Trauma
Reconstr. 2009;2:85–90.
Latham RA, Deaton TG. The structural basis of the
philtrum and the contour of the vermilion border:
a study of the musculature of the upper lip. J Anat.
1976;121(Pt1):151–60.
Long V, Lo LJ, Chen YR. Facial reconstruction after
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Injuries oftheEars
9
9.1 Anatomy
The external ear, the auricle (pinna) (Fig.9.1),
consists of a cartilage-supported part and a loose,
adipocutaneous part, the lobule. The auricle is
attached to the side of the head behind the temporomandibular joint and in front of the mastoid
on a line from the eye to the external occipital
protuberance, at a variable angle (ca 30°). Its
skeleton is a folded, elastic, brocartilaginous
plate (Fig. 9.2). Its lateral surface shows two
irregular, concentric, C-shaped grooves above
and behind the opening of the external acoustic
meatus, which lies at the anteroinferior end of the
deeper, inner groove, the concha, partly overlapped (anteriorly) by the tragus. The two grooves
are separated by the antihelix, which frequently
splits above to enclose the triangular fossa. The
outer groove, the scaphoid fossa, is limited by the
rolled, outer margin of the auricle, the helix. The
latter begins in the concavity of the concha above
the external acoustic meatus (crus of the helix)
and ends postero-inferiorly by entering the lobule
of the ear close to the antihelix. The antitragus
usually points laterally and, partly overlapping
the postero-inferior part of the concha, is separated from the tragus by the incisura intertragica
(intertragic incisure). The shape of the auricle is
extremely variable. In the newborn, its length is
approximately one-third of that in the adult, and
it increases in size and thickness in old age.
Fibrocartilages, ligaments, rudimentary muscula-
ture, and a skin covering compose the auricle.
The brocartilages are thin, exible structures
covered by a rmly attached perichondrium supporting the auricle. It is absent from the lobule,
which is composed of fat and broareolar tissue.
Extrinsic ligaments attach the auricle to the temporal bone, while intrinsic ligaments maintain the
cartilages in position. The skin of the auricle is
thin, smooth, and adherent to the perichondrium
on the lateral aspect, but mobile on the medial
surface. A potential space exists between the cartilage and the perichondrium that can allow the
accumulation of blood after an injury. The cartilaginous skeleton has the same contour as the
auricle and is continuous with that of the external
acoustic meatus in latus by a narrow strip medial
to the deepest part of the incisura intertragica,
where the skin of auricle and meatus become
continuous.
A fairly rich arterial supply for the auricle
arises from the external carotid artery by way of
the supercial temporal artery (anteriorly) and
the posterior auricular artery (posteriorly). The
latter sends three or four branches which also
give twigs to the lateral surface through the cartilage and round the margin of the helix. The
venous drainage enters the supercial temporal
vein in front and the external jugular vein below.
The cartilaginous folds assist in the acquisition
and amplication of sound and create shadow
and curves that must be diligently recreated in
wound repair.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
C. A. Ioannidis, Soft Tissue Injuries of the Head and Neck,
https://doi.org/10.1007/978-3-031-14915-3_9
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86
Concha
Antiheli
agus
Helix
Antihelix
of tragus
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Fig. 9.1 Schematic
representation of the
right external ear
9 Injuries oftheEars
x
Fig. 9.2 Schematic
representation of the
brocartilaginous
skeleton of the right
external ear
Helix
Tr
Lobule
Plate
9.2 Auricular Hematoma,
“Cauliower Ear”
lacerations, knowledge of the anatomy and physiology, especially of the ear cartilage, and a
meticulous technique will prevent sequelae and
the need for future cosmetic surgical intervenA precise, delicate repair of complex ear lacerations is necessary to achieve a cosmetically
appealing result. As in most facial injuries and
tions. Cartilage is avascular, and thus its meta-
bolic support is provided by the surrounding
perichondrium. If deprived of the nutrients, pro-
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