Embryology and anatomy of the lips
Knowledge of the embryology of the lips serves as the foundation for understanding the basics of many modern surgical interventions on the lips. During development of the fetus, the upper lip is formed from two separate pairs of structures - lateral maxillary processes and median nasal processes. They fuse with each other and form the upper lip. Thus, its characteristic outlines are the result of the unification of these structures. The lower lip is formed by the fusion of fusion of paired mandibular processes, which leads to the formation of a simpler and less defined structure. Due to embryological differences, the functions of the upper and lower lips vary considerably. The upper lip has greater mobility than the lower lip.
The defining points of the upper lip are in the central complex of the Cupid arch, the line defining the border of the skin and the red border of the upper lip. This complex is formed by two highest points of the red border, lying on the edges of the tray groove on each side, and a V-shaped notch between them. The most prominent points of the red border of the lower lip are parallel to the points of the upper lip, but there is no central recess on it. Another characteristic feature of the lips is the presence of a white line or roller. This structure is a raised line of skin that separates the red border of the lips from the dermal part of the upper and lower lips. The function of the white roller is unknown; However, Giles hypothesized that he serves as a reservoir of the skin, allowing the lip to perform such complex movements as when wrinkling, smiling, talking and eating.
In the skin of the lips there are hair follicles, sebaceous and sweat glands. The color of the red border of the lips is due to the absence of a layer of keratinized cells and a developed capillary plexus. Red lip rim consists of dry and wet parts. The dry part contacts the air and, in general, is the visible part of the red border of the lips. In front, it borders on the skin of the lip, and behind it is separated from the wet part by a damp line.
The volume of the lip is formed from the circular muscles of the mouth. Red lip rim and adjacent skin are delimited from the underlying muscle by a thin fascial layer. In the center of the upper lip, the fibers of the circular muscle cross in a crosswise manner and are inserted into the edge of the tray groove from the opposite side. Lip adhesions are complex areas where the fibers of the circular muscle cross and the muscles that lift the lip, lowering the lip and the buccal muscle are combined.
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Aesthetics of the lips
There is no perfect standard for perfect lips. Everyone has an opinion about what beautiful lips are. One likes a more full lower lip, while others prefer a more prominent upper lip. But despite individual preferences, there are fundamental proportions and anatomical characteristics that determine the external appeal.
The distance from the menthone (the lowest anthropometric point of the chin) to the subnazal (the points where the columella touches the upper lip) should be one-third the distance from the menton to the hair growth line on the forehead. If the patient has a high forehead, the first measurement should be equal to the distance from the subnazale to the glabella (the most prominent forehead point). The upper lip should occupy one-third, and the lower one - two-thirds the length of the lower third of the face.
In the profile, to assess the lip protrusion, you can use a line drawn from the subnazal to the soft tissue limb (the most prominent point of the chin). Earlier, some authors, Burstone, referred to these rules (that is, "the upper lip should lie 3.5 mm anterior to this line, and the lower lip 2.2 mm) .But because of the difference in individual aesthetic ideals, it is difficult to establish concrete the size of the lip protrusion The defining moment in assessing the lip protrusion is the consideration of the position of the teeth.The lips cover the teeth, and therefore the insufficient and excessive lip protrusion may reflect the incorrect position of the underlying teeth.
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The aging process
Thin, poorly outlined lips can be both congenital, and result of a trauma or process of aging. This process is a reflection of two separate factors. The first factor determining aging, largely relates to the hereditarily programmed aging. The size of the lips increases until puberty due to hypertrophy of the muscular and glandular component, and then begins to gradually decrease. The second factor is due to external influences, such as insolation and smoking, which can enhance the aging process. The age-old evolution of the lips reflects changes not only in the skin, but also in the surrounding tissues (muscles, fat, teeth, bones). Over time, a well-marked, raised white roller, surrounding the upper and lower lips, begins to flatten. This, in turn, leads to a smoothing of the Cupid's arc and a reduction in the visible part of the red border of the lips. Thinning of the subcutaneous layer and a decrease in muscle tone cause a decrease in the protrusion of the lips. These processes also lead to the lowering of the corners of the mouth. Because of the combination of a decrease in the volume of supporting elements and a loss of skin tone, wrinkles appear on the red border and the dermal part of the lips. Thus, long, poorly outlined lips are formed with a small red border and a minimal protrusion.
Objectives of lip surgery
Many patients turn to a plastic surgeon with very specific ideas about the operation. Others have not so accurately defined their goals and have only a general idea. During the consultation it is very important to determine what patients expect from the surgical intervention on the lips. That is, whether their lip length, the outline of the Cupid's arc, the size of the visible red lip rim, the degree of protrusion, the presence of wrinkles on the red border and the skin of the lips, the lowering of the corners of the mouth, or the possible loss of contour along the white ridges and the edges of the tray groove? It is useful to put the patient in front of a mirror and mark areas of interest, thereby achieving mutual understanding with the patient.
The history should include all information about previous interventions on the lips, diseases and injuries. This applies to previously performed collagen injections, which can cause fibrosis in the area of the lips, as well as the transmitted herpetic infection, allergic and other important medical conditions.
The procedure for examining the lips is performed with a relaxed face of the patient according to the following scheme.
- Assessment of occlusion.
- Analysis of the proportions of the face: checking the vertical thirds and measuring the length of the upper and lower lips.
- The degree of expression of Cupid's arc.
- Expression of the edges of the tray groove.
- Expression of white ridges along the upper and lower lips.
- The size of the visible red border of the upper and lower lips.
- Visibility of the teeth (in young patients a few millimeters of the central teeth are visible, but, as the lips are lengthened with age, the teeth become less visible).
- The position of the corners of the mouth.
- Condition of the epithelium of the red border of the lips.
- Condition of the epithelium of the skin of the lips.
- Evaluation of the lips.
- The position of the chin (microgenia can make full lips even more).
Following this scheme, the surgeon must determine the states underlying the patient's requests. Their correct diagnosis will be the cornerstone of a successful treatment outcome.
Photography plays a very important role in cosmetic surgery. With regard to the lips, it allows the surgeon to identify and confirm the asymmetry before the operation, for its proper planning. It also enables patients to compare their pre-operative status with that obtained after it, in order to visualize the changes that have occurred. Before taking photographs, you must remove any make-up. Borders of sighting images should be: on top - the lower edge of the orbit, from below - the hyoid bone. Usually, the pictures are taken in the frontal, right and left oblique, right and left lateral projections at rest, as well as in the frontal projection of smiling and wrinkled lips.
The area of the upper and lower lips is very easy to anesthetize by a local blockade. 4% lidocaine jelly (Xylocaine) is applied to the mucous membrane of the upper and lower lips. The regional blockade of the chin nerves, the infraorbital nerves and the large palatal branch is done through the mucous membrane of the mouth with a mixture of equal volumes of 0.5% bupivacaine with adrenaline 1: 200,000 in a mixture with an equal volume of 1% lidocaine with adrenaline 1: 100,000. After it is performed, 1% lidocaine with adrenaline 1: 100,000 and hyaluronidase mixed in a ratio of 10 ml to 1 ml, respectively, can be topically applied to the lips. This mixture is introduced along the lips in the dissection plane. The volume of the anesthetic should be limited to avoid distorting the shape of the lips. When using dermal matrix transplants, the enzyme is not used to reduce the probability of its destruction. Depending on the sensitivity of the patient and the plan for performing other operations, additional anesthesia may be administered, from oral administration of 20 mg of diazepam or hydrocodone bitartrate (Lortab) to general anesthesia.
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Interventions on the skin cube and red border
Wrinkles appear in the perioral area as a result of aging. This process is accelerated by insolation and smoking. Often such changes reflect damage to both the dermis and the subcutaneous layer, with the loss of the volume of the red border of the lips. Short-term correction of skin wrinkles is carried out by the introduction of collagen into perioral lines. However, due to the mobility of this area, collagen can last up to 2 weeks. A longer correction is given by grinding the skin around the mouth. Initially, dermabrasion in the penis was just about the perioral wrinkles. Modern methods of grinding are represented by a wide range of methods - from hardware peeling for very superficial wrinkles to chemical peeling and grinding with a C02 laser of deep wrinkles. The deepest wrinkles can often be treated with acetone, followed by applying a Baker solution for chemical peeling on a phenolic basis with the wooden end of a cotton applicator. This peeling solution can also be applied to the dry portion of the red border of the lips. Then laser polishing is carried out to the red border, including the zones of the previous point peeling. This leads to a softening of the wrinkles of the lips and an increase in the visible part of the red border. Deep lines on the red border are often the result of loss of the tissues of the lips, which is very similar to the decrease in the amount of air in the balloon. Smooth wrinkles on the red border can be by restoring the volume of the lips with modern materials.
Lengthening Lip Surgery
The enlargement of the upper and lower lip may involve the use of autologous materials such as the dermis, fat, fascia, superficial muscular aponeurotic system, or materials such as AlloDerm (grafts of the cell-free base of the human dermis), Gore-Tech, collagen, silicone, Dermologin and many others.
The main principles of the increase consist either in increasing the vertical length of the lip, or in increasing the protrusion of the lips. The first goal is to achieve the establishment of implants. When the goal is to lengthen the lip, the implant material is usually placed in the submucosa or in the tunnel along the lower part of the upper lip and the upper part of the lower lip. If an attempt is made to increase the protrusion, the implant is placed either in the submucosal layer along the front surface of the lip, or in the tunnel along the front surface. Since the lips are very mobile, prolonged retention of the implanted material in the lip is a difficult task. Autologous materials are usually readily available; However, the application also presupposes the existence of a donor site and related problems. It is established that the fat remains unpredictable, which often leads to uneven surface of the lips. The likelihood of success increases with the washing of fat with Ringer-lactate solution to remove damaged and destroyed fat cells, as well as blood and serum. Dermal grafts and SMAS due to the dense cellular nature of these materials usually do not survive very long in the lips. The temporal fascia is usually very thin and in most patients does not give a significant increase in volume.
Bull collagen is plastic, which allows it to be inserted into white rollers, along the tray groove and the red border of the lips. To detect possible allergic reactions about 4 weeks before its application, it is necessary to conduct skin testing of patients. Despite the negative result of a single skin test, some patients may experience allergic reactions to the material. In the area of the lips, collagen can be held for 2 weeks to several months. It also helps smooth out some of the fine wrinkles around the mouth. To reduce the likelihood of formation of seals, patients should massage the injection areas.
Transplants of the cell-free base of human dermis were originally developed to cover large areas of burns. However, they were also successfully used as implants for the lips. The material for the transplant is obtained from a certified tissue bank. After removing the cells from the dermis, the material is dried by sublimation. As a result, an acellular base is obtained that allows the tissue to grow and the cell population of the base to grow (AlloDerm). As a result of a permanent reorganization of the graft, by the end of the year, AlloDerm is no longer present in the recipient organism, but completely replaced by its tissue. This is an excellent sequence of setting a temporary framework that stimulates the growth of new tissue. AlloDerm is injected into the lips after regional anesthesia through incisions in the adhesion of the corner of the mouth. Along the front or bottom edge of the lip, depending on the purpose of the operation, a submucosal tunnel is used as a tool for carrying the tendon. After the instrument is released from the opposite side, an AlloDerm fragment of the appropriate size is inserted into the pocket. Applying this material, the surgeon should remember that after spreading, the rehydrated form will shrink in the recipient organism to a size close to the original size of the dry material. Therefore, the surgeon must determine the volume of the desired increase in the dry fragment of AlloDerm, and not by its rehydrated form. Usually two thirds can be placed in the upper lip, and one-third of a 3 x 7 cm plate can be placed in the lower lip. However, it is often possible to insert an entire plate into each lip. The tunnel in the submucosal layer should be created deep enough that the implant material does not shine through the lip. If, after surgery, a small area of material is exposed in the corner of the mouth or on the edge of the red border, it can be cut off without consequences. Now the injection form AlloDerm is being tested. Preliminary results look promising. You can achieve the same degree of lip augmentation, as with a plate, but the edema will last only 2-3 days. Unlike bovine collagen, which is a skin implant, the particle size of the AlloDerm injection mold allows it to be used as a subcutaneous implant. A 5-centimeter needle 25 G is injected along the middle line, with a puncture of the lip in the desired plane (in the same plane as when inserting the AlloDerm plates). The finely ground AlloDerm is evenly introduced into the fabric as the needle is withdrawn. Dermologin is a chemically dissolved acellular base of the dermis. It is believed that as a result of chemical dissolution, various proteoglycans are removed that would promote tissue ingrowth. The results of the first observations of the use of this material are very disappointing, since it does not last longer than bovine collagen.
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Porous polytetrafluoroethylene (pPTPE, Gore-Tex) is widely used to increase the volume of the lips for many years. It does not undergo resorption. However, when installed in the lip around it, a capsule forms, which can tighten and compact the lip. Another drawback of this material is that patients can sense the PTFE in the lip. Complex movements of the upper lip make it very difficult to hold the implant inside it, and often it extrudes. Producers are trying to increase the flexibility of large fragments of pTTPE by creating a multicellular structure of the implant. This works well on the lower lip, however, according to the author's experience, the upper lip is unacceptable.
Small-drip silicone is a possible material for lip augmentation, which has been widely used in the past. However, due to the position of the US Food and Drug Administration, it is not currently used by many physicians. Sometimes it is possible to observe reactions to the introduction of microdroplets, which is probably due to the insufficient purity of the silicone itself.
The movement of VY, or augmenting cheyloplasty, a technique that has been known for many years and was originally used to correct the whistle deformity of the lips, implies mucosal closure by the principle of translating V to Y. The entire mucosa can be moved forward by performing two adjacent V-shaped incisions "W") and transforming them into a Y-shaped figure. The exact amount of magnification may not be predictable enough. To promote the lateral section of the red border, it is necessary to extend the W-plastic to spikes. Flaps are allocated, and the cuts are closed according to the VY principle. Scars are not significant and do not create seals, felt by the patient.
Surgery that shortens the lips
Moving the lips or moving the red border
The movement of the lips or the red border was first described by Gilles, and then perfected by other surgeons. It is performed by removing an elliptical piece of skin adjacent to the red border of either the upper or lower lip. In the case of a long upper lip with a fuzzy arc Cupid, this technique can be used to restore the central reference points. It is often convenient to ask the patient to mark with a marker on the upper and lower lips the shape and size that they would like to receive. This can be done while sitting in front of the mirror, which will allow us to achieve a better understanding of the surgical and patient purposes of the operation. It is necessary to note and discuss before surgery all the disproportions in the tissues of the lips. After marking the areas, you need to excise an additional 1 mm of tissue to compensate for the "recoil effect" of the lip. The ellipse is excised in the plane of the face, directly under the skin, above the muscle. This will help to recreate the fullness of the white roller adjacent to the red border.
Do not go below the surface plane of the dissection, otherwise contraction and scarring may occur. The points of the upper lip are gathered together by vertical mattress sutures without crossing the adjacent edges. The final closure of the wound is performed with a continuous subcutaneous seam Prolene 5-0 with additional strengthening by resorbable sutures, if necessary.
Resection of the base of the nose
Resection of the base of the nose is an excellent operation for patients with a long upper lip, well-defined areas of Cupid's arch and the base of the nose. The ellipse of the skin at the base of the nose must have a gull shape and correspond to the contours of the base of the nose. Depending on the anatomical structure of the supporting protrusion of the base of the nose, the incision can extend to this region. A line parallel to this projection is drawn, creating an excised ellipse of the skin. The skin is excised in the subcutaneous plane; the wound is sutured in two layers. Millard said that the distance from the beginning of the tray tray to the base of the nose to the red border of the lips is up to 18 to 22 mm. If the lip exceeds this size or is longer than the relative proportions of the face, the patient may be shown a resection of the base of the nose.
Haloplasty, or reduction of the red border, can be performed by excising its equal amounts on either side of the moist line of the lip. The aim is to make a cut along a wet line or a little bit behind it. Depending on the volume of the diminished lip, the incision can capture not only the mucosa. Then the incisions are closed with absorbable sutures. Usually, to compensate for the effect of postoperative lip resurfacing, excessive correction is required. Reduction cheyloplasty should affect each component of the enlarged lip, including protrusion, the vertical height of the lip and the visible portion of the moist portion of the red border. To reduce the hypercorrection of the mucous membrane, one can first cut one side of the ellipse, then cut the mucous membrane and hypertrophied glandular tissue, and, leading them backward, cut the excess. It is necessary to keep the height of the lower lip at the level of the lower incisors.
The use of permanent cosmetic tattooing can help emphasize the shape of the lips or, possibly, align the postoperative asymmetry. This procedure can be performed on an outpatient basis under local anesthesia.
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