Defects and deformations in the mouth area: causes, symptoms, diagnosis, treatment

Defects and deformation of the lips and the entire prenatal zone - cheeks, chin - may result from accidental trauma, surgical intervention (due to congenital defect, neoplasm, fresh trauma, inflammation), specific (syphilis, lupus erythematosus, anthrax, etc.) and nonspecific (nome, carbuncle, furuncle, phlegmon) inflammation.

Localization distinguishes median, lateral, total defects of the lips, and the depth and extent of damage to the tissue components - within the limits of only the red border, all three layers of the actual lip (cutaneous, intermediate and mucous) or one of them. In other words, defects can be either superficial, or through, and sometimes even hidden.

Along with this, there are defects in the lip, combined with a defect or deformation of the jaw (all or only its frontal region), cheeks, chin, nose, eyelids, whole face.

[1], [2], [3], [4], [5], [6]

Symptoms of defects and deformities of lips and mouth area

Damage to the mouth area is accompanied by various functional disorders, which are expressed in the facial cosmetic disfigurement, difficulty in pronouncing sounds (especially labial and dental), eating disorders, and sometimes breathing. Nasal breathing becomes nasal-mouth, which leads to dryness of the oral cavity, changes in its mucous membrane and increased thirst.

Treatment of defects and deformities of the lips and mouth area

The procedure of the operation depends on the nature and magnitude of the defect. Many of them arise during surgery and can be immediately eliminated by local plastic surgery. In most cases it is possible to reconstruct the shape of the lips, corners of the mouth, cheeks and chin with a local-plastic technique. Moreover, the procedure of the procedure for the removal of fresh traumatic defects and chronic, surrounded by scars, is different.

Fresh traumatic defects can be eliminated by wide mobilization of the edges of the wound, the formation and use of tilted skin flaps and subcutaneous tissue, the movement of countercutaneous cutaneous triangular flaps, the closing and opening of the corners of the wound, the formation of skin-subcutaneous flaps on the foot, a combination of several of the above techniques of local plastic surgery.

Old defects and deformities bordered by scars are corrected by various methods: AA Limberg, Yu. K. Shimanovsky, VP Filatov, GV Kruchinsky, Abbe, Bruns, Burian, Burow, Diffenbach, Estlander, Gnus, Lexer, etc. Often surgeons use several methods of plastic surgery, for example, they resort to a Filatov stalk transplant, a free skin and mucosal transplant or a combination of these two tissues.

Let us dwell on the most common methods of local plastic surgery on the lips.

Plastic surgery with triangular patches by the Serre-A method. A. Limberg

This plastic is usually used for the cicatricial deviations (distortions) of the mouth slit, the lowering or raising the angle of the mouth, etc. To eliminate these drawbacks, triangular flaps of skin are formed in the region of the lip or cheek (45 and 90, 45 and 135, 45 and 120 ° or in other proportions - depending on the condition of the surrounding tissues). Indications for this form of plastic are also linear rubies and deformations of the lips.

Rectangular plastic lips according to the method of Yu. K. Shimanovsky-N. A. Shnbireva

Rectangular plastic lips according to the method of Yu. K. Shimanovsky-N. A. Shinbireva can be used for defects of half or 1/3 of the lips that have arisen due to neoplasia or traumatic defects having a relatively regular rectangular shape. The disadvantage of the method is that a protruding cone is formed on the chin, which can be eliminated only by excision of a fairly large triangular area of the skin and muscles of the chin.

NA Shinbirev improved Shimanovsky's method in the following way: from the lower edge of the defect of the lip to both sides make loosening cuts, the length of which should be at least half the width of the defect of the lip. From the ends of the loosening incisions, additional incisions are made upward through the entire thickness of the cheek, equal to 1/4 of the width of the defect or slightly larger; As a result, two incisions are obtained at an angle resembling a poker. Apply a seam-"holder" on the mucous membrane and muscles, pulling them closer and move the flaps to the middle line. In this case, the angles are opened in the area of additional cuts ("pokers"). The mucous membrane of the lips and cheeks is fixed with catgut sutures, beginning with the cheeks and gradually moving to the middle line, first on one side, then on the other. The muscles are stitched with catgut, and the skin with nylon. When the wound is sewed up due to the opening of the corners, "pokers" get such a growth of tissues, which is necessary to close the defect of the lip without tension in the seams . The small protruding cones that form on the cheeks are removed, which improves the cosmetic effect of the operation directly on the operating table.

Transplanting tissues from the opposite lip

This method is especially shown when, due to the long existence of the defect of the upper lip, the lower lip is compensatoryly hypertrophic and looks very massive, and at rest it hangs.

Operation using the Abbe method

Surgery according to the Abbe method is most indicated in the through defect of the upper lip, which has a triangular shape with a base more than 1.5-2 cm. It should be borne in mind that with a similar defect in the lower lip, the borrowing of tissues from the middle of the upper lip can lead to the elimination or distortion of the filter on it; this is a deterrent to the application of this technique. The operation is as follows. The distance from the base of the triangular defect to the prospective line of closure of the lips is measured vertically. The same distance is marked from this line downwards and along the chin the methylene blue line is drawn on the chin. From this line, the blue isosceles triangle is also marked on the lower lip. One of its sides is brought only to the red border (in order not to damage the lower labial artery) - the area of the leg of the proposed triangular flap.

A triangular flap on the foot is layered to the edges of the defect (the mucosa of the flap is connected with the mucosa of the edges of the defect with catgut, the muscle layers are also catgut, and the skin - polyamide or polypropylene thread).

As a result of transplanting a triangular flap on the donor lip, the same triangular defect arises; It is sutured with three layers of stitches to the very foot of the flap.

After the first stage of the operation, the mouth slit somewhat narrows and divides into two parts. Between the stages of the operation the patient is fed with a drinker with a narrow drainage rubber tube on the spout.

After engraftment of the transplanted flap (usually 8-10 days, and in children 6-7 days later), the second stage of treatment is performed - clipping of the flap leg and formation of a red border on both lips.

Based on our own experience, we recommend cutting off the legs of the bridge flap at an earlier time - 3-5 days after sewing its upper end into the resulting defect of the upper lip. The possibility of this acceleration was recently confirmed by the authors who proposed a free transplant of the full-layer fragment of the lower lip to the upper one.

Operation by the method of GV Kruchinsky

Operation by the method of GV Kruchinsky is a further development of the Abbe technique. Applicable in the following cases:

1. with combined defects of the upper lip after repeated operations for her congenital nonsense;
2. when the cicatrized lip is shortened in the horizontal and vertical directions;
3. when the defect of the upper lip is combined with the narrowing of the nostrils on the side of the former non-affection.

It differs from the operation of Abbe in that instead of the usual wedge-shaped flap on the lower lip, a figured cutaneous-muscular-mucosal flap is cut out , the outlines of which correspond to the contours of the defect that is formed after dissecting the upper lip and repositioning its fragments in the correct position. As a result of transplanting this flap, the upper lip increases not only in the transverse, but also in the vertical dimension, and the previously broken Cupid line becomes normal.

Operation by Estländer's method (Estlander)

Operation by Estländer's method (Estlander) is indicated with a subtotal imperfection of the upper lip. On the lower lip, having retreated from the corner of the mouth 1-2 cm, make a cut 2.5-3 cm long through all the tissues obliquely down from the red border. From the lower end of this incision make a second incision 1-2 cm long through the entire thickness of the lip to the point located on the cheek along the horizontal line of closure of the mouth (corresponding to the size of the defect of the red border of the upper lip). As a result, a triangular flap is formed, which includes the skin, muscles, the mucous membrane of the lip and partially the cheeks. The feeding leg is a patch of unshaded red border of the lower lip. The flap is placed in the area of the defect and layer-by-layer sewn (catgut sutures - mucous membrane and muscles, line - skin). Red border of the upper lip is formed due to the red border of the flap and its mucous membrane. The edges of the defect formed on the donor soil are separated from and cut off layer by layer.

Operation by the method of AF Ivanov

Operation by the AF Ivanov method is an improvement of the operation using the Estlander method. In accordance with the shape and magnitude of the defect, AF Ivanov moves from one lip to another not triangular but rectangular, G- or T-shaped flaps, whose dimensions can reach 5x3 cm. The Ivanov method is especially convenient when it is necessary to increase the defect due to excision of extensive scars around it.

The procedure is as follows: the edges of the defect are excised to give it a more definite shape, to provide better adhesion to the flap. By means of additional linear cuts and by cutting off the edges of the defect, some reduction is achieved due to the movement and suturing of adjacent tissues . Cut a flap on a leg of the appropriate size and shape (on the opposite lip), move it to the defect area and layer by layer. After 14-17 days the feeding leg is cut off, the red border at the corner of the mouth is modeled and carefully sutured.

Operation by NM Aleksandrov's method

The lateral tightening of the lower lip, which gives the impression of a sharp microgenia-retrognathia, can be eliminated by modifying the Abbe operation developed by NM Aleksandrov, who suggested replacing the two flaps from the upper lip to the lower one, vertically dissecting it in one or two places.

Flanegin operation

The Flanegin method involves free transplantation of all layers of the lower lip portion to disperse and increase the width of the upper lip. The author used a narrow wedge-shaped transplant (1 cm wide red border) from the middle part of the lower lip for transplantation. According to available data, the operation is effective when transplanting a transplant with a width of no more than 1.2-1.5 cm.

According to GV Kruchinsky, in the early days the transplant has a pale white color, then it is cyanotic, but after 3-4 days it grows lighter and gradually acquires an almost normal color.

It is recommended to remove the stitches on the skin on the 6th, and on the mucous membrane - on the 8th day after the operation.

Operation by the Dieffenbach-Bergman method (Dieffenbach-Bergman)

It is indicated with total resection of the lower lip for cancer or an old traumatic defect of the entire lip. Additional cut-through incisions on the necks lead from the corners of the mouth to the outside in both directions - to the front edge of the masticatory muscles; from here cuts are directed down and forward - up to the middle of the chin areas. Skin-muscular-mucosal flaps are cut off from the outer surface of the lower jaw, while retaining the periosteum. By moving these buccal flaps to the midline and sewing together, the defect of the lower lip (c) is eliminated.

With a total defect of the upper lip, the method Brans or Sedillot can be successfully used .

Operation by the method of Bruns (Bruns)

Operation by the Bruns method is performed as follows. With a symmetrical defect of the lip, two identical flaps are cut on the cheeks (width - about 3-4 cm, length - 5-6 cm). If the defect is asymmetric, then the flaps take correspondingly different lengths. When forming flaps, a L-shaped incision is made, so that the mucosa-lined lower edge of the flap can be used to recreate the red rim. The final part of the external incision should not be made through the entire thickness of the cheek so as not to damage the artery feeding the flap. Both flaps pull together with each other without tension and are stitched together (the mucous membrane and muscles are catgut, and the skin is a synthetic thread). If the lower edge of the flaps is not trimmed with a mucous membrane but with scars, they are cut off and, by cutting off the mucous membrane at the lower edges of the flaps, are turned off, imitating the red border.

Operation by method Sedillo (Sedillot)

Operation by the method Sedillo (Sedillot) is carried out on the same principle as the operation by the method of Bruns, with the only difference that the base of the flaps is not drawn down (to the edge of the lower jaw), but upwards.

Operation by the method of Joseph (Joseph)

In the case of cicatricial scarring and insufficiency of the lower lip, expressed in its descent, the method of Joseph can be applied; through a horizontal incision below the preserved red border or a strip of mucosa on the lower lip, it is given the correct position. Two symmetrical pointed flaps are cut on both necks, which, if necessary, must also include the mucous membrane of the cheek. Both flaps rotate medially and downward, laying the lips in the defect area, layered together with each other, and the remaining part of the lower lip - with the upper flap. The lower edge of the mucosa of the lower flap is hemmed to the edge of the mucosa of the lower arch of the vestibule of the mouth behind the newly created lip. The wounds on both cheeks are sutured with a three-layer suture.

Plastic with a visceral flap according to the method of Lexer-Burian (Lexer-Burian)

It is advisable to use only in men with a total defect of the lip, when it is necessary to provide hair growth in this area. For this purpose, two flaps on the legs facing the edge of the defect are returned to their original place after the cut-off for the second and third weeks. This trains their nutrition through the legs. Then the flaps are removed again and the inner lining of the lip is formed from them. The wound at the place of borrowing the flaps, if possible, is reduced by the method of cutting and suturing the edges.

According to the Lexer method, a skin flap is prepared on the crown of the head on two legs (in the temporal areas) and moved to the area of the defect of the lip. The wound on the top of the head is temporarily closed with a sterile ointment dressing.

After engrafting the middle part of the flap in the area of the defect of the lip, its lateral sections are cut off and returned to its original place in the temporal regions. The middle part of the wound on the crown is closed due to a free skin graft.

Operations by the method of OP Chudakova

Elimination of end-to-end lip defects with an epithelial skin flap according to the method of OP Chudakov is based on the idea of LK Tychinkina - the application of a flap, formed beforehand under immersion conditions. In the region of the nasolabial fold (if it is necessary to remove the defect of the upper lip), the chin (with defects of the lower lip), the upper part of the anterior surface of the chest or the shoulder (with combined defects in the lips, corners of the mouth and cheeks), a tongue-shaped or bridged skin flap thickness up to 1 cm), the wound surface of which is epidermalized by a freely transplanted autodermatomic split flap (from the inner surface of the shoulder) with a thickness of 0.35 mm, returned to its original position and sutured to the edges of the wound with nylon sutures made of polyamide thread oh. After 12-14 days, the formed epithelial flap (with a well-established split internal dermatograft) is again cut out and moved directly to the edge of the defect, where it is hemmed with three-layered sutures: the edges of the mucosal defect - with a split graft on the epithelial flap of the muscle layer rim - with subcutaneous tissue flap, the skin edges of the defect - with the skin of the flap.

In those cases where the surrounding defect of the tissue of the lower lip and chin is scarly altered or previously exposed to radiation, which makes it impossible to horizontally displace tissues by means of rectilinear incisions, and when there is no confidence in the viability of the epidermis flap on one leg, partial through defects of the lower lip should to remove by a flap on two legs, and total - by two "counter" flaps, each of which has one leg.

Lip plastic surgery Philatian stem and Bernard's method (Bernard) -H. I. Shapkia

The plasticity of the lips with the Filatov stem is produced only with extensive combined defects in the soft tissues of the face, when it is not possible to use the methods of Shimanovsky, Bruns, Sedillot, OP Chudakova, etc. For this purpose. Bernard (1852) exfoliation of the buccal tissues together with chewing muscles from the body and the branch of the lower jaw. To eliminate the often significant tension of the buccal flaps, SD Sidorov proposed to exfoliate the soft tissues from the posterior edge of the mandible.