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

Defects and deformations of the lips and the entire perioral area - cheeks, chin - can occur as a result of accidental trauma, surgical intervention (due to a congenital defect, neoplasm, fresh trauma, inflammation), specific (syphilis, lupus erythematosus, anthrax, etc.) and non-specific (noma, carbuncle, furuncle, phlegmon) inflammation.

By localization, there are median, lateral, total defects of the lips, and by depth and degree of damage to tissue components - within only the red border, all three layers of the lip itself (cutaneous, intermediate and mucous) or one of them. In other words, defects can be both superficial and through, and sometimes even hidden.

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

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Symptoms of defects and deformations of the lips and mouth area

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

Treatment of defects and deformations of the lips and mouth area

The surgical technique depends on the nature and size of the defect. Many of them arise during the surgery and can be immediately eliminated by local plastic surgery. In most cases, it is possible to restore the shape of the lips, corners of the mouth, cheeks and chin using local plastic surgery. Moreover, the surgical technique for eliminating fresh traumatic defects and old ones surrounded by scars is different.

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

Old defects and deformations bordered by scars are corrected by various methods: A. A. Limberg, Yu. K. Shimanovsky, V. P. Filatov, G. V. Kruchinsky, Abbe, Bruns, Burian, Burow, Diffenbach, Estlander, Gnus, Lexer, etc. Often, surgeons use several plastic methods during the operation, for example, they resort to transplantation of the Filatov stem, free transplantation of the skin and mucous membrane, 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 counter triangular flaps using the Serre-A. A. Limberg method

This type of plastic surgery is usually used for cicatricial deviations (distortions) of the oral slit, lowering or raising of the corner of the mouth, etc. To eliminate these defects, triangular flaps of skin are formed in the lip or cheek area (45 and 90°, 45 and 135°, 45 and 120° or in other proportions - depending on the condition of the surrounding tissues). Indications for this type of plastic surgery are also linear scars and lip deformations.

Rectangular lip plastic surgery using the method of Yu. K. Shimanovsky - N. A. Shnibirev

Rectangular lip plastic surgery by the method of Yu. K. Shimanovsky-N. A. Shinbirev can be used for defects of half or 1/3 of the lip that have arisen as a result of a neoplasm or for traumatic defects that have a relatively regular rectangular shape. The disadvantage of the method is that a protruding cone is formed on the chin, which can only be eliminated by excising a fairly large triangular area of skin and muscles of the chin.

N. A. Shinbirev improved Shimanovsky's technique as follows: relaxing incisions are made from the lower edge of the lip defect in both directions, the length of which should be at least half the width of the lip defect. From the ends of the relaxing incisions, additional incisions are made upwards through the entire thickness of the cheek, equal to 1/4 of the width of the defect or slightly more; as a result, two incisions are obtained at an angle resembling a poker. A "holder" suture is applied to the mucous membrane and muscles, pulling which brings together and shifts the flaps to the midline. This opens the angles in the area of the additional incisions ("poker"). The mucous membrane of the lips and cheeks is fixed with catgut sutures, starting from the cheeks and gradually moving toward the midline, first on one side, then on the other. Sutures are applied to the muscles with catgut, to the skin - with nylon. When suturing the wound, by opening the corners of the "poker", we get the tissue growth that is necessary to close the lip defect without tension in the sutures. The small protruding cones that form on the cheeks are removed, which improves the cosmetic effect of the operation directly on the operating table.

Tissue grafting from the opposite lip

This method is especially indicated when, due to the long-term existence of a defect in the upper lip, the lower lip is significantly hypertrophied in compensation and appears very massive, and sags when at rest.

Abbe operation

The Abbe operation is most indicated for a through defect of the upper lip, which has a triangular shape with a base of more than 1.5-2 cm. It should be taken into account that with a similar defect of the lower lip, borrowing tissue from the middle of the upper lip can lead to the elimination or distortion of the filter on it; this is a limiting factor in the use of this technique. The operation is as follows. The distance from the base of the triangular defect to the supposed line of lip closure is measured vertically. The same distance is marked down from this line and a horizontal line is drawn on the chin with methylene blue. An isosceles triangle is also marked with blue from this line on the lower lip. One of its sides is brought only to the red border (so as not to damage the inferior labial artery) - the area of the pedicle of the supposed triangular flap.

A triangular flap on a leg is sutured layer by layer to the edges of the defect (the mucous membrane of the flap is connected to the mucous membrane of the edges of the defect with catgut; the muscle layers are also connected with catgut, and the skin is connected with a polyamide or polypropylene thread).

As a result of the triangular flap transplantation, the same triangular defect appears on the donor lip; it is sutured with three layers of sutures up to the very pedicle of the flap.

After the first stage of the operation, the oral slit narrows somewhat and is divided into two parts. Between stages of the operation, the patient is fed using a sippy cup with a narrow rubber drainage tube on the spout.

After the transplanted flap has taken root (usually after 8-10 days, and in children - after 6-7 days), the second stage of treatment is carried out - cutting off the flap stalk and forming 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 suturing its upper end into the formed defect of the upper lip. The possibility of this acceleration was recently confirmed by the authors who proposed free transplantation of a full-layer fragment of the lower lip to the upper lip.

Operation according to the method of G.V. Kruchinsky

The operation according to the method of G. V. Kruchinsky is a further development of the Abbe method. It is used in the following cases:

1. in case of combined defects of the upper lip after repeated operations for its congenital non-unions;
2. when shortening the cicatricially altered lip in the horizontal and vertical directions;
3. when a defect of the upper lip is combined with a narrowing of the nostril on the side of the former non-union.

It differs from the Abbe operation in that instead of the usual wedge-shaped flap on the lower lip, a shaped skin-muscle-mucous flap is cut out, the outlines of which correspond to the contours of the defect formed after the dissection of the upper lip and the reposition of its fragments into the correct position. As a result of transplanting such a flap, the upper lip increases not only in transverse but also in vertical size, and the previously broken Cupid's line becomes normal.

Operation according to the Estlander method

The Estlander operation is indicated for a subtotal defect of the upper lip. On the lower lip, 1-2 cm from the corner of the mouth, a 2.5-3 cm long incision is made through all the tissues obliquely downwards from the vermilion border. From the lower end of this incision, a second 1-2 cm long incision is made through the entire thickness of the lip to a point located on the cheek along the horizontal line of closure of the mouth (corresponding to the size of the defect of the vermilion border of the upper lip). As a result, a triangular flap is formed, including the skin, muscles, mucous membrane of the lip and partially the cheek. The pedicle is a section of the uncrossed vermilion border of the lower lip. The flap is placed in the defect area and sutured layer by layer (with catgut sutures - mucous membrane and muscles, with fishing line - skin). The vermilion border of the upper lip is formed due to the vermilion border of the flap itself and its mucous membrane. The edges of the defect formed on the donor soil are separated and sutured layer by layer.

Operation according to the method of A. F. Ivanov

The operation according to the method of A. F. Ivanov is an improvement of the operation according to the method of Estlander. In accordance with the shape and size of the defect, A. F. Ivanov moves from one lip to the other not triangular, but rectangular, L- or T-shaped flaps, the sizes of which can reach 5x3 cm. The method of A. F. Ivanov is especially convenient when it is necessary to increase the defect by excising extensive scars around it.

The surgical technique is as follows: the edges of the defect are excised to give it a more defined shape and ensure better fusion with the flap. Additional linear incisions and separation of the edges of the defect are used to achieve some reduction of the defect by moving and suturing adjacent tissues. A flap on a pedicle of the appropriate size and shape is cut out (on the opposite lip), moved to the defect area and sutured layer by layer. After 14-17 days, the feeding pedicle is excised, the red border in the area of the corner of the mouth is modeled and carefully sutured.

Operation according to the method of N. M. Alexandrov

The transverse tightening of the lower lip, which creates the impression of sharp microgenia-retrognathia, can be eliminated by a modification of the Abbe operation, developed by N. M. Aleksandrov, who proposed transplanting two flaps from the upper lip to the lower lip, vertically dissecting it in one or two places.

Operation by Flanegin method

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

According to G.V. Kruchinsky, in the first days the transplant is pale white, then bluish, but after 3-4 days it becomes lighter again and gradually acquires an almost normal color.

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

Operation using the Dieffenbach-Bergman method

It is indicated for total resection of the lower lip due to cancer or an old traumatic defect of the entire lip. Additional through-cuts on the cheeks are made from the corners of the mouth outward in both directions - to the anterior edge of the masticatory muscles; from here the cuts are directed downwards and forwards - to the middle of the chin areas. The skin-muscle-mucous flaps are separated from the outer surface of the lower jaw, preserving the periosteum on it. By moving these cheek flaps to the midline and suturing them together, the defect of the lower lip is eliminated (c).

In case of a total defect of the upper lip, the Brans or Sedillot method can be successfully applied.

Bruns operation

The Bruns operation is performed as follows. In case of a symmetrical lip defect, two flaps of the same length (width - about 3-4 cm, length - 5-6 cm) are cut out on the cheeks. If the defect is asymmetrical, then the flaps are taken of correspondingly different lengths. When forming the flaps, an L-shaped incision is made so that the lower edge of the flap, bordered by the mucous membrane, can be used to recreate the red border. 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 that feeds the flap. Both flaps are brought together without tension and sutured layer by layer (the mucous membrane and muscles - with catgut, the skin - with synthetic thread). If the lower edge of the flaps is bordered not by mucous membrane, but by scars, they are cut off and, having separated the mucous membrane at the lower edges of the flaps, they are turned back, thereby imitating a red border.

Sedillot operation

The Sedillot operation is performed on the same principle as the Bruns operation, with the only difference being that the base of the flaps is not directed downwards (towards the edge of the lower jaw), but upwards.

Operation using the Joseph method

In case of cicatricial contraction and insufficiency of the lower lip, expressed in its drooping, the Joseph method can be used; a through horizontal incision below the preserved vermilion border or strip of mucous membrane on the lower lip is used to give it the correct position. Two symmetrical pointed flaps are cut out on both cheeks, which, if necessary, should also include the mucous membrane of the cheek. Both flaps are turned medially and downwards, placed in the area of the lip defect, sutured to each other in layers, and the preserved part of the lower lip is sutured to the upper flap. The lower edge of the mucous membrane of the lower flap is sutured to the edge of the mucous membrane of the lower fornix of the vestibule of the mouth behind the newly created lip. The wounds on both cheeks are sutured with a three-layer suture.

Lexer-Burian visor flap plastic surgery

It is advisable to use it only in men with a total lip defect, when it is necessary to ensure hair growth in this area. For this purpose, two flaps on legs facing the edge of the defect are returned to their original place after separation for 2-3 weeks. This trains their nutrition through the legs. Then the flaps are separated again and the inner lining of the lip is formed from them. The wound at the site of borrowing the flaps is, if possible, reduced by separating and suturing the edges.

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

After the middle part of the flap has taken root in the area of the lip defect, its lateral parts are cut off and returned to their original place in the temporal regions. The middle part of the wound on the crown is closed by free skin grafting.

Operations according to the method of O. P. Chudakov

Elimination of through defects of the lips with an epithelialized skin flap according to the method of O. P. Chudakov is based on the idea of L. K. Tychinkina - the use of a flap formed in advance under immersion conditions. In the area of the nasolabial fold (if it is necessary to eliminate a defect of the upper lip), chin (for defects of the lower lip), upper part of the anterior surface of the chest or shoulder girdle (for combined defects of the lips, corners of the mouth and cheeks) a tongue-shaped or bridge-shaped skin flap (up to 1 cm thick) is cut out, the wound surface of which is epidermized with a freely transplanted autodermatome split flap (from the inner surface of the shoulder) 0.35 mm thick, returned to its original place and sewn to the edges of the wound with knotted sutures made of polyamide thread. After 12-14 days, the formed epithelialized flap (with a well-grafted split dermatograft on the inner side) is cut out again and moved directly to the edge of the defect, where it is sutured with three-layer sutures: the edges of the mucous membrane defect - with the split graft on the epithelialized flap, the edges of the muscle layer - with the subcutaneous tissue of the flap, the skin edges of the defect - with the skin of the flap.

In cases where the tissues of the lower lip and chin surrounding the defect are cicatricially altered or have previously been exposed to radiation, which makes horizontal tissue displacement impossible using straight incisions, and also when there is no certainty in the viability of the epidermized flap on one leg, partial through defects of the lower lip should be eliminated with a flap on two legs, and total defects - with two "counter" flaps, each of which has one leg.

Lip plastic surgery with Filatov stem and Bernard method (Bernard) - H. I. Shapkiia

Lip plastic surgery with a Filatov stem is performed only in cases of extensive combined defects of the soft tissues of the face, when it is not possible to use the methods of Shimanovsky, Bruns, Sedillot, O. P. Chudakov, and others for this purpose. The Bernard method (1852) as modified by N. I. Shapkin involves wide separation of the cheek tissues together with the masticatory muscles from the body and branch of the lower jaw. To eliminate the significant tension of the cheek flaps that is often observed in this case, S. D. Sidorov proposed additionally separating the soft tissues from the posterior edge of the branch of the lower jaw.