Defects and deformities of the lips that result from cheyloplasty due to congenital non-affection

Defects of the upper lip on the soil of non-affection of its fragments are often accompanied by such deformations that can not always be eliminated during cheyloplasty; they may appear immediately after surgery or after a while.

Deformities of the upper lip can be divided into residual, secondary and surgical.

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

What causes defects and deformities of the upper lip?

Under residual postoperative deformation is meant a deformation that existed before the operation and is not completely eliminated during the operation.

Secondary deformation is considered in the event that it was eliminated during the operation, but for some reason appears again.

In cases where the deformation is generated by the operation itself (due to mistakes made by the surgeon or for other reasons), it is called surgical.

Such division of postoperative deformations allows to more accurately comprehend their genesis, ways of prophylaxis and methods of treatment.

As a rule, all residual deformities of the lip and nose that have arisen after operations with one-sided lip incisions are combined.

Depending on the degree of primary underdevelopment of the lip, defect and deformation of soft tissues, cartilage of the nose and disfiguring of the upper jaw, IA Kozin recommends the allocation of four groups of patients.

• I group. All the elements of the lip are preserved, there are only small deformations along the course of the rumen; asymmetry of the nostrils, flattening of the wing and tip of the nose are insignificant and more noticeable in the position with the head thrown back.
• Group II. The wing and tip of the nose have an average degree of flattening, the base of the wing is mixed to the side and back, a moderate underdevelopment of the edge of the pear-shaped aperture and the alveolar process of the maxilla; the septum of the nose is slightly deformed.
• III group. The pronounced disfigurement of the external nose and nasal septum, gross postoperative scars, a significant defect in the soft tissues of the lip and nose, underdevelopment and deformation of the upper jaw, incorrect bite, often observed naso-oral anastomoses; Nasal breathing is difficult due to deformation of the cartilage and bones of the nose.
• IV group. Severe degree of disfigurement of the entire middle third of the face due to severe deformation and underdevelopment of bones and defect of the tissues of the lip and nose; requires multi-stage reconstructive surgery.

Based on the interests of planning operations, it is more specific to classify the defects and deformities of the upper lip in previously operated patients:

1. flattening or underdevelopment of the frontal part of the upper jaw, as a result of which the entire upper lip looks fused behind;
2. transverse narrowing of the upper jaw;
3. flattening and unfolding of the wing of the nose;
4. coracoid curvature of the tip of the nose due to the shortening of the skin of its septum;
5. insufficient height of upper lip;
6. excess height of the upper lip (most often - after operations on Hagedorn);
7. zigzag- or dome-shaped deformation of the Cupid line;
8. islet germination of the red border into the dermal part of the lip and vice versa;
9. cicatrical deformation of the lip (scar wide, pigmented or, conversely, depigmented, and therefore very noticeable);
10. no upper vestibule of the mouth behind the upper lip;
11. the divergence of immersion sutures superimposed on fragments of the circular muscle of the mouth, resulting in a pattern similar to subcutaneous (concealed) non-growth of the lip;
12. displacement (sliding) of the upper lip upwards and displacement of the premaxillary bone downwards, because of which the gum and teeth are exposed with a smile and even with limited opening of the mouth;
13. combination of several symptoms listed above.

Symptoms of defects and deformities of the upper lip

All these defects lead not only to cosmetic, but also to functional disorders, since the flattening of the wing of the nose is often associated with the difficulty of breathing through the nose.

With an upturn (shortening) of the lip, the moistening of the anterior surface of the upper incisors is not permanently moistened, as a result of which they begin to break down (chalk spots, carious cavities appear).

The deformations of the wing and the tip of the nose produce a particularly unpleasant impression on the surrounding people, which are most often explained by the innate underdevelopment of the upper jaw, the absence under the restored nostrils of a firm bone foundation, the presence of a crooked defect in the gum and in the region of the pear-shaped aperture.

Treatment of defects and deformities of the upper lip

The discrepancy of fragments of the lip along the Cupid line is usually easily eliminated by the method of moving counter triangular flaps of the skin.

In the case of a significant flattening of the nose wing and deformation of its tip that have arisen after a one-sided cheiloplasty, it is possible to resort to a second operation without touching the red border and the Cupid line. If this deformity is combined with a shortened vertical postoperative scar and a filter, L-shaped deviation of the Cupid line, it is possible to perform a second operation using the Tennison-A method. A. Limberg, or reconstruction by the method of IA Kozin.

If after the operation, the deformity of the upper lip does not coincide with the deformation of the bony linden, a deformity develops in the partially exploded type (in the lower part of the lip) and partially concealed defect (in the upper part of the lip), complete excision of the postoperative scar, muscles of the mouth and sewn them with a thin catgut.

With cicatricial shortening of the upper lip, distortion of the Cupid line, combined with unfolding and flattening of the nose wing, underdevelopment of the upper jaw, it is possible to recommend the method of heylorinoplasty according to Millard, modified by I. A. Kozin, having previously compensated the bone tissue in the region of the nose wing (osteoplasty of the alveolar process, jaws and edges of the pear-shaped aperture by the method of our employee AA Khalil, 1970).

In the absence of the upper arch of the vestibule of the oral cavity, it can be deepened by scraping the mucosal flaps on the lateral sections of the lip and lining them with the newly created vestibule of the mouth. If mobilization of such flaps due to cicatricial deformity of the mucous membrane is not possible, a free transplantation of the split or epidermal skin flap is used, which is fixed with a special forming plastic liner. This method can be used to treat children older than 2 years, since the liner should be worn for 4-5 months.

Operations, correcting the vestibule of the mouth, it is desirable to produce as late as possible to fix the seedling of the skin and form the vestibule with a plastic liner fixed on the denture; without this, the "shallowing" and "overgrowing" of the achieved arch will inevitably arise again.

The bilious, flattened shape of the tip of the nose due to unsuccessful cheyloplasty due to bilateral non-resection can be eliminated by lengthening the skin in the region of the septum of the nose (according to the Burian method) due to a horn-shaped skin flap with a base at the tip of the nose, the ends of which are combined and stitched.

If the flattening of the tip of the nose is accompanied also by the divergence of large cartilages of the wings of the nose, then during the operation these cartilages are separated from the loose fiber interposed between them, removed, and the cartilages are sewn together with U-shaped catgut sutures.

The pronounced lack of transverse and vertical dimensions of the upper lip usually results from the healing of the wound by secondary tension, and also after the operation with resection of the intermaxillary bone. Eliminate it by transplanting a three- or quadrangular flap from the lower lip by the method of Abbe or GV Kruchinsky.

Prevention of postoperative lip deformities

Prevention of postoperative deformations consists in careful planning and implementation of the most effective methods of cheyloplasty. In particular, in order to prevent depressions and flattening of the nose, it is necessary (in addition to its wide separation and the use of the Limberg flap), in a number of cases (with especially wide incisions of the pear-shaped aperture and gum) to pre-implant the implantation of an allo-graft transplant of the appropriate shape. In recent years, attempts have been made simultaneously with cheloplasty to perform bone grafting of the alveolar process with autorobrom or allogeneity, but this has not yet found wide application.

IV Berdyuk with unilateral combined nonunions produces cheyloplasty in two stages: the first is the movement of the inferior nasal shell to the underdeveloped edge of the pear-shaped aperture, the second - the plastic of the lip and the correction of the nose. The second stage is performed 3-4 weeks after the strong fusion of the displaced nasal concha.

In our opinion, the simplest and most accessible way to create a solid foundation for the nose wing is implantation (for replenishing the underdeveloped edge of the pear-shaped aperture) allochia or allochondria.