Defects and deformities of the lips resulting from cheiloplasty for congenital nonunion

Defects of the upper lip due to non-union of its fragments are often accompanied by deformations that cannot always be eliminated during cheiloplasty; they can be revealed immediately after the operation or after some time.

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

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What causes defects and deformities of the upper lip?

Residual postoperative deformity refers to a deformity that existed before surgery and was not completely corrected during surgery.

A deformation is considered secondary if it was corrected during surgery, but for one reason or another it reappears.

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

This division of postoperative deformations allows us to more accurately understand their genesis, prevention methods and treatment methods.

As a rule, all residual deformities of the lip and nose that arise after operations for unilateral non-unions of the lip are combined.

Depending on the degree of primary underdevelopment of the lip, defect and deformation of soft tissues, nasal cartilage and disfigurement of the upper jaw, I. A. Kozin recommends distinguishing four groups of patients.

• Group I. All elements of the lip are preserved, there are only minor deformations along the scar; 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 a moderate degree of flattening, the base of the wing is shifted to the side and back, moderate underdevelopment of the edge of the piriform aperture and the alveolar process of the upper jaw; the nasal septum is slightly deformed.
• Group III. Severely pronounced disfigurement of the external nose and nasal septum, coarse postoperative scars, significant defect of the soft tissues of the lip and nose, underdevelopment and deformation of the upper jaw, malocclusion, frequently observed nasal-oral fistulas; nasal breathing is difficult due to deformation of the cartilages and bones of the nose.
• Group IV. Severe degree of disfigurement of the entire middle third of the face due to severe deformation and underdevelopment of bones and tissue defects of the lip and nose; requires multi-stage reconstructive surgeries.

Based on the interests of planning operations, it is necessary to more specifically classify 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 appears sunken backwards;
2. transverse narrowing of the upper jaw;
3. flattening and unfolding of the nasal wing;
4. beak-shaped curvature of the tip of the nose due to shortening of the skin of its septum;
5. insufficient height of the upper lip;
6. excessive height of the upper lip (most often after Hagedorn operations);
7. zigzag or dome-shaped deformation of the Cupid's line;
8. insular growth of the red border into the cutaneous part of the lip and vice versa;
9. cicatricial deformation of the lip (the scar is wide, pigmented or, conversely, depigmented, and therefore very noticeable);
10. absence of the upper vault of the vestibule of the mouth behind the upper lip;
11. divergence of the immersion sutures placed on fragments of the orbicularis oris muscle, resulting in a picture similar to subcutaneous (hidden) non-union of the lip;
12. displacement (sliding) of the upper lip upward and displacement of the intermaxillary bone downward, due to which, when smiling and even with limited opening of the mouth, the gums and teeth are exposed;
13. a combination of several of the symptoms listed above.

Symptoms of defects and deformations of the upper lip

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

When the lip is upturned (shortened), the front surface of the upper incisors is not constantly moistened, as a result of which they begin to deteriorate (chalk spots and carious cavities appear).

Deformations of the wing and tip of the nose make a particularly unpleasant impression on others, which are most often explained by congenital underdevelopment of the upper jaw, the absence of a strong bone foundation under the restored nostril, the presence of a cleft defect in the gum and in the area of the edge of the piriform aperture.

Treatment of defects and deformations of the upper lip

Misalignment of lip fragments along the Cupid's line is usually easily corrected by moving opposing triangular skin flaps.

In case of significant flattening of the wing of the nose and deformation of its tip, which arose after unilateral cheiloplasty, it is possible to resort to a repeated operation, without affecting the red border and Cupid's line. If the said deformation is combined with shortening of the vertical postoperative scar and filter, L-shaped deviation of the Cupid's line, it is possible to perform a repeated operation using the Tennison-A. A. Limberg method or reconstruction using the method of I. A. Kozin.

If, after surgery for a complete non-union of the upper lip, not combined with deformation of the lip bones, a deformation develops according to the type of a partially obvious (in the lower part of the lip) and partially hidden defect (in the upper part of the lip), it is possible to limit oneself to complete excision of the postoperative scar, isolation of fragments of the orbicularis oris muscle and suturing them with thin catgut.

In case of cicatricial shortening of the upper lip, distortion of the Cupid's line, combined with the unfolding and flattening of the wing of the nose, underdevelopment of the upper jaw, we can recommend the modified method of cheilorhinoplasty according to Millard by I. A. Kozin, having previously compensated for the bone tissue in the area of the wing of the nose (osteoplasty of the alveolar process, body of the upper jaw and edges of the piriform aperture according to the method of our employee A. A. Khalil, 1970).

In the absence of the upper vault of the vestibule of the oral cavity, it can be deepened by cutting out flaps of the mucous membrane on the lateral parts of the lip and lining the newly created vestibule of the oral cavity with them. If the mobilization of such flaps is impossible due to cicatricial deformation of the mucous membrane, a free transplant of a split or epidermal skin flap is used, which is fixed with a special forming plastic insert. This method can be used to treat children over 2 years old, since the insert must be worn for 4-5 months.

It is advisable to perform operations that correct the vestibule of the mouth as late as possible in order to fix the skin graft and form the vestibule with a plastic insert fixed to the dental prosthesis; without this, the “shallowing” and “overgrowing” of the achieved vault inevitably reoccurs.

The beak-shaped, flattened shape of the tip of the nose, caused by unsuccessful cheiloplasty for bilateral non-union, can be eliminated by lengthening the skin in the area of the nasal septum (using the Burian method) using a slingshot-shaped flap of skin with a base at the tip of the nose, the ends of which are aligned and sutured.

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

A pronounced deficiency of the transverse and vertical dimensions of the upper lip usually occurs as a result of wound healing by secondary intention, as well as after surgery with resection of the intermaxillary bone. It is eliminated by transplanting a triangular or quadrangular flap from the lower lip using the Abbe or G. V. Kruchinsky method.

Prevention of postoperative lip deformities

Prevention of postoperative deformations consists of careful planning and implementation of the most effective methods of cheiloplasty. In particular, to prevent the sinking and flattening of the ala of the nose, it is necessary (along with its wide separation and the use of the Limberg flap) in some cases (with particularly wide non-unions of the pyriform aperture and gum) to preliminarily use the implantation of an allograft of the appropriate shape. In recent years, attempts have been made to simultaneously perform bone grafting of the alveolar process with autorib or allograft bone along with cheiloplasty, but this has not yet found wide application.

I. V. Berdyuk performs cheiloplasty in two stages for unilateral complete combined nonunions: the first is the displacement of the inferior nasal concha to the underdeveloped edge of the piriform aperture, the second is lip plastic surgery and nose correction. 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 strong base for the ala of the nose is the implantation (to fill the underdeveloped edge of the piriform aperture) of allograft bone or allograft cartilage.