CHAPTER XIIIMELOPLASTY(Surgery of the Cheeks)
This branch of surgery has to do with the reconstruction or restoration of the cheek following the excision of scars or the extirpation of malignant growths. The procedure is also recognized as genioplasty.
Where the defect occasioned by the ablation is of small extent, the free and somewhat undermined margins of the wound, which should be made in elliptical form, are neatly brought together with several retention sutures alternating with superficial sutures of fine twisted silk.
If deeper structure than the skin be involved, the diseased area should be carefully removed even to the limitation of the buccal mucous membrane, the soft parts detached from the mucous membrane to render them mobile, and the wound brought together by suture. Care must be exercised so that the tension of the suture does not create a new deformity, such as blepharal ectropium, distortion of the rima oris or the alæ of the nose. If there is enough mucous membrane after the excision of the diseased area, Oberst advocates closing the defect with two pedunculated flaps made each from the mucous membrane of the cheek and of the lip.
In cases where the whole thickness of the cheek is involved the cheek can be incised from the angle of the mouth as far as the border of the masseter muscle downto the adipose layer. A part of the fatty tissue is exsected and pushed aside, the thumb of the operator being introduced into the buccal cavity and pressed outward against the cheek to determine the position and extent of the pathological involvement. The diseased area is cut out with curved scissors, going well into the healthy tissues.
The wound is then brought together by suture while the defect of the mucous membrane is tamponed for four or five days, when it can be covered with Thiersch grafts. The latter in a short time takes on the appearance of mucous membrane and overcomes the contraction of the ordinary sutured wound (Edward-Albert).
Serre Method.—For still larger defects Serre makes the ablation in rectangular form, as shown atA,Fig. 258, and forms a longer flap of rectangular form from the tissue of the cheek and neck. This flap he dissects off from the margin of the maxillary bone to give it the proper mobility. The flap is drawn upward and sutured, as inFig. 259.
There is little retraction experienced in this method, and answers well for defects of medium extent.
Fig. 258.Fig. 259.Serre Method.
Fig. 258.Fig. 259.Serre Method.
Fig. 258.Fig. 259.
Serre Method.
In larger defects the flaps to be utilized in overcoming the deformity must be taken from the cheek above as well as the anterior chin, as shown inFigs. 260 and 261.
Fig. 260.Fig. 261.Correction of Angle of Mouth.
Fig. 260.Fig. 261.Correction of Angle of Mouth.
Fig. 260.Fig. 261.
Correction of Angle of Mouth.
Another method is to cut the two flaps as inFig. 262.
These flaps are made of the entire thickness of the cheek tissue, and are slid down into position and sutured or approximated, as inFig. 263.
Fig. 262.Fig. 263.Correction of Extensive Defect at Angle of Mouth.
Fig. 262.Fig. 263.Correction of Extensive Defect at Angle of Mouth.
Fig. 262.Fig. 263.
Correction of Extensive Defect at Angle of Mouth.
As a rule the excised mucous membrane subsequently prevents a free opening of the mouth added to by the contraction of the flaps themselves.
To overcome this a flap of skin with its epidermal surface turned inward is sutured into the defect, as will be shown presently, or a pedunculated flap formed at thewound surface before its transplantation into the defect may be covered with skin grafts (Thiersch).
Bayer Method.—Bayer has successfully utilized a large flap from the mucous membrane of the palate and covered it externally with a flap of skin taken from the submaxillary region.
Kraske Method.—Kraske forms the flap to be turned into the defect of the tissue immediately surrounding it, as shown inFig. 264. This flap may heal into position, even though its pedicle is made up only of subcutaneous tissue, according to Gersuny.
The epidermal surface of such flap is made to form the inner or mucous surface of the repaired cheek (seeFig. 265), while its external surface and the secondary wound are covered with Thiersch grafts, at one and the same sitting.
The only difficulty experienced in the case with men is that the bearded surface of this inturned flap offers considerable discomfort to the patient, although in the majority of cases the skin thus inverted soon takes on the appearance of the mucosa, the objectionable hairs falling out and the hair follicles becoming obliterated.
Fig. 264.Fig. 265.Kraske Method.
Fig. 264.Fig. 265.Kraske Method.
Fig. 264.Fig. 265.
Kraske Method.
Israel Method.—To overcome the above objection Israel makes his flaps from the skin of the side of the neck, the flap being elongated and attached at its upper end, as inFig. 266.
This flap he turns upward into the defects with its epidermal surface facing inward and sutures it into place, as shown inFig. 267, leaving the outer surface to granulate over and thicken on the sutured marginsto heal into place. This requires from fourteen to seventeen days, when the pedicle is severed and the lower or freed portion of the flap is brought forward. The granulation of the entire surface is scraped off and the free end of the flap is turned over upon itself, as it were, and its margins sutured to the descended skin margin, as inFig. 268.
Fig. 266.Fig. 267.Fig. 268.Israel Method.
Fig. 266.Fig. 267.Fig. 268.Israel Method.
Fig. 266.Fig. 267.Fig. 268.
Israel Method.
Bardenheuer Method.—Bardenheuer has given this subject a great deal of attention, and advocates the use of the skin of the forehead for closing these buccal or oraldefects. The skin of the forehead is without hair, is well nourished, and has little adipose tissue underlying it, facts that make it especially useful for these operations. The skin surface he turns into the mouth cavity, while the outer or raw surface is covered with a pedunculated skin flap taken from the region of the intramaxillary region.
The secondary wounds of the forehead and below the jaw should be covered with Thiersch grafts at the same sitting.
The best cosmetic results are obtained by correcting the entire defect at one sitting, as the subsequent contraction of the flaps do not allow of it in successive operations.
The apposition of the raw surfaces of the flap from the forehead and that of the cheek or chin greatly increases their vitality and overcomes markedly the cicatricial contraction.
The pedicle of the forehead flap is cut apart about the fourteenth day and replaced.
In the case depicted inFig. 269a large portion of the cheek and the whole upper and a part of the lower lip had to be removed. A large flap taken from the forehead that turned into the defect (seeFig. 270), and a flap taken from the intramaxillary region, were brought over the major and lower portion of its raw and outer surface.
Fig. 269.Fig. 270.Bardenheuer Method.
Fig. 269.Fig. 270.Bardenheuer Method.
Fig. 269.Fig. 270.
Bardenheuer Method.
InFigs. 271, 272, and 273the various steps of the same operation are more fully shown, including the placing of the Thiersch grafts and the replacing of the pedicle inFig. 274.
Fig. 271.Fig. 272.Fig. 273.Fig. 274.Bardenheuer Method.
Fig. 271.Fig. 272.Fig. 273.Fig. 274.Bardenheuer Method.
Fig. 271.Fig. 272.Fig. 273.Fig. 274.
Bardenheuer Method.
A still more extensive restoration of the cheek isshown inFigs. 275, 276, and 277, and the position of the skin grafts and replaced flap pedicles inFig. 278.
Fig. 275.Fig. 276.Fig. 277.Fig. 278.Bardenheuer Method.
Fig. 275.Fig. 276.Fig. 277.Fig. 278.Bardenheuer Method.
Fig. 275.Fig. 276.Fig. 277.Fig. 278.
Bardenheuer Method.
Staffel Method.—Staffel has also utilized pedunculated flaps taken from the forehead to correct defects of the cheeks and mouth.
His method of procedure in an aggravated case resulting from mercurial stomatitis with resultant cicatricial trismus is shown inFigs. 279 and 280.
Two pedunculated forehead flaps were employed in the above case as well as two flaps each attached by a broad pedicle from the skin under the chin Tripier fashion, and although the patient thus operated upon was only five years of age, an excellent result was obtained.
Fig. 279.Fig. 280.Staffel Method.
Fig. 279.Fig. 280.Staffel Method.
Fig. 279.Fig. 280.
Staffel Method.
When the defect of the cheek due to the removal of a greater part of its structure is so large as to frustrateall attempts at its correction we may resort to the employment of protheses made for the purpose.
InFig. 281a case of Morris is shown following the removal of a myeloid sarcoma involving a greater part of the upper cheek, the eye, and the palate. The operator had a prothesis constructed by Hayman, which provided not only an artificial cheek, but also an eye and the palate.
Fig. 281.—Cheek Prothesis, after Removal of Sarcoma.(British Medical Journal.)
Fig. 281.—Cheek Prothesis, after Removal of Sarcoma.(British Medical Journal.)
Fig. 281.—Cheek Prothesis, after Removal of Sarcoma.(British Medical Journal.)
How excellently this has been accomplished is depicted inFig. 282. This prothetic contrivance not only improved the patient’s appearance, but also enabled him to speak intelligibly, which had been impossible, owing to the absence of a greater part of the soft palate.
Fig. 282.—Prothesis Applied to Face.(British Medical Journal.)
Fig. 282.—Prothesis Applied to Face.(British Medical Journal.)
Fig. 282.—Prothesis Applied to Face.(British Medical Journal.)
Hayman describes what he did as follows:
“I obtained a model of the mouth, after which an ordinary plate was made, then a special obturator to correct the palatine defect. With the obturator in positiona model of the remaining hollow was taken, and from this a silver plate was struck, which filled accurately into the hollow and under the right ala of the nose; a small tongue of silver was adjusted over the bridge of the nose, and on to this the spectacles were subsequently soldered. An artificial cheek and eye were then modeled in wax to match the other side of the face. A second silver plate was struck upon a metal cast taken from the model, soldered to the inner plate as a cover is fixed to a box. An artificial eye was then fixed to the plate in the proper situation, and the face portion painted flesh-color and japanned. In order to keep the mask in position, a strong wire, fixed to the posterior edge of the artificial cheek, passes around the right ear, and the ear pieces of the spectacles are joined behind the head by an elastic band.”
Fig. 283.—Circulation of the Head.A, Supra-Orbital Vein.B, Supra Palpebral Vein.C, Angular Vein.D, Nasal Vein.E, Facial Vein.F, Temporal Vein.G, Ext.-Jugular Vein.H, Post-Auricular Vein.I, Occipital Vein.J, Post-Ext.-Jugular Vein.K, Sup. Labial Vein.L, Inf. Labial Vein.M, Transverse Facial Vein.N, Communicating Br. Ophtal Vein.O, Angular Artery.P, Ant. Temporal Artery.Q, Post Temporal Artery.R, Sup. Coronary Artery.
Fig. 283.—Circulation of the Head.A, Supra-Orbital Vein.B, Supra Palpebral Vein.C, Angular Vein.D, Nasal Vein.E, Facial Vein.F, Temporal Vein.G, Ext.-Jugular Vein.H, Post-Auricular Vein.I, Occipital Vein.J, Post-Ext.-Jugular Vein.K, Sup. Labial Vein.L, Inf. Labial Vein.M, Transverse Facial Vein.N, Communicating Br. Ophtal Vein.O, Angular Artery.P, Ant. Temporal Artery.Q, Post Temporal Artery.R, Sup. Coronary Artery.
Fig. 283.—Circulation of the Head.