CHAPTER XIISTOMATOPLASTY(Surgery of the Mouth)
This branch of surgery has to do with the plastic restoration of the oral orifice. Operations of this kind are required to enlarge a contracted mouth, termed microstoma, whether the same be due to congenital origin or to cicatricial contraction after operative interference about this origin.
Stomatoplasty may also be needed to rebuild an abnormally enlarged mouth, termed macrostoma, which has already been described on page 149.
The operative methods to correct the latter need little mention, since there is usually sufficient tissue present from which the orifice can be properly formed.
The simplest method is to excise the borders of the enlarged mouth or buccal clefts, whether unilateral or bilateral, and to bring the raw edges together by suture. These sutures should be made nearly through the muscular walls of the cheek and at sufficient distance from the edges of the wounds to avoid tearing through.
When the cleft is of sufficient length to warrant tension sutures, they may be employed, alternating with superficial sutures to neatly coapt the skin surfaces.
The mucous membrane should also be sutured with fine silk to insure a perfect closure of the parts, and to avoid, as far as possible, intra-oral infection.
When possible the vermilion borders of the lips should be neatly brought out to the angles of the mouth, where they should be sutured one to the other somewhat diagonally. This will tend to give the angles a normal appearance and shape.
Dieffenbach-Von Langenbeck Method.—It is not unusual after the extirpation of a malignant growth that a greater part of the prolabium has been sacrificed in either of the lips. In this event the vermilion border must be carefully and neatly trimmed away from the healthy lip, leaving a median attachment (seeFig. 251).
The two strips of prolabium will be found to stretch easily. They are utilized to line the entire denuded raw surface and are held in position by a number of fine silk sutures, as shown inFig. 252.
Fig. 251.Fig. 252.Dieffenbach-Von Langenbeck Method.
Fig. 251.Fig. 252.Dieffenbach-Von Langenbeck Method.
Fig. 251.Fig. 252.
Dieffenbach-Von Langenbeck Method.
Accessory mobilizing incisions, as shown in the above figures, may be necessary to contract the oral orifice sufficiently to permit of such a prolabial grafting, especially where a greater part of the vermilion border has been destroyed. These extra incisions are not necessary when only a small part of the latter is lost; a partial unilateral dissection in that case would suffice to restore the part.
This prolabial lining of the mouth gives it a puckered and contracted appearance for a time only, because theparts soon stretch, while oral gymnastics will help much in restoring its size and usefulness.
The objection to the above method is the danger of partial or total gangrene of that part of the prolabium which has been dissected up and stitched to line the mouth as a result of lack of nutrition or to the bruising or rough handling of the delicate strips during the operation.
Tripier Method.—Tripier refashions the prolabium of the mouth by means of a mucous strip taken from the inner surface of the lip. This strip is left attached at both ends, forming a bridge flap of mucous membrane, the pedicles of the ends giving nourishment to the whole. The bridging strip is slipped into place and is sutured to the outer skin by its superior border, so as to restore the normal appearance and thickness of the lip.
Antisepsis must be carried out scrupulously and a strip of iodoform gauze be placed between the lips operated upon and the gum. In forty-six cases operated upon by this method forty-two were successful, while in two of the unsuccessful cases there was partial gangrene of the flap.
Macrostoma and Overdevelopment of the Lips.—In the cosmetic correction of macrostoma there may be an overdevelopment of one or both lips as well as the wide oral fissure. In such cases the lip structures is to be reduced by the methods heretofore given, before shortening of the mouth line is undertaken, because of the greater freedom allowed the surgeon to correct the deformity.
If possible the operation at the oral angles above referred to should be avoided because of a certain amount of scarring of the skin at either side of the mouth and the resultant stiffness of the parts due to the surgical interference; therefore, when practicable, or when the deformity is of moderate extent, the angles of the mouth should be advanced toward the median vertical of the lips. In such case it is best to do suchoperations before any labial corrections are undertaken.
Author’s Method.—The method advised by the author is the employment of the Dieffenbach procedure as follows:
A V-shaped incision, its apex pointing inward and its distal ends a half inch from the prolabial line, is made quite deep through the mucosa and muscular tissue, as shown inFig. 253. The part included in the V is now drawn toward the median line of the lip, causing the wound to gape. The latter is then sutured with deep and superficial silk sutures in the form of a Y, as shown inFig. 254. The same operation is repeated at the other angle of the mouth.
Fig. 253.Fig. 254.Author’s Method.
Fig. 253.Fig. 254.Author’s Method.
Fig. 253.Fig. 254.
Author’s Method.
When the oral orifice has become lessened, as is frequently the result of cicatricial contraction following ulcerations or operative interference, but which may, too, occur congenitally, the condition is termed microstoma.
Dieffenbach Method.—Dieffenbach advocates the following operation for the correction of this abnormality:
Two lateral incisions are made outward from the mouth across the cheeks and through their entire thickness, extending in length a little beyond the intended angle of the mouth (seeFig. 255). The mucous membrane from within is brought forward and is sutured superiorly and inferiorly to the skin with fine silk sutures.
If there be any difficulty experienced in accomplishing this, owing to the presence of cicatricial thickening of the parts, the latter must be excised in gutterlike fashion (author), and the mucous membrane be freed from its attachment until it comes into place readily.
Care should be especially exercised in lining the angles of the newly formed mouth.
The subsequent contraction of the rima oris following the above operation is prevented only by lining the angle with mucous membrane, healing into place by first intention.
Fig. 255.Fig. 256.Dieffenbach Method.
Fig. 255.Fig. 256.Dieffenbach Method.
Fig. 255.Fig. 256.
Dieffenbach Method.
Rose Method.—Rose advises sewing a small triangular flap of mucous membrane into each angle to overcome the contraction.
Heuter Method.—Heuter employs an artificial mouth of hard rubber tubing of a size corresponding to the new mouth made in the form shown inFig. 257.
This ring is forced into the oral opening and the patient is instructed to wear it for some weeks after the operation or until the tissues have become softened and elongated and will no longer retain it.
Fig. 257.—Artificial Mouth.(Heuter.)
Fig. 257.—Artificial Mouth.(Heuter.)
Fig. 257.—Artificial Mouth.(Heuter.)
Nonoperative Treatment.—Smaller operations about the mucosa alone are of no avail to correct this deformity, but where the contraction of the oral orifice is moderate and of recent origin, exercising the mouth and stretching the angles forcibly may help to overcome the deformityto a great extent. Smaller deformities due to contraction usually subside after a time from the normal use of the mouth.
The hypodermic injection of a solution of thiosanimin or fibrolysin (Mendel) are of import in cases where an operation cannot be undertaken. Their use is more fully described in a later chapter.