Fig. 202.—Buck Method.
Fig. 202.—Buck Method.
Fig. 202.—Buck Method.
Estlander-Abbé Method.—Estlander and Abbé employed a transplantation flap of triangular form taken from the lower lip to restore median defects of the upper lip, whether due to a deficiency of the latter following harelip operation or the extirpation of a malignant growth.
Where the tissues operated upon warrant such procedure this operation will give excellent results, leaving the mouth almost normal in shape and size.
The lower pedunculated flap is made by cutting directly through the entire thickness of the lip, including the prolabium atA(Fig. 203), and downward toward the median line to the pointB, thence upward to the margin of the vermilion border atG, leaving the latter to form the pedicle of the flapF. The defect is freshened by either a median incision,D,E, or the ablation is made in triangular form.
The flapFis now rotated upward and sutured into the upper lip, as shown inFig. 204. The triangular defect thus made in the lower lip is sutured along the median line.
The prolabial pedicle of the flapFis not divided until about the eighth day, when the vermilion borders of both the upper and lower lips are restored by the aid of the free stump ends, which are neatly sutured into position, as shown inFig. 205.
Fig. 203.Fig. 204.Fig. 205.Estlander Method.
Fig. 203.Fig. 204.Fig. 205.Estlander Method.
Fig. 203.Fig. 204.Fig. 205.
Estlander Method.
This operation may also be used in the unilateral type of defect. It will be described in the operation of the lower lip, where it is more frequently employed than in connection with faults of the upper lip.
Apart from harelip operation, those for the separation of the lower lip are the most common about the mouth. This is due in a great measure to the fact that malignant growths so frequently attack this part of the human economy and almost exclusively in the male. Out of sixty-one cases von Winiwarter found only one female thus affected. It has not been determined whether the habit of pipe smoking has been a factor in establishing this unequal proportion, yet it is acceded to be the fact, so much so that neoplasms of the lip in men have been commonly termed smoker’s cancer.
The ulcerative forms of syphilis and tuberculosis seem to be met with more in the lower than in the upper lip; likewise is this true of burns and acute traumatisms.
Defects in the lower lip are, therefore, due principally to the extirpation of carcinomata or other malignant growths and less frequently to the other causes mentioned.
The classification and extent of such involvement has already been referred to.
In operations intended to extirpate a growth of malignant nature the incisions should be made sufficiently distant from the neoplasm to insure of unaffected or uninvolved tissue to avoid a recurrence of the disease.
These growths appear at first in wartlike formation,becoming thicker in time, and bleeding readily upon interference. They seem to develop horizontally, and invariably in a direction toward the angle of the mouth. There is more or less involvement of the lymphatic glands, especially of the submaxillary, quite early in the attack.
An early extirpation of such growths is to be recommended, and while it is true there may be a question of primary syphilitic induration instead of the malignant variety no harm is done if the diseased area be at once excised.
This is especially true of patients beyond the thirtieth year. When such indurations occur before that age the patient may be put under a proper course of treatment to determine the nature of the infiltration for a period of three or four weeks; if this does not resolve it operative measures should be resorted to. It is to be remembered that syphilitic induration may involve the upper as frequently as the lower lip, a fact not as likely referable to cancer.
In sixty-seven cases reported from Billroth’s Clinic there were sixty-five cases of carcinoma of the lower lip and only two of the upper. Yet this proportion hardly applies to the experience of most surgeons. The age factor is not to be overlooked.
The author does not mean to claim that the differential diagnosis of these diseases is at all difficult, yet in patients beyond the admissible age early and radical treatment should not be neglected, considering what great amount of misery and suffering, not to mention disfigurement, can be overcome by prompt action.
Usually these neoplasms, when superficial, are found directly in the prolabium, are unilateral, and occupy a place midway between the angle of the mouth and the median line of the lip.
Richerand Method.—Very small or superficial neoplasms may be removed by lifting up the growth with a fixation forceps and cutting away the convexity so established asdeeply as necessary with the half-round scissors, or the faulty area is neatly outlined in spindle form (Richerand) with the bistoury, as inFig. 206, and then excised according to the method selected by the operator.
The wound is sutured horizontally, as shown inFig. 207.
Fig. 206.Fig. 207.Richerand Method.
Fig. 206.Fig. 207.Richerand Method.
Fig. 206.Fig. 207.
Richerand Method.
If the neoplasm or defect is of a more extensive form, involving most or all of the prolabium, the entire area, including the necessary allowance of healthy structure, may be raised up by a clamp, as shown inFig. 208, and excised. The mucous membrane from the anterior surface of the lip is then brought forward and sutured to the skin margin, as inFig. 209. The disfigurement in this operation is surprisingly little, and the mucous membrane thus everted takes on the appearance of the vermilion border of the lip in a short time.
Fig. 208.Fig. 209.Extirpation of Entire Vermilion Border.
Fig. 208.Fig. 209.Extirpation of Entire Vermilion Border.
Fig. 208.Fig. 209.
Extirpation of Entire Vermilion Border.
Celsus Method.—When the neoplasm has become more than superficial, or the defect or deformity involves more than the prolabium, it must be ablated by a wedge-shaped incision, the base upward including the vermilion borderand the apex extending downward upon the anterior chin.
This is best performed by piercing the tissue with a sharp bistoury, the blade penetrating the mucosa, while an assistant compresses the coronary vessels with his fingers at either angle of the mouth.
The incision must be made well into the healthy tissue, or at least 1 cm. from the boundary of the defect. The incision is made, as outlined inFig. 210, from below upward while the operator draws up the triangular mass to be removed with the fingers of his left hand. The same method is followed on the other side. The wound margins are then to be examined microscopically for any sign of malignant involvement. If there be any it should at once be removed, irrespective of the size of the wound occasioned thereby. For this reason the area excised may be so large as to prevent the ready apposition of the raw edges. Should this occur, the lip halves may be made more mobile by adding a horizontal incision continuous from the angle of the mouth outward and over the cheek, as shown in the lineA,C.
A single incision for a unilateral defect and one on either side for a median excision, as shown by the linesA,C, andB,C, in the same figure.
This operation is known as the Celsus method. The parts are brought together and the sutures placed as inFig. 211, beginning the first deeply and nearly to the mucous membrane, just below the prolabial margin,which controls the bleeding. One or two of the sutures should be made deeply to overcome the tension of the parts as far as possible.
A few fine stitches are taken in the vermilion part of the lip and several in the mucous membrane to permit of close apposition and to insure primary union. Wounds of the lips heal very well, and the defects occasioned by even extension operations which involve as much as one half of the lip soon lose their acute hideous appearance.
Fig. 210.Fig. 211.Celsus Method with Additional Horizontal Incisions.
Fig. 210.Fig. 211.Celsus Method with Additional Horizontal Incisions.
Fig. 210.Fig. 211.
Celsus Method with Additional Horizontal Incisions.
Estlander Method.—Estlander corrects a unilateral defect by excising the neoplasm in triangular fashion, and cutting out a triangular flap from the upper and outer third of the upper lip, leaving, however, the prolabium intact, which answers for the pedicle (seeFig. 212).
This triangular flap is rotated downward, and is sutured into the opening in the lower lip, as shown inFig. 213.
Where this method can be employed it does very well, as it overcomes the secondary defect so common with most of these operations, while a small operation may be undertaken later to correct the mouth formation if necessary.
Fig. 212.Fig. 213.Estlander Method.
Fig. 212.Fig. 213.Estlander Method.
Fig. 212.Fig. 213.
Estlander Method.
Bruns Method.—Bruns removes the defect in quadrilateral form when the disease involves one half or more ofthe lower lip, as shown inFig. 214. He encircles the mouth by two curved incisions to aid in mobilizing the edges of the wound, which he sutures, as shown inFig. 215, leaving two crescentic wounds at either side of the mouth, which are allowed to heal by granulation.
Fig. 214.Fig. 215.Bruns Method.
Fig. 214.Fig. 215.Bruns Method.
Fig. 214.Fig. 215.
Bruns Method.
Buck Method.—Buck has corrected a unilateral defect by employing the wedge-shaped incision, as shown byB,C,DinFig. 216. After removing the triangular infected area he detaches the remaining half of the lip from the jaw as low down as its inferior border and as far back as the last molar tooth. A division of the buccal mucous membrane along the same line more readily permits of sliding the remains of the lip over to meet the raw surface opposite.
If the latter was not possible he obtained additional tissue by making a transverse incision from the angle of the mouth across the cheek to the pointA, or within a fingers breadth of the muscle. A second incision is made downward fromAand a little forward to the pointE. This quadrilateral flap thus formed, with its upper half lined with mucous membrane is dissected up from the jaw except at its lower extremity. It is glided forward edgewise to meet the remaining half of the lip, where it is sutured into place, as shown inFig. 217.
To cover the triangular raw space occasioned by the sliding forward of the flapA,B,C,E, another transverse incision is made through the skin continuing the lineA,D,Fig. 217, to the extent of one inch. The skin is then dissected up as far as this incision will allow and is stretched forward until the edge meets the outer skin margin of the quadrilateral flap, to which it is sutured. A later operation for the restoration of the mouth has to be made.
Fig. 216.Fig. 217.Buck Method.
Fig. 216.Fig. 217.Buck Method.
Fig. 216.Fig. 217.
Buck Method.
Dieffenbach Method.—Dieffenbach’s method is very similar to the above, but is applicable only to cases where the entire lower lip is involved and is extirpated (seeFig. 218). The wound is sutured as inFig. 219. The secondary wounds are either sutured as in Buck’s method or they are covered immediately by Thiersch grafts (author’s method).
Dieffenbach allowed these secondary wounds to heal by granulation.
Fig. 218.Fig. 219.Dieffenbach Method.
Fig. 218.Fig. 219.Dieffenbach Method.
Fig. 218.Fig. 219.
Dieffenbach Method.
Jäsche Method.—Jäsche’s method is to be preferred to that of the foregoing author. After a cuneiform excision of the defect he adds two curved incisions extending downward at either side to insure mobility of the parts, as shown inFig. 220.
In bringing the wound together, as shown inFig. 221, he overcomes the large secondary defects of the operation last considered by suturing the skin margins.
Fig. 220.Fig. 221.Jäsche Method.
Fig. 220.Fig. 221.Jäsche Method.
Fig. 220.Fig. 221.
Jäsche Method.
Trendelenburg Method.—Trendelenburg has modified the method of Jäsche by shortening the curve of the cheek incisions so that their outer borders were made to lie anterior to the facial artery (seeFig. 222), theparts being approximated and sutured, as shown inFig. 223.
To obtain sufficient mucous membrane to cover the superior margin of the two flaps when brought together he made the cheek incision only down to the mucosa, dissected up the latter a short distance from the upper part of the cheek, and divided it about one half centimetre above the line of the external incision. This flap of mucous membrane on either side was used to line the lip in place of the prolabium.
Fig. 222.Fig. 223.Trendelenburg Method.
Fig. 222.Fig. 223.Trendelenburg Method.
Fig. 222.Fig. 223.
Trendelenburg Method.
Bruns Method.—Bruns excises the defect when not involving the whole lip in quadrilateral form, and takes up a flap from the anterior region of the chin to cover it, as shown inFig. 224.
This flap is rotated upward into the wound made, and is sutured in place, as shown inFig. 225. The secondary wound is brought together by suture.
Fig. 224.Fig. 225.Bruns Method.
Fig. 224.Fig. 225.Bruns Method.
Fig. 224.Fig. 225.
Bruns Method.
In cases where the entire lip is removed he cuts twosquare flaps from the upper anterior region of the cheeks extending as far upward as the alæ of the nose (seeFig. 226).
He rotates these flaps into the open wounds and sutures them into place, as shown inFig. 227.
The border of the lip is lined with the mucous membrane of the cheek flaps then brought down. If the latter has become too stretched longitudinally, he relieves it at its base by transverse incisions.
Fig. 226.Fig. 227.Bruns Bilateral Method.
Fig. 226.Fig. 227.Bruns Bilateral Method.
Fig. 226.Fig. 227.
Bruns Bilateral Method.
Buchanan Method.—Buchanan’s method consists of removing the diseased area by an elliptical incisionA,B,A. A second oblique incisionB,C, and a third of the same obliquityB,C, is made downward and outward upon the anterior chin. From the pointsC,C, two curved incisions parallel to the upper incisionA,B,A, and equal to their lengths, are made to the pointsD,D, as shown inFig. 228.
The latter incisions provide two flaps, as shown inFig. 229. They are dissected off from their attachment to the lower jaw and raised upward so that their upper lineBis raised on a level with the former margin of the lipA,A.
The oblique marginsC,B,Care thus brought together vertically and sutured in the median line. The mucous membrane is brought from within outward and stitched to the skin margin.
The operation leaves two triangular wounds, whichare to be healed by granulation. The result of the rotation and apposition of the flaps is shown inFig. 230.
Fig. 228.Fig. 229.Fig. 230.Buchanan Method.
Fig. 228.Fig. 229.Fig. 230.Buchanan Method.
Fig. 228.Fig. 229.Fig. 230.
Buchanan Method.
Syme Method.—Syme removes the affected area in triangular fashion, and from the apex of the wounds carries two curved and sweeping incisions downward from the anterior chin and beneath, terminating at the angles of the jaw (seeFig. 231).
These two large flaps are dissected from their attachment to the jaw and are slid upward until the sides of the triangular wound are raised to a horizontal line corresponding to the superior border of the lower lip, when the flaps are sutured vertically upon the anterior chin and to the triangular island of undisturbed tissue underneath the chin, as shown inFig. 232.
The advantage of this operation is that no secondary wounds are left to granulate, the whole healing by primary union.
Fig. 231.Fig. 232.Syme Method.
Fig. 231.Fig. 232.Syme Method.
Fig. 231.Fig. 232.
Syme Method.
Blasius Method.—The method of Blasius is very similar to the foregoing, except that this author does not carry his two curved incisions as far downward and backward (seeFig. 233).
The two semilunar flaps are made from the tissue ofthe anterior chin and slid upward, and sutured in the median line and to the intermedian spur of undisturbed tissue, as inFig. 234.
Fig. 233.Fig. 234.Blasius Method.
Fig. 233.Fig. 234.Blasius Method.
Fig. 233.Fig. 234.
Blasius Method.
Bürow Method.—Bürow, who favors the excisions of two triangles of healthy tissue in restoring an entire loss of the lower lip, proceeds by ablating the diseased area in triangular form. From the angles of the mouth he cuts two transverse incisions, upon which he outlines two triangles, as inFig. 235.
The tissue included in these triangles is removed entirely, an unnecessary loss and one unwarrantable, but he saves the mucosa of these excised portions with which he lines the upper margin of the newly formed lip.
The freed lateral chin flaps he slides forward so that their oblique borders meet vertically in the median line, where they are sutured.
The triangular wounds in the cheeks are by this sliding process obliterated, and their raw edges are sutured vertically, as shown inFig. 236.
Fig. 235.Fig. 236.Bürow Method.
Fig. 235.Fig. 236.Bürow Method.
Fig. 235.Fig. 236.
Bürow Method.
Von Langenbeck Method.—Von Langenbeck, contrary to the double-flap methods, uses only one flap, with a lateral pedicle from the anterior chin.
After a semilunar excision of the diseased area, he cuts obliquely downward upon the anterior chin, then rounds his incision and continues it along, just above the margin of the chin, gradually cutting upward until its extremity is obliquely opposite to the angle of the mouth, as inFig. 237.
The flap thus formed will be seen to have a pedicle at this point. It is dissected away from its mucous attachment and is rotated upward, jumping it over the triangular spur, which has also been mobilized by a sliding dissection.
The flap is sutured into position, as shown inFig. 238. Unfortunately, the flap does not permit of lining the raw margin of the wound with mucous membrane turned outward from within, hence it is best to take sufficient of the mucous membrane from the cheeks to accomplish this, or the vermilion border of the upper lip may be carefully cut away from the lip at its outer sections just above the prolabial line, and elongated by stretching upon the raw surface of the under lip, to which it is sutured.
Fig. 237.Fig. 238.Von Langenbeck Method.
Fig. 237.Fig. 238.Von Langenbeck Method.
Fig. 237.Fig. 238.
Von Langenbeck Method.
Morgan Method.—For an extensive loss of the lower lip Morgan operates in the following manner:
After a thorough elliptical extirpation of the diseased area, he makes a curved incision in the tissue under the chin, conforming in its curvature to the incision made below the diseased area of the lip (seeFig. 239). The length of this incision is about twelve centimeters.
This bridging flap is carefully dissected up from its basement membrane. Any infected glandular tissue encountered in the meantime is removed thoroughly.
The whole bridge of tissue is now crowded upward, until it displaces the defect in the lip. It is sutured on either side, as shown inFig. 240, to hold it in position.
Several sutures are introduced along its inferior margin, to tie it to the tissue of the anterior jaw border and to prevent its sliding downward.
Strips of borated gauze are laid into the fold between the raw surface of the flap and the jaw.
The secondary elliptical submental wound is drawn together by suture as far as possible; the remaining raw surface is either allowed to heal by granulation or is covered immediately with Thiersch grafts (Wölfler, Regnier).
The objection experienced with the method just considered is found in the difficulty with which the bridgeflap is carried upward over the prominence of the jawbone. It is very essential, therefore, to give as much freeness to this flap as possible, a fact necessitating considerable injury to the flap by handling and cutting, although the result of the operation, if carefully done, is excellent; the lip, owing to its solid form and undisturbed mucous membrane, does not contract as readily as with the average lip operation, and consequent ectropion is overcome to a great extent.
Fig. 239.Fig. 240.Morgan Method.
Fig. 239.Fig. 240.Morgan Method.
Fig. 239.Fig. 240.
Morgan Method.
Zeis Method.—To overcome the difficulty of sliding this bridgelike flap, Zeis advocates ablating the diseased area in quadrilateral form and forming the lip of unbroken tissue by making the flap two-tailed (seeFig. 241), each flap meeting anteriorly in a bridge of tissue sufficiently wide to permit of the formation of the required lower lip and extending obliquely downward and backward upon the submental surface, having their pedicles as far back and upon the neck as is necessary to allow the two-tailed flap to move forward into position.
The parts are slid into position and sutured, as shown inFig. 242.
Unfortunately the tissue of the neck is not very thick, nor is it well nourished, factors that do not make it very satisfactory for cheiloplastic purposes.
Fig. 241.Fig. 242.Zeis Method.
Fig. 241.Fig. 242.Zeis Method.
Fig. 241.Fig. 242.
Zeis Method.
Delpech Method.—Delpech has utilized the skin of the anterior neck region in the following manner: He ablates the extensive diseased area, as shown inFig. 243, and dissects up an inverted triangular pedunculated flap ofskin from the hyoidean region of the neck, having its raw surfaces brought face to face at its distal extremity sufficiently to line the newly formed lip with skin which eventually would take on the function of mucous membrane.
The whole flap was now rotated upward on an arc of 180° and sutured into the labial defect, as shown inFig. 244.
The large wound of the neck was readily drawn together by suture, leaving only a small triangular space to heal by granulation.
As has been mentioned, the skin of the neck is not adaptable for this purpose, not only because of its poor nourishment and extreme thinness, but because a flap made therefrom is devoid of muscular structure, contracts easily, and is devoid of a mucous-membrane prolabium, the greatest objection being in the resultant contraction of the lip so formed, which usually constitutes so high a degree of ectropion of the lip as to allow the saliva to escape from the mouth.
Apart from the ingenuity of the method it has no practical value, for the reasons given.
Fig. 243.Fig. 244.Delpech Method.
Fig. 243.Fig. 244.Delpech Method.
Fig. 243.Fig. 244.
Delpech Method.
Larger Method.—Larger restores two thirds of the lower lip after the ablation of an epithelioma, as follows:
1. An incision is made from the union of the left thirdwith the right two thirds of the upper lip, directed toward the alæ of the nose and including the entire thickness of the lip, thecul-de-sac, and the buccal mucous membrane.
2. A second incision is made from the upper extremity of the first incision downward from the nasolabial fold to a point on the cheek a little below and to the left of the left labial commissure. The flap being turned down, is sutured by its three edges to the lip of the quadrangular breach, after the lower edges of the flap has been freshened; this border being formed by the mucous membrane of the upper lip, the membrane is destroyed in order to permit of the edge being sutured to the horizontal branch of the loss of substance. The upper lip is then sutured vertically to the cheek.
Guinard Method.—Guinard modifies the above method by making the operation bilateral and symmetrical instead of unilateral, thus giving marked facial symmetry; the mucous membrane forming the free edge of the upper lip, instead of being destroyed, is dissected, turned over, and is sutured in a groove in front of the maxillary in such a way as to reconstitute the buccal vestibule; the mucous membrane of the deep surface of the lip is sutured to the skin by eversion in order to form a new mucous border.
With the above modification of the Larger method a considerable loss of substance can be restored, the new lip being constructed of normal tissue of the lip lined with mucous membrane retaining the saliva. Naturally the secondary deformity, while great, is one that only changes the physiognomy, leaving the face symmetrical with slight cicatrices.
Berger Method.—Berger advocates replacing a large loss of skin from the lower lip, the result of burns, lupus, or syphilitic ulceration, by employing a pedunculated flap made from the arm.
The free borders of the flap are sutured into thedefect and the arm is bandaged to the head in the proper position. The pedicle on the arm is not divided until the flap has become thoroughly reunited, which is at the end of eight to twelve days.
He dissects up and divides the free border of the mucosa until it is free from its attachments to fibers of the orbicularis muscle. This he utilizes in lining the flap.
The flap taken from the arm may be made large enough to cover the entire anterior aspect of the chin.
When the mucosa has been destroyed partially he advises releasing whatever remains of the mucous membrane, either as it may be, and loosening it so as to inclose the buccal orifice. He slides a flap taken from the subhyoid region to reconstruct the lip over this, or resorts to the Italian method just described.
Where the lip structure has become flattened and thinned as a result of tension following the exsection of a part of the lip, as in harelip, or the ablation of malignant growths, operations may be undertaken to give the tissue a better cosmetic appearance.
Estlander’s operation, described on page 171, gives, perhaps, the best results in these cases, but the objection to this procedure to make up the deficiency in the other, and often necessitating a later stomatoplasty to overcome the oval shortening occasioned by the rearrangement of the prolabium. This, of course, is a matter of little consequence where the primary fault is due to the ulcerative inroads of syphilis or the cicatricial contraction following burns. At any rate, the triangular flap implantation method is to be preferred to any other cutting procedure.
In simple cases where a triangular ablation has caused the flattening the defect can be overcome to agreat extent by employing the subcutaneous method of Gersuny.
Author’s Method.—The author recommends a subcutaneous division of the scar line in cases permitting such procedure prior to the injection of the tissues. This is accomplished with a fine tenotome, which requires only the making of a small opening in the skin through which the filling can be introduced. A single suture may be made through the lips of the wound, which is tied immediately after the filling has been introduced to avoid the displacement or pressing out of the injected mass at this point, which is sure to result if the suture be introduced after the injection.
A secondary filling may be found to be necessary subsequently to obtain the desired cosmetic result. The process of subcutaneous filling is fully considered in Chapter XIV.
When the lower lip is extremely flattened by the tension of cicatricial contraction of burn wounds of the mental region with more or less ectropion of the lip.
Teale Method.—Teale advocates the following method:
Two cheek flaps are formed by making a curved outward and upward incision upon either cheek, terminating at the second molar tooth of the upper jaw and corresponding to the linesA,A, inFig. 245. These terminate anteriorly in two vertical incisions about three quarters of an inch long, made through the entire lip structure down to the bone on a line with the canine teeth.
The upper extremity of the two vertical incisions are united with a horizontal incision through the thinned-out or everted prolabium.
The two cheek flaps are dissected off from the bone, the mucous membrane uniting them to the alocoli being freely divided.
A base surface is made along the alocolar border of the median portion of the lip between the upper extremities of the two vertical incisions first made.
The flapsA,Aare then brought together so that their vertical margins meet at the median line, where they are sutured. A few fine sutures are taken through the vermilion border.
A secondary wound,C,C, at either side is thus occasioned (Fig. 246), which can at once be covered with Thiersch grafts or is allowed to heal by granulation.
Fig. 245.Fig. 246.Teale Method.
Fig. 245.Fig. 246.Teale Method.
Fig. 245.Fig. 246.
Teale Method.
Where the deficiency is due to cicatricial contractions of the submental tissue the latter must be divided horizontally from one healthy border to the other, the parts freed well from all subcutaneous adhesions in the cellular structure. The head should be forcibly raised and a flap of skin be placed into the elliptical wound thus formed either by the rotation of a pedunculated neck or thorax skin flap or the implantation of Wölfler or Thiersch grafts.
Carefully keeping the head in an extended position during the healing in of these grafts will overcome the primary defect, unless the lip itself, too, has become tied down, when the bridge flap method of Morgan or Zeis can be undertaken in conjunction with the skin-grafting method to correct the fault.
Eversion of the lip may be due to cicatricial contraction of ulcerative wounds, burns, and traumatisms of the skin, or it may be hereditary. In the latter case theentire lip structure is more or less overdeveloped, as in the negro, especially in the lower lip, so that the thickened lip droops forward and downward. This condition is termed macrocheila.
Ectropion of the lower lip is more common than in the upper lip. The defect may be slight and only of cosmetic importance or it may be so extensive as to permit an overflow of the saliva from the mouth.
When the cause of deformity is due to a cicatrix of the skin, as often met with in the lower lip, a flap should be neatly raised by a V incision, as with ectropium of the lower lid on page 104, and the wound sewed in the Y form (Dieffenbach).
In cases of severer form the cicatrix is removed by an elliptical incision, the lip returned to its natural position, and a pedunculated flap of skin is taken up from the chin or the cheek which is rotated into the wound, or a skin graft is implanted into the area by the Wölfler method and sutured to the free margins of the skin, or the Thiersch method may be employed.
In hereditary cases of mild form or partial ectropion the author advocates making two vertical incisions in the mucous membrane, half an inch long, one half inch distant from the median line of the lip, and suturing them horizontally, as shown inFigs. 247 and 248.
Fig. 247.Fig. 248.Author’s Method.
Fig. 247.Fig. 248.Author’s Method.
Fig. 247.Fig. 248.
Author’s Method.
In some cases the ectropion, whether partial or more or less general, is caused by protrusion of the teeth either of the upper or lower jaw; more commonly of the alveolar structure of the superior maxillary bone. In such cases a cosmetic operation on the mucosa will dolittle to restore the deformity. Such cases should be corrected primarily by a surgeon dentist, the teeth being forced back into place by proper metal springs or splints—a tedious process requiring from six months to two years’ time.
If, after the teeth have been brought back to the normal bite, the lip still shows an abnormal contour, the surgeon may restore this by several small incisions in the mucosa, as above advised, at the various protruding points of the lip.
When the simple vertical-line incisions sutured horizontally will not accomplish the result, the excision of small triangles or elliptical pieces of the mucosa may be made, bringing the distal edges of the wounds together horizontally with silk sutures, which are found best for suturing wounds about the buccal cavity.
The same methods as above given apply to the correction of upper-lip deformities.
Where the fault is too great to be overcome by this method, the author advocates removing an elliptical or diamond-shaped piece of the lip from the inner surface or mucosa, the whole length of the lip and wide enough to correct the fault, as shown inFig. 249, and bringing together the margins by an interrupted suture, as inFig. 250. This is the most satisfactory method to restoreeither the upper or lower lip to normal position. The resulting cicatrix of the mucous membrane offers no objection whatever, and soon becomes obliterated.