B

The Scar Solution Natural Scar Removal

The Scar Solution Ebook By Sean Lowry

Get Instant Access

Figure 6 (A) Large defect of left central region of upper lip. (B) Typical rotation/advancement flap with some early local distortions apparent. (C) Result at about one year after tissues have settled. Very slight asymmetries still present, but acceptable for this case. This flap is easier to use when defect involves more lateral portion of upper lip.

Figure 6 (A) Large defect of left central region of upper lip. (B) Typical rotation/advancement flap with some early local distortions apparent. (C) Result at about one year after tissues have settled. Very slight asymmetries still present, but acceptable for this case. This flap is easier to use when defect involves more lateral portion of upper lip.

Figure 7 (A) Typical forward advancement of labial buccal mucosa after conservative undermining. (B) Immediate postoperative result. (C) Different patient who has had extended flap dissection and now shows later effect of contraction, causing anterior vermilion margin to be pulled back to a less favorable position.

Figure 7 (A) Typical forward advancement of labial buccal mucosa after conservative undermining. (B) Immediate postoperative result. (C) Different patient who has had extended flap dissection and now shows later effect of contraction, causing anterior vermilion margin to be pulled back to a less favorable position.

two pedicles, one made separately at both ends, similar to the "handle" of a bucket (1,3). The anterior margin for this type of flap design is typically made immediately posterior the posterior vermilion line so that it does not produce a visible donor site scar. This type of flap can be designed relatively long and narrow because the labial artery is incorporated into the pedicle. Division of the pedicle(s) can be done safely at about three weeks. While this method of vermilion repair is more complicated than the simple mucosal advancement flap, it can include some muscle and provide a thicker unit of soft tissue when necessary. The single pedicled design can be particularly helpful when there is need to fill a more focal or "notch-like" vermilion defect (3).

Mucosal tissue can also be transferred from the tongue in a similar two-staged manner. A variety of pedicled designs are possible to accomodate to various defect situations (3,6,7). The papillated surface of glossal mucosa and the inherent awkwardness of even temporarily limiting tongue mobility make this a less desirable choice for vermilion restoration. Care must be taken to avoid impairment to speech articulation.

Buccal mucosa may be transferred as a free graft for vermilion restoration. Proper immobilization of the graft can be awkward and graft take is not always certain. When the situation is more complicated, it is acceptable to make use of a skin graft or extended portion of a cutaneous flap to provide at least initial coverage over the free margin of the lip. Replacement with some form of mucosal tissue could be then done later and with greater precision if desired.

LIP REPAIR TECHNIQUES Technique

The V-lip procedure is designed as a triangle with two lines of incision, one on each side of a given unit of tissue that is to be excised, and the base portion being the free margin of the lip (Fig. 8A and B). The two lines of incision are angled in opposing fashion so that they meet at some distance away from the lip margin. Design for a V-lip excision and closure should be done with attempt to be as compatible as possible with the relaxed skin tension lines normal to that particular region of the lip (3). The classic V design is appropriate for excision and repair involving the central region of either lip, while a slanted V or "hound's tooth" design is more appropriate in situations involving lateral regions of the lip (Fig. 9A and B). The line of closure should be planned so that a line passing from the center of the vermilion portion of the defect to the apex of the V should match that of the relaxed skin tension line for that same location on the lip.

For cosmesis, it is ideal if the apex of a V design can be kept confined within the lip and not extend beyond either the melolabial or mental crease. With excision of bulky tumors it can sometimes be awkward to design a V comfortably around the lesion and stay confined within the lip. In these cases the V design may be modified to a W shape, in which the lateral members of the excision design do not converge so acutely (Fig. 10A). The two angles of the W should be slanted and often of varied size when excision involves more lateral regions of the lip, again with attempt to make the lines of repair as compatible as possible with the natural relaxed skin tension lines of the lip.

Closure of any full-thickness defect of the lip is best done in at least four layers: mucosa (or submucosa), muscle, subcutaneous tissue, and skin. Good approximation of all four layers will help minimize the effects of scar contracture through

Figure 8 (A) Typical outline for V-lip excision. (B) Result at one year with good scar camouflage.

the body of the lip as the wound matures. Particular attention should be made to assuring good approximation of muscle tissue immediately beneath the vermilion, as this will minimize the chance for later development of a depressed or notched appearance along the free margin of the lip. Early identification of the anterior vermilion line on each side is very helpful as a reference point to assure proper alignment of tissues in the closure. This point does not have to be closed immediately, but clearly established as a reference point before other approximations are done (Fig. 10A). Because tissue from the lateral portion of the lip is naturally thinner, it is helpful to next identify the most appropriate site on each side that should become the posterior vermilion line, so that any disparity in width can be adjusted for early in the closure.

Advantages/Disadvantages

The V-lip procedure is the most basic technique for both lip tumor excision and good full-thickness restoration of the lip. There is no need for releasing incisions and preservation of both motor and sensory functions is expected to be near-complete. With good technique, there should be optimal matching of tissue at the free margin of the lip and the single line of scar should hide well, reflecting the natural skin tension

Figure 9 (A) Offset ''hound's tooth'' V-lip design for more lateral region of lip. (B) Result immediately after closure with orientation reasonably compatible with relaxed skin tension line for this region of lip.

line for that site on the lip. A depression is more likely to be seen in the scar line with the lip in repose if the orbicularis muscle tissue has not been fully approximated in the closure.

As with any lip tissue repair there can be issue with infection, although it is rarely a problem and patients are normally allowed to eat and drink with gentle effort immediately after the repair is done. Suture abscesses are not uncommon, particularly in those with heavy bearded or sebaceous skin. The most common faults seen with V-lip repair are contour irregularity at the free lip margin and depression of the line of scar with the lip in repose, both of which can generally be avoided with good technique. Planning the V-excision must not be done with compromise to the adequacy of proper margins for tumor resection.

Limitations

It is generally taught that V-lip excision can involve as much as one-third of the lip without producing a result that would he considered as too tight or otherwise unsightly. This tends to be truer in older patients who tend to have relatively greater

Figure 10 (A) Beginning of closure for defect with W design. Note suture marking the anterior vermilion line which helps to keep proper orientation as other layers are closed first. (B) Early closure result.

laxity and redundancy in their lip tissue. Because of the philtrum and greater variation in height across the upper lip, aesthetically there are more limits for comfortable size of V-lip excision in the upper lip.

Was this article helpful?

0 0
How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

Get My Free Ebook


Post a comment