Brirish Journalof Plastic Surgery (1989), 42,526-529 0 1989 The Trustees of British Assoaation of Plastic Surgeons

0007-1226/89/0042-0526/$10.00

Reconstruction of traumatic loss of vermilion and mucocutaneous junction of the lips

S. SR IVASTAVA

West Midlands Regional Plastic and Jaw Surgery Centre, Wordsley Hospital, Stourbridge

Summary-Traumatic loss of vermilion and mucocutaneous junction is not uncommon. It is usually treated by wedge resection of lip. When the defect is large, resection may lead to compromise of oral aperture. An alternative method of reconstruction with twin subcutaneous advancement flaps used in three cases is presented. The author has not come across a similar method in the literature for lip reconstruction.

Traumatic loss of vermilion and the adjacent mucocutaneous junction is not an uncommon injury. The commonest cause is a dog bite and either of the lips may be affected. Frequently it is found that the vermilion over a quarter of the width of the lip has been lost along with the adjacent white roll (Fig. 1A). The usual method of treatment in these circumstances is to carry out a wedge resection of the lip, often including the muscle. Although resection of up to a third of the lower lip in adults is said not to produce any disability, resection of the upper lip can lead to distortion of the philtral columns. Also while resection of the normal tissue adjacent to the defect is acceptable when dealing with malignant tumours of the lip, such a sacrifice of normal tissue is less acceptable in order to repair traumatic defects. To overcome these objections and provide a satisfactory recon- struction of the vermilion and the new mucocuta- neous junction, the following technique was developed.

Operative technique

Patients with localised loss of vermilion with or without the loss of adjacent mucocutaneousjunction but without gross crushing of the adjacent lip or significant muscle loss are suitable candidates for this technique.

Under general anaesthesia the margins of the wound are squared by debridement and the wound is irrigated by dilute solution of hydrogen peroxide. Two island advancement flaps of V-Y type are marked, one from the skin side of the defect and the other from the mucosal side of the defect. The height of the triangle should preferably be slightly

more than the transverse dimension of the defect. In injuries involving the lower lip, the skin incision can be W-shaped. The skin is incised along the markings down to subcutaneous tissue and the skin flap mobilised towards the free border of the lip (Fig. 1B) by spreading dissection with the scissors. Similarly, a mucosal flap is fashioned (Fig. 1C). The leading edges and the tails of the flaps are released from the subcutaneous and submucosal tissues, leaving the central part of the flap attached to the underlying muscle which is not disturbed. Traction on the leading edge of the flap in the direction of the defect demonstrates any further fibrous band which may be teased out or divided to improve the mobility of the flap. The mobility of the mucosal flap is greater and this flap can be rolled right over the edge of the defect to be sutured to the advanced skin flap in such a way that the new suture line becomes the continuation of the mucocutaneous junction (Fig. 1D). The skin flap is sutured to the adjacent skin in its advanced position by fine absorbable dermal sutures to prevent retraction of the skin mucosal junction in either direction. Antibiotics are given to cover the operating and immediate postoperative period. Any thinness of the lip at the level of the repair immediately after this procedure usually disappears within a week. If the defect does not involve the mucocutaneous junction, a mucosal advancement flap should be sufficient.

Results

Eleven cases of dog bite involving the lips were seen in this Unit during the year 1986. Some of

526

RECONSTRUCTION OF TRAUMATIC LOSS OF VERMILION AND MUCOCUTANEOUS JUNCTION OF THE LIPS

Fig. I

Figure I---C;rsr -7. (A) Defect of skin and vermilion involvmg left upper lip. (B) Skin island belng fashioned. (Cl Mucosal island being fashioned. (D) Result after suture.

these had injuries and losses unsuitable for recon- appearance of his lip was regarded as very satisfac- struction by this method. tory.

The method was used in three cases, all males. In the first case the defect was largely confined to the vermilion of the right upper lip and a mucosal advancement flap was sufficient for a satisfactory repair (Fig. 2). In the second case the defect involved the skin and vermilion of the left upper lip and this was repaired by twin advancement flaps of skin and mucosa (Fig. 1). In the third case a similar defect of the lower lip was repaired by the same technique (Fig. 3). Two patients have been followed up for 2 years and the late results are satisfactory. There is no sensory disturbance or instability of the new vermilion. The second patient (Fig. 1) dropped out of follow-up after 6 months and has been untraceable. On his last visit the

Discussion

Subcutaneous pedicle V-Y sliding/advancement flaps have been described by various authors including Atasoy et al., 1970, Trevaskis et al., 1970 and Zook et al., 1980. Recently Chan (1988) has published a good description of the technique with mobilisation of the leading edge and the apex of the flap thus reducing the size of the pedicle and increasing the mobility. This technique has been used in our Unit for several years for closure of a variety of defects. Several authors (Trevaskis et al., 1970; Zooketal., 1980: Chan, 1988) have described the use of bilateral subcutaneous advancement flaps

BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 2

Fig. 3

Figure 2-Case 1. (A) Loss of vermilion and white roll of right upper lip. (B) Result 2 years later. Figure 3-Case 3. (A) Skin and vermilion loss from left lower lip. (B) Immediately after repair. (C) Result 2 years later.

RECONSTRUCTION OF TRAUMATIC LOSS OF VERMILION AND MUCOCUTANEOUS JUNCTION OF THE LIPS 529

of V-Y type for the repair of a central defect but this author has not come across any description of a similar technique for repair of traumatic defects of vermilion and recreation of mucocutaneous junction. In 1834 Dieffenbach described lateral advancement flaps of vermilion to repair a small defect (Mazzola and Lupo, 1984). The method described in this paper utilises the tissues which are sacrificed in a wedge resection with the added advantage that the oral aperture is not compro- mised. This method would be especially suitable for loss of skin and vermilion of the central upper lip where a wedge resection would lead to a tight, featureless lip with obliteration of philtral columns. Although it has been used in traumatic cases, the method would be suitable for repair of other non- malignant localised defects of vermilion and white roll but would probably be unsuitable if the defect involved more than one-third of the width of the lip. If the lip adjacent to the defect is crushed, a temporary skin graft followed later by delayed repair using this technique may be possible to allow recovery of the crushed tissue in selected cases. This technique cannot be applied to those cases where there is significant skin or muscle loss. In these cases a wedge resection of the lip may be needed for a smaller defect, while cases of gross skin loss may need full thickness skin grafting. If the defect involves the muscle and vermilion with the preservation of the skin, an unusual event in traumatic cases, a musculomucosal rotation ad- vancement (Watson, 1973) may provide a satisfac- tory reconstruction.

The advantage of the method described in this paper is that by the use of a simple, well used technique, small to medium sized defects of the lip can be repaired satisfactorily with no sacrifice of the width of the lip. In the patients on whom this technique was used, scarring was not significant and sensation in the advanced flaps was normal. The other advantage of this technique is that should

the reconstruction be judged to be unsatisfactory it can easily be converted into a wedge resection with no additional loss of tissue.

Acknowledgements

The author wishes to thank the Consultants at the We\t Midlands Regional Plastic and Jaw Surgery Unit. Wordsley Hospital. for allowing him to use this technique of repan on their patients, the photographic department at Wordsley Hospital for the illustration and Mrs J. Olive and Miss G. Lock at Mount Vernon Hospital, Northwood, for preparation of the final manuscript.

References

Atasoy, E., loakimidis, E., Kadsam. M. L., Kutz, J. E. and Kleinert, H. E. (1970). Reconstruction of the amputated fingertip with a triangular volar flap. Journcrlof Bonr md JoB7t Surgery, 52A. 921.

Chan, S. T. S. (1988). A technique for undermining a V-Y subcutaneous island flap to maximise advancement. &it&h Journalof Plastk Surgery, 41. 62.

Mazzola, R. F. and Lupo, G. (1984). Evolving concepts in lip reconstruction. Clinics in Plastic Surgery, Il. 583.

Trevaskis, A. E.. Rempel, J., Okunski, W. and Rea, M. (1970). Sliding subcutaneous pedicle flaps to close a circular defect. Plastic und Reconstructiw Surgery. 46, 155,

Watson, A. C. H. (I 973). An innervated mucomuscular flap for the correction of defects of the vermilion border of the lop. British Journulq~ Plastic Surgery. 26. 355.

Zook, E. G., van Beck, A. L., Russell, R. C. and Moore, J. B. (1980). V-Y advancement flap for facial defects. Plastic ad Reconstructire Surgery, 65. 786.

The Author

Shekhar Srivastava, FRCS(Eng). FRCS(Ed), Locum Consultant Plastic Surgeon. Department of Plastic Surgery. West Nor- wich Hospital. Bowthorpe Road, Norwich NR:! 3TU; formerly Registrar in Plastic Surgery, Wordsley Hospital, Stourbridge. West Midlands.

Requests for reprints to the author at Norwich.

Paper received 27 September 1988. Accepted 4 January 1989 after revision.