Thursday, January 31, 2008

Elbow (Olecranon) Bursitis

Odd topic for a plastic surgeon. Maybe. Maybe not when it's the plastic surgeon who has the problem (olecranon bursitis). That's right, earlier this week, (truly out of the blue) I set my left elbow down on the desk while writing a note. I noticed it was kind of sore/tender. Ignored it, but as the day went on it became more so. I went to the full length mirror in one of the exam rooms so I could really look at it. Red, swollen, no breaks in the skin. I didn't recall any trauma to my elbow. None of that "I hit my funny bone" stuff that makes you take notice. I still ignored it for another day as I had no elevated temp. It got worse. I called up one of the hand surgeons I had done my fellowship with back in 1989-1990. He is an orthopedic trained hand surgeon. He worked me into his busy schedule. The x-rays of my elbow were pristine. No joint abnormalities, no bone spurs, no hairline fractures, nada. That's good, but then what set off my elbow bursa? He wasn't any more sure than I was. He put me on antibiotics (red, warm to touch) and had his therapists make me a splint. He wanted to put me on an anti-inflammatory, but Aleve (helps my joints, etc) gives me severe esophagitis. Severe--burns from the posterior tongue all the way to the stomach.

Damn, I hate this splint. It's amazing the elbow motions you take for granted and the shoulder can only move in so many ways.

  • I hold the phone with my left hand, so my right is free for taking notes. Can't do that with the splint on.
  • Can't scratch my nose or much of any area above the waist, front or back, with my left hand with the splint on.
  • Tough to reach into the washer to pull out clothes with the left arm. Hadn't realized that I used my left arm for that more than the right (interesting).
  • Can't scrub in for a case with the splint on.
  • Not sure it would inspire confidence in me if patients saw me using it

Okay, I love the splint for these reasons:

  • Keeps me from knocking my elbow on the washing machine, the car door, the table top, etc
  • Able to wash dishes with the splint on (started to put this in the neutral or hate column, but recalled my Thanksgiving post and couldn't do it)

Neutral about the splint for these reasons:

  • Able to use the keyboard while wearing the splint.
  • Able to walk my dog in the splint fairly normally.
  • Did manage to do some quilting (both hand and machine) with the splint on.
  • Did manage to drive my car (safely) with the splint on.

Interesting insights, but Thank God it's not my right!!! I will honestly admit I don't wear the splint full time, but do think I have done better than 50%. My elbow is improving quickly (not as fast as the bursitis appeared but). Also, the elbow joint will get stiff if not moved. I have tried to be (and think I have) careful of not banging it or putting any pressure on it when the splint is off. I don't sleep with it on, I'm afraid I might accidentally hit my husband with it.


Here are a couple of sights with more information (medical) on elbow bursitis:
Elbow Bursitis -- American Association of Orthopedic Surgeons
Olecranon Bursitis; Patrick M Foye MD and Todd P Stitik MD; eMedicine Article, November 22, 2006

Wednesday, January 30, 2008

Lip Reconstruction -- Part II

Refer back to Lip Reconstruction -- Part I for the basic information and history. As with the smaller, non-full thickness defects, symmetry should be strived for with as little disturbance of the surrounding anatomic features as possible. Keep in mind the subunits of the lip and landmarks (white roll, philtrum, etc).

Small full-thickness defects of both the upper and lower lip can usually be treated with wedge excision and primary closure (less than a fourth to a third of the total lip missing).

For optimal cosmetic and functional results, full-thickness lip resections should be repaired in 4 layers.

  • First, the submucosa is repaired by using a small-caliber (5-0), soft, nonirritating suture such as silk or Vicryl. The knots should be buried to prevent irregular wound contours and suture spitting.
  • Second, the orbicularis oris is repaired by using an absorbable suture (4-0 or 5-0) such as Vicryl, Dexon, or PDS. Careful and meticulous reapproximation of the orbicularis oris is necessary to maintain competence of the oral sphincter.
  • Third--realign the vermilion-cutaneous border with an epidermal vertical mattress suture prior to proceeding with the dermis/subcutaneous layer of the cutaneous lip. Proper and exact restoration of this border is crucial for a good aesthetic outcome. At the risk of being redundant, even a 1 mm discrepancy in the outline of the white roll is noticeable at a distance of 3 feet (Zide).
  • Fourth, the skin is closed with a monofilament suture, taking great care to maximally evert the wound edges to prevent a depressed and noticeable scar. Small-caliber 5-0 or 6-0 sutures are preferred in this area.

RECONSTRUCTION OF Large Full-Thickness Defects

Upper lip reconstruction is guided by the need to provide a central philtrum and two lateral elements.

Subtotal central defects are best addressed by advancement of lateral elements carrying the orbicularis oris sphincter into an Abbe-Sabattini flap philtral reconstruction.

  • Abbe-Sabattini Flap -- First record of this flap belongs to Pietro Sabattini (1838). Gurdon Buck used a cross-lip lap during the Civil War, but it wasn't until 1898 when Robert Abbe pulished his "new plastic operation" that other surgeons took note and named the procedure after him. It is good for replacement of one third to one half of the upper or lower lip. It allows for immediate reconstruction and will give continuity to the oral stoma (mouth). The donor site is closed primarily. The patient must be cooperative as the two lips will be temporarily "connected" until the flap is divided at a second procedure 10-14 days later.

  • Reverse Fan Flap -- The flap is based inferiorly rather than superiorly. With the fan flap the lip may have some sensation, but muscular function may be compromised.













  • Webster's Combination procedure adds a cross-lip lap to form the philtrum.











  • Von Bruns's Nasolabial Flaps (1857) --the flaps are inferiorly based and pivoted on the commissures. The mucosa lining the flaps is later everted to form the vermillion. There are variations of this flap by Fujimori, Gurel, Mavili, and Meyer.




  • Karapandzic's Inferiorly based Orbicularis Rotation Flap or Reversed Karapandzic Flap-- This innervated orbicularis oris flap was described in 1974 by Karapandzic and is often called by that eponym. It is composed of the orbicularis oris muscle with vermilion, overlying skin, and underlying mucosa mobilized on peripheral neurovascular pedicles containing the fifth and seventh cranial nerves. This flap preserves motor and sensory innervation, and provides excellent functional restoration. The principal limitation of this technique is the increasingly severe microstomia and accompanying abnormal appearance that result with progressively larger lip defects.


When a lateral element is completely missing, a flap designed as a lateral element aesthetic unit is transferred from a nasolabial site or lower lip midline to replace the missing lateral lip elements. Inclusion of the levator anguli oris muscle in a distally based nasolabial flap restores the oral sphincter of the upper lip.

  • Reverse Estlander Flap--In 1872 Estlander described a rotation flap from the lateral upper lip around the commissure to repair a defect of the lateral lower lip. The classic Estlander flap will need a secondary revision to restore the sharp angle (commissure) at the corner of the mouth. However, the modified Estlander or reverse Abbe flap preserves the commissure. Photo here
  • Webster's Flap adds crescentic perialar excisions to bilateral cheek advancement flaps to yield excellent results in lateral upper lip defects. It is not sufficient for total upper lip reconstruction.
  • Levator anguli oris flap (Tobin and O'Daniel, 1990) is an innervated flap that is based at the oral commissure and transposed to replace the lateral lip element.

Lower lip reconstruction

In the lower lip, innervated advancement of the preserved lateral lip elements are preferred to depressor anguli oris flaps unless the defect reaches the commissure on one side.

  • Bilateral orbicularis oris flaps (Karapandzic) can be used to reconstruct as much as three fourths of the lower lip. While it provides a complete oral sphincter and oral competence, it often results in a small oral aperture which can be a problem for denture wearers.
  • Freeman (1958) or Webster-Coffey-Kelleher (1960) modification of the Bernard bilateral cheek advancement flap technique. Both approaches preserve motor and sensory innervation to the residual lateral lip elements although both distort the oral commissures, and oral circumference is progressively lost as the defect enlarges.
  • Gillies's fan flap is basically an extension of the Estlander-type vermillion-bordered flap, enlarged to include tissue lateral to the corner of the mouth. When used unilaterally it is good for defects up to a half of the lower lip. It does not decrease the size of the stoma (mouth opening) much, if at all. The donor defects close directly. The commissure and width of the mouth remain unchanged. However, there is little or no muscular function because it is a denervated flap. This can lead to problems with oral competence and decreased/poor sensation. There may also be some blunting or obliteration of the nasolabial folds.

RECONSTRUCTION of Total Lip

Upper lip reconstruction

  • The Abbe-Sabattini flap philtral reconstruction may be performed either concurrently with the lateral element reconstruction or later. Deferring it can be particularly valuable if the reconstruction is asymmetric because the Abbe flap can be placed precisely in the midline after the lip has settled and the lateral element junctional scar ignored.
  • Bilateral levator anguli oris flap (Tobin and O'Daniel, 1990) is an innervated flap that is based at the oral commissure and transposed to replace the lateral lip element. In combination with an Abbe flap, it can reconstruct the entire upper lip.
  • Bilateral Karapandzic's Inferiorly based Orbicularis Rotation Flap use in combination with an Abbe flap. (picture)


  • Bilateral Fan Flap (Gillies') is good for total defects of both the lower or upper lip.


  • Kazanjian-Converse technique of superiorly based lower cheek flaps



Lower lip reconstruction

  • Bilateral, innervated, depressor anguli oris myocutaneous flaps serve well. These flaps provide a superior functional restoration compared with previously described methods.
  • Webster Cheek Advancement Flap can be used for total lower lip reconstruction. It can often result in a tight lower lip and poor lip function.
  • Bilateral Fan Flap --see above Gillies's fan flap
  • Karapandzic's Technique can be used to reconstruct up to three fourths of the lower lip.


COMPLICATIONS

  • Infection is uncommon but is usually heralded by pain on days 4 to 8. They are managed by antibiotics and wound care.
  • Hematomas and seromas can occur and will increase the likelihood of flap necrosis.
  • Flap cyanosis in the immediate postoperative period is often the result of venous congestion. If thought to be due to excessive wound tension, suspicious stitches can be removed in an attempt to optimize the outcome.
  • Flap failure or necrosis is often due to poor planning or design which underscores the need for careful preparation. Cigarette smoking can increase the risk of flap loss by up to three-fold. When necrosis does occur it will usually involve the distal tip and should be managed expectantly. Unless there are signs of local infection, debridement should not be performed as the eschar will serve as a biologic dressing at worst.

Note--most of the photos were scanned in from the SRPS (5th reference below). This is by no means an exhausted review of the flaps possible for lip reconstruction. When the cheek, as well as the lip is missing often free flaps will need to be done to bring into the area new tissue. Often it is the radial forearm flap that is used when that is necessary.

REFERENCES

RECONSTRUCTION OF THE LOWER LIP BY MENTAL V-Y ISLAND NEUROVASCULAR ADVANCEMENT FLAP; Burić Nikola, Krasić Dragan, Vučković Ivica

Lip Reconstruction by Michael R Shohet MD and Maurice M Khosh MD; eMedicine Article; August 19, 2005

Lip Reconstruction; Gordon R Tobin MD and Wayne Stadelmann MD; eMedicine Article, January 30, 2005

V-Y Advancement Flap in Upper-Lip Reconstruction, IDEAS AND INNOVATIONS; Plastic & Reconstructive Surgery. 105(7):2464-2466, June 2000; Narsete, Thomas A. M.D.

Lip, Cheek, and Scalp Reconstruction and Hair Restoration; Selected Readings in Plastic Surgery, Vol 8, No 14; W P Adams Jr MD, S J Beran MD, and F J Tittle MD

Lip Reconstruction; Yamilet Tirado, M.D.; Baylor College of Medicine Grand Rounds, October 6, 2005

Zide B: Deformities of the lips and cheeks. In: McCarthy JG, ed. Plastic Surgery. Vol 3. Philadelphia, Pa: WB Saunders; 1990.

Lip Reconstruction; Plastic & Reconstructive Surgery, Vol 120, No 4, pp57e-64e, September 15, 2007; Anvar, Bardia A. M.D.; Evans, Brandon C. D.; Evans, Gregory R. D. M.D.

Advancement Flaps; Desire Ratner MD and Joseph M Obadiah MD; eMedicine Article, December 4, 2006

Atlas of Head & Neck Surgery--otolaryngology By Byron J. Bailey; Google eBook

Lip Reconstruction; Sarah Weitzul MD and R Stan Taylor MD; eMedicine Article, April 11, 2006

Local Flaps in Head and Neck Reconstruction; Ian T Jackson MD; The C V Mosby Company, 1985.

Tuesday, January 29, 2008

Reconstruction of the Lip -- Part I

There are many reasons that the lip may need surgical repair or reconstruction.

  • Neoplastic disorders make up the majority of lip pathology encountered by surgeons. Squamous cell carcinoma (SCC) is the most common malignancy affecting the lip with 90% occurring on the lower lip. Basal cell carcinoma is the most common tumor of the upper lip.

  • Trauma -- includes animal bites, automobile accidents, interpersonal violence, and electrical burns. Picture is of a dog bite to the lower lip, before and after repair.

The first mention of a labial repair was made in India back in 1000 b.c.. Most modern techniques were developed during the nineteenth century and have continually evolved since that time. Tagliacozzi originally popularized tissue transfer techniques in the late 16th century. Von Burrow first used the technique of skin triangle excisions to facilitate flap advancement in the early 19th century. In 1834, Dieffenbach described the first cheek advancement flap techniques. The late 19th century was a time of the popular contributions of Abbe, Sabattini, and Estlander whose names remain attached to flaps they described and continue to be used today. Karapandzic introduced the myoneurovascular pedicled advancement flap, and Hari and Ohmori performed the microvascular free tissue transfer for lip reconstructions in 1974.

The essential components of lip reconstruction are:

  • Complete skin cover and oral lining
  • Semblance of a vermillion
  • Adequate stomal diameter (large enough mouth opening)
  • Sensation
  • A competent oral sphincter (controls drool and food loss)

Before proceeding with a lip reconstruction, there are many factors that need to be considered.

  • The age of the patient -- An elderly patient, for example, has more loose soft tissue from the relaxed skin tension lines as a result of dynamic facial movements that result in a better ability for advancement, rotation and transposition of the tissues.
  • Sex of the patient-- In males , there is the need to consider hair bearing skin prior to advancement or rotation of flaps. On the other hand, women have the ability to apply cosmetics for camouflage, such as lip liner and permanent tattooing.
  • Previous operations that may have compromised the labial vessels may be a contraindication to the use of a pedicled labial flap.
  • The hexagonal lip esthetic subunit must be consider. In general, entire subunits must be excised and reconstructed to conform to the esthetic principles of scar camouflage.
  1. The cosmetic subunits of the upper lip include two lateral segments and one central or philtral unit.
  2. The lower lip is a single unit. Still, it is helpful to consider whether the defect is more central or lateral.
  3. Another cosmetic subunit to consider is the vermillion. Defects involving only the vermillion should be reconstructed within that cosmetic subunit whenever possible.
  • Local tissue should be used whenever possible. This helps to provide both minimal donor-site morbidity and the best overall color and texture match.
  • Vermillion and skin must be excised to allow tension-free closure.
  • The oral sphincter is reconstructed whenever possible by transposition of the donor muscle into alignment with the sphincteric muscle.
  • Categorization into partial or full-thickness defects also identifies ideal reconstructive methods. Defects that involve a full-thickness portion of the lip (i.e., skin, muscle, and mucosa) require full-thickness repair.
  • Small full-thickness defects, between a fourth and a third of the lip, may be closed primarily. A major exception is a defect ablating the philtrum, which destroys a significant aesthetic anatomic feature. Such defects are best reconstructed with an Abbe flap from the lower lip midline.
  • The junction between the vermilion and surrounding skin is outlined by a linear prominence, the white roll. The excision of the white lip will allow symmetry in primary closure. Excision of tissue is usually in the shape of a V; however, a pentagonal or W technique for resection can be performed. (check out the above photo of the dog bite patient)
  • Surgical incisions must cross the skin-vermillion junction at 90-degree angles. This junction must be re-aligned properly during the closure as even a 1-mm discrepancy in the outline of the white roll is noticeable at a distance of 3 feet (Zide).

Partial Thickness Defects of the Vermillion

Small superficial defects limited to the vermillion may be allowed to heal by secondary intention with good results. However, larger or deeper defects or wounds near the vermillion border risk distortion if allowed to heal in this manner. Full-thickness grafts from the labial or buccal mucosa may be used, but often develop trapdoor deformity or mismatch color, texture, and thickness with the surrounding vermillion.

Defects that are less than 40% of the vermillion width may be repaired using a bilateral vermillion rotation flap. This flap utilizes adjacent vermillion to rotate centrally. The arcs of the rotation flap are drawn along the vermillion border with the redundant triangle of skin (dog ear) removed posteriorly.

Advantages include:

  • Maintains the anterior-posterior dimension of the lip
  • Avoids redirection of beard hairs,
  • Decreased risk of persistent hypoesthesia compared to mucosal advancement flap repair.

For defects approaching 50% of the vermillion width or greater, a complete vermillionectomy and mucosal advancement flap repair may be necessary.

Advantages include:

  • Useful for large defects of the vermillion subunit.
  • The removal of the entire vermillion reduces the risk of subsequent malignancy from adjacent actinic cheilitis.
  • The "cosmetic unit" is maintained by treating the entire vermillion unit.

Disadvantages include:

  • May decrease the anterior-posterior dimension of the lip
  • May give a more rounded and reddish color to the reconstructed vermillion
  • Patients may have persistent hypoesthesia (decreased sensation)

Cutaneous Lip Defects

Often small cutaneous (skin only, not vermillion, not muscle)defects of the lateral cutaneous lip can be closed in a simple, linear fashion along the relaxed skin tension lines (think of the lines formed when using a straw). It is better for the closure to cross (at 90 degree angle) the vermillion border than to stop short and create a protrusion of tissue.

For larger defects,

Advancement flaps are the very useful for repair for partial-thickness defects of the lateral cutaneous lip. These flaps works well for the upper and lower lip due to the abundant reservoir of cheek and jowl tissue. Advancement flaps are created by incisions which allow for a “sliding”movement of the incised tissue. The movement is in one direction and the flap "advances" directly over the primary defect. The basic design of an advancement flap is to extend an incision along parallel sides of the defect and then directly advance the tissue over the defect. Complete undermining of the advancement flap as well as the skin and soft tissue around the flap pedicle is very important.

The classically designed advancement flap has a flap length to width ratio of around 1:2 and advances tissue a distance approximating the width of the flap. Advancement beyond this is possible, but the tension of the flap may increase dramatically, and the distal blood flow may become compromised and lead to distal flap necrosis. The following are different types of advancement flaps:

  • Monopedicle is a single pedicle advancement flap is the most basic of the advancement flaps. The typical ratio of defect length to flap length is 3:1. It is made by wide undermining prior to parallel incisions preferably in skin crease lines. The flap is inset with key stitches prior to removal of standing cones.
  • Bipedicle advancement flap is typically made when a single-pedicle advancement flap does not allow sufficient tissue for closure of the defect. The basic principles and technique are the same as those for the monopedicle advancement flap. A disadvantage of this flap may be the potentially long suture line.
  • V-Y flap is a unique flap where a V shaped flap is moved into a defect with primary closure of the donor area leaving a final Y shaped suture line. It is pedicled from the underlying subcutaneous tissue rather than the surrounding skin.
  • A-T flap represents a type of bilateral advancement flap where a triangular defect is closed by advancing tissue from either side of the defect. The advantage is that the defect can be divided in half by the use of the two flaps allowing placement of the incisions in natural creases, junctions of aesthetic units, or in the hairline. It works very well along the lip with the horizontal limb at the vermillion.
  • Cheek advancement flaps are optimally used in the cheek where the increased elasticity and mobility of the skin here allows for wide undermining and closure of medium to large defects along the medial cheek. This flap is not a pure advancement, but also relies on rotation.

The basic rotation flap is a simple pivotal flap. It is curvilinear in shape and rotates around a pivotal point near the defect. It is designed immediately adjacent to the defect and only one side of the defect is the advancing edge of the flap. As with all pivotal flaps, a dog-ear will develop at the base of the flap. A Burow’s triangle can be removed to facilitate repair to the donor site wound. If done at the base of the flap, it will shift the position of the pivotal point and thus change the wound-closure tension vector as well as the location of the standing cutaneous deformity.

There are many advantages to the rotation flap. The flap has only two sides, thus it does lend itself very well to having both edges placed in borders of aesthetic units of the face or into one aesthetic border and one RSTL. The flap is broad based and therefore its vascularity tends to be reliable.

The island pedicle flap can also be useful for defects of the lower lip and the upper lip. This flap carries it's blood supply with it, but the vessels will also limit how far it can move. Care must be taken to adequately undermine and dissect this flap to assure minimal tension on the mobile vermillion border.

Transposition flaps are harvested at one site and transferred to a site immediately adjacent to the base of the flap. They differ from rotation flaps in that their final axis is linear, whereas the rotation flap has a curvilinear axis. This difference enables the final closure to have less wound tension and a scar in a more favorable axis. The most important element of design of a transposition flap is the location of the pivot point. These flaps include:

  • Rhomboid or Limberg flap is based on four equal sides with corresponding 60 and 120 degree angles. After careful design there are four potential donor flaps from which to choose in order to appropriately align the final scar in an inconspicuous area and prevent surrounding tissue distortion.
  • Dufourmental flap is slightly more complicated with angles varying from 60 to 90 degrees but there still exists the choice of four potential donor flaps.
  • Bilobed flaps are double transposition flaps that share a single base. They move around a pivotal point and invariably develop a standing cone (dog-ear) that is dependent upon the arc of rotation. The primary flap is to repair the surgical defect and the secondary flap is used to repair the flap donor site. The secondary flap defect is then closed primarily. The primary use is in closing defects of the lower third of the nose. A disadvantage of the flap is that the resulting scar is unable to follow skin tension lines in many cases.

COMPLICATIONS

Fortunately, complications are not common with local flaps in the face which accounts for their popularity.

  • Infection is uncommon but is usually heralded by pain on days 4 to 8. They are managed by antibiotics and wound care.
  • Hematomas and seromas can occur and will increase the likelihood of flap necrosis.
  • Flap cyanosis in the immediate postoperative period is often the result of venous congestion. If thought to be due to excessive wound tension, suspicious stitches can be removed in an attempt to optimize the outcome.
  • Flap failure or necrosis is often due to poor planning or design which underscores the need for careful preparation. Cigarette smoking can increase the risk of flap loss by up to three-fold. When necrosis does occur it will usually involve the distal tip and should be managed expectantly. Unless there are signs of local infection, debridement should not be performed as the eschar will serve as a biologic dressing at worst.

REFERENCES

Lip Reconstruction; Yamilet Tirado, M.D.; Baylor College of Medicine Grand Rounds, October 6, 2005

Zide B: Deformities of the lips and cheeks. In: McCarthy JG, ed. Plastic Surgery. Vol 3. Philadelphia, Pa: WB Saunders; 1990.

Lip Reconstruction; Plastic & Reconstructive Surgery, Vol 120, No 4, pp57e-64e, September 15, 2007; Anvar, Bardia A. M.D.; Evans, Brandon C. D.; Evans, Gregory R. D. M.D.

Lip Reconstruction; Gordon R Tobin MD and Wayne Stadelmann MD; eMedicine Article, January 30, 2005

Novel Flaps for Lip Reconstruction; Advances in Derm Surg, Vol 11, No 6; Daufman A J, Rohrer T E

Advancement Flaps; Desire Ratner MD and Joseph M Obadiah MD; eMedicine Article, December 4, 2006

Monday, January 28, 2008

Lip Reduction

Not all of us may want larger, fuller lips. Many people (both men and women) believe that their lips are too big, and want them reduced. Younger patients are often plagued by insecurities brought on by having larger than average lips and the teasing their classmates may do. These younger patients should wait until their late teens to have their lip size reduced due to maturing of the facial features.

Macrocheilia or prominent lips has multiple etiologies affecting one or both lips. Those caused by disease can become a functional issue and not simply cosmetic in nature.

Congenital causes include

  • Double lip deformity occurs because of the persistence of the transverse sulcus between the inner lip (pars villosa) and the outer lip (pars glabra), resulting in glandular hypertrophy along with redundant labial mucosa. The excess tissue forms an accessory lip, which is apparent during smiling. The underlying orbicularis oris muscle is not involved.

  • Labial "pits" -- usually described as blind epidermal invaginations of lip mucosa with occasional drainage of minor salivary gland secretions

  • Ethnic variations demonstrate diffuse thickening of all lip structures and may require resection of muscle.

Acquired causes include

  • Trauma -- result in an inflammatory infiltration leading to fibrosis and subsequent lip enlargement
  • Infections
  • Neoplasms
  • Syndromes
  1. Melkersson-Rosenthal Syndome -- Miescher granulomatous macrocheilitis is a mono-symptomatic presentation of Melkersson-Rosenthal syndrome that is characterized by granulomatous swelling of the lips. The full syndrome is a condition characterized by the triad of facial paralysis, facial edema, and lingua plicata (furrowed tongue), similarly results in an infiltrative process of the lips.

  1. Ascher syndrome is identical to double lip deformity with associated blepharochalasis and endocrine disorders.
  • Port-wine (capillary) vascular malformations that enlarge the lips (port-wine macrocheilia) are a different category of lesions that have a different pathophysiology and may require complex reconstruction.

CLINICAL PRESENTATION/ EXAM

The patient will most often present complaining of prominent lips or facial disproportion. The protruding lip or lips often stand out as the most prominent feature of the face, attracting undesirable attention.

Functional difficulties may include labial incompetence, interfere with speech, problems with salivary control (drooling), and problems with mastication (chewing).

The lip and its relationship to other facial structures are evaluated by frontal and profile views. If there is a possibility of underlying dental or facial bone problems to explain the prominent lips, then appropriate x-rays should be done. It is important to assess the lips and the relationship to the nose and chin.

From the face-on-view, evaluate the visible vermilion (vertical height) and the transverse lip excess.

From the profile view, evaluate the upper to lower lip relationship as well as the degree of lip eversion.

Prominent lips are not always the result of lip volume but may be caused by lip ectropion or labial eversion. Furthermore, the orbicularis musculature is assessed for its tone and muscular ring for its competence.

MEDICAL TREATMENT

Medical therapy has limited usefulness in treating prominent lips. It can however help alleviate the underlying cause or associated anomalies. Steroid therapy, antibiotics, salazosulfapyridine, and radiation have shown limited success.

SURGICAL TREATMENT

The goals of lip reduction surgery are to achieve a harmonious upper to lower lip relationship that is in balance with the entire face as well as to attain normal lip competence.

The treatment of macrocheilia is should be individualized to the etiology and patient's needs. Some general principles include the following:

  1. Correct underlying dento-osseous (teeth/bone)deformities.
  2. Establish a balance between upper and lower lips with the individual patient in mind
  3. Do not reduce lips if excessive interlabial distance exists.
  4. Optimal frontal aesthetics is more important than profile aesthetics

The basic surgical procedure of lip reduction surgery is a transverse fusiform or elliptical mucosal incision between 1 and 11/2 cm dorsal to the vermillion border between the lateral commissures (Conway method). W- or Z-plasties may be added to prevent dog ears.

The Mouly method may be added. This method includes the excision of two sagittal triangular wedges at the lateral eminences of the philtrum. This enables the natural protrusion of the eminences and the normal central depression of the upper lip to be preserved. The undermining of the wound edges should be limited to that needed for appropriate tissue apposition. Closure of the resection defects is usually performed in two layers, and sutures are removed 7 to 10 days after surgery.

At other times, a wedge excision may be most appropriate.

Surgical methods. A and B, Conway procedure with transverse sickle-shaped mucosal excision. C and D, Conway procedure in sagittal projection, with excision of mucosal and submucosal tissue. E and F, Central wedge excision. G and H, Z-plasty after wedge resection. I and J, Mouly procedure. (from the second reference article)

Some tips from Drs Dev and Wang's article:

  • When designing the incision it is imperative to place the anterior aspect of the incision posterior to the lip seal and wet line (transition from inner mouth mucosa and vermillion).
  • Avoid the area of Cupid's bow as well. Cupid's bow should always be preserved during correction of a prominent upper lip since it is an important landmark of the lip.
  • The marking should be made prior to the use of local anesthetics, which tend to distort the lip architecture.
  • The goal should be removal of hypertrophied labial glands, fibrosis from an infiltrative process, or generalized thickened redundant tissue.
  • In the upper lip, macrocheilia usually affect the lip in the vertical dimension. If the dry vermilion is not excessively large, the reduction surgery is designed as a transverse ellipse behind the wet line. However, if the entire vermilion is enlarged, then design of the excision may include the dry vermilion.

COMPLICATIONS

Unfortunately, all surgery has risks and complications.

Infection

Chance of asymmetry

Hypertrophic scarring

Numbness -- usually subsides within the first few weeks, but may be permanent

General dissatisfaction

REFERENCES

Lip Reduction by Vipul R Dev MD and Peter Wang MD--eMedicine Article, June 14, 2006

Surgical Treatment of Persistent Macrocheilia in Patients With Melkersson-Rosenthal Syndrome and Cheilitis Granulomatosa; Arch Dermatol. 2005;141:1085-1091; Birgit Kruse-Lösler, MD, DMD; Dagmar Presser, MD; Dieter Metze, MD; Ulrich Joos, MD, DMD

Macrocheilia due to hyperplasia of the labial salivary glands: operative correction. Surg Gynecol Obstet. 1938;66:1024-1031; Conway H

Correction of hypertrophy of the upper lip; Plast Reconstr Surg. 1970;46:262-264; Mouly R

Sunday, January 27, 2008

This and That, Catching Up

We made it to the Canstruction. Here's a photo of the Simpsons I took. If you want to see the other photos I took, you can check them out here. I really liked the Big Can Bridge, but don't think it shows as well in the photos as the Simpsons.

Also want to remind everyone about SurgeXperiences #114. It will be hosted at Anesthesioboist on February 3. The deadline for submissions is February 1. The current edition, SurgeXperiences 113 is up over at Counting Sheep. Terry calls her edition "Operating After Hours".
 
 
And last, but not least I want to give a "heads up" to an upcoming HBO documentary that is due to air January 29, 2008. It is called "Badhdad Hospital, Inside the Red Zone". As you all may know, Chris over at "Made A Difference For That One: A Surgeon's Letters Home From Iraq" has recently returned to the United States from Iraq. He has the following to say about the upcoming show:
 
"I only got to see life within the rarified confines of Balad airbase, and once the 86th CSH in Baghdad, so this is a perspective of Iraq I did not have. I will say that I heard some of my patients say things very similar to those portrayed in the clips.
 
Clip 1: Ambulance pickup at a market after a suicide http://www.youtube.com/watch?v=zUMzO8x0QxM
 
Clip 2: Introduction in the hospital http://www.youtube.com/watch?v=nkVMm6AgStg I think that the clips were filmed in 2007. Hopefully we see less of thes attacks as time goes by. In the first clip when I heard the line "Only the children playing outside." I could feel a sense of a parent's worry for their own children above one's own safety, yet also a feeling of guilt in knowing they were someone's children."

Saturday, January 26, 2008

Snail's Trails or Virginia Reel

I bought these fabrics to plan an Amish Bars quilt which I ended up using only two of the colors. You can see it here in the post on Marking. I am hand quilting it. Then I needed to use the other and left-over fabric, so I decided to try a Snail's Trail in the four colors. Snail's Trail is also known as the Virginia Reel. It can be a challenge keeping the fabrics straight so that the turns of the "trail" stay oriented correctly. There is a nice website (Block Central) that has several blocks put together into a coloring book. These pages can be printed off so that you can play with the colors you want or just color them, so you can keep yours straight. When only using two colors, all the blocks will be the same. When using four colors, the blocks are like this.

This is how I have put mine together. It is 48 inches X 48 inches. I want to put a border around it of the dark brown and lighter brown. Then I plan to machine quilt this one and perhaps use it as a wall hanging quilt. Or if my friend whom I am making the Amish Bars for wants both, I guess I will give him both as he is the one who wanted "mustard yellow" and "brown".

Friday, January 25, 2008

Lip Augmentation

Appearance of the lips has always played an important role in the perception and assessment of facial beauty. Since the beginning of the 1990s there has been increasing public demand for changing the outer appearance of the lips. Until recently, plastic surgeons were concerned with techniques of rejuvenation of aging lips, generally in patients at least 40 years of age. Lately, young women have been requesting aesthetic enhancement of the lips.

Lip deficiencies may arise from facial aging, previous ablative procedures or congenital absence of lip volume. The goals of lip augmentation are to increase deficient vermillion volume and elevate the ptotic vermillion border.

There are many techniques available to enhance the lips. The shear number of procedures testifies to the lack of a surefire, non-nonsense method. The volume and shape of the thin upper lip have been enhanced with addition of material (synthetic and autogenous) and by recruitment of local tissue.

TECHNIQUES

The following techniques are used for lip augmentation:

I. AUTOGENOUS FILLERS (the patient's own tissue), such as temporalis fascia, dermal grafts, palmaris longus tendon graft or fat. Some of these procedures can be "invasive".

Autologous fat has become a more popular choice. The distinct advantage of fat as a volume augmenter is that it uses your own tissue. The risk of allergic reactions is avoided since the fat used is the patient's own tissue. As much as 30% of the injected fat can persist after transplantation with appropriate technique, and in some patients almost complete survival of the graft has been reported. Survival of fat graft is decreased in smokers. A disadvantage of using fat injections is that it may be absorbed (note the above mention that often only 30% persists) and repeat treatments are often necessary to obtain/maintain results desired.

Fat Harvest and Transfer

The average volume of purified fat needed for both upper and lower lip augmentation is 6 ml (3 ml each). If no larger volume liposuction is being done at the same time, then the fat can be harvested (technique from the 6th reference below) as follows:

  • 80-cc normal saline and 20 cc of 1% lidocaine with 1:100,000 epinephrine mixed together is injected into the proposed donor site (most commonly the infraumbilical abdomen)
  • Wait 8-10 minutes, then harvest the fat using gentle aspiration with a 10-cc syringe and a short 3-mm cannula (Byron Medical, Tucson, Ariz.). Gentle means "Only 1 cc of negative pressure, as measured by the scale imprinted on the side of the 10-cc syringe, is applied."
  • Wash the harvested fat by rinsing with normal saline over a tea strainer until clear of bloody and oily residue.
  • Dry the fat between a Telfa gauze and manually clear of fibrous remnants
  • Transfer the fat into 3-cc syringes.

To transfer the fat use a Coleman cannula in the standard fashion:

  • Inject the fat evenly as the cannula is withdrawn from a channel.
  • Fat is first placed very superficially along the vermilion border and then into the muscular substance of the lip proper, using many passes along different channels.
  • The relative volume and placement of the fat is a fairly artistic endeavor. More often than not, a total of 6 cc of purified fat will be needed for upper and lower lip augmentation.

Dermis-Fat Graft

If the patient has any previous scars, such as a post-appendectomy (old McBurney's, not laproscopic), this can be used.

  • The graft is obtained from the area adjacent to the scar. In the process, the patient gets a scar revision. In the absence of scars, a good site is the lower abdomen on the border of the pubic hair in women.
  • Dermis shrinks after excision, so the donor area should be marked slightly larger than needed and measured, for both lips, about 8 × 2 cm.
  • It is easier and more precise to remove epidermis in situ, before the graft is excised. After excision, the dermis-fat graft tissue is trimmed with sharp scissors to a final size of about 75 mm (length) × 8 mm (width) × 6 mm (height) for each strip. The bulk of the various parts of the graft can be altered at preparation if there is a desire for greater augmentation of the philtrum area or laterally or if the lip is asymmetric.
  • One 4-mm-long horizontal stab incision is made on inside of each lip commissure, allowing access for graft introduction to both the upper and lower lip. Sharp-pointed, curved Iris scissors are used to create a narrow tunnel 4 to 5 mm deep to the white roll. A specially designed graft passer should be introduced through the proximal end of the tunnel and gently pushed forward, distending the lip and coming out through the incision in the opposite commissure.
  • The dermis-fat graft, protected by gauze soaked in normal saline solution, is introduced. Care should be taken to place the smooth dermis surface of the graft outward and the more irregular subcutaneous fat surface inward. One or two 5-0 Chromic sutures are used to close the incision in the mucosa and to anchor the graft.

II. LOCAL TISSUE REARRANGEMENTS, such as lip border advancement, double V-Y plasty (horizontal and vertical) are more permanent. They are also more invasive and have a longer recovery time.

Mucosal Advancement

V-Y plasties evert and direct localized wet oral mucosa to the exterior to become "vermilion". Careful analysis of lips is necessary to plan the position and determine the size of the proposed V-Y-plasties. Placement can be critical in dictating the final shape of the lips. Most often, however, three upper V-Y mucosal advancements and a wide, single, central lower one are designed and carried out. There are nice pictures in the 6th reference below.

  • The designs of the three upper and one lower V-Y-plasties are first applied to the exterior of the lip.
  • The base of each V should lie above the white roll (or below, in the case of the lower lip). The width of each base may vary between 1 and 2 cm, depending on the patient's presentation.
  • 1% lidocaine with 1:100,000 epinephrine mixed with Wydase is injected into the labial mucosa. While awaiting the vasoconstrictive effect of the epinephrine to occur, the lip is everted and a 25-gauge needle is used to transcutaneously translate the external markings (the three points of each V) to the internal labial mucosa. Needle emergence sights are marked with Bovie electrocautery.
  • Before proceeding, verify the final symmetry while the lip is everted by applying even, outward pressure at the oral commissures simultaneously.
  • The incisions are then made and the flaps raised by gentle scissor dissection with care being taken to preserve as many cutaneous nerves as possible. In the upper lip the lateral two mucosal advancements are performed before the central one.
  • In generally, each V-Y is advanced 1 cm. Closure is performed by means of horizontal mattress sutures of 5-0 chromic and facilitated by triangulating the wound with hooks placed at each of the two corner bases of the raised V flap.
  • When all flaps are securely advanced, symmetry should be present. No dog-ears should be visible.

III. HETEROLOGOUS MATERIAL used both as FILLERS and as IMPLANTS, such as silicone, collagen, polytetrafluoroethylene (Gore-Tex), and AlloDerm . You may want to check out my post on Dermal Fillers.

FILLERS

Lip augmentation with the use of injectable fillers allows quick results to be obtained with minimal downtime. Materials used include:

  • Collagen -- They are user friendly, relatively easy to inject, and can be integrated into a simple office visit for the patient requesting dermal augmentation. A skin test must be done. The filling agent is technique dependent for longer lasting results, proportional to the clinician's ability to place the collagen correctly. More often used for the peri-oral wrinkles or to enhance the white roll/outline than to enlarge the lips. This is a temporary solution and the results are not permanent. The three main variation used in the US are:
  1. Zyderm I collagen is a 25% suspension of purified bovine dermis in saline with 0.3% lidocaine. The saline carrier is absorbed and the remaining implant persists for 3-10 months. Zyderm I is used most successfully to treat shallow distensible scars and fine rhytides. Zyderm I has a longevity of 6 weeks to 3 months.
  2. Zyderm II has double the concentration and is a more viscid substance. The longevity of scar correction is increased and it can be used for larger filling defects. Longevity is 4-5 months.
  3. Zyplast is a cross-linked derivative of bovine collagen, which is a heavier filling material and has greater longevity. Zyplast can be used for larger scars that require a greater and deeper filling of volume and lasts longer. It is placed deeper in the dermis and requires 100% correction at the time of implantation, rather than the 150% used for Zyderm I. Expected longevity is 9 months to 1 year, especially in a relatively immobile scar.
  • Cymetra is a micronized form of AlloDerm (see below) that is injectable. This material is rehydrated with lidocaine in the physician's office before injection. Because it is human-derived collagen, no skin test is required by the manufacturer. Clinical trials of 200 patients to date show no evidence of allergic reactions. Results last in the range of 3-6 months.
  • Hyaluronic acid preparations such as Restylane or Perlane . Restylane was approved by the FDA in 2003. Both are free from animal proteins which limits any risk of animal-based disease transmissions or development of allergic reactions to animal proteins. Perlane is a more robust form of Restylane intended for use in the deep dermis and at the dermal-fat junction. The most commonly observed side effects are temporary redness and swelling at the injection site, which typically resolve in less than seven days. Both are made by Medicis.

  • ArteFill is made of permanent, non-resorbable microspheres (20%) of polymethylmethacrylate (PMMA) which become part of the patient’s own tissue, filling in the wrinkle for enduring correction. ArteFill is contraindicated in anyone with a known allergy to bovine collagen or lidocaine. A skin test must be done. If the skin test response is positive, the patient must not be treated with ArteFill. Technique is critical in minimizing these reactions. It is recommended that the linear retrograde tunneling method be used in working with ArteFill. It is a product of Artes Medical. Adverse reactions include granulomas.

  • Radiesse is composed of microspheres of calcium-hydroxylapatite suspended in an aqueous gel carrier. The biodegradable microspheres serve as a lattice upon which the body forms scaffolding for tissue infiltration. The spheres slowly degrade. The improvement is effective for 9-18 months. Radiesse is biocompatible and does not require pre-testing. Side effects may include swelling, bruising, pain, itching, and tenderness at the injection site. These conditions typically resolved on their own within one to two days. It is a product of BioForm Medical.
  • Bioplastique is a filler available in the United States with similar characteristics consisting of 38% biphasic polymer textured silicone particles suspended in a 62% bioexcretable gel carrier.

Significant ease of use, “off the shelf” availability, and widespread acceptance by the public make collagen one of the most common fillers used. Precautions regarding mode of injection and quantity of the substance injected vary widely within this family of products.

IMPLANTS

Lip augmentation can be obtained by the implantation of various synthetic materials, including polytetrafluoroethylene (PTFE; SoftForm--no longer available as of November 2006; Fulfil by Evera--approved spring 2007), as well as biomaterials such as fascia, dermis, and decellularized donor dermis (AlloDerm). Insertion of these implants require the use of local anesthesia by nerve block, local infiltration, or both.

SoftForm

  • An local block using 1% lidocaine with 1 part per 100,000 parts epinephrine and 0.5% Marcaine in a 50/50 mixture is used for anesthesia. The skin is cleansed with Betadine solution. The entry and exit sites are approximately 2 mm medial to the commissure in the lower lip. To introduce the implant beneath the dermis, a Keith needle is used.
  • The current recommendations for SoftForm use are one implant for the upper lip and one implant for the lower lip. These should be at least 9.0 cm long and 3.2 mm thick (11.0 cm long and 4.8 mm thick for greater augmentation).
  • Implant placement in the lip varies depending on the type of implant used. If the strands are used, gently stretch the tissue of the lip. Do not stretch the lip tissue if using SoftForm. Lip implants are placed to enhance the vermillion border and augment the lip's fullness. If using SoftForm, the larger diameter implant accomplishes these goals. If strands are used, the number and exact placement can be varied to not only enhance the contour but also enhance the degree of augmentation.
  • Push the needle to the desired exit spot and make an incision of similar size to the entry wound. Externalize the needle and cut the polymer to size so that the distal end is not protruding from the entry wounds. Skin is closed with 6-0 white nylon, and Steri-Strips are applied to the skin. Sutures are removed after 5-7 days.

AlloDerm is an acellular human dermal graft processed from tissue bank–derived skin. It has been used since 1992 on more than several thousand patients; initially, it was used for burn victims and, later, in oral surgery and soft tissue augmentation. It is available in sheets 1-2 mm thick and is not injected but implanted surgically. After rehydrating the graft in normal saline, the dermal sheet is rolled and trimmed to the appropriate length of the defect. A tunnel is then created under the scar or contour deformity and an instrument is used to pass the tissue to the opposite side, where it may be sutured into place. Results from AlloDerm last for approximately 6-12 months, but persistence of grafts can reach several years. AlloDerm appears to have greater longevity than collagen fillers, though no controlled studies have been performed.

IV. A COMBINATION of TECHNIQUES, such as fat transfer and simultaneous mucosal advancement (FATMA)

POSTPROCEDURE AFTERCARE
  • Discomfort is most apparent in the first 48 hours postoperatively but rapidly subsides thereafter, usually treated with judicious amounts of nonsteroidal antiinflammatory medication.
  • The areas treated with injectable materials require little postoperative care. Coat lips treated by surgical advancement or implantation with antibiotic ointment 3-4 times per day for 1 week postoperatively. Then follow with use of Aquafor or petroleum jelly to prevent dryness.
  • Ice packs are used extensively in the first 24 hours.
  • Encourage patients to limit talking, smiling, and laughing for 5-7 days postoperatively.

Follow-up care:

  • Significant postoperative swelling is common to all techniques of lip augmentation. With the surgical procedures, the swelling may be significant enough to interfere with your social routine for 2 weeks or more. It may take 8-10 weeks to completely resolve.
  • Recommended postoperative care includes ice packs, sun avoidance, liquid diet, perioral care with saline rinses, and rest for 24-48 hours, depending on the extent of surgery. Use of a sippy cup rather than a straw will help, as it is difficult to use a straw or purse one's lips when swollen.
  • One of the most common complaints after surgical advancement is persistent numbness and/or paresthesias around the augmented lips. This problem usually resolves in 4-6 weeks but may become a significant nuisance for patients.
  • Follow-up care consists of office visits 1, 7, and 30 days postoperatively, at which time shape, symmetry, function, and wound healing are assessed.

COMPLICATIONS

All this improvement may not come without a price. The cost in some patients is lip tightness, resulting in a restricted smile and an adynamic central upper lip. With all the procedures, there is the possibility of disappointment in the final results (both too big or too small) -- reported in up to 10% of patients. In doing this post, I came across these photos of Meg Ryan. I personally like her lips before she had any augmentation work done. I wonder how she feels.

Complications of collagen injection include allergic reaction to the compound, possible intravascular injection, skin slough, scarring, granuloma formation, and hematoma. Testing for sensitivity to bovine collagen must be performed prior to injection and observed for 4 weeks.

Complications of fat transfer include donor site hematoma, scarring, infection, lumpiness, asymmetry, infection, hematoma, intravascular injection, and possible skin slough.

Complications of synthetic material implantation include infection, asymmetry, sensitivity to the material, extrusion, need for removal of the implant because of hardening, interference with lip function, and sensation changes.

Complications of surgical advancement, lift, and roll include hypertrophic scarring, asymmetry, numbness, and lumpiness.

REFERENCES

Lip Augmentation by Jorge de la Torre, MD and Mario Diana MD-- eMedicine Article, June 12, 2006

Lip Implants by Daniel C Daube MD --eMedicine Article, April 4, 2006

Autologous Lip Augmentation: A Comparative Analysis; Plastic & Reconstructive Surgery. Abstract Supplement. 118(4), Supplement:49-50, September 15, 2006; Trussler, Andrew P. MD; Dickinson, Brian P. MD; Keagle, Jennifer J. MD; Bradley, James P. MD; Kawamoto, Henry K. MD, DDS

Correction of thin lips: a 1 7-year follow-up of the original technique; Plast Reconstr Surg, 11 2(2):670-5, 2003; Yoskovitch A, Fanous N.

Lip Enhancement: Surgical Alternatives and Histologic Aspects; Plast Reconstr Surg. 105(3):11 73-83, 2000; Niechajev I

Customizing Perioral Enhancement to Obtain Ideal Lip Aesthetics: Combining Both Lip Voluming and Reshaping Procedures by Means of an Algorithmic Approach; Plast Reconstr Surg. 11 3(7):2182-93, 2004; Haworth R.D.

Lip Service for the Stiff Upper Lip; Plastic & Reconstructive Surgery. 105(3):1154-1158, March 2000; Zide, Barry M. M.D.; Bradley, James P. M.D.; Longaker, Michael T. M.D.

Narsete, T. A. V-Y advancement flap in upper-lip reconstruction. Plast. Reconstr. Surg. 105: 2464, 2000

Collagen Injections by Thomas J Gampper MD -- eMedicine Article, May 3, 2007

Implants, Soft Tissue, Gore-Tex by Michael Mercandetti MD -- eMedicine Article, Jan 8, 2008

Thursday, January 24, 2008

2007 Medical Weblog Awards Winners!

BEST MEDICAL BLOG:

Running a Hospital, the blog by Paul Levy, CEO of Beth Israel-Deaconess in Boston, MA

Other finalists: Kevin, MD , Surgeonsblog , Respectful Insolence, and DiabetesMine

BEST NEW MEDICAL BLOG:

Dr. Val, and the Voice of Reason Part of the Revolution Health Network, she brings a very human approach to medicine, balancing news and research with anecdotes and humor. Congratulations Dr Val!

Other finalists: Doctor David's Blog, The Happy Hospitalist, The Physician Executive, and Suture for a Living.

BEST LITERARY MEDICAL BLOG:

Random Acts of Reality by Tom Reynolds of the London Ambulance Service. Tom's gripping tales from the frontlines of the human condition are what won him this category in 2005 (the year he also took top honors for Best Medical Blog).

Other nominees included Dr. Hébert's Medical Gumbo, intueri, A Chronic Dose, and Surgeonsblog.

BEST HEALTH POLICIES / ETHICS BLOG:

Running a Hospital, see above. Yes, it won two awards!!

Other finalists: Dr. Wes (who will be the guest on Dr Anonymous' Blog Talk Radio show tonight--check it out), The Physician Executive, Respectful Insolence, and the Carlat Psychiatry blog

BEST MEDICAL TECHNOLOGIES / INFORMATICS BLOG:

They've got a bit of a dilemma here. So are going to hold off on naming a winner in this category, until they review the voting data, and consult an ethicist (perhaps one of the nominees in the previous category...)

BEST CLINICAL SCIENCES WEBLOG:

New York Emergency Medicine, the innovative new blog that features interviews with leading figures in EM, quizzes with cash prizes, and interesting medical and legal case discussions.

Other finalists: Sumer's Radiology Site (who won in 2005), Clinical Cases and Images, and Aetiology.

BEST PATIENT BLOG:

Chronic Babe, a site created for young women by Jenni Prokopy who faces her debilitating chronic illness with a positive outlook.

Other finalists: Six Until Me, Billy Bob's Wild Ride, The biopsy report, and DiabetesMine (see above, nominated for best blog)

Congratulations to all the winners!

Wednesday, January 23, 2008

Lips--Anatomy and Function

Our lips are very important in many ways:

  • Visual look of face
  • Food intake, drool prevention
  • Speech articulation
  • Playing musical instruments
  • Tactile sensory organ

There are many phrases related to the lips. Here are a few:

Read my lips--meaning "pay close attention to my words" (link)

Lip service--meaning "minimal compliance only" (link)

Hot Lips -- usually a nick name ; Major Margaret J. "Hot Lips" Houlihan (MASH); Oran Thaddeus Page (jazz trumpeter known as Hot Lips Page by the public and Lips Page by his fellow musicians).

Fat Lip--(idiom) A swelling on the lip

Don't give me any lip --meaning "insolent talk" (link)

My lips are sealed --meaning "one will reveal nothing, especially about a secret" (link)

There are many emotions invoked just by looking at someone's lips/mouth. By the look and by the movements. "Thin-lipped" is most often used to describe someone who is strict or stern. In general, fuller and thicker lips are seen as more youthful and more attractive. So I hope I don't ruin the sensual, pleasurable aspect of lip psychology for you by delving into the anatomy of lips. (It hasn't for me.) I want to cover the anatomy prior to moving on to future posts on lip reconstruction and augmentation. The picture above is of Louis Armstrong blowing his trumpet. You can hear him here (A Kiss to Build a Dream On).

ANATOMY

The Upper (Labium superioris) extends from the base of the nose superiorly, to the nasolabial folds laterally, and to the free edge of the vermilion border inferiorly.

The lower lip (Labium inferioris) extends from the superior free vermilion edge superiorly, to the commissures laterally, and to the mandible inferiorly. The lower lip is usually somewhat larger (for youthful lips approximately twice as full as the upper).

The vermilion is the "colored" portion of the lips. The skin here is very thin. In light-skin people, the underlying blood vessels appear more readily through the skin which leads to their notable red coloring. With darker skin color, this effect is less prominent.

Around the circumferential vermilion-skin border, a fine line of pale skin "(the white roll") accentuates the color difference between the vermilion and normal skin. When repairing lacerations, it is crucial to match this "roll". A 1-mm discrepancy can be noticed at a distance of 3 feet.

Cupid's bow is formed by the two "peaks" of vermilion of the upper lip. The philtrum is located between the two raised vertical columns of tissue, from the vermilion to the columella above.

The labiomental (lip-chin)crease passes horizontally in an inverted u-shape across the lower lip, which intraorally corresponds to the depth of the gingivolabial sulcus

BLOOD SUPPLY

The inferior and a superior labial artery are branches of the facial artery. They follow a course beneath the orbicularis oris muscle and anastomose with the contralateral vessel. The superior labial artery usually branches from the facial artery 1.1 cm lateral and 0.9 cm superior to the oral commissure. The inferior labial artery branches from the facial artery 2.6 cm lateral and 1.5 cm inferior to the oral commissure. The facial artery then ascends in the nasolabial groove as the angular artery, forming branches to the nasal ala and anastomosing with the dorsal nasal artery.

LYMPHATIC DRAINAGE

Lymphatic drainage from the upper lip is unilateral except for the midline. The lymphatics coalesce and drain mainly to the ipsilateral submandibular nodes, with some drainage also going to the periparotid lymph nodes. Occasionally, some drainage may be available to the ipsilateral submental lymph nodes.

The lower lip lymphatics also coalesce and drain into bilateral submental nodes from the central lip and unilateral submandibular lymph nodes from the lateral lip.

The submental, submandibular, and parotid lymph nodes are the first level of lymph drainage for the lips. Submental nodes secondarily drain to ipsilateral submandibular nodes, and both submandibular and parotid nodes secondarily drain to ipsilateral jugulodigastric lymph nodes.

SENSORY INNERVATION

The upper lip is innervated by the terminal branch of the maxillary nerve. It supplies sensation to the lateral nasal sidewall, ala, columella, medial cheek, and upper lip.

The lower lip and chin receive sensory innervation from branches of the mandibular nerve. The mental nerve supplies sensation to the lower lip skin down to the labiomental fold and, occasionally, down the chin as well. The nerve is located in the submucosa as it exits the foramen and frequently is visible in this location. The inferior alveolar nerve, a branch of the mandibular nerve, inconsistently supplies the chin and region immediately lateral to it.

MOTOR (MUSCLE) INNERVATION

The motor innervation to the perioral musculature uniformly is from the seventh cranial nerve (CN VII). It is the buccal and marginal branches of the facial nerve that primarily supply innervation to the perioral musculature.

MUSCLES

The perioral musculature (link shows muscles and discusses phonetics) can be classified into 3 groups based on insertion.

  • Group I -- insert into the modiolus (a tendinous thickening at each commissure that serves as an attachment site for several of the upper and lower lip muscles)
    • Orbicularis oris --forms a sphincter around the mouth. This muscle purses the lips and presses them against the teeth upon contraction.
    • Buccinator --functions to press the lips and cheek against the teeth
    • Levator anguli oris -- acts to superiorly elevate the commissure
    • Depressor anguli oris -- functions to depress and laterally move the commissure
    • Zygomaticus major -- elevates and laterally moves the commissure
    • Risorius -- draws the commissure laterally and produces the sardonic smile (Warren Oates, 1928-1982)

  • Group II -- insert into the upper lip
    • Levator labii superioris -- elevates the upper lip
    • Levator labii superioris alaeque nasi -- dilates the nostril and elevates the upper lip
    • Zygomaticus minor -- elevates and pulls the commissure laterally. Its contraction contributes to the nasolabial fold.
  • Group III -- insert into the lower lip
    • Depressor labii inferioris -- depress the lower lip and pulls it slightly laterally (outward)
    • Mentalis is a paired central muscle of the lower lip. Since its muscle fibers pass in an inferior direction, the action of the mentalis upon contraction is to elevate the lower lip. The insertion site of the mentalis fibers into the dermis can be observed in the pout expression.
    • Platysma is a lip depressor.

The picture below is from the second reference article. If you begin with the upper muscle beside the nose as A, then they are as follows: A – m. levator labii superioris, B – m. zygomaticus minor, C - m. zygomaticus major, D - m. risorius, E - m. depressor anguli oris, F - m. labii inferioris, G - m. orbicularis oris

The picture shows the muscles which are important for movement of lips with the vectors of muscle action. The article begins a discussion of relating the 1) implementation of the function of facial muscles and 2) the interconnection with the voice synthesis application in the world of Animation. Isn't it disconcerting to have the sound and picture of a television show not synchronized? It is for me. I have to just listen and not watch when that happens.

It is important to all the functions of the lips/mouth that these muscle work well. I know this first hand from my episode of Bell's Palsy. With poor control over the right side of my mouth, some words were not easy to pronounce (plosive constant's need a good lip seal). You may know it somewhat from the lingering (temporary) effects of local numbing at the dentist office and the lack of drool control.

REFERENCES

Lips and Perioral Region Anatomy; Babak Jahn-Oarwar MD, Keith Blackwell MD; eMedicine Article, October 9, 2007

Visualization of Talking Human Head; Martin Simunek; Department of Computer Science and Engineering, Czech Technical University, Prague / Czech Republic

Tuesday, January 22, 2008

Arkansas Canstruction 2008

I find it amazing that the above was constructed with cans! It is made from cans of food which will be donated to the Arkansas Foodbank after the exhibit ends. Canstruction, here in Little Rock kicked off January 17th. The teams, comprised of local engineers, architects, and construction worker, had 12 hours to build the elaborate works. This coming weekend I hope to find the time to go see the exhibit. This year it is housed at the Clinton Library.

Canstruction® (from their web site--where you will find more wonderful photos) is the most unique food charity in the world!

A foundation of the Society for Design Administration (SDA), Canstruction® is a design/build competition currently held in cities throughout North America. Teams of architects, engineers, and students mentored by these professionals, compete to design and build giant structures made entirely from full cans of food.
The results are displayed to the public as magnificent sculpture exhibits in each city where a competition is held. At the close of the exhibitions all of the canned food used in the structures is donated to local food banks for distribution to emergency feeding programs that include pantries, soup kitchens, elderly and day care centers.
Since its inception, ten million pounds of food has been donated to aid in the fight against hunger. Initiated by the Denver, Seattle and New York Chapters of the SDA in 1992/93, Canstruction® now has over one hundred individual competitions scheduled to take place during the 2007-2008 cycle.

Monday, January 21, 2008

Orbital Blowout Fractures

Orbital fractures are challenging injuries. They frequently are a component of a more global facial injury. With this post, I'm going to try to concentrate on the orbital fracture, not the broader picture.

In 1957, Smith and Regan (in one article--5th reference) and Smith and Converse (6th reference) coined the term "blow-out fracture" when describing inferior rectus entrapment with decreased ocular motility in the setting of an orbital floor fracture. Pure orbital floor fractures are also referred to as isolated floor fractures.

ANATOMY

Seven bones make up the orbit: the frontal bone, maxilla, zygoma, ethmoid, lacrimal bone, greater and lesser wings of the sphenoid, and palatine bone.The orbital process of the frontal bone and the lesser wing of the sphenoid form the orbital roof. The orbital plate of the maxilla joins the orbital plate of the zygoma and the orbital plate of the palatine bones to form the floor. The medial wall of the orbit consists of the frontal process of the maxilla, the lacrimal bone, the sphenoid, and the thin lamina papyracea of the ethmoid. The lateral wall is formed by the lesser and greater wings of the sphenoid and the zygoma.

The major nerves and vessels to the orbit and globe enter through 3 openings: 1)the superior orbital fissure, 2) the infraorbital fissure, and 3) the optic canal. These three "fissures" create weak points.

For a complete discussion of the anatomy of the orbit, including the vessels, nerves, and ocular muscles, go to this eMedicine article: Orbit Anatomy by Guy J Petruzzelli MD (December 15, 2005).

The article by Manson (9th reference) gives an excellent description of the anatomy of the ligamentous support of the globe. Lockwood's suspensory ligament is a fascial hammock that extends from the medial to the lateral wall of the orbit, cradling the eyeball and helping maintain the vertical level of the globe. When intact, it can support the globe even when the bony orbital floor may be compromised.

MECHANISM OF INJURY

Fractures of the orbit usually result from an impact injury to the globe and upper eyelid. The object is usually large enough not to perforate the globe and small enough not to result in fracture of the orbital rim. Examples include a fist, tennis ball, baseball, snowball or door knob. These fractures are more common in males, between the ages of 21 to 30 years.

The mechanism of a blow out fracture is controversial. There are two main theories that are likely: 1) The fracture results from a sudden increase in intraorbital pressure when the globe is being pushed posteriorly. 2) The fracture is the result of "buckling" forces which are transmitted to the orbital bones by transient deformity of the orbital rim.

Fractures of the inferior orbital wall are most common because of a combination of factors, namely the thinness of the maxillary roof, presence of the infraorbital canal, and the curvature of the floor. Immediately posterior to the rim, the orbital floor is concave and farther back it becomes convex. This configuration predisposes it to buckling and plays a major role in posttraumatic enophthalmos. Isolated fractures of the orbital roof are uncommonly seen in the absence of a fracture of the superior orbital rim. Isolated roof fractures are more common in the presence of a well-pneumatized orbital roof, and have a better prognosis when the orbital rim is spared.

Significant ocular injuries occur in 22-29 % of cases. A careful eye examination is critical. The profound swelling in the periocular region may somewhat limit the eye exam, as may the associated head injury. Globes with a history of cataract removal or other surgery are at much greater risk for perforation following trauma. Any history of previous visual problems or the use of contact lenses or glasses should be documented.

CLINICAL SIGNS AND SYMPTOMS

The main signs of orbital blowout fracture are

I. Diplopia is usually caused by restricted ocular movement, particularly in the upward gaze.

  • It is primary when in the central visual field. Under normal circumstances the eyes seldom deviate more than 20 degrees from the central axis, so diplopia in the the central visual field is very significant.
  • It is secondary when present only on extreme peripheral gaze. This may only be an issue when the patient looks out of the "corner of the eye".

Non-mechanical causes are less common and include injury to one or more of the extraocular muscles (EOM), damage to one of the nerves to an EOM, hematoma, and edema.

The Forced Duction Test is unreliable during the first week after injury because of non-mechanical causes of restriction very often give spurious results. For more on Diplopia see this article by Dr Jeff Mann.

  • 6th nerve palsy => diplopia is greatest when looking to the affected side (abduction)
  • 3rd nerve palsy => diplopia is greatest when looking up and to the opposite side (adduction)
  • 4th nerve palsy => diplopia is greatest when looking down and to the opposite side (adduction)

II. Enophthalmos

Posttraumatic enophthalmos results from

  • Escape of orbital fat
  • Enlargement of the bony orbital volume
  • Muscle entrapment causing backward pull on the globe with secondary contracture
  • Orbital fat necrosis

III. Hypesthesia (or anesthesia) of the infraorbital nerve is common. It manifests as numbness of the gingiva and of the skin of the midface. If there is anesthesia of the gums--think posterior blowout fracture.

IMAGINING

Accurate characterization of all orbital fractures requires a CT scan. It is critical that coronal views be obtained. This may be problematic for patients with suspected cervical spine injuries, as coronal imaging requires hyperextension of the neck. In these patients, the axial images should be reformatted to provide coronal information. Sagittal reconstructions may also be helpful, particularly for those less experienced with orbital trauma. These provide a graphic representation of the superior incline of the orbital floor as one approaches the apex, something often not fully appreciated on the coronal images. Unlike the other facial fractures, evaluation of the soft-tissue windows is helpful with orbital injuries. The soft-tissue details help to show entrapment and/or displacement of the periorbital tissues including the extraocular muscles.

MEDICAL MANAGEMENT

Patients without significant enophthalmos (2 mm or more), a lack of marked hypo-ophthalmus, absence of an entrapped muscle or tissue, a fracture less than 50% of the floor, or a lack of diplopia can be treated conservatively. They will need to be followed closely to make sure nothing changes over the first few weeks/months.

  • The patient should be treated with oral or IV antibiotics (due to the disruption of the integrity of the orbit in communication with the maxillary sinus).
  • A short course of oral prednisone also may benefit the patient by reducing edema of the orbit and muscle. This also may allow for a more thorough assessment of the relative contribution to enophthalmos or entrapment from the fracture versus that from edema.
  • Discourage nose blowing to avoid creating or worsening orbital emphysema. Nasal decongestants can be used if not contraindicated.

SURGICAL MANAGMENT

Timing remains a controversial issue, though it is rarely ever considered emergent. Exceptions to this include situations when muscle is entrapped and possibly ischemic.

  • The classic example of this is the pediatric trap door injury, in which a defect opens in the floor and, because of the greenstick nature of the fracture, subsequently closes again.
  • Findings of entrapment include not just diplopia but often a vagal response, including nausea and syncope secondary to trapped parasympathetic nerve fibers that travel with the muscle.

So with the exception of entrapment, delaying the operation is feasible. This delay is beneficial in allowing the orbital swelling to resolve which improves exposure for the procedure. It takes 1-2 weeks for the swelling to resolve.

Prolonged delay may lead to suboptimal results. Up to 38% of patients who had surgery 2 months or longer after injury may be found to have diplopia compared to only 7% in those who had surgery within 2 months. It has been shown that 72% of patients who had operative repair after 6 month had enophthalmos compared to only 20% who had surgery within 2 weeks of injury.

Indications for surgery

  • Enophthalmos greater than 2 mm during the first 6 weeks
  • Significant hypoglobus
  • Diplopia, especially in the primary field of gaze that fails to resolve after 2 weeks
  • Large floor defect--defined by most as greater than 1 sq cm.

Significant advancements have been made in the evaluation and treatment of internal orbital fractures. Early operative intervention combined with wide exposure, meticulous reduction, and rigid fixation has significantly enhanced the treatment of internal orbital fractures.

BLINDNESS following blunt facial trauma is a rare but devastating injury caused by optic nerve compression. In 1982, Anderson reported on 7 cases of monocular blindness following frontal head trauma treated with megadose steroids or optic nerve decompression. Half had good response to steroids, while 1/4 had minor return of function after decompression. At Baylor, the following protocol is recommended:

  1. Steroid therapy initially for all patients with optic nerve injury.
  2. Decompression for all patients with subtotal or delayed vision loss and significant bony impingement or canalicular hematoma by CT.
  3. Decompression for patient without CT findings that fail to respond to steroids within 12 hours
  4. Decompression is not recommended for immediate blindness.

Dexamethasone Steroid Protocol ( from Anderson et al):

  • loading dose 0.75mg/kg
  • 0.33 mg/kg q 6h x 24h
  • 1 mg/kg q day x 1 - 2 days
  • If no response in 48 h, steroids stopped
  • If response, slow taper for 5 - 7 days, then quick taper off

COMPLICATIONS

Lid Retraction

  • This can be minimized with avoidance of the subciliary incision.
  • If retraction is appreciable in the early postoperative period, aggressive lower eyelid massage and forced eye closure exercises are instituted. This resolves the majority of cases.
  • Early operative intervention should be avoided unless significant corneal exposure and irritation are encountered. This is rarely seen with ectropion but is common in entropion, as the eyelashes are a source of constant irritation.
  • After 4 to 6 months of conservative therapy, unresponsive retractions may be better managed operatively. Regardless of initial incision, operative correction of lower lid retraction should be approached by means of a transconjunctival incision. Release of the middle lamella, the most common cause of significant postoperative retraction, should be followed by filling the defect with a graft of hard palate mucosa and a lateral canthoplasty.

Ocular Motility Deficits

  • Deficits in extraocular movements may be manifest as diplopia in the postoperative period. Although there is always concern regarding entrapment of these muscles, a normal forced duction test at the end of the procedure should effectively rule this out.
  • Frequently, periorbital swelling or muscular contusion and edema may be the underlying cause. Many patients with diplopia only at the extremes of gaze are not sufficiently bothered to seek intervention.
  • Diplopia is more problematic when in the primary field or in downgaze, which may interfere with walking.
  • When the deficit appears first following surgery, a computed tomographic scan should be performed to determine whether the implant is causing interference with the extraocular muscles. If the implant is well positioned, the patient should be followed conservatively along with the ophthalmologist. The need for future surgery and its timing is determined in large part by whether or not any improvement is noted and how distressing these symptoms are to the patient. The majority of these cases will resolve without intervention.

Enophthalmos is perhaps one of the most distressing and common problems seen in orbital fracture management.

  • The majority of cases are the result of persistent orbital volume enlargement secondary to nonanatomical restoration of the orbital cone.
  • On occasion, the implant may have been unintentionally placed in a horizontal orientation into the maxillary sinus.
  • The initial evaluation of postoperative enophthalmos should include a computed tomographic scan to determine implant location and to characterize intraorbital volume.
  • In some cases, the existing implant may be repositioned. This maybe difficult, however, as scarring of the periorbita can impede removal of the implant. In these cases, the implant should be elevated with the periorbita and a second implant placed. If this does not result in an appropriate globe position, additional volume should be added to the orbit. This can be done by placing a carved wedge of high-density porous polyethylene in a posterolateral location within the orbital cone. This allows the globe to project further without altering the vertical position. Just as with primary cases, the position of the globe should be overcorrected.

REFERENCES

Comprehensive Management of Orbital Fractures; Plastic & Reconstructive Surgery. Craniofacial Trauma. 120(7) Supplement 2:57S-63S, December 2007; Cole, Patrick M.D.; Boyd, Vincent M.D.; Banerji, Soumo B.S.; Hollier, Larry H. Jr M.D.

Mechanisms of Extraocular Muscle Injury in Orbital Fractures; Plastic & Reconstructive Surgery. 103(3):787-799, March 1999; Iliff, Nicholas M.D.; Manson, Paul N. M.D.; Katz, Joel M.S., M.D.; Rever, Linda M.D.; Yaremchuk, Michael M.D.

Facial Trauma, Orbital Floor Fractures (Blowout) by Adam Cohen MD and Michael Mercandetti MD --eMedicine Article, December 18, 2006

Evaluation and Management of Acute Orbital Trauma by Philip A. Matorin, M.D.; Grand Rounds --Baylor College of Medicine; April 20, 1995

Blow-out fracture of the orbit; mechanism and correction of internal orbital fracture. Am J Ophthalmol 1957 Dec; 44(6): 733-9; Smith B, Regan WF Jr: [Medline]

Enophthalmos and Diplopia in Fractures of the Orbital Floor; Br J Plast Surg 9:265, 1957; Converse JM and Smith B

Superior Blowout Fracture of the Orbit: The Blowup Fracture; AJNR Am J Neuroradiol 19:1448–1449, September 1998; Rothman MI, Simon EM, Zoarski GH, and Zagardo MT

What are the origins, insertions, attachments, actions and blood supply of the Extraocular Muscles? by Ben Glasgow MD; MedRounds, March 2, 2006

Mechanisms of Global Support and Posttraumatic Enophthalmos: I. The Anatomy of the Ligament Sling and Its Relation to Intramuscular Cone Orbital Fat; Plastic & Reconstructive Surgery. 77(2):193-202, February 1986; Manson, Paul N. M.D.; Clifford, Carmella M. M.A., B.S.; Su, C. T. M.D.; Iliff, Nicholas T. M.D.; Morgan, Raymond M.D.