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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 3  |  Page : 247-250

Bilateral oral commissurotomy and buccal mucosa advancement flaps in the reconstruction of post-burns microstomia


Department of Surgery, Division of Plastic Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Date of Web Publication28-Mar-2014

Correspondence Address:
Abdulrasheed Ibrahim
Department of Surgery, Division of Plastic Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.129580

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  Abstract 

Microstomia following burns of the face remains a significant challenge. This article describes the experience in the reconstruction of post-burns microstomia with bilateral oral commissurotomy and buccal mucosa flaps. Four patients aged from 15 to 29 years had commisurotomy and buccal mucosa advancement flaps. All the patients were operated under local anesthesia with sedation. The procedure was bilateral in three patients. There were three females and one male. The most common cause of microstomia was flame burns in three patients while one patient sustained burns to the face following assault with acid. Pre-operative mean mouth opening was 20 mm and post-operative mean mouth opening was 35 mm in the four patients. Median follow-up was 57 days (range 12-472 days). Late follow-up visits revealed that the improvement in mouth opening remained satisfactory. The technique remains useful in restoration of the oral aperture. The operation is easily performed and it is recommended for immediate and delayed reconstruction of the commissure. The functional and aesthetic results are generally well-acceptable.

Keywords: Advancement flap, commissurotomy, microstomia, oral aperture


How to cite this article:
Ibrahim A, Abubakar ML, Maina DJ, Adebayo WO, Asuku ME. Bilateral oral commissurotomy and buccal mucosa advancement flaps in the reconstruction of post-burns microstomia. Arch Int Surg 2013;3:247-50

How to cite this URL:
Ibrahim A, Abubakar ML, Maina DJ, Adebayo WO, Asuku ME. Bilateral oral commissurotomy and buccal mucosa advancement flaps in the reconstruction of post-burns microstomia. Arch Int Surg [serial online] 2013 [cited 2019 Aug 24];3:247-50. Available from: http://www.archintsurg.org/text.asp?2013/3/3/247/129580


  Introduction Top


The lips and the perioral region are the dynamic center of the lower third of the face. Any other tissue does not replicate their role in speech, facial expression, deglutination and aesthetics. [1] The lips and commissures assist in the production of uttered sounds that facilitate spoken language and provide changes of facial expression that facilitate unspoken language. [2] They also function to provide competence to the oral cavity during mastication and at rest by acting as a sphincter mechanism to accept food and fluid and closing to prevent spillage. [3] It is also well-recognized that disfigurements of the lips and commissures causes significant emotional distress. This is because any deformity of the face has always been considered as one of the least desirable handicaps. [4],[5],[6]

A hallmark of the lips and the perioral region is their mobility, which is critical for function and natural appearance. [7] Deep burns of the face and perioral tissues heal with scar formation and contracture with marked reduction in the ability to open the mouth. The end-result is mirostomia, an undesirable narrowing of the oral aperture. [4] Whilst the average intrinsic vertical mouth opening measures 40-50 mm, an opening of 25-35 mm is functional and 10-24 mm is severely limiting. [8] Loss or considerable destruction of these structures has substantial ramifications in the performance of activities of daily living. [3] These essential functional and esthetic requirements thus place exceptional demands on reconstructive techniques. [9] This article describes the experience in the management of post-burns microstomia using buccal mucosa advancement flaps.


  Case Report Top


Surgical technique

The procedure can be performed under local or general anesthesia. Prior to infiltration with a local anesthetic (0.5% lidocaine with 1:200,000 epinephrine), a marking pen is used to outline the points of the new commissure [Figure 1]a. This is determined by a perpendicular line dropped from mid-pupil up to 1 cm lateral to the commissure. Full-thickness skin incisions are made with no. 15 blade. The triangular area of scar tissue on the lateral side of the vermilion is dissected sharply and excised [Figure 1]b exposing the oral mucosa and orbicularis oris [Figure 1]c. It is important to preserve muscle to maintain contour and functional competence of the lips. A vertical incision is made in the buccal mucosa to approximately 1 cm lateral to the skin incision, after which curved vertical incisions are made. This creates three mucosal flaps-superior, inferior and lateral [Figure 1]d. The flap of lateral buccal mucosa is advanced to create the new oral commissure and sutured in place with 5/0 monocryl sutures. This lateral suturing of the mucosal flap is an important factor in preventing contraction of the commissure during the healing stages. The edges of the superior and inferior mucosal flaps are trimmed, undermined and advanced to form the new vermilion border. These flaps are approximated with the mucocutaneous junction of the upper and lower lips using 5/0 monocryl sutures [Figure 1]e. The sutures were removed on the 5 th post-operative day.
Figure 1: (a) Marking of the neo-commissure and outline of skin incision. (b) Excision of scar tissue. (c) Exposure of the oral mucosa and orbicularis oris (superior and inferior mucosa flaps identified with skin hooks). (d) Mucosa advancement flaps elevated. (e) Mucosa flaps sutured to skin edge

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  Results Top


Four patients had commissurotomy and buccal mucosa advancement flaps between March 2010 and April 2013. There were three females and one male. Age at the time of the procedure ranged from 15 to 29 years (median age 21 years). The most common cause of microstomia was flame burns in three patients while one patient sustained burns to the face following assault with acid. All the patients were operated under local anesthesia with sedation. The procedure was bilateral in three patients. Pre-operative mean mouth opening was 20 mm and post-operative mean mouth opening was 35 mm in the four patients. Considerable improvement in mouth opening was obtained intra-operatively [Figure 2]a and b. Median follow-up was 57 days (range 12-472 days). At the 1 st week of follow-up visit, there was a substantial improvement in mouth opening and the esthetic appearance of the commissures was satisfactory. Late follow-up visits revealed that the improvement in mouth opening remained satisfactory.
Figure 2: (a) Pre-operative. (b) Post-operative

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  Discussion Top


Microstomia following burns of the face remains a significant challenge requiring the plastic surgeon to seek creative reconstructive options. [4] The complex anatomy of the oral commissure and modiolus with the extremely specialized functions makes them more difficult to recreate. [4] Reconstruction thus requires thoughtful planning. The goals of reconstruction are both functional and aesthetic and the surgical techniques employed are often overlapping. [7],[9] The functional goals are to maintain intraoral mucosal lining and to preserve the surface area of the commissure and the oral aperture. The competence of the orbicularis muscle sphincter must also be maintained, as this is critical to achieving a functional recovery. The aesthetic goals of reconstruction are to provide adequate replacement of external skin while maintaining the esthetic balance of the vermiliocutaneous junction and lip esthetic units. [1]

Several detailed reviews have described the full spectrum of reconstructive options involving the use of local, regional and pedicle flaps. [4],[5],[10],[11] In the year 1829, the first technique to correct microstomia was presented by Dieffenbach. It involved the advancement of superior, inferior and lateral mucosal flaps to reconstruct the corner of the mouth after removal of a triangular wedge of scar tissue. The same technique was modified by Converse and later by Friedlander et al. in 1974. [9],[12] After commissurotomy, the authors used either a vermilion advancement or the transposition of the buccal mucosa. [11] Gillies and Millard used a vermilion flap for the upper lip and advanced the oral mucosa to cover the deficient area in the lower lip. Berlet et al. addressing the problems of post-operative contracture presented a technique involving opening of the shortened commissure and rotating two rectangular buccal mucosa flaps to cover the raw surfaces. They placed the suture line on the inner aspect of the cheek, thereby discouraging contracture by pulling the corner of the mouth laterally toward the tragus and thus avoiding a rounded or square commissure. [12] Sari et al. advocate the creation of multiple small flaps with different axis. This also has the potential to diminish the chance of recontraction of the commissure because all the flaps have different vectors of contraction. Similar to the principle of the basic Z-plasty procedure, as the vectors of contraction are broken and shifted to different poles, a scar will not be able to contract in the same direction again. [13] The technique described by Villoria transposed inner and outer orbicularis oris muscle flaps and advanced oral mucosa to form the new vermilion. Fairbanks and Dingman reconstructed the oral aperture by obliquely dividing the existing vermilion into two diminishing flaps approximated to the new commissure. [11]

More recently, another alternative for microstomia repair with local oral mucosal flaps has been reported by Johns et al. with the use of two triangular oral mucosal flaps adjacent to the commissure to be reconstructed. One flap was based superiorly and the other was based inferiorly and they were transposed to the new commissural point while their tips were sutured to each other. Although the two techniques mentioned provide lengthening of the horizontal distance from one commissure to the other, a lack of vermilion border continuity from the upper to the lower lip may look unpleasant. Furthermore, both techniques were dependent on only two mucosal flaps that were sutured to each other at the new commissural region. [7]

Microstomia after burns is a contracture caused by the fold in which the external sheet is the scar and the internal sheet is mucosa. [10] Our report describes a technique in the correction of microstomia by elongation of the oral fissure with a V-shape excision of scar tissue (commisurotomy) and restoration of the angle of the mouth with mucosa flaps (buccal mucosa advancement flap). This is similar to the technique described by Sari et al. However, their technique involves breaking the contraction vectors causing blunting of the commissure using an asterisk design (commisurotomy) and restoring the integrity of the oral sphincter using a combination of skin, vermilion and mucosa flaps (Z-plasty). [13] We have used the technique of commissurotomy and buccal mucosa advancement flaps with results that were functionally satisfactory and esthetically acceptable. This technique solves two problems: First, it restores the size of the oral aperture by releasing the contracture at the commissure; and second, it minimizes any esthetic defect caused by deformation of the commissure. It is necessary to take into consideration that the exterior surface of the normal oral angle consists of healthy skin - no red mucosa is visible when mouth is closed; after burns, the cheeks and the upper and lower lips are covered with scars; the vermilion border of the lips is often damaged and loses its brightness. [10]

The advantage of the surgical technique is that it requires minimal dissection. It is technically simple and may be performed under local anesthesia. The buccal releasing incision (commissurotomy) is the most contributory factor for prevention of relapses, which ensures predictable results. [9] However, its main disadvantages include the tendency to post-operative recontracture; [7] It must be emphasized that the most important cause of post-operative relapses are the size and thickness of the lateral mucosal flap, which must not be sutured under tension. [8] This technique may however need additional support with an extra-oral splinting device in selected patients. The principles of surgical post-burn scar correction are valid for comissurotomies as well. Functional corrections must be made before the scars causing these limitations have fully matured to prevent limitation of full range of motion by scar contracture. When performing early functional corrections, esthetic aspects often cannot be weighted equally and in addition to producing a less-than-ideal esthetic outcome, these procedures have an increased risk of being marred by recurring scar contracture. [8]


  Conclusion Top


Given the advantages and limitations of this technique, it can be expected to increase the width and size of the oral aperture. It is recommended for immediate and delayed reconstruction of the commissure. To date, the results appear to be functional and esthetically pleasing for patients.

 
  References Top

1.Baumann D, Robb G. Lip reconstruction. Semin Plast Surg 2008;22:269-80.  Back to cited text no. 1
    
2.Bailey BJ, Johnson JT, Newlands SD. Head and Neck Surgery: Otolaryngology. 4 th ed. Vol. 1, Philadelphia: Lippincott Williams & Wilkins; 2006.  Back to cited text no. 2
    
3.Clayton NA, Ledgard JP, Haertsch PA, Kennedy PJ, Maitz PK. Rehabilitation of speech and swallowing after burns reconstructive surgery of the lips and nose. J Burn Care Res 2009;30:1039-45.  Back to cited text no. 3
    
4.Ayhan M, Aytug Z, Deren O, Karantinaci B, Gorgu M. An alternative treatment for postburn microstomia treatment: Composite auricular lobule graft for oral comissure reconstruction. Burns 2006;32:380-4.  Back to cited text no. 4
    
5.Jin X, Teng L, Zhao M, Xu J, Ji Y, Lu J, et al. Reconstruction of cicatricial microstomia and lower facial deformity by windowed, bipedicled deep inferior epigastric perforator flap. Ann Plast Surg 2009;63:616-20.  Back to cited text no. 5
    
6.Vegter F, Hage JJ. Clinical anthropometry and canons of the face in historical perspective. Plast Reconstr Surg 2000;106:1090-6.  Back to cited text no. 6
    
7.Monteiro DI, Horta R, Silva P, Amarante JM, Silva A. A simple "fishtail flap" for surgical correction of microstomia. J Craniofac Surg 2011;22:2292-4.  Back to cited text no. 7
    
8.Zweifel CJ, Guggenheim M, Jandali AR, Altintas MA, Künzi W, Giovanoli P. Management of microstomia in adult burn patients revisited. J Plast Reconstr Aesthet Surg 2010;63:e351-7.  Back to cited text no. 8
    
9.Koymen R, Gulses A, Karacayli U, Aydintug YS. Treatment of microstomia with commissuroplasties and semidynamic acrylic splints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:503-7.  Back to cited text no. 9
    
10.Grishkevich VM. Post-burn microstomia: Anatomy and elimination with trapeze-flap plasty. Burns 2011;37:484-9.  Back to cited text no. 10
[PUBMED]    
11.Jaminet P, Werdin F, Kraus A, Pfau M, Schaller HE, Becker S, et al. Extreme microstomia in an 8-month-old infant: Bilateral commissuroplasty using rhomboid buccal mucosa flaps. Eplasty 2009;10:e5.  Back to cited text no. 11
    
12.Mehra P, Caiazzo A, Bestgen S. Bilateral oral commissurotomy using buccal mucosa flaps for management of microstomia: Report of a case. J Oral Maxillofac Surg 1998;56:1200-3.  Back to cited text no. 12
    
13.Sari A, Aksoy A, Basterzi Y, Unal S. Reconstruction of the oral commissure with the use of a new technique: The asterisk design. J Craniofac Surg 2009;20:1256-9.  Back to cited text no. 13
    


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Abstract
Introduction
Case Report
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Discussion
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