REVASCULARIZATION OF UPPER LIP FOLLOWING.pptx

revascularization of lip following avulion injury

1. REVASCULARIZATION OF UPPER LIP FOLLOWING AVULSION INJURY Dr.Ritika Parmar Dept. of Plastic and reconstructive surgery

2. ANATOMY OF LIP

3. INTRODUCTION Upper lip avulsion injuries/amputations are uncommon. Since lip is one of the presenting feature of the face, scar deformity is easily visible; functioning upper lip is also important for speech and oral competence, and hence, a meticulous and good repair is important. These injuries may be due to accidents, or dog/human bite but injury with cutter machine is uncommon. We hereby describe a case of upper lip avulsion injury by cutter machine and its management.

4. CASE REPORT HISTORY 28 year old male patient presented to our casualty room with history of accidental avulsion injury of upper lip while working with cutter machine. On examination, the patient was hemodynamically stable, there were multiple lacerated wounds over both upper and lower lip. A segment involving central and right third upper lip were completely avulsed except bridge of soft tissue in gingivolabial sulcus. This segment was dusky and ischemic. Two other lacerations were present near the left commissure. Right commissure was intact. The columella and the nose were spared. There were no other injuries anywhere else in the body. Patient had no facial fractures or dental injuries.

5. PROCEDURE Patient was taken for emergency E xploration under general anesthesia with nasal intubation, the wound was cleaned and debrided and left superior labial artery was found divided at two levels in the two wounds near the left commissure. The stumps of the severed artery were isolated and prepared for anastomosis. Two microvascular anastomoses were done with no.9-0 nylon (Figure 2). No veins were found in wound for anastomosis. After anastomosis, the central avulsed part was pink and showed normal vascularity. The edges of the wound which showed ischemic changes had to be debrided. The wound was repaired in layers without undue tension.

6. POST OPERATIVE T he patient was administered antibiotics and painkillers and application of a local antibiotic-based ointment was done. Oral hygiene was maintained with mouth wash. Ryle’s tube feeding was done for 5 days. At discharge, ryle’s tube was removed, suture removal was done and oral liquids were started and gradually increased to semi-solid and normal diet as the wound healed. The patient was followed up on regular intervals. There were no post-operative complications and the wound healed uneventfully.

7. At follow up, 24 months postoperatively, the aesthetic results were satisfactory in terms of form, skin color, scar, vermilion match and the function- lip continence.

8. DISCUSSION Facial injuries are common as it is the most exposed part of the body. These injuries have a major impact functionally, aesthetically and psychologically. Lip avulsion injuries are rare and have severe consequences. Considering the anatomy of the lip, reconstruction of any loss of lip tissue, especially upper lip is difficult due to lack of similar tissue elsewhere in the body. Therefore, in cases with lip injuries involving labial artery, microvascular revascularization becomes the first choice of management. The only possible contraindication to this surgery would be if there are other serious injuries whose treatment cannot be deferred primarily.

9. Avulsion of a lip segment can be partial or full thickness involving epidermis, dermis, orbicularis muscle, and labial mucosa. Other options of reconstruction are: 1. primary suturing of the avulsed segment if an intact artery is found. 2. STSG/FTSG if the wound is not full thickness . 3. local/pedicled flap. Small amputed segments (<1.5 cm) can survive as composite grafts. However, with larger segments the chance for the survival of a composite graft is unpredictable.

10.  Replantation is done by anastomosing the labial artery through one or more arterial microanastomoses . There are no venae comitantes accompanying the labial artery. Venous drainage of the lip is through a subdermal and submucosal venous plexus. Complications associated with replantation includes venous congestion, partial tissue loss, continued bleeding from suture sites and acute blood loss; requirement of multiple blood transfusions. These are not a contraindication to replantation surgery and other ways of relieving the venous congestion can be followed like leech therapy, the local use of heparin, local injections of anticoagulants in the replanted part, systemic anticoagulant therapy and allowing the edge of the wound to bleed in the critical neogenesis phase. In our case these methods of relieving venous congestion were not necessary as the narrow bridge of tissue was sufficient for venous drainage.

11. CONCLUSION Lip avulsion injuries with vascular compromise can have devastating consequences. There are several options for reconstruction of lip but preserving the vital lip tissue gives the best result cosmetically and functionally. Hence, microvascular repair of the damaged vessel is the best option whenever possible.

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