STOMATOPLASTY
(_Surgery of the Mouth_)
This branch of surgery has to do with the plastic restoration of the oral
orifice. Operations of this kind are required to enlarge a contracted
mouth, termed microstoma, whether the same be due to congenital origin or
to cicatricial contraction after operative interference about this origin.
Stomatoplasty may also be needed to rebuild an abnormally enlarged mouth,
termed macrostoma, which has already been described on page 149.
THE CORRECTION OF MACROSTOMA
The operative methods to correct the latter need little mention, since
there is usually sufficient tissue present from which the orifice can be
properly formed.
The simplest method is to excise the borders of the enlarged mouth or
buccal clefts, whether unilateral or bilateral, and to bring the raw
edges together by suture. These sutures should be made nearly through the
muscular walls of the cheek and at sufficient distance from the edges of
the wounds to avoid tearing through.
When the cleft is of sufficient length to warrant tension sutures, they
may be employed, alternating with superficial sutures to neatly coapt the
skin surfaces.
The mucous membrane should also be sutured with fine silk to insure
a perfect closure of the parts, and to avoid, as far as possible,
intra-oral infection.
When possible the vermilion borders of the lips should be neatly brought
out to the angles of the mouth, where they should be sutured one to the
other somewhat diagonally. This will tend to give the angles a normal
appearance and shape.
=Dieffenbach-Von Langenbeck Method.=—It is not unusual after the
extirpation of a malignant growth that a greater part of the prolabium
has been sacrificed in either of the lips. In this event the vermilion
border must be carefully and neatly trimmed away from the healthy lip,
leaving a median attachment (see Fig. 251).
The two strips of prolabium will be found to stretch easily. They are
utilized to line the entire denuded raw surface and are held in position
by a number of fine silk sutures, as shown in Fig. 252.
[Illustration: FIG. 251. FIG. 252.
DIEFFENBACH-VON LANGENBECK METHOD.]
Accessory mobilizing incisions, as shown in the above figures, may be
necessary to contract the oral orifice sufficiently to permit of such
a prolabial grafting, especially where a greater part of the vermilion
border has been destroyed. These extra incisions are not necessary when
only a small part of the latter is lost; a partial unilateral dissection
in that case would suffice to restore the part.
This prolabial lining of the mouth gives it a puckered and contracted
appearance for a time only, because the parts soon stretch, while oral
gymnastics will help much in restoring its size and usefulness.
The objection to the above method is the danger of partial or total
gangrene of that part of the prolabium which has been dissected up and
stitched to line the mouth as a result of lack of nutrition or to the
bruising or rough handling of the delicate strips during the operation.
=Tripier Method.=—Tripier refashions the prolabium of the mouth by means
of a mucous strip taken from the inner surface of the lip. This strip is
left attached at both ends, forming a bridge flap of mucous membrane, the
pedicles of the ends giving nourishment to the whole. The bridging strip
is slipped into place and is sutured to the outer skin by its superior
border, so as to restore the normal appearance and thickness of the lip.
Antisepsis must be carried out scrupulously and a strip of iodoform gauze
be placed between the lips operated upon and the gum. In forty-six cases
operated upon by this method forty-two were successful, while in two of
the unsuccessful cases there was partial gangrene of the flap.
=Macrostoma and Overdevelopment of the Lips.=—In the cosmetic correction
of macrostoma there may be an overdevelopment of one or both lips as
well as the wide oral fissure. In such cases the lip structures is to be
reduced by the methods heretofore given, before shortening of the mouth
line is undertaken, because of the greater freedom allowed the surgeon to
correct the deformity.
If possible the operation at the oral angles above referred to should be
avoided because of a certain amount of scarring of the skin at either
side of the mouth and the resultant stiffness of the parts due to the
surgical interference; therefore, when practicable, or when the deformity
is of moderate extent, the angles of the mouth should be advanced toward
the median vertical of the lips. In such case it is best to do such
operations before any labial corrections are undertaken.
=Author’s Method.=—The method advised by the author is the employment of
the Dieffenbach procedure as follows:
A V-shaped incision, its apex pointing inward and its distal ends a half
inch from the prolabial line, is made quite deep through the mucosa and
muscular tissue, as shown in Fig. 253. The part included in the V is now
drawn toward the median line of the lip, causing the wound to gape. The
latter is then sutured with deep and superficial silk sutures in the form
of a Y, as shown in Fig. 254. The same operation is repeated at the other
angle of the mouth.
[Illustration: FIG. 253. FIG. 254.
AUTHOR’S METHOD.]
THE CORRECTION OF MICROSTOMA
When the oral orifice has become lessened, as is frequently the result of
cicatricial contraction following ulcerations or operative interference,
but which may, too, occur congenitally, the condition is termed
microstoma.
=Dieffenbach Method.=—Dieffenbach advocates the following operation for
the correction of this abnormality:
Two lateral incisions are made outward from the mouth across the cheeks
and through their entire thickness, extending in length a little beyond
the intended angle of the mouth (see Fig. 255). The mucous membrane from
within is brought forward and is sutured superiorly and inferiorly to the
skin with fine silk sutures.
If there be any difficulty experienced in accomplishing this, owing to
the presence of cicatricial thickening of the parts, the latter must be
excised in gutterlike fashion (author), and the mucous membrane be freed
from its attachment until it comes into place readily.
Care should be especially exercised in lining the angles of the newly
formed mouth.
The subsequent contraction of the rima oris following the above operation
is prevented only by lining the angle with mucous membrane, healing into
place by first intention.
[Illustration: FIG. 255. FIG. 256.
DIEFFENBACH METHOD.]
=Rose Method.=—Rose advises sewing a small triangular flap of mucous
membrane into each angle to overcome the contraction.
=Heuter Method.=—Heuter employs an artificial mouth of hard rubber tubing
of a size corresponding to the new mouth made in the form shown in Fig.
257.
This ring is forced into the oral opening and the patient is instructed
to wear it for some weeks after the operation or until the tissues have
become softened and elongated and will no longer retain it.
[Illustration: FIG. 257.—ARTIFICIAL MOUTH. (Heuter.)]
=Nonoperative Treatment.=—Smaller operations about the mucosa alone are
of no avail to correct this deformity, but where the contraction of the
oral orifice is moderate and of recent origin, exercising the mouth and
stretching the angles forcibly may help to overcome the deformity to
a great extent. Smaller deformities due to contraction usually subside
after a time from the normal use of the mouth.
The hypodermic injection of a solution of thiosanimin or fibrolysin
(Mendel) are of import in cases where an operation cannot be undertaken.
Their use is more fully described in a later chapter.