MELOPLASTY
(_Surgery of the Cheeks_)
This branch of surgery has to do with the reconstruction or restoration
of the cheek following the excision of scars or the extirpation of
malignant growths. The procedure is also recognized as genioplasty.
SMALL AND MEDIUM DEFECTS
Where the defect occasioned by the ablation is of small extent, the
free and somewhat undermined margins of the wound, which should be made
in elliptical form, are neatly brought together with several retention
sutures alternating with superficial sutures of fine twisted silk.
If deeper structure than the skin be involved, the diseased area should
be carefully removed even to the limitation of the buccal mucous
membrane, the soft parts detached from the mucous membrane to render them
mobile, and the wound brought together by suture. Care must be exercised
so that the tension of the suture does not create a new deformity,
such as blepharal ectropium, distortion of the rima oris or the alæ of
the nose. If there is enough mucous membrane after the excision of the
diseased area, Oberst advocates closing the defect with two pedunculated
flaps made each from the mucous membrane of the cheek and of the lip.
In cases where the whole thickness of the cheek is involved the cheek
can be incised from the angle of the mouth as far as the border of the
masseter muscle down to the adipose layer. A part of the fatty tissue
is exsected and pushed aside, the thumb of the operator being introduced
into the buccal cavity and pressed outward against the cheek to determine
the position and extent of the pathological involvement. The diseased
area is cut out with curved scissors, going well into the healthy tissues.
The wound is then brought together by suture while the defect of the
mucous membrane is tamponed for four or five days, when it can be covered
with Thiersch grafts. The latter in a short time takes on the appearance
of mucous membrane and overcomes the contraction of the ordinary sutured
wound (Edward-Albert).
=Serre Method.=—For still larger defects Serre makes the ablation in
rectangular form, as shown at _A_, Fig. 258, and forms a longer flap of
rectangular form from the tissue of the cheek and neck. This flap he
dissects off from the margin of the maxillary bone to give it the proper
mobility. The flap is drawn upward and sutured, as in Fig. 259.
There is little retraction experienced in this method, and answers well
for defects of medium extent.
[Illustration: FIG. 258. FIG. 259.
SERRE METHOD.]
LARGE DEFECTS
In larger defects the flaps to be utilized in overcoming the deformity
must be taken from the cheek above as well as the anterior chin, as shown
in Figs. 260 and 261.
[Illustration: FIG. 260. FIG. 261.
CORRECTION OF ANGLE OF MOUTH.]
Another method is to cut the two flaps as in Fig. 262.
These flaps are made of the entire thickness of the cheek tissue, and are
slid down into position and sutured or approximated, as in Fig. 263.
[Illustration: FIG. 262. FIG. 263.
CORRECTION OF EXTENSIVE DEFECT AT ANGLE OF MOUTH.]
As a rule the excised mucous membrane subsequently prevents a free
opening of the mouth added to by the contraction of the flaps themselves.
To overcome this a flap of skin with its epidermal surface turned inward
is sutured into the defect, as will be shown presently, or a pedunculated
flap formed at the wound surface before its transplantation into the
defect may be covered with skin grafts (Thiersch).
=Bayer Method.=—Bayer has successfully utilized a large flap from the
mucous membrane of the palate and covered it externally with a flap of
skin taken from the submaxillary region.
=Kraske Method.=—Kraske forms the flap to be turned into the defect
of the tissue immediately surrounding it, as shown in Fig. 264. This
flap may heal into position, even though its pedicle is made up only of
subcutaneous tissue, according to Gersuny.
The epidermal surface of such flap is made to form the inner or mucous
surface of the repaired cheek (see Fig. 265), while its external surface
and the secondary wound are covered with Thiersch grafts, at one and the
same sitting.
The only difficulty experienced in the case with men is that the bearded
surface of this inturned flap offers considerable discomfort to the
patient, although in the majority of cases the skin thus inverted soon
takes on the appearance of the mucosa, the objectionable hairs falling
out and the hair follicles becoming obliterated.
[Illustration: FIG. 264. FIG. 265.
KRASKE METHOD.]
=Israel Method.=—To overcome the above objection Israel makes his flaps
from the skin of the side of the neck, the flap being elongated and
attached at its upper end, as in Fig. 266.
This flap he turns upward into the defects with its epidermal surface
facing inward and sutures it into place, as shown in Fig. 267, leaving
the outer surface to granulate over and thicken on the sutured margins
to heal into place. This requires from fourteen to seventeen days, when
the pedicle is severed and the lower or freed portion of the flap is
brought forward. The granulation of the entire surface is scraped off and
the free end of the flap is turned over upon itself, as it were, and its
margins sutured to the descended skin margin, as in Fig. 268.
[Illustration: FIG. 266. FIG. 267. FIG. 268.
ISRAEL METHOD.]
=Bardenheuer Method.=—Bardenheuer has given this subject a great deal of
attention, and advocates the use of the skin of the forehead for closing
these buccal or oral defects. The skin of the forehead is without hair,
is well nourished, and has little adipose tissue underlying it, facts
that make it especially useful for these operations. The skin surface he
turns into the mouth cavity, while the outer or raw surface is covered
with a pedunculated skin flap taken from the region of the intramaxillary
region.
The secondary wounds of the forehead and below the jaw should be covered
with Thiersch grafts at the same sitting.
The best cosmetic results are obtained by correcting the entire defect at
one sitting, as the subsequent contraction of the flaps do not allow of
it in successive operations.
The apposition of the raw surfaces of the flap from the forehead and
that of the cheek or chin greatly increases their vitality and overcomes
markedly the cicatricial contraction.
The pedicle of the forehead flap is cut apart about the fourteenth day
and replaced.
In the case depicted in Fig. 269 a large portion of the cheek and the
whole upper and a part of the lower lip had to be removed. A large flap
taken from the forehead that turned into the defect (see Fig. 270), and
a flap taken from the intramaxillary region, were brought over the major
and lower portion of its raw and outer surface.
[Illustration: FIG. 269. FIG. 270.
BARDENHEUER METHOD.]
In Figs. 271, 272, and 273 the various steps of the same operation are
more fully shown, including the placing of the Thiersch grafts and the
replacing of the pedicle in Fig. 274.
[Illustration: FIG. 271. FIG. 272. FIG. 273. FIG. 274.
BARDENHEUER METHOD.]
A still more extensive restoration of the cheek is shown in Figs. 275,
276, and 277, and the position of the skin grafts and replaced flap
pedicles in Fig. 278.
[Illustration: FIG. 275. FIG. 276. FIG. 277. FIG. 278.
BARDENHEUER METHOD.]
=Staffel Method.=—Staffel has also utilized pedunculated flaps taken from
the forehead to correct defects of the cheeks and mouth.
His method of procedure in an aggravated case resulting from mercurial
stomatitis with resultant cicatricial trismus is shown in Figs. 279 and
280.
Two pedunculated forehead flaps were employed in the above case as well
as two flaps each attached by a broad pedicle from the skin under the
chin Tripier fashion, and although the patient thus operated upon was
only five years of age, an excellent result was obtained.
[Illustration: FIG. 279. FIG. 280.
STAFFEL METHOD.]
EMPLOYMENT OF PROTHESES
When the defect of the cheek due to the removal of a greater part of its
structure is so large as to frustrate all attempts at its correction we
may resort to the employment of protheses made for the purpose.
In Fig. 281 a case of Morris is shown following the removal of a myeloid
sarcoma involving a greater part of the upper cheek, the eye, and the
palate. The operator had a prothesis constructed by Hayman, which
provided not only an artificial cheek, but also an eye and the palate.
[Illustration: FIG. 281.—CHEEK PROTHESIS, AFTER REMOVAL OF SARCOMA.
(_British Medical Journal._)]
How excellently this has been accomplished is depicted in Fig. 282. This
prothetic contrivance not only improved the patient’s appearance, but
also enabled him to speak intelligibly, which had been impossible, owing
to the absence of a greater part of the soft palate.
[Illustration: FIG. 282.—PROTHESIS APPLIED TO FACE. (_British Medical
Journal._)]
Hayman describes what he did as follows:
“I obtained a model of the mouth, after which an ordinary plate was
made, then a special obturator to correct the palatine defect. With the
obturator in position a model of the remaining hollow was taken, and
from this a silver plate was struck, which filled accurately into the
hollow and under the right ala of the nose; a small tongue of silver was
adjusted over the bridge of the nose, and on to this the spectacles were
subsequently soldered. An artificial cheek and eye were then modeled in
wax to match the other side of the face. A second silver plate was struck
upon a metal cast taken from the model, soldered to the inner plate as a
cover is fixed to a box. An artificial eye was then fixed to the plate
in the proper situation, and the face portion painted flesh-color and
japanned. In order to keep the mask in position, a strong wire, fixed to
the posterior edge of the artificial cheek, passes around the right ear,
and the ear pieces of the spectacles are joined behind the head by an
elastic band.”
[Illustration: FIG. 283.—CIRCULATION OF THE HEAD.
A, Supra-Orbital Vein.
B, Supra Palpebral Vein.
C, Angular Vein.
D, Nasal Vein.
E, Facial Vein.
F, Temporal Vein.
G, Ext.-Jugular Vein.
H, Post-Auricular Vein.
I, Occipital Vein.
J, Post-Ext.-Jugular Vein.
K, Sup. Labial Vein.
L, Inf. Labial Vein.
M, Transverse Facial Vein.
N, Communicating Br. Ophtal Vein.
O, Angular Artery.
P, Ant. Temporal Artery.
Q, Post Temporal Artery.
R, Sup. Coronary Artery.]