Case Report: Surgical reduction for hypertrophied lip using electrocautery

Historical background

Reduction cheiloplasty was first described by Stucker FJ Jr. In the case of a Black rhinoplasty patient, an adjuvant operation.⁴

Anatomy of the lip

Understanding the lower face’s surface anatomy, underlying muscle architecture, and neurovascular anatomy is necessary for lip surgery. The philtrum and tubercle in the middle, the two philtral columns on either side, and the white roll of the vermiliocutaneous junction make up the upper lip. The orbicularis oris muscle functions as a circumoral sphincter to maintain oral competence. Its horizontal fibres connect the philtral and modiolus columns, causing the upper lip to tighten as a result. The upper lip is made to evert by oblique fibres that run between the commissure and nasal floor. The mimetic muscles in the area that raise and lower the body act on the orbicularis. The mentalis, depressor labii inferioris, and depressor anguli oris draw the lip downward, whereas the levator labii superioris, levator anguli oris, and the zygomaticus major and minor lift the upper lip.

The inferior labial artery supplies the lower lip while the superior labial artery and its branches from the angular artery serve the upper lip. The blood supply to the lips is obtained from the facial artery. The buccal and marginal mandibular branches of the facial nerve produce motor innervation, whereas the infraorbital nerve V2 and mental nerve V3 supply sensory and motor innervation, respectively, to the upper and lower lips.

The mucosa of the inner lip and the skin of the outer lip are divided by the lip vermilion. It is made up of sebaceous glands and keratinizing glabrous epithelium. Mucocutaneous end organs are heavily innervated in the region that separates the keratinizing vermilion epithelium from the nonkeratinizing labial mucosa.³

Etiology

Surgical procedure

The typical method recommended in the literature for treating hypertrophic lips advises removing a horizontal wedge of soft tissue from both the top and lower lips. Hence lip reduction procedures have historically concentrated on reducing the size of both the top and lower lips without taking into account the relative volume balance between the lips.⁵

Initial therapy

Initial treatment for the patient included instructions about oral hygiene, scaling, and professional polishing using a rubber cup and a low-abrasive polishing paste. For brushing, a modified bass brushing technique was suggested. Plaque control instructions were repeated until patients achieved a plaque score of ≤ 1 PI score. The patient’s plaque control and tissue response were re-evaluated six weeks later. After phase 1 therapy was finished, it was decided to proceed forward with surgically treating the swollen upper lip. Before starting the treatment, the patient was informed of the procedure and informed written consent was obtained.

Measurements of the lip

The following measurements of the lip were made with the help of a dental floss and William’s graduated periodontal probe (Figure 1). For the upper lip, the distance from the vermillion border (A) to the lipline at midline (A¹) was recorded. The line on the left that represents the height was formed by connecting two spots B1 and C1 after two measurements were taken at a distance of 5 mm from the midline. A line was also drawn connecting B and C on the right side. The separation between the two peaks (B and B1) that represent the philtral ridges in their resting position was calculated (Figures 1 and 2).⁵

Figure 1. Ideal shape and measurements of the lip.

Figure 2. Measurements of the lip.

Surgical procedure

A surgical protocol emphasising comprehensive asepsis and infection control was followed, and it was advised to rinse with 0.2% Chlorhexidine gluconate (Hexidine-ICPA Health Product Ltd., India) for one minute before to the surgical procedure. Figure 3 shows the clinical pre-op view. With the aid of an adjuvant pinch technique and tissue forceps, the superfluous mucosa was evaluated after the surgical region had been sufficiently dried. Excessive mucosal tissue was delineated and marked using a marker pencil. Markings were applied as depicted in Figure 4. It was elliptical in shape, narrow at the center and wider at the periphery (Figure 5). With the help of an anaesthetic solution (2% Lidocaine, 1:100,000 epinephrine), adequate anaesthesia was produced, and infraorbital, mental, and oral commissural blocks were given. A number 15 blade was used to make a slightly bevelled incision on one hand, clamping the upper lip between the fingers of the left hand to stop any bleeding, and excising a triangular wedge of mucosal tissue. Using electrocautery with a fine needle tip, hemostasis was obtained (Figure 6). Figure 7 shows the excessive mucosal tissue after it was excised. Figure 8 shows the operating site after the excision. Suturing was done in two stages with 4-0 silk sutures, initial closure of the deep layer followed by suturing of the cutaneous layer using interrupted sutures. No surgical dressing was given (Figure 9).

Figure 3. Clinical pre-op view.

Figure 4. Markings applied.

Figure 5. Elliptical in shape, narrow at the center and wider at the periphery.

Figure 6. Using electrocautery hemostasis was obtained.

Figure 7. Excessive mucosal tissue excised.

Figure 8. Operating site after the excision.

Figure 9. Suturing of the cutaneous layer using interrupted sutures.

Post-operative care

Antibiotics and analgesics were prescribed for 5 days during the post-surgical period. The patient was instructed not to brush for first 3 weeks after surgery at the treated site. Rinsing with 0.2% chlorhexidine gluconate twice daily for 3-4 weeks was advised.

The patient was told to limit lip movement for two to three days. For four to five days, a liquid diet was advised. At intervals of 10 days, 4 weeks, and 3 months, the patient was called back for reevaluation. Each recall visit reinforced maintaining oral hygiene. At 4 weeks and 3 months after surgery, the pre-operative clinical parameters were redone (Figure 10).

Figure 10. Post-op view after 4 weeks and 3 months.