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Management of Severe Burn Microstomia

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A 67-year-old man developed severe microstomia caused by bilateral scar contractures as a result of flame burn injuries sustained to the head and neck regions... He underwent bilateral commissuroplasty after nonoperative splinting therapy failed... As a result of his severe microstomia, our patient was able to eat only pureed foods, avoided conversation due to speech difficulty, and had a blunted affect from his limited ability to communicate and from appearance of his face, especially his mouth... Despite his pureed diet limitations, preoperative testing did not reveal any nutritional deficiencies... Following commissuroplasty, complications include oral incompetence secondary to orbicularis muscle injury or dysfunction, tongue or lip adhesions, recurrent contracture, and even carcinoma from chronic burn scar... Optimal prognosis hinges on preserving the reconstructed oral aperture through splinting and mouth therapy, which will decrease risk of recurrence and other complications... Postoperatively, our patient has been much more compliant with his speech therapy and splinting as opposed to after his initial burn injury... He is undergoing balloon catheter buccal dilation for a total of 1 hour per day, as well as multidirectional splinting to maintain and improve his oral aperture... At 5 weeks, his interlabial gap measures 2.7 cm (Fig 5), and he reports enjoying eating again with increased enteral intake from a variety of solid foods... In addition, his affect has improved considerably and his family reports he is much more verbal than prior to his commissuroplasty.

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Y-V mucosal advancement flaps originally described by Dieffenbach, with later modifications by Converse.
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Figure 2: Y-V mucosal advancement flaps originally described by Dieffenbach, with later modifications by Converse.

Mentions: Dieffenbach first established a technique in 1831 to treat microstomia, which involved a Y-V advancement of superior, inferior, and lateral mucosal flaps after a wedge-shaped excision of the scar.5 Modifications have since been introduced by Converse,6 Kazanjian and Roopenian,7 and others, who describe a combination of a vermillion advancement or buccal mucosal transposition (Fig 2).2 Alternative surgical options include z-plasties, rhomboid flaps, and scar excision with full-thickness or split-thickness skin grafts.8 We used the technique described by Dieffenbach to reconstruct the commissures bilaterally. Using the mid-pupillary line as a landmark for the lateral commissure (Fig 3), we performed a triangular wedge skin excision and burn scar release, preserving the orbicularis oris muscle. We then developed a plane between the posterior orbicularis muscle and the buccal mucosa to allow creation and advancement of the mucosal flap. A Y-shaped incision was created to form 3 separate mucosal flaps. The central flap was closed to the acute angle of the oral commissure, followed by advancement of the remaining 2 flaps to reconstruct the lateral upper and lower lips (Fig 4).


Management of Severe Burn Microstomia
Y-V mucosal advancement flaps originally described by Dieffenbach, with later modifications by Converse.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5120371&req=5

Figure 2: Y-V mucosal advancement flaps originally described by Dieffenbach, with later modifications by Converse.
Mentions: Dieffenbach first established a technique in 1831 to treat microstomia, which involved a Y-V advancement of superior, inferior, and lateral mucosal flaps after a wedge-shaped excision of the scar.5 Modifications have since been introduced by Converse,6 Kazanjian and Roopenian,7 and others, who describe a combination of a vermillion advancement or buccal mucosal transposition (Fig 2).2 Alternative surgical options include z-plasties, rhomboid flaps, and scar excision with full-thickness or split-thickness skin grafts.8 We used the technique described by Dieffenbach to reconstruct the commissures bilaterally. Using the mid-pupillary line as a landmark for the lateral commissure (Fig 3), we performed a triangular wedge skin excision and burn scar release, preserving the orbicularis oris muscle. We then developed a plane between the posterior orbicularis muscle and the buccal mucosa to allow creation and advancement of the mucosal flap. A Y-shaped incision was created to form 3 separate mucosal flaps. The central flap was closed to the acute angle of the oral commissure, followed by advancement of the remaining 2 flaps to reconstruct the lateral upper and lower lips (Fig 4).

View Article: PubMed Central - PubMed

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

A 67-year-old man developed severe microstomia caused by bilateral scar contractures as a result of flame burn injuries sustained to the head and neck regions... He underwent bilateral commissuroplasty after nonoperative splinting therapy failed... As a result of his severe microstomia, our patient was able to eat only pureed foods, avoided conversation due to speech difficulty, and had a blunted affect from his limited ability to communicate and from appearance of his face, especially his mouth... Despite his pureed diet limitations, preoperative testing did not reveal any nutritional deficiencies... Following commissuroplasty, complications include oral incompetence secondary to orbicularis muscle injury or dysfunction, tongue or lip adhesions, recurrent contracture, and even carcinoma from chronic burn scar... Optimal prognosis hinges on preserving the reconstructed oral aperture through splinting and mouth therapy, which will decrease risk of recurrence and other complications... Postoperatively, our patient has been much more compliant with his speech therapy and splinting as opposed to after his initial burn injury... He is undergoing balloon catheter buccal dilation for a total of 1 hour per day, as well as multidirectional splinting to maintain and improve his oral aperture... At 5 weeks, his interlabial gap measures 2.7 cm (Fig 5), and he reports enjoying eating again with increased enteral intake from a variety of solid foods... In addition, his affect has improved considerably and his family reports he is much more verbal than prior to his commissuroplasty.

No MeSH data available.