Abstract
Postoperative evaluation of results of reconstructive procedures of the lips mainly consists of describing the technique, complications and subjectively interpreted patient photographs. The authors present a photo-assisted pre- to postoperative evaluation of reconstructive procedures of the lips based on anthropometric measurements and functional outcome. Forty-eight patients underwent partial or full thickness excision of tumours of the lips and subsequent reconstruction. An analysis of standardized pre- and postoperative photographs included measurements of intercanthal width, mouth width, philtrum width, lateral upper lip height, upper and lower lip height, cutaneous upper and lower lip height, upper and lower vermilion arc and upper and lower vermilion height. Assessment of functional outcome consisted of the evaluation of oral competence, changes of oral opening and sensation. The effects on the described parameters were analysed, when partial or full thickness reconstruction had to be performed. Intercanthal mouth width index, vermilion arc index, vermilion and cutaneous total lower lip height index showed statistically significant effects postoperatively which indicates a postoperative tightened lower lip, when full-thickness excision was performed. In all patients the indices were proven reproducible and reliable. The standardized measurements described are accurate and objective for evaluating postoperative results.
The lips are of great functional and cosmetic importance for the perception of facial beauty. Exposure of the lips to solar radiation and chronic irritation from tobacco predisposes this region to neoplasia. Lip cancer peaks in the sixth to seventh decades. Common clinical signs are ulceration, encrustation, and soreness. The surgical technique used in these patients depends on the location and size of the tumour, tumour entity, local tissue capacity, and functional needs.
According to the authors’ experience most patients ask for postoperative facial distortion before undergoing surgery of the lips. The face is of essential interest for the patients’ psychosocial health and social integration. Naturally patients want to look as normal as possible after surgery.
To date surgeons have normally performed intraoperative estimation and postoperative evaluation of reconstructive surgery of the lips and perioral region by eye. This type of evaluation requires that the observing surgeon has experience and a complete understanding of the functional, aesthetic and anatomic relations of the perioral region.
Normative anthropometric measurements of the face are related to normality and attractiveness. Their benefit is widely recognized. They have been proved to be useful in aesthetic surgery and in planning changes of facial proportions for example by orthodontics.
The authors think that established photo-assisted anthropometric measurements of the perioral region may help to double check postoperatively the measurements taken intraoperatively in this area. Smaller distortions of the perioral region, which do not lead to obvious disfiguration, may be detected by anthropometric measurements. Also in judicial affairs and legal reports these measurements may be helpful to give objective and reproducible data.
In this study the authors present anthropometric measurements of standardized pre- and postoperative photographs after reconstruction of the lips.
Patients and methods
All the operations were performed in a standardized manner as previously described. Care was taken to reconstruct the continuity of the anterior vermilion border so it was marked before surgery began. Permanent sections of all margins were examined histologically, and closure was performed either immediately as a one-stage procedure or delayed reconstruction was performed secondarily after some days if further resections were necessary and tumour free margins were confirmed histologically. For small lesions, excision and direct wound closure were performed. Isolated vermilion defects were covered by advancement of labial mucosa, which was redraped over the underlying orbicularis muscle. Full thickness resection of the lip, up to one-third, was performed using a wedge-shaped excision and direct closure. Resections of up to two-thirds of the lip were closed by advancement flaps from the chin, cheek, or submandibular region combined with a labiobuccal advancement of mucosa as described by Coppit et al. In case of resection of two-thirds or more, the modified Bernard–Fries technique was performed with a curved incision in the labiomental fold and excision of Burow triangles in the submental and nasolabial folds. After dissection and identification of all three layers (mucosa, muscle, and skin) reconstruction of the continuity of all three layers was performed.
A photographic comparison of the pre- and postoperative situation of two acceptable aesthetic results is given in Fig. 1 .
Objective rating scheme
Coloured frontal view and profile photographs were taken before surgery. Postoperative photographs were taken, when the oedema of the operation had resolved completely, with a Nikon D 80 camera (objective: Nikon AF Micro Nikkor 105 mm 1:2.8 D; aperture: f13; Nikon Corp, Tokyo, Japan) in a standardized manner as described elsewhere. Only photographs in which the patient’s face was clearly at rest were used for further analysis using the Adobe Photoshop CS2 (Adobe Inc., San Jose, CA, USA) software tool. In edentulous patients, the prosthesis was set to support the lower lip.
Based on anthropometric values described by Farkas predefined anatomical landmarks ( Table 1 ) and data ( Table 2 ) were used to calculate the following indices in the frontal view photographs ( Fig. 2 ): intercanthal-mouth width index, representing the intercanthal width (IW, en-en), as a percentage of the mouth width (MW, ch-ch); philtrum mouth width index, the philtrum width between the two crista philtre (PW, cph-cph), as a percentage of the mouth width between the two cheilions (MW, ch-ch); upper lip height mouth width index, representing the upper lip height, the vertical distance between the subnasale and the stomion (ULH, sn-sto) as a percentage of the mouth width (MW, ch-ch); medial-lateral cutaneous upper lip height index representing the cutaneous upper lip height, the vertical distance between the labiale superius and the subnasale (CULH, sn-ls), as a percentage of the lateral upper lip height, the vertical distance between the subalare and the lateral labiale superius beyond the subalare (LULH, sbal-ls′); upper vermilion contour index, the mouth width (MW) as a percentage of the upper vermilion arc (UVA, ch-ls-ch); lower vermilion contour index, the mouth width (MW) as a percentage of the lower vermilion arc (LVA, ch-li-ch); vermilion arc index, the lower vermilion arc (LVA) as a percentage of the upper vermilion arc (UVA).
| En: | Endocanthion |
| Ch: | Cheilion |
| Cph: | Crista philtre |
| Sn: | Subnasale |
| Sbal: | Subalare |
| Sl: | Sublabiale |
| Sto: | Stomion |
| Ls: | Labiale superius |
| Ls′: | Labiale superius vertical beyond the subalare |
| Li: | Labiale inferius |
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