Management of microstomia in adult burn patients revisited

Prevention and treatment of microstomia

The mouth, located in the lower third of the face, is a uniquely visible structure. It serves as a vital organ both aesthetically and functionally, playing a key role in speech, expression, and fundamental oral functions. Consequently, any alterations or defects in its shape, due to various causes, can lead to aesthetic and functional deficiencies. These issues may also result in challenges with social interactions and a decrease in confidence. In cases of microstomia, various surgical approaches are proposed based on the location, extent, shape, and cause of the defect, leading to numerous case reports. Plastic surgeons are proficient in oral reconstruction; however, cases of microstomia are relatively rare, which reduces their familiarity and interest in these cases. Additionally, preferences for oral size and shape vary according to factors such as geographical region and ethnicity, further complicating the functional definition of microstomia. Therefore, both subjective patient and physician judgments play crucial roles in the diagnosis and treatment of microstomia, as these may vary depending on individual and societal aspects. This review aims to classify the various causes and definitions of microstomia, as well as its non-surgical and surgical treatment options, with the goal of the treatment of this condition.

Periorbital and Perioral Defect Reconstruction Using the Split Pre-Expanded Medial Arm Flap Aided by Using Indocyanine Green Angiography

ABSTRACT

The pre-expanded medial arm flap provides suitable skin for the resurfacing of a periorbital or perioral defect. However, the flap must be intraoperatively split to imitate the appearance of the oral or ophthalmic fissure, which can compromise flap perfusion. This study aimed to evaluate the safety and effectiveness of splitting pre-expanded medial arm flaps with the aid of indocyanine green angiography. All 8 patients underwent periorbital or perioral soft tissue reconstruction using a split pre-expanded medial arm flap. Flap splitting was aided by indocyanine green angiography. It was used during 2 stages of the procedure, tissue expander placement and flap transfer. The pedicle was divided 3 weeks later, and the flaps were used to resurface the defect. The distal portion of the flap was split into a fishmouth pattern in 5 patients and a window pattern in 3 patients. The donor sites were closed directly or by using a latissimus dorsi myocutaneous flap. There were no perioperative complications or flap necrosis. A pre-expanded split medial arm flap could be an option for the reconstruction of periorbital and perioral defects. With the assistance of indocyanine green angiography, vessel distribution and distal flap perfusion can be reliably evaluated, facilitating the safe splitting of the flap for the reconstruction of defects.

Lip and Perioral Trauma: Principles of Aesthetic and Functional Reconstruction

Successful management of lip and perioral trauma requires a nuanced understanding of anatomy and surgical techniques. Surgical correction is particularly challenging in instances of tissue loss, due to a narrow tolerance for aesthetic deformity and highly specialized functions of the perioral region, including facial expression, communication, and oral competence. Restoring continuity of the orbicularis oris musculature is critical for dynamic sphincter function of the upper and lower lips. Lip and perioral tissue symmetry are also critical for aesthetic balance, and failure to restore a natural appearance can adversely affect personal identity, with attendant psychological trauma. This discussion of lip and perioral trauma management encompasses lip and perioral anatomy, evaluation of injuries, reconstructive techniques, and prevention and management of complications. Perioral injuries are classified by size, depth, and extent of injury, and the corresponding reconstructive approaches are a function of complexity. These approaches proceed sequentially up rungs of the reconstructive ladder including primary repair, local flaps, grafting, regional flaps, as well as microvascular free tissue transfers. Procedures may be single stage or require multiple stages or subsequent refinement. Regardless of the defect size or location, the guiding principle of repair in the perioral region is restoring natural function and aesthetic appearance. This still-evolving area of facial plastic and reconstructive surgery lends itself to artistry and technical precision, offering opportunities for further innovation to improve the outcomes of patients with lip and perioral trauma.

Posterior Based Triangular Mucosal Advancement Flap for Surgical Correction of Scleroderma-Induced Microstomia

ABSTRACT

Systemic sclerosis is a complex autoimmune connective tissue disease of unknown cause that causes sclerosis and inflammation of the skin and subcutaneous tissue. Sclerosis involving the face can lead to microstomia, leading to difficulties with mastication, phonation, and oral hygiene. Although many agents have been used to treat internal organ involvement, they often have compromised efficacy on cutaneous manifestation including facial dermal sclerosis. In this case presentation, we will introduce a surgical technique to correct scleroderma-induced microstomia.

Oro-facial fibrosis in systemic sclerosis: a reconstructive journey

Oro-facial fibrosis presents a significant disease burden in patients with systemic sclerosis, but there remains no established treatment modality. Autologous fat grafting is a minimally invasive surgical procedure that is now increasingly recognised for its regenerative capacity, propagating an expansion of heterogeneous indications beyond volume restoration, including fibrotic diseases such as systemic sclerosis. We present a 42-year-old woman with oro-facial involvement of systemic sclerosis leading to severe limitation in mouth opening and closure, with marked retraction of the lower lip and gingival display. We describe the reconstructive journey over a 12-year period, where the antifibrotic effect of autologous fat grafting served as the basis on which a series of surgical procedures were performed to achieve functional and aesthetic improvement. Autologous fat grafting provides a novel treatment modality for oro-facial skin fibrosis, previously considered a non-treatable disease manifestation of systemic sclerosis.

Orofacial rehabilitation after severe orofacial and neck burn: Experience in a Brazilian burn reference centre

OBJECTIVE

To quantify the benefits of a functional oral rehabilitation program for impairment caused by full thickness orofacial and neck burns, comparing the effects of early and late intervention.

METHODS

An observational cross-sectional study was conducted in a burn reference center over a two-year period. Patients with full thickness orofacial and neck burns were divided in two groups: Group 1 was composed by 14 patients who began the rehabilitation program 3-12 months after the burn injury; Group 2 was composed by 15 patients who began the rehabilitation program more than 12 months after the burn injury. Treatment was based on current strategies of non-surgical exercises for orofacial contracture management. Outcome measurements included an oral motor clinical evaluation and the assessment of the mandibular range of movement.

RESULTS

The functional rehabilitation program was effective in reestablishing the oral motor functions (i.e deficits reduced to approximately 15% when compared to the optimal possible scores) and in restoring horizontal mouth opening dimensions, with more than 70% of the patients presenting measurements within the expected normal limits at the end of treatment. Our results did not indicate differences in performance between the group of patients in neither set of assessments, i.e. pre and post treatment (p > 0.05).

CONCLUSION

The results of this study indicate that non-invasive orofacial contracture management is effective for patients with orofacial and neck burns, including those with long term sequelae.

Reconstruction of microstomia considering their functional status

Background

Microstomia is defined as a condition with a small sized-mouth that results in functional impairment such as difficulty with food intake, pronunciation, and poor oral hygiene and cosmetic problems. Several treatment methods for microstomia have been proposed. None of them are universally applicable. This study aims at analyzing the cases treated at our institution critically reviewing the pertinent literature.

Methods

The medical records of all microstomia patients treated in our hospital from November 2015 to April 2018 were reviewed retrospectively. Of these, all patients who received surgical treatment for microstomia were included in the study and analyzed for etiology, chief complaint, surgical method, and outcomes. The functional outcomes of mouth opening and intercommissure distance before and after the surgery were evaluated. The cosmetic results were assessed according to the patients’ satisfaction.

Results

Five patients with microstomia were corrected. Two cases were due to scar contracture after chemical burn, two cases derived from repeated excision of skin cancer, and one patient suffered sequela of Stevens-Johnson syndrome. The following surgical methods were applied: one full-thickness skin graft on the buccal mucosa, three buccal mucosal advancement flaps after triangular excision of the mouth corner, and one local buccal mucosal flap. Mouth opening was increased by 6.0 mm, and the intercommissure distance improved by 7.2 mm on average. Follow-up was 9.6 months (range, 5–14 months). Cosmetic assessment was as follows: two patients found the results excellent, three judged it as good.

Conclusion

Microstomia has several causes. In order to achieve optimal functional recovery and aesthetic improvement it is important to precisely evaluate the etiologic factors and the severity of the impairment and to carefully choose the appropriate surgical method.

Early surgical correction of microstomia following Stevens-Johnson syndrome

Stevens-Johnson syndrome (SJS) is a rare disease in which extensive toxic epidermolysis occurs after medication. Skin and mucous membranes are involved in about 90% of SJS cases, and webbing of mouth corners (microstomia) may occur when they are affected. Few reports have been issued on microstomia in SJS, and no consensus has been reached regarding treatment methods, timings, or results. We encountered a case of microstomia following SJS after ofloxacin medication in a 22-year-old woman treated by commissuroplasty using a lozenge-shaped excision. We present an appropriate correction method and surgical timing for microstomia following SJS.

The Importance of Dental Appliances for Oral Commissure Reconstruction in Trauma-Induced Microstomia: A Clinical Report

Reconstruction of the oral commissure is necessary after trauma, pathological resection, or electrical, chemical, or thermal burns. Using dental appliances is strongly recommended to prevent microstomia in victims with oral commissure injury caused by burns. These appliances can be modified from dynamic to static for more patient comfort during the healing period and used in trauma patients to prevent rounding of the labial commissure. Preventing relapse of microstomia and forming acute angles at the corner of the mouth are 2 optimal goals when performing this surgery.

Correction of Microstomia Reconstruction With the Use of Acellular Dermal Matrix for Buccal Reconstruction

Correction of microstomia is challenging with a high rate of recurrence. We report the successful treatment of microstomia using acellular dermal matrix (ADM) as an adjunct for intraoral lining with >1 year of follow-up.A 9-year-old international patient with severe immunodeficiency presented with severe microstomia because of recurrent oral infections. She had undergone 3 previous failed attempts to re-establish an adequate oral opening and was dependent on enteral nutrition via gastrostomy tube. She underwent release of the oral commissure scar contracture and orbicularis oris and the resultant mucosal defect was lined with ADM. A postoperative splint was used for 8 weeks. One-year follow-up demonstrated maintenance of the oral aperture with complete mucosalization of the ADM; the patient was able to resume oral diet and regular dental hygiene.Mucosal reconstruction with ADM is a viable alternative to local flaps and in this case exhibited minimal soft tissue contraction.

Head and Neck Reconstruction

Management of head and neck burns involves acute and intermediate phases. Acutely, the goals are establish a secure airway and treat life-threatening injuries. Then, optimize nutrition, assess extent of the burn, perform local wound care, and provide eye protection. Management depends on the degree of the head and neck burn. Postinjury splinting and rehabilitation are vital to healing. After the acute inflammation has resolved and the scars have matured, reconstruction begins with the goals of restoring both function and aesthetics. Reconstruction ranges from simple scar release, to skin grafting, and possibly free flap reconstruction.

Heterotopic Ossification and Hypertrophic Scars

Burns and trauma cause superficial and deep soft tissue wounds that cannot heal to the preinjury state. Healing requires cell proliferation and differentiation into the injured tissue type, laying down extracellular matrix, often as collagens. Heterotopic ossification causes severe pain, nonhealing wounds, and restricted range of motion. Treatment includes radiation therapy, nonsteroidal anti-inflammatory drugs, bisphosphonates, and possibly surgical excision and prophylactic measures. Hypertrophic scars, nonosseous lesions caused by excessive collagen deposition, are often painful, functionally limiting, and aesthetically displeasing. Treatment includes CO2 laser application, steroid injections, and excision with skin grafting. This article reviews the management of these pathologic wounds.

Intensive swallowing and orofacial contracture rehabilitation after severe burn: A pilot study and literature review

BACKGROUND

Dysphagia following severe burns can be significant and protracted, yet there is little evidence describing the rehabilitation principles, process or outcomes.

PURPOSE

Outline current evidence and detail the clinical outcomes of two cases who underwent a multifaceted intensive treatment programme aimed at rehabilitating dysphagia by strengthening swallow function and minimising orofacial contractures after severe head and neck burns.

METHODS

Two men (54 and 18 years) with full-thickness head and neck burns and inhalation injury underwent intensive orofacial scar management and dysphagia rehabilitation. Therapy was prescribed, consisting of scar stretching, splinting and pharyngeal swallow tasks. Horizontal and vertical range of movement (HROM; VROM), physiological swallow features, functional swallowing outcomes and related distress, were collected at baseline and routinely until dysphagia resolution and scar stabilisation.

RESULTS

At presentation, both cases demonstrated severely reduced HROM and VROM, profound dysphagia and moderate dysphagia related distress. Therapy adherence was high. Resolution of dysphagia to full oral diet, nil physiological swallowing impairment, and nil dysphagia related distress was achieved by 222 and 77 days post injury respectively. VROM and HROM achieved normal range by 237 and 204 days.

CONCLUSION

Active rehabilitation achieved full functional outcomes for swallowing and orofacial range of movement. A protracted duration of therapy can be anticipated in this complex population.

Treatment of microstomia caused by burn with a nasolabial flap--an ingenious approach for tugging and fixation of the oral commissure

The objectives of surgical treatment for microstomia due to cicatricial contracture after burn are to obtain sufficient oral aperture, while maintaining sphincter function of the orbicularis oris muscle, and to secure favorable function for eating and conversation in addition to good oral health.The lips of the mouth have a free border, and the oral aperture, which has been enlarged by the operation, tends to be reduced, because of the actions of the orbicularis oris muscle. When the orbicularis oris muscle is resected, putting a priority on sufficient oral aperture and prevention of redevelopment of contracture, the function of the sphincter is often damaged. With the exception of those cases with deep extensive burn that damages a wide area of orbicularis oris muscle, the muscle should be preserved as expeditiously as is practical. In such cases, however, preventive measures for the redevelopment of microstomia should be established. As a postoperative adjuvant therapy, the usefulness of splint therapy has been suggested in many reports. However, a splint should be used for a long period after the surgery, and in some cases, pain is observed with therapy. When a splint is not used for an appropriate period, microstomia may redevelop. It would be ideal to take preventive measures against the redevelopment of contracture during surgery.We provided treatment with some ingenious attempts for the nasolabial flap to a patient with microstomia caused by cicatricial contracture after burn. We obtained favorable results with no postoperative use of a splint.

Complete Denture in a Microstomia Patient

Microstomia is the term used to describe a condition of reduction in the size of oral aperture which can be either acquired or congenital and affects the quality of life. Dentists occasionally come across patients with constricted oral openings. Limited oral opening makes access to the oral cavity for any dental procedure difficult. It's the duty of a dentist to provide every possible care to the patient with microstomia. This paper describes the treatment of a microstomia patient requiring complete dentures using sectional dentures. The cause of microstomia in the indexed patient was developmental in nature as all other causes of related conditions were ruled out. Finally upper and lower complete denture with sectional components were given to the patient after modification in conventional steps of its construction.

Review of burn research for the year 2010

Like the previous year, 2010 was another active year for research in burn care. For this year, more than 1200 burn-related articles were published on a diverse array of topics. In this review, we focus on innovative and impactful burn injury-related research. As in the previous review, we group articles according to the following categories: critical care, infection, inhalation injury, epidemiology, psychology, wound characterization and treatment, nutrition and metabolism, pain and itch management, burn reconstruction, and rehabilitation. We have found that burn research continues to be prolific throughout the world and reflects the wide-ranging and complex care requirements of burn survivors.