Step 5 Closure

Restitution of the nasolabial muscles is performed as three uniform steps during closure of the maxillary vestibular incision. The first step involves identification and resetting of the alar bases, the second involves eversion of the tubercle and vermilion, and the last involves closure of the mucosa.

To help control the width of the alar base, an alar cinch suture is placed before suturing the lip. Suture placement is accomplished in one of two ways. With one technique, small toothed forceps placed through the vestibular incision grasp the insertion of the transverse nasalis muscle. Pulling the forceps medially allows one to see the change that occurs in the alar base. A slowly resorbing suture is passed through this tissue, taking care to engage adequate tissue to resist the pull of the suture, but not so much that a subcutaneous dimple occurs when the suture is pulled medially. The suture is then passed through the opposite side and temporarily tightened to examine the effect of the medial pull of the alar bases on the nose (Fig. 7-7). Another method is to evert the tissue into the incision area by pressing the thumb or finger into the alar facial groove (Fig. 7-8). A suture can then be passed through the incision, into the tissues, the depth of placement being guided by palpation of the thumb or finger. Whichever method is used to pass the suture through the nasalis muscle, the appearance must be symmetric and the desired curvature and definition of the alar base should be achieved after provisional tying. Tying the suture is delayed until a second suture is passed. The second suture is placed at a higher level or more laterally on the alar base, depending on the desired rotation of the ala. Generally, two sutures are adequate.

Figure 7- 7 Effect of the alar cinch technique of the width of the alar base. Note the difference after tying the suture.

A V-Y advancement closure of the maxillary vestibular incision is recommended where the incision has been placed across the base of the nose and subperiosteal dissection of the tissues along the piriform aperture has occurred. In closing the maxillary vestibular incision, a skin hook engages the labial mucosa incision in the midline and pills it away from the maxilla (Fig. 7-9). Three or four interrupted resorbable sutures are used to gather lip tissue in the midline. The mucosa and labia musculature are engaged by the needle on either side of the incision and then sutured. In most cases, 1 cm of tissue is closed in this manner, creating a pout in the midline of the lip. When this step is performed properly, the lip bulges anteriorly in the midline and the exposed vermillion is full. Within 7 to 10 days, this fullness gradually settles and a more normal appearance returns.

Figure 7- 9 V-Y closure of a lip incision. A skin hook is placed in the midline and tissue is gathered for approximately 1 cm with suture.

After closing the vertical limb of the V-Y advancement, a single suture is placed across the incision in the midline to ensure symmetric closure of the horizontal posterior incisions. When closing the horizontal incision, one should begin in the posterior and work anteriorly with a running resorbable suture (3-0 chromic catgut) through mucosa, submucosa, musculature, and periosteum. The superior aspect of the incision is gradually advanced toward the midline by passing the needle anteriorly in the lower margin of the incision as compared to the upper margin. This maneuver, in addition to the V-Y closure, helps lengthen the relaxed musculature so that it reattaches in its proper position (Fig. 7-10). From the canine-to-canine area, the suture is passed close to the edges of the incision to prevent gathering of the mucosa, which rolls the lip inward and reduces the amount of exposed vermilion.

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