15. Lip shaving of leukoplakia of the vermilion border by means of rapid pulsed timedsurgical cutting
KEYWORDS: lip shave, leukoplakia of the vermilion, Timed apparatus, rapid pulsed timedsurgical cutting, Electromaniple EM10 Green
This patient, a heavy smoker, has had a white thickened patch on the vermilion border of the lower lip for 18 months.
Owing to the size, position and gravity of this precancerous lesion, we have decided to carry out lip shaving by means of rapid pulsed timedsurgical cutting.
After marking the center of the vermilion, we outline the area of the precancerous lesion. Excision will be extended up to the labial commissures on both sides.
Loco-regional anesthesia is obtained with 2% lidocaine and epinephrine; ½ mg of epinephrine is added to 10 ml of lidocaine.
Ten minutes after the anesthetic solution has been injected, excision begins by means of rapid pulsed timedsurgical cutting at 38 W. The area to be removed is outlined.
As is known, timedsurgical cutting does not burn the tissues and, in the mucosa, the incision is hardly visible. The program data of the Timed apparatus (Korpo srl- Genova-Italy) are: Direct Pulsed 0.3/5.3 Cut, and a 0.10 mm diameter EM10 Green electromaniple is used. Once the operator has delimited the area of mucosa to be removed, the power is increased to 50 W and excision of the mucosal flap begins.
As excision proceeds, the operator inserts absorbable muscle stitches in order to reconstruct the vermilion.
About 70% of cases of leukoplakia are smoking-related, on account of the carcinogenic agents contained in cigarette smoke or because of the heat generated by pipe-smoking. Other causes may be: irritation due to rough teeth, fillings or crowns, or dentures that rub. Prolonged exposure to the sun, poor oral hygiene, alcohol use and oncogenic viruses can also facilitate the development of leukoplakia.
The peak power of 50 W seals the small capillaries. Larger-caliber vessels are sealed by means of electrocoaptation with very fine tweezers, while maintaining the same cutting program.
The muscle suture continues; this also has a hemostatic effect and keeps the operating field dry.
Leukoplakia lesions are potentially malignant, and the body of the lesion presents dysplastic foci. The possible presence of a carcinoma in situ cannot be totally excluded. For this reason, radical surgical excision is the safest treatment.
In this region, non-radical treatments, such as cryotherapy or laser therapy, enable the lesions to heal rapidly. However, the mucosa may be only apparently healthy, and there remains a high risk of invasive carcinomas in areas that are not completely treated.
Once the muscle margins have been brought together, the operator sutures the mucosa with a spiral of 5.0 nylon thread. No signs of burning are seen at the margins. The conical electrode has a triangular cross-section and cuts at a speed that cannot be equaled by any human hand – the return speed of a spring. Cutting is limited to the last few millimeters of the electrode tip, where the concentration of energy is greatest.
Healing of timedsurgical incisions in the mucosa is always excellent; scars are practically invisible and never hypertrophic. This is particularly important in areas that are visible and subject to movement, such as the lip. For this reason, we use pulsed timedsurgical cutting in all surgical procedures performed on the upper and lower vermilion borders, and also to reshape lips that have been deformed by the injection of silicone and permanent fillers.
Campisi M., Capurro S. (2018): Lip shaving of leukoplakia of the vermilion border by means of rapid pulsed timedsurgical cutting. CRPUB Medical Video Journal. Timedsurgery section. https://www.crpub.org
The operation we've just seen is simple and yields a very natural result. What other pathologies is this technique used for?
Although lip shaving dates back to the 1950s, it is little-known but very useful. As well as for treating "precancerous" lesions of the vermilion border of the lip (leukoplakia, keratoses, chronic solar or actinic cheilitis, radiation ulcers, cutaneous horns, chronic fissures, cheilitis glandularis, etc.) lip shave is used to remove superficial or multicentric malignant tumors and in situ or non-invasive carcinomas of the vermilion, and to treat congenital hypertrophy of the lower lip ("Hapsburg lip or negroid lip"), macrocheilia of either lip and diffuse pigmentation of the lip (lentigo). Today, however, most of our lip-shaving procedures are performed to correct the unsightly results of the injection of silicone and permanent fillers into the vermilion border of the upper and lower lips.
With rapid pulsed timedsurgical cutting, are the scars always so good, practically invisible?
The scars are hardly visible. This means that we can even reshape lips that have been deformed by the injection of silicone or other permanent fillers; to do this, we use multiple micro-excisions until we achieve the result that the patient wants.
Do many patients request reduction of the lips?
Yes. A lot of patients want to have natural lips again – with the right proportion between the upper and lower lip and the right harmony of the vermilion. However, reduction is not indiscriminate; it is carried out where it is necessary. If the previous volume increase is esthetically advantageous, we leave it.
When lip shaving is performed in men, are facial hairs a hindrance? If so, what do you do?
We eliminate these hairs by means of definitive rapid epilation. Pulsed timedsurgical epilation enables us to selectively and definitively eliminate all the hair terminals present.
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