26. Rapid pulsed timedsurgical cutting to remodel lip deformities due to over-injection of silicone oil
KEYWORDS: lip remodeling, silicone injections, rapid pulsed timedsurgical cutting
A vermilion border that has been enlarged and deformed by injections of silicone oil can be reduced and corrected. This is done by means of rapid pulsed timedsurgical cutting, which leaves practically invisible scars. It should, however, be borne in mind that the incisions must be made in a non-visible area. The preoperative design must be very precise. Moreover, we need to evaluate any congenital asymmetries of the lip, which is often longer on one side, and the asymmetries caused by the injection of silicone oil. The operator must also bear in mind that the vermilion border of the upper lip is normally one-third narrower than that of the lower lip. In this patient, excisions are to be carried out in both lips.
The Timed apparatus is programmed with the rapid pulsed cutting program data: Direct Pulse 0.3/5.3 hundredths of a second, Cut, 27 or 38 Watt, 0.08 mm diameter EM10 White electromaniple. The return electrode is positioned on the chest, in contact with the skin; in programmable diathermocautery, as is well known, the return electrode must be placed close to the operating field.
Incision begins in the upper lip, and from the posterior line of the design. The 0.08 mm diameter EM10 White electromaniple is the finest of the electrodes and concentrates the energy of the Timed apparatus at its tip.
The operator incises the mucosa, following the preoperative design. The microelectrode of the 0.08 mm diameter EM10 White electromaniple is kept under elastic tension.
Timedsurgical cutting does not burn the edges of the incision and is extremely precise. Indeed, the specific modulated pulsed current prevents overheating; moreover, the conical electrode has a triangular cross-section and acts like a spring. No human hand can equal the speed of its cutting. The availability of a cutting modality that does not leave visible scars is very useful in this procedure, as subsequent small corrections may be required. The operator can carry these out without having to worry about scarring.
Once the incision of the mucosa has been completed, the excess tissue is removed. The power of the Timed apparatus is raised to 50 Watt and the EM10 White electromaniple is replaced by a 0.15 mm diameter EM10 Gray electromaniple. Reduced conductivity and the consequent reduction in the speed of cutting are indicative of the presence of silicone. Excision begins at the extremity of the skin flap. Several millimeters of muscle tissue imbued with silicone are removed. The floor of the excision must be regular along its entire length. In this phase, it is useful to assess the thickness of the lip by holding it between two fingers.
After completing the excision, the operator inserts a stitch into the exact center of the vermilion. Double-spiral suturing with a 5-0 or 6-0 thread is then carried out.
The spiral suture begins from the lateral margin of the skin flap. The first suture draws together the edges of the lip mucosa. The second suture is more external and its spirals are more widely spaced; this suture serves to compact the muscle tissue. In this region, which is particularly mobile, it is important that the suture draws the tissues firmly together and does not open.
A skin flap is now removed from the vermilion of the lower lip, which must have a greater volume than the vermilion of the upper lip. In this case, removal is simple and does not require as much caution as in the vermilion of the upper lip.
Reducing the volume of the vermilion of the upper and lower lips may cause unaesthetic lengthening of the lip. In this case, lip lifting is carried out to shorten the lip. These two procedures rejuvenate the patient's face, giving it a more natural look.
Pulsed timedsurgical cutting and good suturing result in optimal healing, leaving a scar that is practically invisible.
Capurro S. (2022): Rapid pulsed timedsurgical cutting to remodel lip deformities due to over-injection of silicone oil. Timedsurgery section. https://www.crpub.org
As silicone oil is difficult to eliminate from the lips, does some of it remain?
Yes, some remains in the tissues. However, it is still possible to remodel the lips, reduce their volume and make them look more natural.
Is there any alternative to silicone?
We perform Adipofilling, which involves injecting a suspension of tiny lobular fragments and adipocytes and stromal cells. The suspension is injected into the vermilion through a fine cannula. Adipofilling enhances the volume and exerts a trophic action. Volumetric enhancement of the vermilion by means of fat grafting is a natural biological procedure and gives aged lips a new lease of life. Moreover, as the Adipofilling suspension can be conserved at temperatures between -20°C and -81°C, it can be used for any minor adjustments that may be required.
When do you recommend lip lifting?
If the vermilion borders are markedly reduced, the upper lip loses its support and tends to lengthen. For this reason, we perform lip lifting after a few months, in order to shorten the upper lip. In this procedure, we incise the skin by means of slow pulsed timedsurgical cutting; the incision does not extend beyond the nostrils even if the lip needs to be shortened considerably.
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