Vorzug der Bernardschen Operation als Universalverfahren zur Rekonstruktion der Unterlippe nach Carcinomresektion

Summary

Numerous methods have been reported for reconstructing the lip after excision of carcinomas. All of these have been designed to the size and/or site of the defect.

For more than 10 years, we have used the method of Bernard (1852). With some modifications, Bernard's basic concept has been employed successfully for correcting defects of the lower lip, of the labial commissure, or of the upper lip in a single operation at the time of tumour excision.

The frequent application of one “universal procedure” has given us an opportunity of gathering extensive experience with this method. The present paper describes the technique designed for lower lip defects.

Fig. 1 demonstrates Bernard's original technique. It consists in the excision of paranasal skin-muscle triangles bilaterally, and transposing three-layer (skin, muscle, mucosa) cheek flaps towards the mid-line to replace the lower lip. Transposition along the oral opening prevents asymmetries and gaps; but excision of portions of the orbicularis oris muscle, as is done when using the original technique, results in moderate, temporary functional defects. In addition, the vertical scar ends at the labial commissure and fails to simulate the nasolabial fold.

Fig. 2a and b shows the modified procedure designed for reconstructing rectangular lower lip defects. In these, it is essential that the lower lip bases be equally shifted towards the mid-line, which requires the submental excision of skin triangles bilaterally.

The diagram illustrates further modifications. As can be seen, the excision of the skin-muscle triangles is made laterally from the nasolabial fold. The new vermilion border is obtained by excision of a narrow dermal strip, which is covered by redundant mucosa of the cheek.

Fig. 2. c Squamous cell carcinoma superimposed on xeroderma pigmentosum. d The surgical field: excision of the lower lip and bilateral submandibular lymph node exstirpation. e Condition one year postoperatively with good function (no recurrence in the past 4 years).

Fig. 3. In less extensive carcinomas, unilateral application of the “universal procedure” is sufficient.

Fig. 4. In extensive tumours, the procedure can be extended, as is done when employing Dieffenbach's method (1845). This was the case in the patient presented, where both the lower lip and portions of the cheek had to be resected.

Merits of the “universal procedure”:

• It can be employed in almost all defects of the mouth (including conditions involving the labial commissure and the upper lip).

• All layers are replaced by a three-layer transposition flap.

• Configuration and function of the mouth can be restored at the time of tumour excision.

• As the transposition flaps are not placed across the mouth, asymmetries, distortions and gaps can be prevented.

• The modifications of the original Bernard technique have resulted in some improvements (nasolabial fold, vermilion border, orbicularis oris muscle).

Zusammenfassung

Zur Beseitigung von Defekten nach Carcinomresektion im Bereich der Unterlippe, aber auch des Mundwinkels und der Oberlippe, sind viele Methoden angegeben worden, welche jeweils einer bestimmten Ausdehnung und Lokalisation der Defekte zugeordnet werden.

Seit über 10 Jahren haben wir bei einer großen Zahl von Defekten zur Rekonstruktion der Mundspalte eine „Universalmethode” verwendet, welche auf der sinngemäßen Modifikation und Abwandlung der Bernardschen Operation (1852) beruht.

Der Vorteil dieses methodischen Grundkonzeptes ist in der wesentlichen Verbesserung der Ergebnisse zu sehen, die sich aus der zunehmenden Erfahrung bei der häufigen Verwendung einer Methode nahezu zwangsläufig ergeben hat.

In der vorliegenden Arbeit werden die Möglichkeiten an ausgewählten Fällen bei Unterlippendefekten demonstriert.