Dr. Joel Aronowitz - Real Patients Real Stories: Complex Chin Laceration Repairs and Revision - From E.R to Post Op
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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “Laura is a 37-year-old woman I first met at St. John's Emergency Room in Santa Monica. She had suffered a laceration to the face, including a severe laceration to the lower lip. Here you can see the through-and-through laceration, which is curvilinear, going all the way through the lower lip into the mouth. There are several teeth which are subluxed and fractured, and there is a laceration on the patient's left to the lower lip itself through the vermilion or the edge of the lip. Also, a very significant degloving injury pulling the inside of the lip tissue and facial tissue away from the bone. So, this laceration was numbed and irrigated. The anatomy was exposed, and she underwent an initial repair in the emergency department under local anesthesia at St. John's. It's probably helpful at this moment to take a little time to go back to the original injury and understanding anatomy of the trauma. So, if you look at number one, this is the edge of the external skin at the bottom of the U. There's a second cut also that you notice, and with the revision surgery, I removed that so that there's only one laceration to heal. Then, number two, that redder tissue, is the orbicularis oris muscle. This is the circular muscle that acts as a sphincter around the mouth, and you can see it's been avulsed or torn loose from the right and left sides, and it's remained attached to the skin, the external skin of the lower lip. Then, when we look down at number three, that's the incisor of the mandible on the patient's left side that has been avulsed, and there are multiple dental injuries. Right below that, number four, is the edge of the gingival mucosa. That is the skin of the inside of the mouth that's applied directly to the alveolar portion of the mandible or the jawbone just below the teeth that will go down, form a gutter, and come back up on the inside of the lip. So, that's been torn completely loose from one side of the mouth to the other, and what we see with number five is the mandible itself just below the teeth, basically at the tip of the roots is the level that we're looking at there. So, on the inside, if we were to be able to see inside the mouth, that avulsion or degloving injury goes around quite a bit, basically to the point that the nerves that come out of the mandible on either side, that's the third branch of the trigeminal nerve, those nerves that give sensation to the lower lip are not torn loose, but they are stretched, and there's a neuropraxic or a stretch injury of those nerves so that it affects sensation. So, if we look at the detail on the opposite side of the screen, number six and number six, those are the two edges of the mucosa that were torn loose from one another. So, when they're sewn together, the number six and number six should go together. So, you can see the extent of that tear, and it actually degloves all the way down to the tip of the chin and takes with it part of the muscle of the chin itself right in the middle of the muscle that crinkles up a little bit when we cry. That is called the, that little square shape or rectangular shape muscle called the mentalis muscle has been torn loose as well. So, because of the injuries to these muscles, because of the extent of the tear of the mucosa as well as the external skin, there's a large amount of scar tissue which is going to occur as this heals. And all of that scar tissue will contract. It will want to get smaller, so it'll contract together and that inhibits movement of the lower lip. It even in this case, because it's so severe, inhibits the movement of the mid face. And that's what's responsible for the patient's complaints of not being able to smile as freely as she did before, because when the corner of the mouth is elevated by the zygomaticus muscle, the muscle that is the main muscle of smiling, it's pulling on all that tissue that now is encased in scar tissue. So, eventually, I go back and removed a lot of that scar tissue and we're going to see that here in just a moment. But I hope that gives you a better idea of why there's so much scar tissue in this case and why it affects even the mid face. Okay, good. Let's just look inside here, gentle, gentle. Touch your chin down a little bit so I can see.
Alright, that looks perfect. That has healed. Very nicely. And the little ball you feel here, that's the scar in the lip, you know. Can I have a pick up, please?”
Laura: “I didn't know if I could touch it. The stare strips just came off like yesterday. It's so hard. It's like, am I supposed to massage it or anything?”
Dr. Joel Aronowitz: “So that's all healing fine. So because of the nature of this scar, the injury, there's a couple of things to expect. One is, because it's gone all the way through, the scar tissue goes all the way through and it kind of goes up and in like that and it spreads open wider on the inside. So it's going through skin and it's going through muscle and it's going through more muscle and then it's going through the inside skin. So all of those layers form scar tissue and that firmness is part of the scar tissue forming process. So that's normal. The other thing is that because of the shape in a U shape, the inside of the U is going to get puffy and the outside of the U is going to stay flatter. And that's why the top here is puffy and the bottom isn't. That's going to get a lot better over time but it's going to take time. And then ultimately we may need to do something with it to even improve that because there may be some puffiness that's left over here.”
Laura: “I'd like to not have puffy.”
Dr. Joel Aronowitz: “Yeah, of course. You're already smiling better than you were.”
Laura: “No, I'm not. I am so restricted. It's like my face feels like, the best way I can describe it is I feel like I'm stuck in a bear trap. My face feels like it's stuck in a bear trap. It's like you've got a trap down here. So that's exactly what you have.”
Dr. Joel Aronowitz: “The tissue that's holding your body together has the same protein as in your muscles. It's contractile and it's getting tight. And then it's forming the protein collagen, which is like a bunch of ropes that are being laid down and they're all being weaved tightly together. Because our face moves a lot, it's responding to any movement. So any movement and any pull, it's going to form more in that direction. So I don't want you to try to smile broadly. You don't need to restrict yourself. Your experiencing is normal and totally expected.”
Laura: “And it looks like it's healing well?”
Dr. Joel Aronowitz: “Yeah, it's healing just perfect. Your teeth look good. On the inside of your mouth, it's perfect. On the outside, your lower lip looks like nothing ever happened.
Laura: “You mean this?”
Dr. Joel Aronowitz: “Not only that, but the whole lip. That lip was like a bridge.”
Laura: “Will the ball in my lip go away?”
Dr. Joel Aronowitz: “Yeah, it'll go away. But nobody even sees it. You just feel it. But this whole segment was a bridge and your lower lip could be in a lot worse shape. You have feeling in your lip, which is a miracle.
Laura: “Yeah, it's great.”
Laura: “And it looks like it's healing well?”
Dr. Joel Aronowitz: “Yeah, it's healing just perfect. Your teeth look good. On the inside of your mouth, it's perfect. On the outside, your lower lip looks like nothing ever happened.
Laura: “You mean this?”
Dr. Joel Aronowitz: “Not only that, but the whole lip. That lip was like a bridge.”
Laura: “Will the ball in my lip go away?”
Dr. Joel Aronowitz: “Yeah, it'll go away. But nobody even sees it. You just feel it. But this whole segment was a bridge and your lower lip could be in a lot worse shape. You have feeling in your lip, which is a miracle.
Laura: “Yeah, it's great.”
Dr. Joel Aronowitz: “Because if you don't have feeling in your lower lip, that's a big problem. And the lip itself, the shape is good and it's symmetrical and all. If you didn't see the chin, you wouldn't know there's anything with it. So now the scar here and the tightness and the restriction, okay, that's going to be a problem for a while. But the more important things are totally good. And this is a very expected thing. It's going to be a long time with that and ultimately, I'll probably need to inject a little steroid. I might even need to do a little minor surgery to make that better. Maybe try to make that scar a little straighter instead of as curved. But not to worry right now. Your how many, what was the? It was two weeks on Monday. Yeah, so you mean you're like 16 days or something. You look fabulous. Okay, cool.
After about three and a half months, the scars have healed. The injury is healed. But there is a robust amount of scar tissue. And now things are mature enough that we are considering revision surgery. You can see this C shaped or U shaped scar, how it's puffy above, it's flat below, and it's creating a constriction. Functionally, it also makes it difficult for the patient to open her mouth widely and smile widely. So today we're going to do a scar revision. This is the patient who had the bad chin laceration from a sailing accident where she fell into the wheel of the boat. And the cut goes all the way through into the mouth. There was a severe embulsion injury involving her lip, the chin, all of the structures in between, as well as some of the dentition, some of the teeth in the lower jaw. So if you come with me, you can see here's the scar. Scar looks very good now that it's blanched from my lidocaine, from the lidocaine with epinephrine. But what you can't see is that this is kind of a smiley face shaped scar. And this part above is very puffy and the part below is not puffy. So this shows up a lot because of the difference in the degree of edema or swelling up here versus down below, which is very predictable with this kind of a scar. So what I'm going to do is try to convert this more to a straight line scar. Remove some of that scar tissue and see if we can give her a scar that is more easily hidden with just a little makeup and doesn't involve such a big contour difference. Here's the scar from below. And I've incised and then I've flattened it out here. And now we're going to excise this intervening tissue as well as some of the scar tissue underneath. So here's the tissue we've removed. And now you can see that this above is too high and I'm going to remove some of the dense scar tissue below. And you can't really visually see it, but you can feel it as you cut how dense this scar tissue is right here. You may be able to see the difference that this color is not normal, that's not normal subcutaneous fat. So I'll go ahead and remove that scar tissue. Of course, it will be replaced by additional scar tissue. And that's one of the conundrums of trying to revise scars is that when you when you read, when you put things back together, of course, it will heal with scar tissue again. With the revision, I want to show you what we've done. So as you saw, if you come a little closer here, the cut was like this. So the scar was a curvilinear. I've partially straightened it out so that it's less of a curve. And I've taken a lot of the scar tissue out from appearance in this out. So there's this top part is going to be flat and even with the bottom part. And I also loosened up the scar tissue so that hopefully her lip will be able to move a little bit more normally. And when she smiles, it will show the lower teeth, which is one of her complaints. So there you have it. We'll follow her along and see how she does postoperatively. Until then, hope you have a wonderful day and we'll see you later back here in Aronowitz land.
How many weeks after the revision now?”
Laura: “It's been just a month.”
Dr. Joel Aronowitz: “Can you smile for us? And it's still a little bit elevated above. And there's a little bit of a bump there on the lip still. And how long ago was the original injury? February 15th, so four months, exactly four months. So looking pretty good. And the teeth are back?”
Laura: “Well, I need an implant still that I'm doing at the end of the month on that.”
Dr. Joel Aronowitz: “All right, very good. Thank you for sharing that with us."
After about three and a half months, the scars have healed. The injury is healed. But there is a robust amount of scar tissue. And now things are mature enough that we are considering revision surgery. You can see this C shaped or U shaped scar, how it's puffy above, it's flat below, and it's creating a constriction. Functionally, it also makes it difficult for the patient to open her mouth widely and smile widely. So today we're going to do a scar revision. This is the patient who had the bad chin laceration from a sailing accident where she fell into the wheel of the boat. And the cut goes all the way through into the mouth. There was a severe embulsion injury involving her lip, the chin, all of the structures in between, as well as some of the dentition, some of the teeth in the lower jaw. So if you come with me, you can see here's the scar. Scar looks very good now that it's blanched from my lidocaine, from the lidocaine with epinephrine. But what you can't see is that this is kind of a smiley face shaped scar. And this part above is very puffy and the part below is not puffy. So this shows up a lot because of the difference in the degree of edema or swelling up here versus down below, which is very predictable with this kind of a scar. So what I'm going to do is try to convert this more to a straight line scar. Remove some of that scar tissue and see if we can give her a scar that is more easily hidden with just a little makeup and doesn't involve such a big contour difference. Here's the scar from below. And I've incised and then I've flattened it out here. And now we're going to excise this intervening tissue as well as some of the scar tissue underneath. So here's the tissue we've removed. And now you can see that this above is too high and I'm going to remove some of the dense scar tissue below. And you can't really visually see it, but you can feel it as you cut how dense this scar tissue is right here. You may be able to see the difference that this color is not normal, that's not normal subcutaneous fat. So I'll go ahead and remove that scar tissue. Of course, it will be replaced by additional scar tissue. And that's one of the conundrums of trying to revise scars is that when you when you read, when you put things back together, of course, it will heal with scar tissue again. With the revision, I want to show you what we've done. So as you saw, if you come a little closer here, the cut was like this. So the scar was a curvilinear. I've partially straightened it out so that it's less of a curve. And I've taken a lot of the scar tissue out from appearance in this out. So there's this top part is going to be flat and even with the bottom part. And I also loosened up the scar tissue so that hopefully her lip will be able to move a little bit more normally. And when she smiles, it will show the lower teeth, which is one of her complaints. So there you have it. We'll follow her along and see how she does postoperatively. Until then, hope you have a wonderful day and we'll see you later back here in Aronowitz land.
How many weeks after the revision now?”
Laura: “It's been just a month.”
Dr. Joel Aronowitz: “Can you smile for us? And it's still a little bit elevated above. And there's a little bit of a bump there on the lip still. And how long ago was the original injury? February 15th, so four months, exactly four months. So looking pretty good. And the teeth are back?”
Laura: “Well, I need an implant still that I'm doing at the end of the month on that.”
Dr. Joel Aronowitz: “All right, very good. Thank you for sharing that with us."
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