Special organs: The eyelids, nose, lips and tongue

The eyelids, nose, lips and tongue are organs in the head and neck region that have special functional and aesthetic significance.  Disease states affecting these organs are functionally significant and affect the quality of life.  Furthermore, the eyelids, nose and lips are of great aesthetic value and many cosmetic procedures are performed for their rejuvenation.  Pathology of these areas result in diminished body image and self-confidence and reduces individuals’ social functioning.  The tongue also has special functional significance and is critical for eating and speech.  Reconstruction of these special organs requires special attention to ensure restoration of functional and aesthetic outcomes.

The eyelids

The eyelids are unique in their form and serve critical function in protecting the eye by blinking and voluntary closure when asleep, as well as adequate opening for vision.  The eyelids also spread a thin tear film across the surface of the eye to ensure that the eye remains adequately lubricated to prevent desiccation (dryness) and prevent corneal ulcers.  It is often said that the eyes are the windows to the soul and the eyelids are important in nonverbal cues and expression, which are integral in social interactions.

Structural defects and functional deficits often coexist.  The clinical presentation of eyelid disease may be divided into:

  • Functional deficits. This includes incomplete eye opening (ptosis) and incomplete eye closure (lagophthalmos).
  • Structural deficits. This includes loosening or loss of the eyelid cartilage (tarsal plate), ligaments or muscle weakness leading to various types of eyelid malposition.  Eyelid malposition may present with vertical descent, inward (entropion) or outward (ectropion) eyelid rotation.  Eyelid malposition may be accompanied by incomplete eye closure (lagophthalmos)
  • Surface deficits.  Surface deficits may be partial thickness (skin, muscle, cartilage) of full thickness eyelid loss involving all layers.

There is a multitude of possible causes of eyelid pathologies.  Accurate clinical assessment is important in determining the appropriate treatment.  These include:

  • Functional pathology. Ptosis is usually the result of weakness or detachment of the upper eyelid elevator muscle causing difficulty in eyelid opening.  This is most frequently due to age-related muscle degeneration.  Lagophthalmos may occur from paralysis of the orbicularis (blink) muscle or the nerve supplying this muscle in conditions such as Bell’s palsy.
  • Structural pathology. Structural deficits involving the eyelid cartilage (tarsal plate), ligaments or muscle may arise from tumor resection surgery, burn injury, and/or traumatic loss.  Paralysis of the orbicularis muscle also leads to loss of support in the lower eyelid and causes structural deficits.

Surface deficits.  These often arise from tumor resection surgery, burn injury, and/or traumatic loss.

The eyelids have critical functions and are central to the aesthetic of an individual.  They are anatomically delicate structures and require particular attention.  Accurate clinical assessment and precise technical execution of surgery are required to ensure functional, attractive and bespoke results.

Surface defects in the eyelids are a common clinical problem.  Direct suturing is used to close small surface defects in eyelids with sufficient skin laxity, while moderate-sized defects are amenable to skin grafts taken from the other eyelid, behind the ear or from the neck.  Large defects may require use of skin flaps taken from the adjacent brow or cheek, or the uninvolved upper or lower eyelids.

Diseases affecting the lower eyelid support ligaments are treated by ligament repositioning or ligament length alteration where appropriate.  Tendon grafts may occasionally be used to lengthen the lower eyelid ligaments or to support a weak orbicularis muscle.

Ptosis is the most common functional problem encountered and is usually due to age-related degeneration.  A detailed description of ptosis and its correction may be found here <clickable link to “Aesthetic services, Face, Droopy eyelids>.  Lagophthalmos treatment is important in reestablishing complete eyelid closure.  A detailed description of lagophthalmos and its correction may be found here here <clickable link to “Reconstructive services, Reconstruction of the Head and Neck, Facial paralysis reconstruction, Facial paralysis reconstruction: Giving life to the face>.

The nose

The nose occupies the central portion of the face and has important respiratory and aesthetic functions that are inseparable.  The nose is the start of the upper portion of the respiratory tract and channels and humidifies the air as it enters.  It has an important structural function to maintain the airway opening and minimize airflow resistance.  The nose is also the central feature of the face and minor anatomical deviations are highly visible.

The nose consists of relatively inelastic skin enveloping a thin layer of nasal muscles, which in turn covers the skeletal structure of the nose.  The upper third of the nose consists of nasal bones that continue onto the forehead and cheek.  In the lower two third of the nose, the central and side supports are derived from cartilages that rest on the underlying facial skeleton.  Strong structural support for the nose is important in keeping the nasal passages during inspiration (breathing in).  Inspiration causes a negative pressure as the air is drawn into the airway and nasal passage collapse occurs in cases where the nasal structural support is insufficient to withstand these negative pressures.

Disease states of the nose may manifest as surface defects and/or structural deficits.  Surface defects involve the loss of skin and/or the muscle covering of the nose.  Structural defects of the nose manifest as deformities that are static (constantly present) or dynamic (present only during certain phases of breathing).  Static deformities may include nasal deviation, collapse of one or both sides of the nose, a shortened nose or narrowing of the nostrils.  Dynamic deformities are manifest as collapse of the nostrils or the nasal sidewalls during inspiration.

Both surface defects and structural defects may arise from tumor resection, burn injury and/or traumatic injury (e.g. interpersonal violence, accidents).

The nose has critical functions and is central to the aesthetic of an individual.  It is a delicate structure that requires special consideration.  Accurate clinical assessment and precise technical execution of surgery are required to ensure functional, attractive and bespoke results.  Good results from nasal reconstruction is important for rehabilitation and societal reintegration.

Surface defects of the nose most frequently arise from resection of skin tumors.  Due to the inelastic nature of the nasal skin, reconstruction with skin grafts or adjacent flap tissue is often required.  A detailed description of skin grafts <clickable link to “Reconstructive services, Reconstruction of the Head and Neck, Surface defects, Treatment, Skin grafts”> and local flaps < clickable link to “Reconstructive services, Reconstruction of the Head and Neck, Surface defects, Treatment, Local and regional flaps“> is found here.  In the nose, skin grafts taken from the back of the ear, the neck or the upper chest provides good color and thickness match.  Local flaps may be harvested from the nose, forehead or cheek to provide reliable and aesthetic soft tissue coverage.

Structural defects of the nose often require reconstruction of the cartilage support.  The native cartilage may be straightened by making fine cuts in the existing cartilage framework, or partial removal and reinforcement with new cartilage.  New cartilage may be harvested from the inside of the nose itself or from the ear and/or ribs.  Recreating a strong and durable support reestablishes the nasal airway and improves the nasal aesthetic at the same time.  The nasal bones, if deviated, may require repositioning to ensure that the final outcome is aesthetic.

The lips

The lips are unique structures in the lower face and support critical functions such as eating, drinking and speech.  They carry significant aesthetic value and are the subject of art and envy in many.  Diseases affecting the lips affect form and function and pose significant disruption to individuals’ quality of life, body image and self-confidence.  Reconstruction of the lips is important in restoring eating and speech as well as aesthetic rehabilitation.  Successful reconstruction helps individuals overcome functional deficits and completes societal reintegration.

The lips are fascinating from anatomists’ and artists’ point of view.  The vermillion of the lips are the only externally visible red structures in the human being.  The upper lip vermillion forms a gentle bow-shape and has two peaks that coincide with a vertical line drawn from inner margins of the nostrils.  The lower lip vermillion is a gentle curve its width gently tapers from the center to the sides.  The lip vermillion are surrounded by the normally pigmented upper and lower lip skin that forms deep contrast with the former.  Beneath this skin envelope lies a thin layer of subcutaneous fat, and beneath this is the dynamic and responsive orbicularis oris muscle.  This muscle forms a ring around the oral cavity and is central to the function of closure of the mouth.  This is important for retaining food and liquids in the oral cavity, and for the production of various speech sounds.  Finally, the inner portion of the lip is lined by a smooth, pink mucosal layer that is in constant contact with the gums and teeth.

Disease of the lips may manifest as partial or full-thickness defects or functional deficits.  Burn cases often manifest as scar contractures and shrunken oral aperture with reduced mouth opening.  The defect size in such cases is only apparent following release at surgery.  Functional deficits of the lip manifest as stiff, inanimate lips unable to move in response to eating, expression or speech.  In cases of complete muscle paralysis, the lower lip loses its muscle tone and droops downwards with gravity, resulting in a downturned mouth corner and occasionally involuntary drooling.

Defects of the lips usually arise out of tumor resection, and less commonly burn injury and traumatic injury.  Functional deficits usually arise from orbicularis muscle weakness due to facial nerve paralysis, in conditions such as Bell’s palsy.

The lips are critical in eating, drinking, speech and conveying emotion.  They are also the central aesthetic feature of the lower face.  Reconstruction of the orbicularis muscle in the mouth and its nerve supply requires close attention to ensure optimal lip function and aesthetic in both the static and dynamic states.  The lip vermillion is a unique structure in its shape, color, form and function and is not easily replicable using other body parts.  Successful reconstruction may be attained in most cases; this restores form and function, improves self-confidence and social functioning.

Defects involving less than 1/3 of the upper or lower lip length are ideally reconstructed by direct wound closure.  Defects involving more than 1/3 of the upper or lower lip are often managed by using the lip tissue from the unaffected lip and turning it into the defect.  This permits reconstruction of the orbicularis muscle, lip vermillion, lip skin and lip mucosa simultaneously.  Larger defects involving 2/3 or more of the upper or lower lips are reconstructed by advancement of cheek or chin tissue as local flaps <clickable link to “Reconstructive Services, Reconstruction of the Head and Neck, Treatment, Local and Regional Flaps>, or distant flaps <clickable link to “Reconstructive Services, Reconstruction of the Head and Neck, Treatment, Distant Flaps> taken from the forearm or the foot.  Distant flaps have the additional advantage of including a tendon, which contributes to lower lip support if required.  These flaps require the application of microsurgical expertise where the blood vessels supplying the flap tissue are joined to blood vessels near the defect site using ultra-fine sutures.

The tongue

The tongue is a unique and important part of the human anatomy.  Its important functions include eating, drinking, swallowing, taste and speech.  The base of the tongue contains muscle, which moves the tongue and forms an important separation of the oral cavity from the neck.  The tongue is thus central to many critical functions of life and diseases affecting the tongue may cause significant disability.

The tongue consists of a mucosal surface that contains salivary glands and taste buds, which covers a complex muscle structure underlying it.  The tongue muscles are strong and dynamic; they move and manipulate the tongue into many different shapes to enable its variety of functions.  The tongue muscle also forms a soft tissue barrier between the oral cavity and the neck and channels the food and saliva into the pharynx and esophagus instead of the neck.

The tongue muscles move the food around within the mouth to enable chewing, and finally pushing the food down the oropharynx and hypopharynx (throat) into the esophagus.  It is the most important articulator of speech and is involved in the production of a wide variety of speech sounds.

Diseases of the tongue may manifest as ulcers, masses or immobility of the tongue.  They may lead to pain or difficulty with swallowing and many individuals may lose weight from suboptimal nutrition.  In addition, certain speech sounds may be impaired or altered due to anatomical and functional changes in the tongue.  In cases of advanced tumors where tongue tumors may be large, impending obstruction of the airway may occur and this may require urgent medical attention.  The degree of functional impairment is dependent on the site of the pathology as well as the extent involved.

The commonest setting in which tongue reconstruction is required is following tongue tumor resection.  Occasionally, individuals may first present months to years after recovery from the tumor resection with functional disability due to radiation changes rendering the remnant tongue scarred and less mobile.

Having a loose tongue and freedom of speech is taken quite literally by reconstructive plastic surgeons!  This requires optimal reconstruction of the tongue following tumor resection and requires recreating a tongue that is of similar shape, size and good mobility.  Experienced reconstructive surgeons deliver the better results in these circumstances: tongue cancer reconstruction will need to take into account the possibility of postoperative radiation with shrinkage of tissue and potentially reduced mobility following radiation therapy.  Good tongue mobility is dependent on having sufficient reconstructed tissue, placed in the correct position and orientation, and sufficient remnant muscle and nerve function to confer good results.  Individuals with optimal tongue reconstruction often have speech that is indistinguishable from normal individuals, able to swallow solids and liquids normally and maintain good body weight.  Restoring these functions are critical for medical rehabilitation and social reintegration following surgery.

Small tongue defects that are close to the tongue tip may be reconstructed by direct wound closure.  Defects that involve half or more of the tongue surface, the muscle floor, or the back of the tongue will usually require reconstruction using regional tissue flaps <clickable link to “Reconstructive Services, Reconstruction of the Head and Neck, Treatment, Local and Regional Flaps> or distant flaps <clickable link to “Reconstructive Services, Reconstruction of the Head and Neck, Treatment, Distant Flaps>.

Regional flaps used for reconstruction are often harvested from the chest and include the pectoralis major muscle and deltopectoral flaps.  Distant flaps have the additional advantage of better functional mobility as they are freed from their site of origin.  Such flaps require the application of microsurgical expertise where the blood vessels supplying the flap tissue are joined to blood vessels near the defect site using ultra-fine sutures that are thinner than a strand of hair.  Distant flaps may be harvested from the thigh, the forearm or the stomach.