Nostril Sill Repair by Muscle Tension Line Group Reconstruction in Patients With Cleft Lip

Mentalis Muscle Reconstruction: An Innovative Technique

BACKGROUND

The mentalis muscle is a significant component of the lower lip; its injury could impair appearance and function. This study presents a surgical strategy for treating mentalis muscle rupture to restore muscle tension and improve function.

METHODS

Medical records and photographs of 2 patients with mentalis muscle rupture were reviewed. After physical examinations, 3-dimensional computed topographies were conducted to evaluate chin appearance further. The surgical strategy was designed according to individual malformations and requests.

RESULTS

Both patients injured their mentalis muscles in childhood and presented to our clinic with a concave deformity at the center of the chin and impaired mentalis muscle function. The surgical procedure involved the reconstruction of the mentalis muscle by reassembling the muscle flaps and releasing the scarred soft tissue. Both patients were satisfied with the outcome.

CONCLUSIONS

Mentalis muscle rupture requires surgical correction. The study proposes an innovative approach that enables patients to achieve a more harmonious appearance and improve function.

A Novel Neurovascular Protection Method In Nasolabial Muscle Biomechanical Bionic Surgery For Secondary Unilateral Cleft Lip Repair: A Three-Dimensional Evaluation Of Short And Long-Term Results

BACKGROUND

Neurovascular protection within the upper lip muscles is essential in muscle tension reconstruction and functional recovery during surgery. This study aimed to investigate a novel neurovascular protection method based on the intramuscular neurovascular partitions of the upper lip applied to nasolabial muscle biomechanical bionic surgery for secondary unilateral cleft lip repair and to evaluate postoperative outcomes.

METHODS

From November 30, 2019 to October 31, 2020, 50 consecutive patients with secondary unilateral cleft lips who underwent the modified biomechanical bionic surgery were reviewed retrospectively. Three-dimensional (3D) photographs of patients were collected preoperatively, 7-day postoperatively, and during long-term follow-up (at least 6 months). The Global Aesthetic Improvement Scale was used to evaluate surgical subjective outcomes, and statistical analysis of nasolabial measurements on 3D photographs was used to evaluate objective outcomes before and after surgery.

RESULTS

The Global Aesthetic Improvement Scale showed that 94% of patients had improved upper lip morphology and 92% had improved nasal morphology 7-day postoperatively. In all, 84% maintained favorable nasolabial morphology during long-term follow-up. Statistical results showed that the postoperative alar width, philtral depth, columellar angle, and nasal base inclination angle were significantly improved compared with preoperatively (P<0.01). The differences between the above 4 indexes were not statistically significant (P >0.05) between 7-day postoperatively and long-term follow-up, indicating that the postoperative lasting outcomes were satisfactory.

CONCLUSIONS

The novel method of neurovascular protection in nasolabial muscle biomechanical bionic surgery can achieve a long-term improvement of labial-nasal morphology and function in patients with secondary unilateral cleft lip.

Cadaveric Study and Micro-Computed Tomography of the Anatomy of Palatine Aponeurosis and its Link to the Soft Palate Muscles and Pharyngeal Muscles

OBJECTIVE

There have been few studies on the anatomy of palatine aponeurosis (PA). Herein, we elucidated the relationship between the PA and soft palate muscles and pharyngeal muscles.

DESIGN

Two cadaveric specimens were dissected to observe the gross anatomy of the PA. Six cadaveric specimens were processed and scanned by micro-computed tomography to determine the elaborate anatomy. Images were exported to Mimics software to reconstruct a three-dimensional model.

RESULTS

The PA covered the anterior (32.1%-38.8%) of the soft palate, extending from the tensor veli palatini (TVP) and connecting to 3 muscles: palatopharyngeus (PP), uvula muscle, and superior pharyngeal constrictor (SC). The SC and PP are attached to the PA on the medial side of the pterygoid hamulus. SC muscle fibers were attached to the hamulus, forming a distinct gap between the hamulus. Some muscle fibers of the PP and uvula originated from the PA. The PA extended from the TVP to the midline and the posterior edge of the hard palate. The PA was not uniformly distributed, which was complementary to the attached muscles in thickness.

CONCLUSIONS

PA, as a flexible fibrous membrane, maintains the shape of the soft palate. It extends from the TVP and covers anteriorly about one-third of the soft palate. The PA provides a platform for the soft palate muscles and pharyngeal muscles, connecting to the PP, uvula muscle, and SC. These muscles are important for palatopharyngeal closure and middle-ear function. It is necessary to minimize the damage to the PA during surgical interventions.

The Role of Nasal Sill Correction in Secondary Cleft Rhinoplasty

BACKGROUND

Evaluating outcomes after cleft rhinoplasty can be challenging because of the lack of objective measures that would lead to a more desirable outcome.

METHODS

This study is a 10-year retrospective review of 30 consecutive patients who underwent secondary unilateral cleft rhinoplasty performed by a single surgeon. Subjective ratings were made using the Unilateral Cleft Lip Surgical Outcomes Evaluation (UCL SOE), which rates 4 components (nose, cupid's bow, lateral lip, and free vermillion) with a score of 0 to 2. Multiple anthropometric measurements (nostril height ratio, width ratio, medial ¼ height ratio, sill ratio, nostril area ratio, columellar angle, tip projection ratio, and nasolabial angle) were taken using a free National Institutes of Health program, ImageJ. Standardized photographs were compared at T0 (preoperatively), T1 (<6 weeks postoperatively), and T2 (>6 weeks postoperatively).

RESULTS

There were 30 patients who met our inclusion criteria: 10 males (66.7%) and 20 females (66.7%). Of these patients, 26 (86.7%) had a complete cleft lip and 4 (13.3%) had an incomplete cleft lip. The patients' average age at time of surgery was 16.2 years with a mean follow-up of 17.9 months. Subjective scores in both nasal and overall UCL SOE ratings improved from T0 to T1, 0.7 to 1.2 (P ≤ 0.001) and 3.6 to 4.7 (P ≤ 0.001), respectively. Visual analog scores in nasal and overall UCL SOE ratings improved between T0 and T2, 0.7 to 0.9 (P = 0.023) and 3.6 to 4.8 (P = 0.002), respectively. Of all the objective measures, nasal sill ratio and cleft height to width ratio correlated with improved subjective ratings across multiple time points.

CONCLUSIONS

Our study shows that objective measures such as nasal sill and nostril shape (cleft height to width ratio) correlate with improved subjective visual analog scale using the UCL SOE. The nasal sill is an often overlooked, yet essential, part of creating an aesthetically pleasing nose during cleft rhinoplasty.

Reconstruction of Muscles in Patients with Macrostomia

Background: Most of the characteristic facial features of patients with unilateral macrostomia are attributed to the malformation of commissure muscles. This study aimed to evaluate a modified surgical treatment for such patients that focuses on both appearance and symmetry. Methods: Twenty-seven patients with macrostomia underwent surgery using the proposed method. Facial measurements were analyzed preoperatively, 1 week postoperatively, and during a long-term follow-up using statistical software. Results: The overall length ratio of the healthy and affected sides of the vermillion preoperatively, 1 week postoperatively, and during the long-term follow-up was 1:1.61, 1:1.01, and 1:1.00, respectively (all, p > 0.05). The overall angle between the pupil line and the commissure line was 9.90° preoperatively, 2.34° postoperatively, and 3.31° during the long-term follow-up. There was no statistically significant difference in the covering relation of the upper and lower lips between the affected and healthy sides postoperatively (p > 0.05). 3dMD Dynamic Surface Imaging System (3dMD, Atlanta, GA, USA) showed a symmetrical three-dimensional commissure structure during long-term follow-up measurements. Conclusions: The symmetry and appearance of patients with macrostomia commissure significantly improved following this modified surgical method.

Muscle Flap Reconstruction Based on Muscle Tension Line Groups to Repair the Philtrum of Patients With Microform Cleft Lip or Secondary Cleft Lip

ABSTRACT

The muscle flap reconstruction technique was developed based on the concept of muscle tension line groups, which elucidates how nasolabial muscle tension helps maintain the shape of the philtrum. To investigate the operative effect, we reviewed 43 patients with microform cleft lip and 102 patients with secondary cleft lip treated with muscle flap reconstruction between January 2018 and June 2020. The patients were scanned using the digital three-dimensional stereophotogrammetry face system pre- and post-operatively, and comparative analysis of three-dimensional (3D) images was used to highlight variations of the philtrum. Visual analog scales were used to assess surgical outcomes. More than 6 months after the surgery, comparative 3D images of 37 patients (86.04%) with microform cleft lip and 86 patients (84.31%) with secondary cleft lip showed visible improvement in the prominence of the affected column. In addition, visual analog scale scores showed that 38 microform cleft lip patients (88.37%) and 89 secondary cleft lip patients (87.25%) had a good appearance. The postoperative prominence of the philtral column in both groups improved significantly compared to before surgery (P < 0.001 and P < 0.001, respectively). There was no significant difference in scores for philtrum prominence pre- and post-operatively between the 2 groups (P > 0.05). Muscle flap reconstruction is an effective means to create the 3D configuration of the philtrum. The biomechanical properties of muscles play a vital role in the morphological maintenance of the philtrum.

Three-Dimensional Anatomy of the Palatopharyngeus and Its Relation to the Levator Veli Palatini Based on Micro-Computed Tomography

BACKGROUND

Although multiple studies have been reported on the palatopharyngeus and levator veli palatini, their subtle anatomy and functions remain unclear. The authors elucidated the relationship between these muscles and their functional implications based on three-dimensional digital techniques.

METHODS

Cadaveric specimens were stained with iodine-potassium iodide and scanned using micro-computed tomography. The muscle fibers were drawn on the exported Imaging and Communications in Medicine images to reconstruct a three-dimensional model and further simplified.

RESULTS

In the soft palate, the palatopharyngeus was divided into three bundles. The largest inferior head was found to attach to the palatine aponeurosis, soft palate, and the hard palate on the oral side, which occupied approximately the anterior 28.4 to 36.2 percent of the soft palate in the midline. The superior head was thin and attached to the palatine aponeurosis and the surrounding mucosa on the nasal side. The posterior head was located posterior to the levator veli palatini with fibers attaching to the levator veli palatini and the median portion of the uvula. The levator veli palatini was clasped by the three heads of the palatopharyngeus. The fasciculi of the palatopharyngeus converged into a bundle of muscles at the pharynx and inserted into the lateral and posterior pharyngeal wall.

CONCLUSIONS

The palatopharyngeus is the largest muscle that connects the soft palate and pharyngeal wall; it closely coordinates with the levator veli palatini to control levator veli palatini overlifting, narrow the velopharyngeal port with the help of the superior constrictor, and elevate the pharynx. The palatopharyngeus and levator veli palatini help each other in velopharyngeal closure through coordination from other muscles.

Micro-Computed Tomography-Based Three-Dimensional Anatomical Structure of the Region Around the Pterygoid Hamulus

OBJECTIVE

Palatoplasty would involve the structures around the pterygoid hamulus. However, clinicians hold different opinions on the optimal approach for the muscles and palatine aponeurosis around the pterygoid hamulus. The absence of a consensus regarding this point can be attributed to the lack of investigations on the exact anatomy of this region. Therefore, we used micro-computed tomography to examine the anatomical structure of the region surrounding the pterygoid hamulus.

DESIGN

Cadaveric specimens were stained with iodine-potassium iodide and scanned by micro-computed tomography to study the structures of the tissues, particularly the muscle fibers. We imported Digital Imaging and Communications in Medicine images to Mimics to reconstruct a 3-dimensional model and simplified the model.

RESULTS

Three muscles were present around the pterygoid hamulus, namely the palatopharyngeus (PP), superior constrictor (SC), and tensor veli palatini (TVP). The hamulus connects these muscles as a key pivot. The TVP extended to the palatine aponeurosis, which bypassed the pterygoid hamulus, and linked the PP and SC. Some muscle fibers of the SC originated from the hamulus, the aponeurosis of which was wrapped around the hamulus. There was a distinct gap between the pterygoid hamulus and the palatine aponeurosis. This formed a pulley-like structure around the pterygoid hamulus.

CONCLUSIONS

Transection or fracture of the palatine aponeurosis or pterygoid hamulus, respectively, may have detrimental effects on the muscles around the pterygoid hamulus, which play essential roles in the velopharyngeal function and middle ear ventilation. Currently, cleft palate repair has limited treatment options with proven successful outcomes.

Nasal sill augmentation: an overlooked concept in rhinoplasty-a technical note and review of the literatures

Background

Nasal sill is one of the components of the alar ring, affecting the esthetic outcomes of rhinoplasty; accordingly, we developed a novel technique to adjust defects in this area and compared it with the available techniques.

Methods

Our technique was based on creating a tunnel access to the nasal sill area through an incision made in the lower third of the columella using the open approach or through a nostril base incision in patients, who underwent alar base reduction, followed by insertion of a cartilaginous graft into the marked defect area.

Results

A total number of 54 patients with a defect in the nasal sill area were included in this study. Thirty-one patients underwent open rhinoplasty with the sill approach from the lower third of the columella, while 23 patients underwent rhinoplasty with a nostril base approach for nasal sill augmentation procedure. There were no reports of patient dissatisfaction, infection, bleeding, sensory dysfunction, or remaining asymmetry of the sill area.

Conclusion

Based on the findings of the present study, this technique can be successfully used in reconstructing the nasal sill area with minimal complications and morbidity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40902-021-00298-3.

Three-dimensional creation of the peak of Cupid's bow by muscle tension line group reconstruction in secondary cleft lip repair

The peak of Cupid's bow is a unique three-dimensional structure. Traditional reconstructive techniques focus only on the correction of vermillion border malalignment and the vertical discrepancy between Cupid's bow peaks from a two-dimensional perspective. The aim of this study was to introduce a novel technique - the muscle tension line group reconstruction technique - to recreate the Cupid's bow peak three-dimensionally in secondary cleft lip repair. With this technique the orbicularis oris muscle is divided into two flaps: a lateral one composed of pars marginalis and a medial one composed of pars peripheralis. The full thickness of the medial flap is sutured to the deep layer of the lateral flap, and the end of the lateral flap is then sutured to the dermis lateral to the philtral dimple to accentuate a depression. In this way, the two muscle flaps exert opposing skin traction on each side of the peak, which improves the vertical height as well as the lateral projection of the Cupid's bow peak. The postoperative outcomes indicate that this is a reliable technique for three-dimensional restoration of the Cupid's bow peak, with a stable and natural reconstructive appearance.

"Three Subunit" Classification of Lesser-Form Cleft Lip and Muscle Analysis and Reconstruction of These Subunits Based on the Microanatomic Structures of Muscles in the Normal Upper Lip

BACKGROUND

The main phenotypic features of lesser-form cleft lip include nasal, philtrum, and vermilion deformities. The manifestations of lesser-form cleft lip vary greatly, and it is difficult to rebuild these subunits during the operation.

METHODS

"Three subunits" classification of lesser-form cleft lip was identified as nasal deformity (N), philtrum deformity (P), or vermilion deformity (V); and slight deformity (0) or obvious deformity (1). A total of 200 patients with lesser-form cleft lip were classified into one of the following 8 types: N1P1V1, N1P1V0, N0P1V1, N1P0V1, N0P0V1, N1P0V0, N0P1V0, or N0P0V0. Then the authors discussed the deformities of the lesser-form cleft lip and the reconstruction of the muscles in these subunits based on the microanatomic structure of the nasolabial muscle.

RESULTS

This retrospective review included 200 patients with a lesser-form cleft lip, who were seen at our center from 2015 to 2017. There were 149 (74.5%) N1P1V1, 11 (5.5%) N1P1V0, 13 (6.5%) N0P1V1, 4 (2.0%) N1P0V1, 8 (4.0%) N0P0V1, 10 (5.0%) N1P0V0, 1 (0.5%) N0P1V0, and 4 (2%) N0P0V0 clefts. The various deformities of nasal floor, philtrum ridge, and vermilion may suggest that the muscle bundles in these subunits are abnormal and the operation should be performed to simulate the running directions and tension lines of these local muscles.

CONCLUSIONS

The microanatomic structure and the tension lines of the nasolabial muscles can provide new perspectives for better understanding and repairing the lesser-form cleft lip in subunits.