Lipofilling in patients with a cleft lip (and palate) - a pilot study assessing functional outcomes and patients' satisfaction with appearance

Use of Hyaluronic Acid Filler in Patients with Secondary Cleft Lip Deformity

METHODS

Retrospective case note review was undertaken of all patients treated in the clinic over a two-year period.

RESULTS

20 patients underwent HA filler injections to the upper lip 26 times. Most were female (F:M = 3:1) and patients were aged 18-58 years. Most patients had a unilateral cleft lip +/- palate (n = 13, 65%). The most common indication was to address upper lip volume (n = 13, 65%). Other indications included vermillion notch (n = 5, 25%), cupid bow peak height asymmetry (n = 4, 20%), scar asymmetry (n = 1, 5%) and nasal sill flattening (n = 1, 5%). Small volumes of filler were used with an average of 0.34 ml (range 0.05-1.2 ml). There were no complications and one patient reported pruritis post procedure.

CONCLUSIONS

HA filler is a safe and reliable treatment for certain aspects of asymmetry following cleft lip repair. It can be used to address volume deficiency and asymmetry, cupid bow peak height discrepancies and a vermillion notch for patients who do not want surgery. Injection of HA to the lips can be performed easily, with appropriate training, in the outpatient setting.

Enhancing the vermilion in adult secondary cleft lip repair with a continuous V plasty without closure of the donor defect-a case series

The aim of this paper was to describe a modification to an old method to enhance the vermillion in adult cleft patients. We present ten consecutive patients who requested enhancement of the upper lip vermillion. The technique involves a continuous V plasty within the non-visible mucosa to elevate the vermillion. Each V incision is of a different size to match the defect. Then the V flaps are sutured to one another but the donor defect is left open to epithelialise. Adjunctive procedures are possible at the same time. There were no major complications but one patient was over corrected and needed reduction of mucosa. The technique offers a permanent enhancement of the vermillion and is a safe alternative to other methods of lip augmentation including fillers.

Fat grafting in patients with cleft lip and palate: A systematic review

This systematic review aims to compare different fat-grafting techniques for cleft lip and palate repair. A search was conducted in PubMed, Embase, Cochrane Library, gray literature and reference lists of selected articles. A total of 25 articles were included, 12 on closure of palatal fistula and 13 on cleft lip repair. The rate of complete resolution of palatal fistula ranged from 88.6% to 100% in studies with no control group, whereas in comparative studies patients receiving a fat graft showed better outcomes than those not receiving a graft. Evidence suggests that fat grafting can be indicated for the primary and secondary repair of cleft palate, with good results. The use of dermis-fat grafts in lip repair was associated with gains in surface area (11.5%), vertical height (18.5%-27.11%), and lip projection (20%). Fat infiltration was associated with increased lip volume (6.5%), vermilion show (31.68% ± 24.03%), and lip projection (46.71% ± 31.3%). The available literature suggests that fat grafting is a promising autogenous option for palate and fistula repair and for improvement of lip projection and scar aesthetics in patients with cleft. However, to develop a guideline, further studies are needed to confirm whether one technique is superior to the other.

Facial Fat Grafting (FFG): Worth the Risk? A Systematic Review of Complications and Critical Appraisal

Introduction: Autologous fat is ideal soft tissue filler. It is easily accessible, biocompatible, cheap, and it provides both volume augmentation and skin quality improvement. Fat grafting has been used since 1893, but it has only gained widespread popularity since the development of modern liposuction by Colemann and Illouz in the 1980s. Every year more than half a million facial fat grafting procedures are carried out worldwide and the trend is rapidly increasing. Overall, general complications associated with facial fat grafting are assumed to be around 2%. Is that true? Material and Methods: Until July 2021, a systematic search of the literature was performed interrogating PubMed search engines. The following algorithm was used for the research: (fat graft OR lipofilling) AND face AND complications. Exclusion criteria applied hierarchically were review articles, not reporting recipient site complications; not in English and paediatric population. Abstracts were manually screened by LS, GS, JM and PDS separately and subsequently matched for accuracy. Pertinent full-text articles were retrieved and analysed and data were extracted from the database. The flow chart of article selection is described following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: In total, 462 papers were identified by PubMed search. A total of 359 were excluded: 38 papers were not in English, 41 were review articles, 279 articles did not report recipient site complications and 1 was not on human subjects. Average complication rate ranged from 1.5% to 81.4%. A total of 298 adverse events were identified: 40 (13.4%) intravascular injections, 13 (4.3%) asymmetry, 57 (19.1%) irregularities, 22 (7.4%) graft hypertrophy, 21 (7%) fat necrosis, 73 (24.5%) prolonged oedema, 1 (0.3%) infection, 6 (2%) prolonged erythema, 15 (5%) telangiectasia and 50 (16.8%) cases of acne activation. Conclusions: FFG related side effects could be resumed in three categories: severe, moderate, and minor. Severe (13.4%) side effects such as intravascular injection or migration require neurological or neurosurgical management and often lead to permanent disability or death. Moderate (38.3%) side effects such as fat hypertrophy, necrosis, cyst formation, irregularities and asymmetries require a retouch operation. Minor (48.3%) side effects such as prolonged oedema or erythema require no surgical management. Despite the fact that the overall general complication rate of facial fat grafting is assumed to be around 2%, the real complication rate of facial fat grafting is unknown due to a lack of reporting and the absence of consensus on side effect definition and identification. More RCTs are necessary to further determine the real complication rate of this procedure.

Cross-Linked Hyaluronic Acid for Cleft Lip and Palate Aesthetic Correction: A Preliminary Report

Background

Surgical treatment of cleft lip and palate is divided into primary and secondary procedures to restore physiological function and appearance of the face, mouth, and nose. Hyaluronic acid (HA) bio-implants have been successfully used for volume loss correction in several medical disciplines. However, there is paucity of information about its use in the management of facial clefting.

Objectives

The aim of this report is to present the preliminary findings on the feasibility of using a cross-linked HA for aesthetic correction in previously surgical treated cleft lip and palate cases.

Methods

The cross-linked HA STYLAGE L, XL, and XXL (LABORATOIRES VIVACY, Paris, France) were used in this case series. Multiple treatment sessions, 4-6 weeks apart, were performed if required.

Results

A total of 15 patients had undergone the HA injections between May 2018 and December 2021. Of these, 13 had simultaneous correction of the nose, lip, and paranasal scar and the remaining 2 only the lip and scar. The procedures were uneventful and well tolerated by the patients. At follow-up, aesthetic improvement was observed in all patients. Moreover, patients reported overall satisfaction with the outcome of the procedures particularly because of its minimally invasive nature.

Conclusions

Cross-linked HA is a feasible and promising complimentary option for aesthetic, and potentially functional, correction in cases of cleft lip and palate. Larger clinical trials are needed to validate these preliminary findings.

Level of Evidence 4

Immediate effects of photobiomodulation on maximum lip pressure

PURPOSE

To verify the immediate effects of different doses of photobiomodulation on maximum lip pressure.

METHODS

Experimental, randomized and triple-blind study. The sample consisted of 23 women and 17 men, age between 18 and 33 years old (average 23.18 years old, SD=2.1), distributed in four groups: CG (control group), G1, G4 and G7. The maximum pressure was assessed with the Iowa Oral Performance Instrument (IOPI). The bulb was placed between the lips and the participants were instructed to press it as strong as possible. Infrared LASER (808 nm), manufactured by DMC, Therapy EC model, 100 mW of power output, was applied. The doses tested were 1 J (G1), 4 J (G4) and 7 J (G7), applied at six points of the orbicularis oris muscle. In the CG there was no intervention. The evaluation procedures were repeated after the LASER application. The results were analyzed with a significance level of 95%.

RESULTS

The maximum lip pressure increased significantly only in the group irradiated with 7 J.

CONCLUSION

Low level LASER therapy with 7 J dose promoted changes in the performance of the orbicularis oris muscle in the maximum pressure task.

Secondary Treatment of Cleft Lip Correction Sequelae With Percutaneous Needleotomy, Autologous Fat Grafting, and Local Flaps: An Integrated Approach

INTRODUCTION

Cleft lip and/or palate (CL/P) is the most common congenital craniofacial malformation. The severity of the anatomic deformity is highly variable and different techniques can be employed depending on whether the defect is unilateral or bilateral, complete or incomplete. Patients usually undergo multiple steps of reconstruction throughout childhood and adolescence and, for this reason, secondary deformities of the nasolabial region of the midface may ensue. Considering our experience in the treatment of scars, we opted to correct the cleft lip surgery sequelae not only with local flaps/scar revisions, but we decided to add the use of the autologous fat grafting (AFG) to induce a regenerative effect in these young patients.

MATERIALS AND METHODS

In this study we present the results obtained from a series of 12 consecutive Caucasian patients aged from 23 to 44 years with widened paramedian lip scars secondary to cleft lip reconstruction surgery, treated with a combination of needle-induced lysis of the scar tissue and AFG from January 2013 to December 2018.

RESULTS

After the procedure we observed an overall improvement in the quality of the scar tissue, in the function of mimic features, in the symmetry and cosmetics of the lower third of the nose. Patients' satisfaction was excellent. Results were long lasting and remained virtually unchanged after 1 year of follow-up.

CONCLUSIONS

Scar release by needle, AFG and local flaps are excellent tools for the treatment of cleft lip correction sequelae, but the combination of these surgical techniques can lead to even better results.Level of Evidence: Level V.