The importance of accurate repair of the orbicularis oris muscle in the correction of unilateral cleft lip

Comparative 3-Dimensional Analysis of Philtral Ridge Projection in Unilateral Cleft Lip Repair Enhanced with Muscle-to-Subdermis Suture

BACKGROUND

Recreating the philtral ridge and restoring orbicularis oris muscle (OOM) continuity in patients with cleft is a challenging task. The muscle-to-subdermis technique introduces an effective method for achieving the desired philtral ridge reconstruction.

METHODS

From August of 2015 to July of 2023, a retrospective study was conducted with a follow-up period of at least 6 months. This procedure involved a suture technique using muscle-to-subdermis sutures. Measurements of philtral projection were taken at 2 distinct points: one above Cupid's bow and the other at the midphiltral level. In the comparative analysis of philtral ridges between the cleft and noncleft sides, the root mean square projection value was assessed. In addition, an analysis of the restoration of the OOM included the use of color mapping from the midsagittal plane and covered 7 different points across 3 distinct horizontal planes: below subnasale, at the midphiltral level, and above Cupid's bow.

RESULTS

A total of 134 patients were included, with a 37.8-month follow-up (SD 9.4). Philtral side projection was well maintained, measuring -0.36 (0.43) mm, -0.24 (0.49) mm in the classic group versus 0.23 (0.29) mm, 0.20 (0.21) mm in the muscle-to-subdermis group ( P = 0.001). The root mean square projection value was 0.57 (0.46) versus 0.14 (0.046), indicating greater symmetry in the muscle-to-subdermis group, with no difference in sagittal vector analysis of the OOM between normal and cleft sides.

CONCLUSIONS

A suturing technique using muscle-to-subdermis sutures has shown promising results in philtral projection and dimple formation. This improvement can be attributed to the combined effect of subdermis and fewer muscle sutures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Force Balance Reconstruction of the Orbicularis Oris in Secondary Unilateral Cleft Lip Deformity

BACKGROUND

Secondary unilateral cleft lip deformities are commonly observed in patients with cleft lip and traditional surgical methods can't completely tackle this problem. The purpose of this study was to evaluate the outcomes of a novel surgical technique using force balance reconstruction of the orbicularis oris.

METHODS

53 patients with secondary unilateral cleft lip deformity were included in this study, in which the orbicularis oris muscle was reconstructed symmetrically to achieve optimal force balance. Photometric 2d indexes were employed to evaluate the outcome of 27 patients, and 3d indexes for the remaining 26 patients. Aesthetic evaluation and parent-patient satisfaction surveys were also recorded.

RESULTS

Significant differences were found in the following: (1) LH (the lip height), LW (the lip width), D1(the vertical distance from the white roll to the vermilion bottom at the christa philtra points) and D2(the vertical distance from the christa philtra points to the facial midline) when comparing preoperative and postoperative 2D images; (2) LH, LW, D1 and D2 when comparing preoperative and follow-up 2D images; (3) RMS (root mean of square) when comparing preoperative and postoperative 3D images. Aesthetic evaluation in the follow-up period was a mean of 4.29, while parent-patient satisfaction of the overall appearance was a mean of 4.41.

CONCLUSIONS

The results suggest this new muscle reconstruction technique can significantly improve the surgical outcome of secondary unilateral cleft lip deformities.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Outcome Comparisons of Two Different Orbicularis Oris Muscle Reconstruction Techniques in Patients with Unilateral Incomplete Cleft Lip

BACKGROUND

The long-term postoperative outcomes of two different orbicularis oris muscle reconstruction techniques in patients with unilateral incomplete cleft lip were compared.

METHODS

Forty-seven patients with unilateral incomplete cleft lip were assessed in this study, where 23 underwent a traditional method of reconstruction and 24 underwent a novel method. Preoperative measurements, postoperative results, and 3-year follow-up outcomes were measured by photographic anthropometric analysis. Five upper lip measurement indices and 8 nostril indices were included.

RESULTS

The postoperative outcomes showed that the shape of the lip and nose was more symmetric with the new surgical method compared with the conventional technique. Long-term outcomes after 3 years, although characterized by minimal changes during maxillofacial development, showed better maintenance of lip and nostril symmetry in the novel-method group.

CONCLUSION

The novel technique seeks to balance the perinasal and perioral muscles, resulting in improved symmetry compared with the traditional reconstruction technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Inclination of the Lip and Nose during Resting and Lip Protrusion in Children with Unilateral Cleft Lip

Objective

To examine morphological changes of the lip and nose during resting and lip protrusion in patients with unilateral cleft lip.

Methods

A total of 41 patients with unilateral cleft lip who underwent primary lip repair were included in the study population. The distortion of the lip and nose was measured and evaluated using photographs of the preoperative and postoperative resting lips and the postoperative protruding lips.

Results

The position of the labial commissure on the affected side was cranially deviated before lip repair, and the deviation remained after surgery. The degree of cranial deviation was increased by lip protrusion. The position of the alar base on the affected side was caudally deviated before lip repair and improved after surgery; however, it was displaced cranially by lip protrusion. Horizontal displacement of the lip and nose was improved after surgery, and there was no change during lip protrusion.

Conclusions

The characteristic facial distortion in patients with unilateral cleft lip were confirmed. Patients with cleft lip had distortions in the labial commissure and the nose. One of the important future challenges in cleft lip treatment is to focus on changes caused by muscle movement and provide natural and symmetrical facial expressions.

Three-Dimensional Anthropometry for Evaluating Philtrum Contour in Patients With Unilateral Cleft Lip: Comparison Between Photographic Assessment and 3-Dimensional Anthropometry

Philtrum reconstruction in patients with unilateral cleft lip is a major concern in cheiloplasty. Moreover, a quantitative evaluation of the philtrum contour has not been possible. Advances in 3-dimensional (3D) imaging technology have enabled highly accurate assessments of facial surfaces. This study aimed to justify using 3D anthropometric measurements to quantify traditional photographic grading systems. Sixty-six children with unilateral cleft lip, aged 4 to 6 years (mean age: 69.1±5.7 mo), who visited the outpatient clinic from January to December 2020 were included. A plastic surgeon panel graded the philtrum contour using digital photographs, and 3D anthropometry was performed using a 3D imaging system. The philtrum height, philtrum height difference, and dimple depth were measured at the middle of the philtrum. The philtrum height did not show significant changes across the photographic scores ( P =0.06), whereas noticeable differences were observed in the dimple depths based on photographic scores ( P <0.001). The correlation analysis revealed the highest correlation between the photographic score and dimple depth (rho=0.897, P <0.001). The philtrum height on the cleft side (rho=0.478, P <0.001) also correlated with the photographic score, but the correlation was weaker than that of the dimple depth. The dimple depth and philtrum height can help define the philtrum contour. Furthermore, the dimple depth reflects the philtrum contour better and is more suitable as a single parameter. However, relying on a single philtrum height measurement may be insufficient for reliable evaluations, as the relative height from the surrounding tissues is more important than the absolute height measured using 3D anthropometry.

Novel Reconstruction of Orbicularis Oris in Unilateral Complete Cleft Lip Repair

Background: Orbicularis oris muscle repair is key to successful unilateral cleft lip repair. Objective: To measure the lip symmetry after repair of the lip muscles in the midline compared with traditional repair on the cleft side. Methods: A retrospective review and photographic analysis of patients with complete cleft lip treated with the modified approach were carried out. Anthropometric analysis was done at pre-, immediate, and 1-year postoperatively, and at 1-year follow-up. Four upper lip and six nostril landmarks were measured. Results: Fourteen patients met inclusion criteria. Immediate postoperatively, the horizontal lip length on the cleft side was shorter than that on the noncleft side, but the discrepancy decreased as facial development progressed over the course of a year. Lip measurements at the 1-year follow-up were approximately symmetrical in vertical lip height, philtral height, and lateral lip height. Small changes in the nasal correction occurred at 1 year. Conclusion: A modified technique in the unilateral complete cleft lip repair seeks to balance the perinasal and perioral muscles and improve symmetric outcomes.

Analysis of Facial Movement in Repaired Unilateral Cleft Lip Using Three-Dimensional Motion Capture

ABSTRACT

Unilateral cleft lip (UCL) is one of the most common craniofacial deformities. Surgical intervention reconstructs lip and nose anatomy; however, some degree of asymmetry persists after repair. This demonstrates a need for a model for studying and improving outcomes for patients with orofacial clefts. This study's main question was whether there is a significant difference in dynamic facial asymmetry between participants with repaired UCLs and control participants during smiling. Ten pediatric subjects with repaired left UCLs and 12 with no craniofacial diagnoses were recorded performing maximum smiles using a markerless 4D video stereophotogrammetrical system. A facial mesh template containing 884 landmarks was conformed to each initial frame and tracked throughout. Kinetic analysis of smiles was performed by calculating landmark 3D Euclidean distance between frames. Patients with left repaired UCL showed increasing facial asymmetry throughout smiling. Oral commissures, upper, and lower lips demonstrated significantly greater movement on the right side (P < 0.05). Control patients showed facial asymmetry during the first half of smiling, with greater movement on the left side. Displacement difference between right and left was significantly greater at oral commissures and upper lips in patients with repaired ULC compared to control patients. This study provides a highly detailed, quantitative analysis of postoperative UCLs, and help improve outcomes of future repair surgeries.

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.

How to Get Consistently Good Results in Cleft Lip Repair

This article serves as a practical guide for plastic surgeons focusing on repair of primary cleft lip and nasal deformity. We discuss the key anatomic disruption present in cleft lip and nasal deformity and the goals of primary repair. In addition, our preferred surgical technique for unilateral and bilateral cleft lip and nasal deformity is summarized along with technical pearls and pitfalls.

Philtral Ridge Projection in Repaired Unilateral Cleft Lip: Three-Dimensional Anthropometry

BACKGROUND

Cleft surgeons try to construct a philtral ridge during primary repair of a cleft lip, but rarely document the results. The authors used three-dimensional photogrammetry to measure projection of philtral ridges after closure of the common forms of unilateral labial cleft.

METHODS

This is a retrospective study of patients with unilateral complete, incomplete (moderate and severe), and microform cleft lip repaired by one surgeon from 2000 to 2013. Cleft type determined the technique for building a philtral ridge. The relative elevation of the ridge on the cleft versus noncleft side was measured on three-dimensional childhood photographs at two locations along the philtrum: just above the Cupid's bow and at the midlabial level.

RESULTS

Thirty-four patients were evaluated at a mean age of 9.25 years. All cleft types exhibited greater projection at the philtral midlabial level compared with the Cupid's bow level. The authors found a trend toward a more prominent cleft side philtral ridge in microforms. In incomplete cleft lips, there was slightly greater philtral ridge projection in severe forms repaired after a preliminary nasolabial adhesion compared with those repaired in a single stage. There was similar projection of the cleft side ridge in two-stage complete and single-stage repaired incomplete lips.

CONCLUSIONS

It is possible to construct a philtral ridge that is as prominent as the noncleft side in all types of unilateral cleft lip. Increased muscle thickness may explain the slightly increased philtral ridge projection in patients with an incomplete cleft repaired in two stages compared to one-stage closure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Strategic management of the minor-form and microform cleft lip: A long-term outcome assessment

OBJECTIVE

The treatment of the lesser form cleft lip deformity (i.e., minor-form, microform, and mini-microform) is challenging to achieve patient satisfaction. There are no studies investigating how treatment outcomes balance patients' expectations and satisfaction with surgical or non-surgical care relative to the initial nasolabial findings.

METHODS

Based on Mulliken's classification, consecutive records of patients with the lesser-form cleft lip from 1990 to 2015 were selected for analysis. Demographics, management, and revisions were reviewed. A panel analysis was performed based on the ratings from both professionals and non-professionals using patients' photographs. FACE-Q questionnaires were used to compare patient/parent-reported satisfaction to the normal controls.

RESULTS

A total of 135 patients were included. All of the minor-form (23/23), 89% (58/65) of the microform, and 62% (29/47) of the mini-microform patients underwent surgery. Fifty-two percent (15/29) of the mini-microform patients, who underwent surgery, showed no significant improvement. Post-operative upper lip scars and remaining nasal asymmetry were the most common concerns in the treatment group. However, the FACE-Q results showed that patients experienced a statistically significant improvement in their overall facial appearance and social function in their respective groups.

CONCLUSIONS

This study showed that differences exist in the perception of facial esthetics between the surgeon and the patient/parent. To achieve optimal individual treatment outcome and patient satisfaction, an awareness of the differences and treatment selection for patients are critical in surgical planning. This understanding and an open detailed discussion of overall long-term outcomes help in the management of patient expectations.

Pilot Study of Visual and Quantitative Image Analysis of Facial Surface Asymmetry in Unilateral Complete Cleft Lip and Palate

Objective:

To visualize and quantitatively analyze facial surface asymmetry following primary cleft lip repair in patients with unilateral cleft lip and palate (UCLP) and to compare this with noncleft controls.

Design:

Retrospective comparative study.

Patients:

Twenty-two patients with complete UCLP who underwent primary lip repair from 2009 to 2013 were enrolled in this study. The preserved 3-dimensional (3D) data of 23 healthy Japanese participants with the same age were used as controls.

Interventions:

All patients had received primary labioplasty in accordance with Cronin triangular flap method with orbicular oris muscle reconstruction.

Main Outcome Measures:

Shadow and zebra images established from moiré images, which were reconstructed from 3D facial data using stereophotogrammetry, were bisected and reversed by the symmetry axes (the middle line of the face). The discrepancies of the gravity and density between cleft and noncleft sides in 2 regions of interest, facial and lip areas, were then calculated and compared with those of healthy participants.

Results:

In the UCLP group, the mean discrepancies of gravity on shadow and zebra images were 1.76 ± 0.70 and 2.63 ± 1.72 pixels, respectively, in the facial area and 1.31 ± 0.36 and 3.83 ± 2.08 pixels, respectively, in the lip area. There was a significant difference in the mean discrepancies of gravity and density on zebra images in the lip area between the UCLP and control groups.

Conclusions:

Our image analysis of digital facial surface asymmetry in patients with UCLP provides visual and quantitative information, and it may contribute to improvements in muscle reconstruction on cleft lip repair.

The effect of facial expression on facial symmetry in surgically managed unilateral cleft lip and palate patients (UCLP)

AIM

To evaluate the symmetry of facial expression in surgically managed UCLP patients.

MATERIALS AND METHODS

The study was conducted on 13 four-year-old children. Facial images were captured at rest and at maximum smile using stereophotogrammetry. A generic mesh, which is a mathematical facial mask consisting of a fixed number of indexed vertices, was utilised for the assessment of facial asymmetry. This was quantified by measuring the disparity between the left- and right-hand sides of the face after superimposing the original 3D images on their mirror copies.

RESULTS

Residual asymmetries at rest were identified at the vermillion of the upper lip and at the nares with a deviation of the philtrum towards the scar tissue. Vertical and anteroposterior asymmetries were identified on the cleft side. At maximum smile, the asymmetry increased noticeably at the vermillion of the upper lip and at the alar base. In the mediolateral direction, the philtrum deviated towards the cleft side with a significant increase of the asymmetry scores.

DISCUSSION

Asymmetry of the upper lip has significantly increased at maximum smile as a result of the upward forces of all perioral lifting muscles, which affected the lip directly.

CONCLUSIONS

The innovation of this study is the measurement of facial asymmetry for the objective outcome measure of the surgical repair of UCLP. The philtrum was the main site of residual asymmetry, which indicates the need for refining the primary repair of the cleft lip. Further corrective surgery may be required.

Comparison of Outcome of Modified Millard's Incision and Delaire's Functional Method in Primary Repair of Unilateral Cleft Lip: A Prospective Study

BACKGROUND

Certain preoperative anatomical features may lead the surgeon to choose one particular incision pattern in preference to another. No one technique of cleft lip repair consistently produces ideal aesthetic and functional results.

OBJECTIVES

This study was conducted to compare the outcomes attained using two different designs of skin incision used for surgical correction of unilateral cleft lip.

MATERIALS AND METHODS

Modified Millard's incision and Delaire's functional method techniques were performed and evaluated on 18 patients who received primary unilateral cleft lip repair. Soft-tissue measurements of the lip and nose were recorded preoperatively. Analysis was based on postoperative assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, and nostril symmetry and appearance of the alar dome and base. Chi-square and Fisher exact test, Student t test (two tailed, independent) and Student t test (two tailed, dependent) were used for statistical analysis of study parameters at 5 % level of significance.

RESULTS

Preconceptions that one particular technique was better suited to certain preoperative cleft anatomical forms were not proven statistically. The outcome of our surgical methods was good and suggested quantitative changes with progressive diminution of asymmetry of the cleft and non cleft sides.

CONCLUSION

Lip length improvement was better in case of modified Millard's incision. The Delaire's functional method of cleft lip repair results in improved nasal symmetry due to correction of the abnormal insertions of the underlying musculature.

[Comparative ultrasonographic and histomorphologic examination of the lips]

BACKGROUND

High-resolution ultrasonography of the lips offers the opportunity to investigate the orbicularis oris muscle (OOM) and evaluate its morphology and function.

OBJECTIVES

The goals of this paper are verification of the lip structures visible on ultrasound images by using histological section preparations and recommendation of uniform standards for sonographic examinations of the lips.

MATERIALS AND METHODS

The lips of 78 healthy volunteers (age 4-77 years) where scanned with a Hitachi Hi Vision Avius ultrasound device equipped with a linear transducer (L75, variable frequency range 5.0-18.0 MHz). Systematic B-mode examination was performed at five defined points, and the lips where also scanned dynamically in multiple directions. The ultrasonography findings were verified by using histologic samples from five male body donors (age 72-83 years).

RESULTS

All parts of the OOM could be well distinguished from one another both histologically and ultrasonographically. Sonographically visible lip structures could be verified histologically. Labial glands and blood vessels of the mucosa could be identified with both methods.

CONCLUSION

Ultrasonography allows identification of lip structures and all parts of the OOM. Scars, injuries and atrophy of the lip musculature are well detectable. Functional examinations can visualize muscular dysfunctions and may support the diagnosis of dystonic or hypotonic functional deficits. The following parameters are mandatory for a standardized examination of the lips: sagittal and transverse images of upper and lower lips; use of anatomical "landmarks"; functional diagnostics in tensed and relaxed conditions.

Assessing the effectiveness of massage therapy for bilateral cleft lip reconstruction scars

Background and Objective

Bilateral cleft lips occur when the bones that form the upper lip fail to fuse at birth. Surgical reconstruction creates scars, which may lead to the following impairments: adhesions, decreased oral range of motion, decreased strength of orbicularis oris muscle, and asymmetry of oral region leading to poor self-esteem. The purpose of this case study is to determine the effectiveness of massage therapy in its ability to improve these impairments.

Methods

A five-week treatment plan consisting of fascial release, kneading, and intraoral techniques. Subjective information was assessed on two scales: restriction of scar and clients attitudes and acceptance of scar. Objective information was cataloged through photographs, a palpatory chart, and a self-created “Pen Test”.

Results

Results included increase range of motion and strength, decrease restrictions (palpable and subjective), and increase of symmetry. Client’s perceived confidence of scar and its appearance increased.

Conclusions

The evidence suggests that massage therapy helped with the impairments associated with scars formed by bilateral cleft lip reconstruction.

"Three-unit" muscle reconstruction in secondary cleft lip repair

Background :  Secondary deformities are common in people born with unilateral cleft lip and palate. In recent years, more and more attempts and efforts have been directed toward muscle reconstruction. The authors present a new method of orbicularis oris repair in correction of secondary cleft lip deformities. Methods :  From April 2009 to April 2013, a total of 28 patients underwent this procedure in the authors' department and had a follow-up with a minimum length of 1 year. Muscle reconstruction was divided into three units that deal with the nasal floor, white lip, and red lip. Common anatomical pathologies including a deviated columella, blunted alar-facial groove, lack of philtral column, "free border" deficiency, and unapparent vermilion tubercle can be corrected in a single operation. Results :  The average follow-up period was 14.6 months (range, 12 to 24 months). Contractubex gel (Merz Pharma, Frankfurt, Germany) was used to treat prominent or reddish scars in 16 patients. No major complications occurred. All the patients were satisfied with their nasolabial appearance. Conclusions :  "Three-unit" muscle repair was found to be effective and practical in secondary repair. Improved aesthetic and functional results can be achieved with this comprehensive procedure.

Esthetic Composition of Smile in Individuals with Cleft Lip, Alveolus, and Palate: Visibility of the Periodontium and the Esthetics of Smile

Objective. To evaluate characteristics of smile related to visibility in individuals with cleft lip, alveolus, and palate. Design. Cross-sectional. Setting. HRAC/USP, Brazil. Patients. Individuals with repaired complete unilateral cleft lip and palate (n = 45), aged 15–30 years. Interventions. Frontal facial photographs were obtained in natural and forced smiles (n = 135). Six specialists in periodontics evaluated the photographs as to the smile line, thickness, and curve of the upper lip. Main Outcome Measures. The cleft area was compared with the contralateral region. Results were expressed as percentages and means. The findings were compared between groups of periodontists. Results. Statistically significant relationship was observed in the smile line between examiners and between natural and forced smiles, regardless of the association with the cleft side. The lip was thicker at rest and thinner in the forced smile, as also evaluated by the group not experienced with cleft care. The curve of the upper lip in natural and forced smiles was considered as close to straight by both groups, regardless of the cleft. Conclusion. The smile in individuals with clefts was regarded as average for both cleft and noncleft sides. The thickness was characterized as average to thin, being thinner in forced smile and when analyzed by the group not experienced with cleft care. In the average, the curve of the upper lip was considered as straight. The present study elucidates some characteristics related to the smile in individuals with repaired unilateral cleft lip, alveolus, and palate.

Thoughts on the Davies repair of unilateral cleft lip

The Davies Z-plasty repair of the unilateral cleft lip can generate adequate lip height with little transverse tightness and should be considered in the presence of a vertically short lateral lip. Separate repair of the orbicularis muscle may contribute to good long-term lip height and shape. It is possible to revise the Z repair to increase height.

The morphological features and developmental changes of the philtral dimple: a guide to surgical intervention in cases of cleft lip

OBJECTIVE

This study was undertaken to analyse in detail the morphological features of the philtral dimple and the developmental changes of philtral morphology, including a comparison with patients with a cleft lip.

PATIENTS AND PARTICIPANTS

Fifty-five normal Japanese adults, seventy-five children and fifteen patients with complete unilateral cleft lip were referred for analysis.

DESIGN

3D facial data were acquired with a non-contacting laser scanner. We calculated the desired linear and angular components, defining the features of the philtrum with analysing software.

RESULTS

The philtral dimple was morphologically expressed by the two different deepest points in the horizontal and sagittal sectional view, respectively. These decreased with age and did not show any correlation. In contrast, philtral measurements on the X-Y coordinates increased during the course of development. Most of the linear and angular variables in the patients with the cleft lip had exhibited greater values than the normal subjects, reflecting the deformed philtral morphology.

CONCLUSIONS

To obtain an optimally natural philtral construction accompanied by a symmetrical lip in cleft surgery, it is critical to take into consideration both the geometric features of the philtral depth and age-appropriate morphological features of the philtrum as objective criteria.

Thickness of orbicularis oris muscle in unilateral cleft lip: before and after labial adhesion

BACKGROUND

Our protocol for closure of unilateral complete or severe incomplete cleft lip begins with active dentofacial orthopedics (Latham device) followed by nasolabial adhesion and alveolar gingivoperioplasty. We have observed that preliminary adhesion provides more orbicularis oris muscle for the second-stage labial repair.

METHODS

A quantitative prospective assessment of all patients undergoing nasolabial adhesion by the senior author between November of 2009 and July of 2010 was undertaken to assess whether there is an increase in lateral orbicularis oris muscle mass by the time of formal repair. Standard anthropometric points were placed before nasolabial adhesion and again at the second-stage closure. Ultrasonographic measurements of orbicularis muscle thickness were made on both lateral labial elements along a line drawn between sbal and cphi. The mean interval increase in thickness of lateral orbicularis oris was determined.

RESULTS

Sixteen patients underwent nasolabial adhesion during the study period. Four patients with asymmetric bilateral cleft lip patients and 2 patients who did not have a second ultrasonographic study were excluded. The remaining 10 patients in the study had a nasolabial adhesion at a mean age of 3.9 months (range, 3.1-4.3 months). Mean orbicularis oris thickness before adhesion was 0.7 mm on the cleft side and 1.2 mm on the noncleft side. The increase in orbicularis thickness after the mean interoperative interval of 2.9 months (range, 2.6-3.5 months) was calculated. On the cleft side, there was 0.8 mm (138%) mean increase in orbicularis oris muscle thickness compared with 0.4 mm (32%) mean increase on the noncleft side.

CONCLUSIONS

Labial adhesion in preparation for repair of unilateral complete or severe incomplete cleft lip results in a measurable increased thickness of lateral orbicularis oris. This additional muscular bulk is useful in construction of the philtral ridge.

Assessment of deformities of the lip and nose in cleft lip alveolus and palate patients by a rating scale

INTRODUCTION

Labial and nasal deformities have always been a fundamental problem in the treatment of cleft lip, alveolus and palate patients. The primary surgical treatment of nasolabial area is of paramount importance in order to obtain both an esthetical correction of the deformity and a progressive and a balanced development of mid-face. In this study the nasal deformities in patients with cleft lip, alveolus and palate (CLAP) were analyzed and the relevant role of the perinasal, perioral muscular balance and the inborn dislocation of the alar cartilages are presented.

PATIENTS AND METHODS

50 CLAP patients were analyzed, 40 UCLP and 10BCLP. The lip repair was done by modification of Millard's technique. The severity of the cleft appearance was evaluated pre and post operatively, according to a pre-agreed visual rating scale. There are 4° of severity of the deformity pre operatively (mild, moderate, severe and very severe) and post operatively 5 categories of outcome (excellent,very good, good, satisfactory and poor), depending on the scores obtained by summing up the points corresponding to different types of deformity. This scale is closely related to the American Cleft Palate classification of clefts.

RESULTS

In the 40 UCLP patients, 8 excellent, 10 very good, 16 good and 6 satisfactory results were obtained following primary cheiloplasty. In 10 BCLP patients 1 very good, 7 good, 1 satisfactory and 1 poor result were obtained.

CONCLUSIONS

During the primary repair, it is important to correct the abnormal position of ala nasi, the nasal floor and the base of the columella. Abnormalities in the insertion of the nasolabial muscles with their abnormal function contribute to the cleft nose deformities. Therefore the reconstruction not only the orbicularis muscle but also of the paranasal muscles is therefore important for a symmetrical growth of the nose. Separate suture of intrinsic orbicularis oris provide a better shape to the vermillion. The position of the alar cartilage plays an important role for the symmetry of the nose. It is necessary to place the alar base symmetrically in three dimensions.

Seven fundamental procedures for definitive correction of unilateral secondary cleft lip nasal deformity in soft tissue aspects

PURPOSE

It is accepted that patients who undergo appropriate primary repair for cleft lip will have secondary deformities. Because these deformities are caused by complex and diverse patterns, the deformities were categorized to provide a standardized treatment for each category.

PATIENTS AND METHODS

Pathologic characteristics of 1,170 patients were classified into 7 categories. Corrections were performed using 7 fundamental procedures corresponding to the surgical resolution of each deformity: 1) transposition of the caudal septum; 2) release of the septal-cartilaginous junction; 3) medial crus elevation; 4) lateral crus elevation; 5) release of the orbicularis oris muscle from the lip elevators; 6) anchoring of the orbicularis oris muscle to the anterior nasal spine; and 7) philtral column formation. A satisfaction survey was performed to evaluate the overall outcomes in 171 patients and an anthropometric analysis was performed in 38 patients.

RESULTS

Satisfactory scores obtained through postoperative follow-up were higher than preoperative scores, and there was no difference between postoperative scores obtained over the short and long term. All preoperative anthropometric measurements were different from the postoperative measurements, indicating that the fundamental procedure achieved effective outcomes.

CONCLUSIONS

These proposed 7 fundamental procedures can be used as guidelines that can always be applied for the correction of any secondary cleft lip nasal deformity to obtain ideal treatment outcomes.

Modification of Reichert's technique based on natural landmarks and individual designs for unilateral repair of cleft lip

We present a new technique for repair of unilateral cleft lip used in 230 patients. This is a modification of Reichert's technique for unilateral cleft lip repair. It is based in three concepts: form, severity, and natural landmarks of the lip. All the incisions are placed on natural landmarks, between the aesthetic subunits of the upper lip. The incision for rotation of the philtrum is designed to imitate the column of the philtrum on the normal side with good aesthetic result. We do not use a subnasal incision on the lateral side. Since 1996, we have used this technique in 230 unilateral cleft lip repairs. We obtained a good functional and aesthetic result in the nose and upper lip. Our failure rate was 14%. We describe Reichert's modified technique, named the Reichert-Millard's technique, with good aesthetic results (fewer scars and more individual designs than traditional techniques) for repair of the lip and nose in patients with unilateral cleft lip.

Anthropometric study of the upper lip of 1500 healthy children in Chengdu, Western China

The aim of this study was to measure and analyse morphological data about the upper lips of healthy children in Chengdu, Western China. The characteristics and patterns of growth and development of the upper lip may be helpful in guiding the treatment of cleft lip. A total of 1500 healthy children aged between 2 and 12 were divided into 11 groups according to their age. Seven points on the upper lip were measured directly: the length from the alar base to the commissure, the length of the philtrum, the length from the tip of the Cupid's bow to the commissure, the width of one limb of the Cupid's bow, the length from the alar base to the central columella, the area of the unilateral upper lip, and the angle of the line of the alar base to the commissure and the line of the tip of the Cupid's bow to the commissure. Five aspects were significantly different among the groups: the length from the alar base to the commissure (p=0.04), the length from the tip of the Cupid's bow to the commissure (p=0.02), the width of the upper lip (p=0.02), the area adjacent to the lip (p=0.03), and the area of the unilateral upper lip (p=0.04). These data may be useful for reference to cleft lip repair.

Functional 3-D analysis of patients with unilateral cleft of lip, alveolus and palate (UCLAP) following lip repair

INTRODUCTION

Particular importance is attached to lip repair cleft surgery, as numerous functional and aesthetic aspects have to be taken into account simultaneously. Spatial assessment of function and depiction of dynamic deviations is reasonable for describing surgical outcome in addition to long standing static analysis. This study aimed at 3D analysis of the oral area after reconstruction in patients with unilateral cleft lip, alveolus and palate.

PATIENTS AND METHODS

Twelve patients with unilateral cleft lip, alveolus and palate who underwent surgery according to Tennison-Randall were enrolled in this study. Soft tissue dynamics was analysed during passive stretching and active contraction of the lips, and photogrammetry was used for comparing relative changes of length and displacement vectors. The spatial coordinates of surgically significant and reproducible landmarks along the red-white lip junction were analyzed.

RESULTS

Static analysis of the lips revealed a good result with far-reaching symmetry in all cases. Regarding dynamic behaviour, two groups could be distinguished showing clear differences of passive distension and contraction behaviour.

CONCLUSION

Despite nominally identical surgical techniques and comparable static-morphological outcomes, dynamic analysis revealed differences pointing to a need for optimization.

Reconstruction of #7 facial cleft with distraction-assisted in situ osteogenesis (DISO): role of recombinant human bone morphogenetic protein-2 with Helistat-activated collagen implant

A case involving concomitant presentation of a #7 lateral facial cleft with a complete cleft of the ipsilateral lip, alveolus, and palate is presented. The mandibular defect was Pruzansky III with a foreshortened body, absent ramus and absent masseter. Taking advantage of developmental field theory, reconstruction of the osseous defect was undertaken using the autogenous periosteum as a source of mesenchymal stem cells. Expansion of the periosteum was followed by implantation of Helistat (Integra Life Sciences, Plainsboro, NJ) collagen sponge saturated with recombinant human bone morphogenetic protein-2. Stimulation of this distraction-induced envelope by rhBMP-2 resulted in abundant production of bicortical membranous bone in situ within 12 weeks. The neoramus was subsequently suspended from the cranial base, and a temporalis muscle transfer was used to provide motor control of the jaw. Synthesis of bone in this manner is termed DISO (distraction-assisted in situ osteogenesis). The biologic rationale and clinical implications of DISO are discussed.

Cleft lip nose: a different approach

The aim of this study is to demonstrate a different manner of treating cleft lip nose by approaching the problem at its origin, the nasolabial gap. The surgical technique we propose corrects the affected structures from the "bottom to the top." First we have to make sure that the orbicularis oris is well oriented, then we have to create space for the twisted alar cartilage, and finally we reach the tip of the nose with less asymmetry to correct, compared with previously published data. Before attempting any additions of grafts, implants, etc. for the restoration of any congenital deformity, especially clefts, the surgical team must try to reposition, reorganize, and reorient the structures affected by a lack of continuity or a gap as a result of the embryogenesis.

Functional matrix cleft repair: principles and techniques

As an application of developmental anatomy, functional matrix cleft repair has scientific value. It tests out many aspects of periosteal physiology, and it is based squarely on concepts central to orthodontics. The "molecular revolution" has melded together developmental anatomy and genetics to create a new and clinically relevant model of facial development. This article outlines the scientific rationale for cleft repair based on this model.

Muscle reconstruction in cleft lip repair

This article presents a method of muscle reconstruction in the cleft lip patient that grossly reproduces the interlacing muscle anatomy in the central portion of the upper lip and thereby addresses both the static and the functional requirements of cleft lip repair. This lip repair procedure is combined with paranasal muscle reconstruction, preoperative nasoalveolar molding, and postoperative nasal stenting to constitute a comprehensive approach to cleft lip/nose repair.

Development of the facial midline

"Intellectual excellence lies in having faith in the observation of apparently nontranscendental and unimportant facts. To observe an anatomic element calmly, with an open, analytical spirit, and with spiritual freedom, can lead to an explosive vortex of new knowledge."-Miguel Orticochea, M.D.(1) Traditional descriptive embryology based upon the interaction of frontonasal, lateral nasal, and medial nasal prominences is incapable of explaining the three-dimensional development of the facial midline. The internal structure of the nose and that of the oronasal midline can best be explained by the presence of paired A fields originating from the prechordal mesendoderm, associated with the nasal and optic placodes, supplied by the internal carotid artery, and sharing a common genetic coding with the prosomeres of the forebrain. Mesial drift of these fields leads to fusion of their medial walls; this in turn provides bilateral functional matrics within which form the orbits ethmoids, lacrimals, turbinates, premaxillae, vomerine bones, and the cartilages of the nose. This two-part paper reports six lines of evidence supporting the field theory model of facial development: (1) An apparent watershed exists in the midline of the base between the territories of the internal and external carotid systems. Isolation of the ICA in injected fetal specimens confirmed that the demarcation was distinct and restricted to the embryonic nasal capsule. (2) Field theory explains the developmental anatomy of the contents of the nasal capsule. (3) The neuromeric model of CNS development provides a genetic basis for the anatomy and behavior of fields. (4) Mutants for the Dlx5 gene demonstrate A field deletion patterns. These experiments relate the nasal placode to the structures of the A fields. (5) Separate regions of the original nasal placodes give rise to neurons, which are dedicated to separate sensory and endocrine systems. The A fields constitute the pathways by which these neurons reach the brain. (6) Non-cleft lip-related cleft palate, holoprosencephaly, and the Kallmann syndrome are clinical models that demonstrate the effects of anatomic disturbances within the A fields.

The functional anatomy of the muscles of facial expression in humans with and without cleft lip and palate. A contribution to refine muscle reconstruction in primary cheilo- and rhinoplasties in patients with uni- and bilateral complete CLP

The great variation of primary cheiloplasty procedures in Cleft Lip and Palate (CLP) patients shows that there is disagreement regarding the embryonic development of this part of the face, the macroscopic and microscopic functional anatomy of the human muscles of facial expression and their role as a functional matrix for balanced and harmonious facial development. The purpose of this study is to present results of microsurgically dissected facial muscles, several parts of the nose and the human midface in specimens with and without cleft lip and palate. The results are compared with those of other investigations. Recommendations are presented for a standardized dissection technique of the facial muscles of expression for different types of primary cheilo- and rhinoplasty techniques.

Lip movement in patients with a history of unilateral cleft lip

OBJECTIVE

The influence of a repaired cleft lip on the stability of coordination between upper and lower lip in nonspeech and speech tasks was investigated.

DESIGN

First, we looked at the effects of a secondary cleft lip repair in three individuals. Second, we compared subjects with a history of repaired unilateral cleft lip and subjects with no history of cleft lip (controls). Lip coordination was measured using continuous estimates of relative phase.

PARTICIPANTS

Subjects were nine children and adolescents with a primary unilateral cleft lip and palate repair and 4 participants without cleft matched for age across different age categories.

RESULTS

In general, the averaged relative phase angle (RPA) angle values were smaller than 180 degrees, indicating an upper lip lead for lip closure. Controls showed a tendency toward a more symmetric type of coordination (close to 180 degrees), compared with subjects with a repaired unilateral cleft lip. The controls also showed less variation in coordination between the lips. For the more complex speech tasks, a general increase in variability of the RPA values for all subjects was observed, most likely suggesting a more flexible type of coordination. Regarding the effect of a secondary cleft lip repair, only one of the three patients showed a clearly less symmetric and less stable type of coordination, compared with preoperation results.

CONCLUSIONS

There appear to be differences in lip coordination between speakers without and speakers with a repaired unilateral cleft lip. Furthermore, it seems that the stability of lip coordination tends to increase with age.

Cleft lip and palate

The most common congenital deformity of the head and neck, cleft lip and palate, presents the surgeon with a unique esthetic and reconstructive challenge. The complexity of these deformities demands the skills of a multidisciplinary team of professionals to optimize surgical outcome. This article discusses the embryology, epidemiology, and genetics of cleft lip and palate and details the history and modern methods of their surgical correction, the proper goal of which is restoration of normal facial form and velopharyngeal function.

Unilateral cleft lip repair--state of the art

OBJECTIVE

A number of surgical techniques are utilized to correct the unilateral cleft lip, including variations of the rotation-advancement technique. This attests to the variability of the original deformity and the esthetic and functional results from any one technique, especially those based on traditional geometric rearrangement of the skin and associated tissues.

RESULTS

Most recent advances in cleft lip repair have occurred in two main areas. The morphological result has been improved by functional muscular reconstruction of the lip with or without orthopedic molding. Early correction of the nasal deformity has also been readvocated based on newer principles with excellent results demonstrated.

CONCLUSION

Further work continues in these areas and improved outcomes will continue to be seen along with a clearer understanding of surgical affects on growth and development.

Reconstruction of orbicularis oris and levator labii superioris muscles in secondary repair of unilateral cleft lip

We devised a new method to repair the depression of the nasal floor and inferolateral displacement of the alar base and to reconstruct the philtrum in the secondary repair of unilateral cleft lip. Depression of the nasal floor and inferolateral displacement of the alar base were corrected by advancing a lump of the levator labii superioris, the levator labii superioris alaeque nasi, and the upper part of the superficial orbicularis oris muscles to the anterior nasal spine. When the depression of the nasal floor was too severe to repair using these muscles only, a cranially-based de-epithelialised flap of the scar region on the upper lip was inserted under the nasal floor. The lower, greater part of the superficial orbicularis oris muscle was dissected to the nasolabial fold, brought towards the midline, and laid on the surface of the same muscle on the medial side to be sutured. When the depression of the nasal floor was not severe, the lower, greater part of the superficial orbicularis oris muscle was passed through a tunnel pierced beneath the de-epithelialised scar tissue and sutured to the corresponding components on the medial side to reinforce the philtral ridge. In both cases, if the deep orbicularis oris muscle in the vermilion had been interrupted, it was reconstructed by end-to-end anastomosis. Operative results were evaluated in 76 patients using photographs taken preoperatively and postoperatively. Elevation of the nasal floor and correction of the alar base were achieved in most patients, while reconstruction of the philtrum was achieved in cases in which the skin tension at the suture line was weak.

Cleft lip: unilateral primary deformities

The understanding and management of all aspects of unilateral cleft lip deformities continue to evolve. Just as we are entering the era of exciting advances in the understanding of the pathogenesis of craniofacial disorders, expansion of our understanding of the dynamic relationships of the structural and soft-tissue components of cleft deformities has assisted surgeons in achieving progressively improved and consistent outcomes for these patients. The anatomic and physiologic complexity of unilateral cleft lip deformities has been recognized for centuries, and generations of researchers have cumulatively contributed to our current understanding. This article examines the history, classification, anatomy, and controversies in the surgical management of unilateral cleft lip deformities, allowing surgeons to formulate a reasoned, longitudinal management plan for their patients on the basis of the available current data.

The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: technical variations and analysis of results

This is an assessment of one surgeon's 15-year experience (1981-1995) using the Millard rotation-advancement principle for repair of unilateral complete cleft lip and nasal deformity. All infants underwent a prior labio-nasal adhesion. Since 1991, dentofacial orthopedics with a pin-retained (Latham) appliance was used for infants with a cleft of the lip and palate. Technical variations are described, including modifications in sequence of closure. A high rotation and releasing incision in the columella lengthens the medial labial element and produces a symmetric prolabium with minimal transgression of the upper philtral column by the advancement flap. Orbicularis oris muscle is everted, from caudad to cephalad, to form the philtral ridge. A minor variation of unilimb Z-plasty is used to level the cleft side of Cupid's bow handle, and cutaneous closure proceeds superiorly from this junction. The dislocated alar cartilage is visualized though a nostril rim incision and suspended to the ipsilateral upper lateral cartilage. Symmetry of the alar base is addressed in three dimensions, including maneuvers to position the deviated anterior-caudal septum, configure the sill, and efface the lateral vestibular web. Secondary procedures were analyzed in 105 consecutive patients, both revised (n = 30) and unrevised (n = .75). The possible need for revision in the latter group was determined by panel assessment of six indicators of nasolabial asymmetry, documented by frontal and submental photographs. In the entire study period, a total of 80 percent of children required or will need nasal revision, and a total of 42 percent required or will require labial revision. In the last 5 years, as compared with the earlier decade, there was a significantly diminished incidence of patients requiring labial revision (54 percent to 21 percent) and alar suspension (63 percent to 32 percent). These improvements are attributable to technical refinements and experience, although dentofacial orthopedics may also have played a role.

The effect of muscle repair on postoperative facial skeletal growth in children with bilateral cleft lip and palate

The effect of orbicularis muscle repair on postoperative facial skeletal growth in bilateral cleft lip and palate patients was studied by analysis of cephalometric radiographs and dental casts. Sixty-two patients operated on between 1961-1989 were selected for the study. They were divided into three groups, group 1a (muscle repair; n = 12), group 1b (failed attempt at muscle repair; n = 5), and group 2 (no attempt at muscle repair; n = 45). Comparison of the morphological measurements among these three groups showed that there was a trend towards crossbite in the muscle repair group, but this difference was not significant. Mechanisms by which muscle repair might influence maxillofacial skeletal growth include the possibility that the area around the nasal septum might be the growth centre. The choice of operative technique in bilateral cleft lip and palate should be important.