Correction of the Cleft Lip Lateral Bulge Deformity Using Anatomic Muscle Repair

Re-Examination of the Maxillary Vestibular Approach with Emphasis on Facial Mimetic Muscle Preservation

Introduction

The standard Keen's or the maxillary vestibular incision allows direct access to the zygomatico-maxillary complex with inadvertent transection of the facial muscles and more laborious visualisation of the zygoma.

Materials and Methods

We describe modifications to the vestibular and Keen's technique, based on identification and re-orientation of the facial muscles as well as utilisation of anatomical gaps between the facial mimetic muscles.

Conclusion

Our modifications are based on the principle of facial mimetic muscle identification, preservation and re-orientation to near normal anatomy.

Diced costal cartilage graft combined with muscle repositioning improves Cleft-Side Alar asymmetry in Asian secondary unilateral cleft rhinoplasty: A three-dimensional evaluation

OBJECTIVES

Asymmetry in a retrusive cleft-side ala situated posterior, lateral, and/or inferior to the non-cleft ala is aggravated by ipsilateral defect of the pyriform aperture. This study assessed diced costal cartilage graft combined with muscle repositioning in enhancing structural base and alar symmetry in secondary cleft rhinoplasty.

METHODS

From 2016 to 2019, 20 consecutive patients who underwent pyriform aperture paranasal augmentation combined with muscle repair secondary unilateral cleft rhinoplasty were reviewed retrospectively. Clinical three-dimensional (3D) photos were analyzed pre- and postoperatively, and the augmentation method and muscle repositioning were described detailedly.

RESULTS

Twenty cases aged 22.2 ± 3.9 years were submitted to secondary cleft rhinoplasty with diced costal cartilage graft to the pyriform rim. They were followed up for 6.2-26.2 months, with postsurgical time averaging 10.3 ± 3.4 months. After total lip takedown by anatomic muscle re-approximation, the cleft to non-cleft side showed enhanced alar symmetry (p < 0.001) and heightened vertical lip length (p < 0.001). Additionally, the alar base inclination was improved toward the horizontal plane (p < 0.001).

CONCLUSIONS

The cleft-side ala was anatomically ameliorated after muscle repositioning combined with diced costal cartilage graft to the pyriform rim, improving alar symmetry. Complications were minimal, indicating the safety of this method.

Sonographic Analysis of the Upper Labial Orbicularis Oris and Its Clinical Implications

BACKGROUND

Purse string lips, which include the vertical wrinkles over the lips, are frequently observed in aged individuals. Botulinum toxin and fillers are routinely injected into these areas to remove the wrinkles; however, the anatomy of the orbicularis oris muscle (OOr) near the vermilion border area has not been well defined.

OBJECTIVES

The aim of this study was therefore to identify any morphological differences of the upper OOr via sonographic imaging.

METHODS

The upper lip muscles as observed utilizing an ultrasound device were divided into 2 muscles (pars peripheralis and pars marginalis) that were subsequently divided into a further 2 types (Type I and Type II) associated with the development of the pars marginalis. Type II was further divided into Type IIa and Type IIb depending on whether the muscle fibers were well developed and connected.

RESULTS

On the midline of the lip, Type I, in which the pars marginalis was rarely observed and only appeared in traces, was observed in 20.0% of the volunteers. Type IIa, in which the pars marginalis was well-developed and appeared continuous, was observed in 42.9% of the volunteers. Type IIb, in which the pars marginalis was observed but appeared discontinuous, was observed in 37.1% of the volunteers.

CONCLUSIONS

The shapes of the upper pars marginalis of the OOr varied markedly between volunteers. Type classification of the OOr based on its shape and the lip appearance serves as a reliable source of reference information to be utilized when injecting botulinum toxin into the upper lip.

The Effects of Secondary Cleft Procedures on Alar Base Position and Nostril Morphology in Patients with Unilateral Clefts

OBJECTIVE

To compare effects of secondary cleft procedures on alar base position and nostril morphology.

DESIGN

Retrospective review.

SETTING

Multidisciplinary cleft clinic at tertiary center.

PATIENTS, PARTICIPANTS

Seventy consecutive patients with unilateral clefts were grouped according to secondary procedure.

INTERVENTIONS

Alveolar bone graft versus total lip takedown with anatomic muscle repair versus single-stage total lip with cleft septorhinoplasty (nose-lip) versus rhinoplasty alone.

MAIN OUTCOME MEASURES

Anthropometric measurements were recorded from pre- and postoperative photographs. Ratios of cleft to noncleft side were compared within and across groups pre- and postoperatively using parametric and nonparametric tests.

RESULTS

Within the bone graft group, no differences were seen postoperatively in alar base position in long-term follow-up. The total lip group demonstrated greater symmetry at the alar base (P < .001), increased vertical lip dimension (P < .001), and decreased nostril height (P = .004) postoperatively. Within the nose-lip group, increased vertical dimension and alar base support (P < .001) were also seen postoperatively. Across groups, the single-stage nose-lip group demonstrated greatest alar base symmetry on worm's-eye view (P < .04).

CONCLUSIONS

Alar base asymmetry in patients with unilateral clefts may be related to soft tissue deficiency and was not affected by alveolar bone grafting. Total lip takedown with anatomic muscle reapproximation was associated with increased alar base symmetry and vertical lip dimension on cleft to noncleft side. Greatest symmetry at the alar base was seen following single-stage nose-lip reconstruction, which may be an effective technique for correcting the secondary cleft lip nasal deformity.

[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.

"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.

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.