Experience with 808-nm diode laser in the treatment of 47 cases of oral vascular anomalies

Treatment of oral vascular anomalies (OVA) has focused on minimally invasive techniques rather than radical surgery. We investigated the efficacy and safety of diode laser using the photocoagulation technique in the management of OVA. Forty-seven subjects with OVA were treated with forced dehydration with induced photocoagulation (FDIP) using diode laser (808 nm/4.5 W). This series consisted mostly of male (63.8%) and non-white (63.8%) patients with a mean age of 57.4 years. Varices (91.5%), venous malformations (6.4%), and hemangiomas (2.1%) with a mean size of 7.1 (±4.9) mm were the conditions treated. OVA presented as a nodular lesion (63.8%) involving mainly the lower lip (46.8%). Pulsed laser mode was used as standard and the number of applications varied from one to four sessions, with the majority requiring only one (83%) FDIP session. Kaplan-Meier analysis revealed that complete clinical healing can occur on the 15th day (n=9/29.5%), followed by the 20th (n=6/45.5%), and 30th (n=7/70.5%) days. Postoperative edema was observed in 31 (66%) patients, and recurrence of the lesion occurred in two (4.2%). Based on the data on complete clinical healing, minimal patient discomfort, and satisfactory esthetic results, we can confirm that FDIP by diode laser is a promising candidate for the safe and efficacious treatment of OVA.

An Anatomical Guide to the Terminal Facial Artery: Lumen Diameter and Associated Anatomy Relevant to Dermatologic Procedures

BACKGROUND

Dermal filler injection in the vicinity of the terminal facial artery (FA) can lead to vascular compromise with devastating consequences, including tissue necrosis, blindness, and stroke.

OBJECTIVE

The purpose of this study was to examine lumen diameter and other anatomical features of the terminal FA relevant to dermal filler injection.

MATERIALS AND METHODS

Eighteen embalmed adult cadavers were dissected along the distribution of the terminal FA. Gross and microscopic measurements were taken at predetermined points in its course.

RESULTS

Mean lumen diameter was largest at the midpoint between the oral commissure and the lateral supra-alar crease (0.81 ± 0.36 mm; point P1) and smallest at the midpoint between the lateral supra-alar crease and the medial canthus (0.43 ± 0.23 mm; point P3). Mean cutaneous depth was deepest at the lateral supra-alar crease (5.06 ± 1.84 mm; point P2) and most superficial at the midpoint between the lateral supra-alar crease and the medial canthus (3.13 ± 2.07 mm; point P3).

CONCLUSION

The large-caliber lumen diameter of the terminal FA creates the potential for intra-arterial injection with commonly used filler needles and blunt-tipped cannulas at all points in its course in the nasolabial fold and midface.

How long does the volumizing effect of a Zingiber officinale-based lip plumper last?

OBJECTIVE

Lip plumpers should enhance lip volume. It has been shown that no noticeable result was obtained after long term use of these products. The present study has been carried out to assess lip plumpers' short term effectiveness within 2 h from application.

METHODS

Effectiveness was assessed using non-invasive techniques. The effect on vascularisation was analyzed with the Mexameter MX 16® , and the volume enhancing effect was assessed by anthropometric measures and profilometry analysis from 3D scanning electron microscope (SEM) images using Alicona's MEX software. Sixty female volunteers were recruited for the study and the measurements were taken 15, 30, 60, 90 and 120 min after product application.

RESULTS

Product application produced a statistically significant increase of lip vascularisation during the first 15 min, which stayed unchanged until the 30th min, then decreased in intensity. The volumizing effect was revealed by 3D profilometry analysis only, not by anthropological measurements. The use of 3D SEM images showed an increase of 0.50 mm in the protrusion of the lip vermilion (MHP parameter) during the first 15 min from product application.

CONCLUSION

Results suggest that the lip plumper temporarily enhances vasodilation and increases lip volume.

Cadaveric Assessment of Lip Injections: Locating the Serious Threats

BACKGROUND

Lip augmentation could be a possible cause of blindness following filler injections. This study evaluated the risk by simulating clinical scenarios of marginal injections to the upper and lower lips and then evaluated the risk of vascular injuries.

METHODS

A 22G cannula was inserted bilaterally along the wet-dry junction of the upper and lower lip margins in fifteen cadavers, and then both lips were dissected to verify possible injuries to the superior and inferior labial arteries. The position of the labial arteries in the vermilion zone was documented to determine the appropriate injection technique.

RESULTS

In the marginal injections to the lips, arterial injuries occurred at the medial segment of the vermilion zone of both the upper and lower lips, at the terminal part of the labial arteries or a distal branch. Considering arterial anatomy, the upper lip has a higher chance of arterial injury than the lower lip. The cannula should not be inserted in the submucosa as it is recommended to evert the vermilion because both the superior and inferior labial arteries are located in the submucosa of the medial and middle segments of the vermilion in all specimens.

CONCLUSION

Awareness of the possibility of vascular injury is necessary during injections of the medial segments of the vermilion of the lips. Vermilion border and marginal injections are recommended for safe and effective lip augmentation. Deep injection around the oral commissure and submucosal injection of the medial and middle segments of the vermilion zone are prohibited because of the high risk of arterial injury.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

A simplified minimally invasive technique for the treatment of venous lakes

A simplified approach to treat venous lakes of the vermillion lip is presented. Our method involves the use of a 30 gauge hypodermic needle to deliver a low-powered, high-frequency electrical current from a hyfrecator power source into the venous lake lesion.

Optical coherence tomography platform for microvascular imaging and quantification: initial experience in late oral radiation toxicity patients

An optical coherence tomography (OCT) microvascular imaging platform, consisting of Doppler (DOCT) and speckle variance (svOCT) modalities, and microvascular image quantification tools are developed. The quantification methods extract blood flow-related parameters from DOCT images and vessel morphological parameters from svOCT images. This platform is used to assess the microvascular (DOCT and svOCT) images obtained during a clinical study on late oral radiation toxicity. This specific pathology was considered a suitable scenario for verifying the performance of the developed quantification platform because late oral radiation toxicity is known to involve microvascular damage. The derived parameters are compared between several DOCT and svOCT images from one patient and one healthy volunteer as proof-of-principle, and the significance of the observed differences is discussed. Given the low number of OCT clinical studies that measure and quantify microvascular images and considering the importance of such quantification in a number of pathologies, this newly developed platform can serve as a useful tool in studying diseases and treatments with microvascular involvement.

[Face replantation using labial artery for revascularization. Case report]

BACKGROUND

Restoration of the face function and cosmetic appearance after a traumatic complex wound is a challenge for the plastic surgeon. Worldwide, few cases have been reported about face replantation.

OBJECTIVE

To present the case of the first partial face replantation reported in the national bibliography, using the labial artery for revascularization.

CLINICAL CASE

On June 19th 2011, a 7 years old male presented to the emergency room of the Mexican Institute of Social Security at Monterrey, Mexico, 4 hours after a partial face amputation secondary to a dog bite. The amputated segment was composed of 75% of the upper lip, 33% of the lower lip, oral commissure and 75% of the left cheek. The labial coronary artery and vein were anastomosed with 11-0 nylon sutures and the miorraphy of the orbicularis oris, the depressor anguli oris and the depressor labii inferioris with 4-0 vycril sutures. Six months after the surgery, the functional and aesthetic outcomes were excellent with reestablishment of total labial continence and total recovery of articulation of words.

CONCLUSIONS

amputations of any facial component should be initially managed with replantation. The function and cosmetics are better than any other technique of reconstruction. The labial coronary artery is an excellent choice for revascularization up to 25% of the face (lips and cheek).

Non-invasive assessment of microcirculation by sidestream dark field imaging as a marker of coronary artery disease in diabetes

PURPOSE

In diabetes, generalised microvascular disease and coronary artery disease (CAD) are likely to occur in parallel. We used a sidestream dark field (SDF) handheld imaging device to determine the relation between the labial microcirculation parameters and CAD in asymptomatic patients with diabetes.

METHODS

SDF imaging was validated for assessment of labial capillary density and tortuosity. Thereafter, mean labial capillary density and tortuosity were evaluated and compared in non-diabetic controls, and in asymptomatic patients with type 1 and type 2 diabetes. In diabetic patients, mean capillary density and tortuosity were compared according to the presence of CAD.

RESULTS

Both type 1 and type 2 diabetes were associated with increased capillary density and tortuosity. In diabetes, mean capillary density was an independent predictor of elevated coronary artery calcium (CAC) (p = 0.03) and obstructive CAD on computed tomography angiography (p = 0.01). Using a cut-off mean capillary density of 24.9 (per 0.63 mm(2)) the negative predictive value was 84% and 89% for elevated CAC and obstructive CAD. Likewise, capillary tortuosity was an independent predictor of increased CAC (p = 0.01) and obstructive CAD (p = 0.04).

CONCLUSION

Assessment of labial microcirculation parameters using SDF imaging is feasible and conveys the potential to estimate vascular morbidity in patients with diabetes, at bedside.

Use of the radial forearm artery for secondary embolization of an extensive life-threatening arteriovenous malformation of the mid-face and anterior skull base - a case report

BACKGROUND

Arteriovenous malformations (AVM) of the head and neck are rare conditions with the majority of primary sites in the mid-face. Progression can lead to massive life-threatening bleeding. Treatment of choice is the combination of embolization and surgical resection. Diagnosis and management of AVM has been facilitated in recent years by the progress in imaging techniques and various microsurgical and endovascular embolization procedures.

METHODS

This report presents the interdisciplinary approach to a case of life-threatening AVM of the mid-face in a 30-year-old patient.

RESULTS

Angiography with embolization followed by resection and plastic reconstruction was performed. Follow-up showed incomplete obliteration of the AVM and lead to additional embolizations via the anastomosed radial artery. Complete eradication of the AVM was not possible during the three year follow-up period.

CONCLUSION

In extensive vascular malformations of the head and neck, complete surgical removal is often impossible and associated with high risk of complications and mortality. Endovascular embolization is limited by the location of the AVM and can potentially cause stroke, ischaemia, necrosis, bleeding, blindness and adverse haemodynamic changes.

Ultrasound-guided intralesional laser treatment of venous malformation in the oral cavity

An ultrasound-guided intralesional photocoagulation (ILP) technique using a laser is described for treatment of deep venous malformations in the oral cavity. ILP is basically a blind operation and has a risk of unintended destruction of surrounding normal tissue, therefore the authors now routinely use guidance by ultrasonography using a mini-probe to improve the safety and reliability of ILP. This approach enables safe fibre insertion, appropriate laser irradiation, and intraoperative assessment of coagulation. The use of this technique is described in 8 patients. The authors conclude that ultrasound-guided ILP with a laser is a promising technique for less-invasive treatment of a vascular malformation in the oral cavity.

Face skin necrosis following embolization for arteriovenous malformations: a case report

INTRODUCTION

Arteriovenous malformations (AVMs) are rare in the oral and maxillofacial regions.

DISCUSSION

AVMs may induce severe complications such as uncontrollable bleeding. Superselective intra-arterial embolization is an effective method for this bleeding that is refractory to conservative treatment. Arterial embolization may cause ischemic complications. We report the case of a patient who developed face skin necrosis following bilateral facial artery embolization.

Reversibility of capillary density after discontinuation of bevacizumab treatment

BACKGROUND

Vascular endothelial growth factor (VEGF) inhibition is known to decrease capillary density. Decreased capillary density may be the basis for VEGF inhibitor-related side-effects. We investigated whether the effects of bevacizumab on capillary density are reversible.

PATIENTS AND METHODS

Capillary density, assessed by sidestream dark field imaging of the mucosal surface of the lip, was measured at baseline, after 6 weeks of bevacizumab treatment and >3 months after discontinuation. Additional measurements included blood pressure (BP) measurements, flow-mediated dilation (FMD), nitroglycerin-mediated dilation (NMD) and aortic pulse wave velocity (PWV).

RESULTS

Fourteen patients were included. Seven patients completed measurements at all three predefined time points. Capillary density significantly decreased after 6 weeks of bevacizumab treatment and was reversible after discontinuation of bevacizumab (P = 0.00001 using a general linear model repeated measures test). BP, FMD and NMD remained unchanged. Mean PWV increased after 6 weeks of treatment (P = 0.027) and decreased after bevacizumab discontinuation. Among the six patients with the best response were the three patients showing the clearest decrease in capillary density after 6 weeks of bevacizumab treatment.

CONCLUSIONS

Bevacizumab-induced decrease in capillary density is reversible. Noninvasive assessment of capillary density during treatment with antiangiogenic drugs may be useful as a marker of treatment efficacy.

Arterial anatomy of the lower lip

The arterial anatomy of the lower lip was investigated in 12 sides of six fresh cadavers that had been injected systemically with a lead oxide and gelatin mixture. We found that the blood supply of the lower lip was derived from the facial artery and three dominant labial arteries: the inferior labial artery, the horizontal labiomental artery, and the vertical labiomental artery. The inferior labial artery was derived from the facial artery or superior labial artery, and ran through the submucous tissue horizontally. The horizontal labiomental artery arising from the facial artery was located between the depressor labii inferioris muscle and orbicularis oris muscle. The vertical labiomental artery arose from the submental artery. These three arteries provided small vessels that traversed vertically. These small vessels and the small branches of the facial artery, that run superficial and deep to the orbicularis oris muscle, formed a vascular network in subcutaneous and submucous tissues and minute vessels branched off to the skin, mucosa, and muscles.

Unusual branching pattern of facial artery and a short review

A detailed knowledge of the facial blood supply is necessary in planning of different types of orofacial surgeries. However abnormal pattern of facial blood supply may modify the result of the treatment, if it is not predicted in advance. Here we report two rare cases of unusual presentation of facial blood supply and the clinical implications of such findings, correlating with the previous studies.

Vascular and psychophysical effects of topical capsaicin application to orofacial tissues

AIMS

To characterize and contrast human sensory and vascular changes produced by topical application of the algesic chemical capsaicin to the glabrous lips and tongue.

METHODS

Applications of 1% capsaicin or vehicle cream to the glabrous lips and tongue were randomized between two two-trial sessions. The capsaicin trial followed the vehicle trial for each session. Before and 5, 15, and 30 minutes after capsaicin or vehicle cream application, six parameters were recorded from the glabrous lips or the tongue dorsum: (1) burning pain intensity, as measured on a visual analog scale; (2) burning pain area, as indicated by subjects on an orofacial drawing; (3) mechanical sensitivity, as measured by a von Frey filament; (4) visual flare; (5) blood flow and temperature, as measured by laser-Doppler imaging and thermography, respectively; and (6) areas of increased temperature (hot spots), as calculated by a digital tracer from the thermographs. Data were analyzed by ANOVAs and Pearson's correlations.

RESULTS

Compared to vehicle application, capsaicin elicited burning pain, increases in blood flow and temperature, but no change in mechanical sensitivity in the glabrous lips or tongue. Greater increases in blood flow and temperature paralleled more intense burning pain and larger areas of perceived pain for the lips compared to the tongue. The location of distinct areas of increased temperature within the orofacial area differed between the capsaicin-lip and capsaicin-tongue trials.

CONCLUSION

The several differences between these responses to noxious stimulation of the glabrous lips and tongue may have implications for examinations of orofacial somatosensory functions.

Laser use for esthetic soft tissue modification

In esthetic dentistry, expanding the evaluation beyond the teeth is necessary to achieve a truly desirable result. The lips, attached and unattached mucosa, free gingival margin, and osseous position and contours must be considered and changed if necessary. Although many treatment modalities are available to accomplish these modifications, the use of lasers of varying wavelengths provides advantages not possible by other means. Lasers are often thought of as generic instruments, but different laser wavelengths function differently, and each has its place in the esthetic continuum. Diode, neodymium:YAG, CO(2) and erbium lasers each have advantages that can be exploited to maximum effect and disadvantages that must be taken into consideration. A thorough understanding of their mechanism of action, their tissue effects, and laser safety is vital to obtaining excellent results.

Evaluation of the treatment of venous lakes with the 595-nm pulsed-dye laser: a case series

Venous lakes (VLs) are common benign venous ectasias in the upper dermis. They are treated to improve cosmesis and occasionally to prevent bleeding. Numerous methods have been used, such as cryotherapy, infrared coagulation and various types of lasers. They are variable in their success and all can be complicated by scarring. We report our experiences of using the 595 nm pulsed-dye laser (PDL), which has not been previously described. Eight patients were treated but sufficient resolution was achieved in only three patients. The limited success with this laser could be attributed to insufficient thermal energy being generated to close all the blood vessels permanently. A large prospective study would provide further data regarding the efficacy of the PDL. The use of compression and longer pulse durations may improve the efficacy of the 595 nm PDL to treat VLs.

Upper lip blanching and diplopia associated with local anaesthesia of the inferior alveolar nerve

A case of transient left lateral rectus nerve palsy, following an inferior alveolar nerve block to enable the surgical removal of a permanent mandibular left third molar tooth, is reported. The anatomy related to this case is considered together with suggestions for management of such patients.

Therapeutic choice for craniofacial venous malformations

Even though the precise mechanisms related to venous malformation are still unclear, the clinical manifestations sometimes threaten vital signs such as mastication, airway and phonics. Our therapeutic modalities were reviewed, and their effectiveness and related complications were analyzed. Between March, 1998 and February, 2006, 11 patients (15-59 years old; average 32.4 +/- 13.60, 4 women and 7 men) with craniofacial venous malformation were included in this investigation. All cases experienced some kind of surgery at least once during clinical follow-up. Direct puncture scintigraphy with technetium-99m Sn colloid-labeled demonstrated low-flow malformations in all cases. Two cases underwent bone surgery and another two cases had static suspensions for facial nerve paralysis. Blood loss from surgery alone was 1352 +/- 1115.0 mL, simultaneous procedures yielded 400 +/- 244.9 mL blood loss and sclerotherapy alone resulted in 187 +/- 284.8 mL of blood loss (surgery alone versus sclerotherapy alone, P < 0.01). Excellent sclerotherapy cases were when the malformation was localized and the number of sclerotherapies was significantly fewer than good cases (1.3 +/- 0.58 times versus 3.6 +/- 1.15 times, excellent, good, respectively, P < 0.05). Although there are difficulties in understanding the mechanisms and multiple therapeutic interventions are required, there have been satisfactory outcomes so far and the development of better sclerosants or a real-time navigation system may benefit more precise therapeutic effects and lower morbidity.

Long-pulsed Nd:YAG laser treatment of venous lakes: report of a series of 34 cases

BACKGROUND

Some venous lakes do not respond well to traditional vascular lasers. The Nd:YAG laser output at 1,064 nm is less well absorbed by hemoglobin but penetrates more deeply into tissue.

OBJECTIVE

This study was undertaken to assess the effectiveness of the long-pulsed Nd:YAG on venous lakes.

METHODS

Thirty-five consecutive adult patients presenting with a venous lake were studied. Four patients had failed to respond to polidocanol 1% sclerotherapy, and 1 patient to pulsed dye laser. Long-pulsed Nd:YAG was administered via a water-cooled tip. Either a 3-mm spot at 250 J/cm(2) and 55 ms or a 5-mm spot at 140 to 180 J/cm(2) was used depending on the size of the lesion. Clinical end points were characterized by hardening of the lesion, central blackening, minimal whitening of the periphery, and in most cases, an audible popping sound. Responses were assessed visually in 50% of cases or by phone contact in the remaining 50% if the lesion had completely disappeared. One patient was lost to follow-up.

RESULTS

After a single treatment, 94% cleared completely; incomplete clearance occurred in 6%. There were no reported complications.

CONCLUSIONS

The long-pulsed Nd:YAG laser is highly effective treatment for venous lakes of the lip and cheeks.

Bicyclic monoterpene diols stimulate release of nitric oxide from skin cells, increase microcirculation, and elevate skin temperature

Bicyclic monoterpene diols (BMTd) stimulate nitric oxide synthesis in melanoma and neuronal cells, representing cell types arising from embryonic neural crest tissue. This study shows that an equimolar mixture of the BMTd's 2,3-cis/exo-pinanediol and 2,3-cis/exo-camphanediol stimulates nitric oxide synthesis in epithelial cells of the skin, specifically normal human epidermal keratinocytes (NHEK) and normal human microvascular endothelial cells (HMVEC). A 1 mM mixture increased nitric oxide 3-fold in HMVEC in the first 24 h after treatment, and a 2 mM mixture produced an equivalent increase in NHEK. We hypothesized that an increase in nitric oxide in skin would lead to an increase in microcirculation, thereby increasing skin temperature. We found that twice daily application of 1mM BMTd lotion significantly increased arm skin temperature by 0.5 degrees C in 14 days compared to placebo, while a 2 mM mixture significantly increased skin temperature by 0.3 degrees C in 7 days (P < or = 0.05; ANOVA). A single application of a 2 mM BMTd mixture applied 30 min before a 30 min cold challenge (6 degrees C), maintained facial skin temperature 1.4 degrees C above untreated control sites (P < or = 0.05; ANOVA). We also tested whether BMTd treatment would benefit people with dark circles under their eyes. Twenty-six panelists with dark undereye circles completed 2-week, twice daily application of a lotion containing the 1mM mixture to one eye while the other eye was untreated. Seven of 26 subjects showed a reduction of darkness of undereye circles (P < or = 0.05; paired t test). Application of 2 mM BMTd lotion to lips resulted in a significant increase in their redness, as measured by the erythema index (P < or = 0.05; ANOVA). These results show that a mixture of BMTd's increases nitric oxide, and application to skin increases microcirculation and skin temperature.

Laser Treatment of Venous Malformations

Venous malformations (VM) are developmental errors comprised of enlarged dysplastic blood vessels. Clinically they manifest as either a faint blue patch or a soft blue vascular mass. Treatment options include a sclerosing agent (such as alcohol or ethiblock), surgery or laser therapy. A review of the literature concerning VM and laser treatment yielded a few sporadic reports describing series of 3 to 46 cases. In this retrospective study we reviewed the files of the relevant cases. The data included the extent of the lesion, the different anatomical sites, age of patient and the extent of clearance of the lesion as the treatment's end point. This study includes 56 cases which makes it the largest series presented. The success rate of laser treatment was 92.8%. The immediate complication rate was very low (approximately 3.57%) including minimal scarring and deformity. No long term complications were noted. Our study concludes that treatment of VM is a difficult task due to the nature of the lesions. Laser treatment of these lesions enables one to obtain good results with a very low incidence of complications. Surgery and other treatment modalities are not always satisfactory, yield similar or less efficient results and have a higher complication rate. Laser treatment can play an important role in the treatment of VM and in fact may be the treatment of choice in some settings.

Arteriovenous fistula of the lower lip: case report of combined intravascular and surgical cure

PURPOSE

We describe a patient presenting with a vascular mass of the lower lip with a history of traumatic lip-biting. The lesion was treated with preoperative intravascular embolic therapy and surgical excision.

SUMMARY

Arteriovenous fistula (AVF) of the head and neck are vascular lesions with a single connection between the involved artery and vein. Trauma to the area, often in the distant past, is often seen as the inciting event. We describe a patient with a lower-lip AVF with repeated episodes of lip biting that caused expansion of the mass. The patient underwent preoperative embolic therapy and surgical excision with excellent functional and cosmetic outcome.

CONCLUSION

Arteriovenous fistula of the lower lip can be successfully managed with preservation of lip function and cosmesis through combined intravascular and surgical therapy.

Calibre persistent labial artery: clinical features and noninvasive radiological diagnosis

Calibre persistent labial artery (CPLA) is defined as a primary arterial branch that penetrates into the submucosal tissue without division or decrease in diameter. It usually presents as an asymptomatic papule on the lower lip and can be easily misdiagnosed as a varix, haemangioma, venous lake, mucocele or fibroma. When it is ulcerated, squamous cell carcinoma is the most usual differential diagnosis. The most frequently used method to confirm the diagnosis of CPLA has been excisional biopsy, which carries the risk of profuse bleeding. Angiography, another invasive method, has also been used. Here, we report a case of a 20-year-old woman with a 5-year history of multiple CPLA lesions involving both upper and lower lips. In this case, the diagnosis was made clinically and confirmed by Doppler ultrasonography, which is a noninvasive and simple diagnostic tool.

A detailed observation of variations of the facial artery, with emphasis on the superior labial artery

The reconstruction of lip defects through the use of the Abbe flap and other lip flap procedures involves surgical manipulation of one of the major branches of the facial artery, specifically the superior labial artery (SLA). We examined 284 hemifaces derived from 142 formalin fixed cadavers. Observations regarding the distribution patterns of the facial artery were recognized and categorized into five Types, labeled "A" through "E". Type A (135, 47.5%): facial artery bifurcates into SLA and lateral nasal (the latter gives off inferior and superior alar and ends as angular); Type B (110, 38.7%): similar to Type A, except lateral nasal terminates as superior alar (angular artery is absent); Type C (24, 8.4%): facial artery terminates as SLA; Type D (11, 3.8%): angular artery arises directly from facial arterial trunk rather than as the termination of lateral nasal, with the facial artery ending as superior alar; Type E (4, 1.4%): facial artery terminates as a rudimentary twig without providing any significant branches. Furthermore, we were able to categorize variations within each Type. Sub-Type variations were examined in Types A through C (A: 1-7; B: 1-4; C: 1-3). Our aim was to equip both the anatomist and surgeon with a more thorough understanding of the vasculature of the face, as well as to enable plastic surgeons to have a more confident approach to reconstructive procedures in this region.

Treatment of vascular lesions in the head and neck using Nd:YAG laser

INTRODUCTION

Vascular lesions in the head and neck region, including both haemangiomas and vascular malformations, are common and many different treatment modalities have been used for their removal. In the past decade, the Nd:YAG laser has emerged as a new mode of treatment for vascular lesions, and the purpose of this paper was to determine its clinical value.

PATIENTS AND METHODS

A prospective study was conducted in 111 patients with vascular lesions in the head and neck region. They were treated with the Nd:YAG laser by photocoagulation. Of these, 96 had small lesions, with surface diameters of less than 3 x 3cm(2), and 5 had large lesions, with surface diameters of more than 3 x 3cm(2). The patients were all followed-up carefully until complete healing was recorded, along with any complications.

RESULTS

In both groups of patients, tissue sloughing occurred within 2-3 days. Healing time in small lesions was 2-3 weeks, and in large lesions 3-4 weeks. Three patients with small lesions and one patient with a large lesion experienced minor complications.

CONCLUSION

The Nd:YAG laser is a safe and effective tool for treating vascular lesions.

[Oral capillaroscopy: a new diagnostic method]

The morphological-functional study of microcirculation is of fundamental importance; in fact, the microvascular bed is directly involved both in autoimmune etiopathogenesis pathologies, and in acute and chronic inflammatory etiopathogenesis pathologies. Oral capillaroscopy is a very stimulating method for studying microcirculation, because of the possibility of studying small vessels in vivo by means of a microscope. Today, it is becoming more reliable thanks to the improvement of the observation tools (photography, videomicroscopy).

Parasympathetic Mediated Pupillary Dilation Elicited by Lingual Nerve Stimulation in Cats

PURPOSE

To determine the autonomic efferent nerve pathways for the reflex pupillary dilation elicited by somatic stimulation in cats.

METHODS

Cats anesthetized with a mixture of alpha-chloralose (50 mg/kg) and urethane (100 mg/kg) were intubated and paralyzed by intravenous injection of pancuronium bromide. The central cut end of the lingual nerve (LN) was stimulated electrically to simulate somatic stimulation, and 1 microL of lidocaine (2%) was microinjected into the Vsp or the EW nucleus to determine its effect on the pupillary dilation induced by LN stimulation. The effect of electrically stimulating the Vsp or sectioning the superior cervical sympathetic nerve (CSN) on the pupillary response was also examined.

RESULTS

Stimulation of the LN or the trigeminal spinal nucleus (Vsp) evoked pupillary dilation in a frequency- and intensity-dependent manner. These responses were not affected by sectioning the ipsilateral or both CSNs. The pupillary responses were markedly suppressed by microinjecting lidocaine into the ipsilateral Vsp or the Edinger-Westphal (EW) nucleus, but not by injection into the contralateral Vsp.

CONCLUSIONS

These results indicate that the Vsp and EW nucleus act as bulbar relay centers for pupillary dilation elicited by LN stimulation and suggest that the efferent arc of the response is a parasympathetic pathway. The contralateral pupillary dilation appears to be mediated, at least in part, by fibers projecting from the Vsp to the contralateral EW nucleus.

Ultrasonography: a noninvasive tool to diagnose a caliber-persistent labial artery, an enlarged artery of the lip

OBJECTIVE

Currently, practitioners use clinical and histopathologic examination to diagnose a caliber-persistent labial artery (CPLA). We illustrate the use of ultrasonography as a noninvasive diagnostic tool to visualize this enlarged artery of the lip.

METHODS

We examined the lips of 3 patients with a suspected CPLA. We localized and determined the extension of the intralabial artery with ultrasonography, including pulsed and color Doppler analysis. We compared the sonograms to the clinical and histopathologic findings.

RESULTS

Sonograms showed clear enlargement of the labial artery in the 3 cases. The course of the constant-diameter artery was either vertical or oblique from the depth of the lip to the surface of the mucosa. This vascular abnormality was confirmed by histopathologic examination.

CONCLUSIONS

Ultrasonography and color Doppler imaging may be useful noninvasive tools for the diagnosis and preoperative evaluation, as well as the follow-up, of labial lesions related to a CPLA, thus eliminating the need for diagnostic surgery in typical pulsatile nodules. Ultrasonography may help distinguish a CPLA from other vascular lesions of the lip such as an aneurysm. Atypical cases or chronic ulcerations mimicking a cancer should undergo biopsy so that a malignant process is not missed.

[Repair of upper lip defects with an island flap based on the inferior labial arterial arch]

OBJECTIVE

To investigate one-stage repairing upper lip defects with an island flap based on the inferior labial arterial arch.

METHODS

An island flap pedicled with the inferior labial arterial arch was used to repair upper lip defects. The size of the wedge-shaped flap ranged from 1.5 cm x 1.5 cm to 1.5 cm x 2.0 cm. Since 1993, fifteen patients with upper lip defects have been treated with this method.

RESULTS

All the flaps survived with satisfactory function and appearance.

CONCLUSIONS

The island flap of the inferior labial arterial arch is effective and applicable in repairing severe secondary deformities of congenital bilateral cleft lips.

Reconstruction of concomitant total loss of the upper and lower lips with a free vertical rectus abdominis flap

Total loss of both lips is fortunately rare as reconstruction of such defects poses an enormous challenge. We present a case of concomitant loss of both lips as a result of fulminant pneumococcal septicemia, which was reconstructed with a free vertical rectus abdominis myocutaneous flap due to lack of traditional donor sites.

Compartmentalization of massive vascular malformations

A total of 18 patients with massive vascular malformations of the head and neck region were treated with compartmentalization using nonabsorbable sutures followed by injection of a sclerosant agent into each compartment. The indication for compartmentalization was either to stop potentially uncontrollable, life-threatening hemorrhage during the dissection of the lesion or to reduce its vascularity to allow a less dangerous subsequent resection. Compartmentalization was used in both high-flow and low-flow vascular malformations. In this technique, large nonabsorbable sutures are placed deeply in multiple areas within the lesion. The aim is to divide the malformation into multiple compartments by changing the direction of the suturing; in this way the sclerosing agent is provided with a more effective environment. The sclerosant used was either sodium tetradecyl sulfate 3%, absolute alcohol, or both. The total amount of infiltrate varied from 3 to 35 cc, according to the size of malformation. After compartmentalization, swelling was the most noticeable complication. With this technique, it was possible to treat what were considered untreatable malformations using standard techniques and to control the inevitable serious bleeding.

Anatomic study of the blood supply of perioral region

The use of flaps to reconstruct lip defects requires detailed knowledge of the local vasculature. New flaps for surgery around the mouth can be devised if the surgeon knows the distribution of the perioral arterial branches. Examination of the anatomy of perioral branches of the facial artery (FA) confirmed the consistent presence of septal and alar branches in the upper lip and a labiomental branch in the lower lip. Mucosal flaps from the upper lip based on the deep septal branch or the alar branch of the FA can be used to restore lower lip defects. A composite flap from the lower lip supplied by the labiomental branch of the FA can be used to restore combined defects of the upper lip and nose or partial defects of the lower lip. We studied the vascular anatomy of the perioral region in 25 cadaver dissections. Fixation was by 10% formaldehyde solution. Red latex was injected into the common carotid arteries before dissection. In the 50 specimens, the primary supplying vessels were identified and the size and distribution of the vessels were investigated. The FA was symmetrical in 17 (68%) of 25 heads. It terminated as an angular facial vessel in 11 (22%), as a nasal facial vessel in 30 (60%), as an alar vessel in six (12%), and as a superior labial vessel in two (4%) facial halves. It terminated as a hypoplastic type of FA in one (2%) facial half. The average external diameter of the superior labial artery (SLA) was 1.6 mm (min-max: 0.6-2.8 mm) at its origin. The origin of the SLA was superior to the angle of the mouth in 34 of 47 specimens (72.3%), and at the angle of the mouth in 13 of 47 specimens (27.7%). In two of the remaining three specimens, the SLA was the continuation of the FA and the other was of the hypoplastic type. The SLA supplied the columellar branches in all specimens except for the hypoplastic type (49 specimens). Columellar branches were classified according to their number and their type. In five specimens (10%) the inferior labial artery (ILA) was not found. In the other specimens, the site of origin of the ILA varied between the lower margin of the mandible and the corner of the mouth. Its external diameter measured min-max: 0.5-1.5 mm. The ILA arose from the FA above the angle of mouth in 4 specimens (8%), inferior to the angle of mouth in 11 specimens (22%), and at angle of mouth in 30 specimens (60%). We observed that the labiomental arteries, which formed anastomoses between the FA, ILA, and submental artery, showed variations in their course in the labiomental region. We suggest that knowledge of the location of arteries with respect to easily identifiable landmarks will help to avoid complications at surgery.

Suppression of inferior alveolar nerve-induced vasoconstrictor response by ongoing cervical sympathetic nerve activity in cat

We examined the effects of ongoing cervical sympathetic trunk (CST) stimulation on the vasoconstrictor responses in the lower lip elicited by electrical stimulation (ES) of the inferior alveolar nerve (IAN) or CST in anaesthetised cats to determine whether (i) the previously reported suppressive effect of ongoing CST activity on IAN-induced vasoconstriction occurs during not only ipsilateral, but also contralateral CST stimulation; and (ii) a vasoconstriction can be elicited by brief CST stimulation during ongoing stimulation of the contralateral CST. The central lower lip blood vessels are innervated by both left and right CST. The fall in central lip blood flow (LBF) elicited by IAN stimulation alone was reduced in a frequency-dependent manner during concurrent CST stimulation at 0.2-2 Hz, and at the high end of this frequency range was transformed to a rise regardless of whether the CST stimulation was ipsilateral or contralateral to the IAN stimulation. The fall in central LBF elicited by stimulation of one CST was not transformed to a rise by ongoing stimulation of the contralateral CST. Possibly, IAN-evoked orofacial vasoconstriction does not occur under physiological conditions (unlike IAN-evoked vasodilatation) because it is suppressed by the spontaneous sympathetic discharge in CST.

Quantifying labial blood flow using optical Doppler tomography

OBJECTIVES

Changes in the oral microvasculature occur in a variety of diseases. Optical Doppler tomography (ODT) combines laser Doppler flowmetry with optical coherence tomography (OCT) to produce high-resolution tomographic images of biological tissues that also detect the velocity and direction of blood flow. The objective of this study was to determine the feasibility of ODT to image labial blood flow. A prototype ODT imaging system was constructed that characterized and measured labial blood flow in healthy subjects.

MATERIALS AND METHODS

A prototype ODT instrument was constructed using a diode light source with a central wavelength of 1300 nanometers, a 40-nanometer spectral width and 2.4 microwatts output power. To verify the accuracy of the system, the flow rates of a phantom material (Intralipid) pumped through a capillary tube at various speeds was measured. To evaluate the clinical feasibility of the ODT prototye, the mucosal aspect of the upper and lower lips at the midline was imaged in 9 healthy volunteers. The sample arm of the instrument consisted of a fiberoptic probe with a 2-mm in diameter polished glass lens attached to the end. The probe was placed approximately 3 mm from the mucosal surface of the lip and oriented perpendicular to the surface. A motorized translation stage moved the fiber in a superior to inferior direction while the subject's head was stabilized by placing the chin into a chin rest. Imaging time for a 12-mm x 2.5-mm scan was approximately 64 seconds.

RESULTS

The phantom experiments revealed that accuracy of this novel ODT prototype to measure flow was within 5%. In vivo labial blood flow velocity ranged from 11.8 to 43.1 mm/second in the upper lip and 8.2 to 53.2 mm/second in the lower lip. There were no statistically significant differences between flow rates in the upper and lower lips. OCT images and Doppler velocity signals were successfully integrated producing in vivo images of labial blood in all of the subjects (15 images). The resulting cross-sectional images revealed microscopic details of labial structures and, to the best of our knowledge, are the first ODT images of the labial microvasculature.

CONCLUSIONS

The results of this in vivo study prove the feasibility of ODT to quantify labial blood flow and produce high spatial resolution images specifically localizing vessels anatomically. ODT provides both flow speed and flow direction information. ODT is noninvasive and offers the advantages of high volumetric flow sensitivity.

Cadaveric Study of the Arterial Anatomy of the Upper Lip

Arterial distribution of the upper lip was investigated in this study. The location, course, length, and diameter of the superior labial artery and its alar and septal branches were determined on 14 preserved cadaver heads. Another cadaver head was used to show the arterial tree by the colored silicone injection technique. The superior labial artery was the main artery of the upper lip and always originated from the facial artery. The superior labial artery was 45.4 mm in length, with a range from 29 to 85 mm. The mean distance of the origin of the superior labial artery from the labial commissura was 12.1 mm. The superior labial artery was 1.3 mm in external diameter at its origin. The mean distance of origin of the superior labial artery from the lower border of the mandible was 46.4 mm. The alar division of the superior labial artery was mostly found as a single branch (82 percent). Its mean length was 14.8 mm and the mean diameter at the origin was 0.5 mm. The distance between the origins of the superior labial artery and the septal branch was 33.3 mm. The septal branch was single in most of the cases (90 percent). The mean length of the septal branch was 18.0 mm and the diameter at its origin was 0.9 mm. After all dissections, it was concluded that the arterial distribution of the upper lip was not constant. The superior labial artery can occur in different locations unilaterally and bilaterally, with the branches showing variability.