Cleft lip scar camouflage using dermal micrografts

The use of dermal micrografts to camouflage cleft lip scars is a simple and effective method. We have used dermal micrografts, some hairbearing, to camouflage hypopigmented scars in 10 patients. This method improves the color of the scar, corrects wound distortion and direction to a certain degree, and enables the resultant scar to blend into the adjacent tissue more naturally. Unlike with other methods of scar revision, additional tissue is not sacrificed and new incision lines are not created.     

The lip lift

Attention is brought to a seldom-considered sign of aging--the lengthening of the upper lip. It is easily corrected by excising a wavy ellipse of lip skin and hiding the scar up under the nose. A vertical midline component may be added. The scars are minimal, and the results have been excellent in 83 patients.     

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.     

Staged sequential flap reconstruction for large lower lip defects

A method for the reconstruction of total or nearly total defects of the lower lip is described that utilizes a staged sequence of flaps that are familiar to most plastic surgeons. The recommended sequence is an extended Karapandzic flap to reestablish the oral sphincter, then two sequential Abbé flaps from the upper lip to restore balance and augment the central lower lip, and finally a commissureplasty using a sliding myomucosal flap in conjunction with final revision of the scars. Intervals of 3 weeks separate the surgical procedures. Using this strategy, essentially normal lip function and a relatively normal appearance have been obtained in four patients with large lip defects.     

Composite upper lip repair with V-Y advancement flaps

In two patients, large but superficial partial-thickness resections of lateral upper lip have been repaired by composite island cutaneous flaps. Upper lip and nasolabial fold flaps, along with lateral vermilion, were advanced and closed in a V-Y manner leaving inconspicuous scars and no contour deformity.     

Rectangular flap for horizontal upper vermilion tightness in secondary cleft lip deformity

Radical paring of the cleft edge during a primary cleft operation or repeated secondary surgeries can result in tightness of the upper lip. The degree of the resulting side-to-side tension can vary, from mild cases for which improvement is sought through realignment of the misplaced oral sphincter muscle in secondary revision, to severe cases for which the possibility of a lip switch flap must be considered. When the lip tightness accompanies more than three-quarters loss of the Cupid's bow, an Abbé flap is an alternative. However, the lip switch flap is far from ideal, in both artistic and functional perspectives, and should be avoided if at all possible in mild to moderate degrees of lip tightness. This study presents a method of correcting horizontal cleft upper lip tightness, especially of the vermilion. The method involves local transfer of an inferiorly based rectangular flap from the relatively redundant upper two-thirds to the lower one-third of the upper lip and vermilion. Primary indications for the technique include vermilion tightness with half to three-quarters loss of Cupid's bow. The method has the advantage of supplementing the horizontal lip dimension on the cleft side and restoring a natural Cupid's bow, thereby repositioning the shifted philtral column and adding fullness to the lower one-third of the upper lip. Incorporation of the upper lip scar in the rectangular flap removes ugly scars and spares the lower lip from surgical violation. The orbicularis sphincter function, as seen in facial animation, was well regained. Twenty unilateral and three bilateral cases with a maximal follow-up period of 4.5 years are presented.     

Aesthetic restoration of one-half the upper lip

Aesthetic units of the face have been previously described. The lip itself may be divided into smaller topographic subunits. The lateral subunit is bordered by philtrum column, nostril sill, alar base, and nasolabial crease, while the medial topographic subunit is one-half the philtrum. When a large part of a subunit has been lost, replacing the entire subunit rather than simply patching the defect often gives a superior result. The only tissue suitable for the aesthetic restoration of moderate-sized defects of the upper lip is lower lip. An exact pattern is outlined and an Abbé flap is taken from the midline of the lower lip and transferred in two stages. Like tissue is replaced in kind, border scars are positioned aesthetically, and the orbicularis sphincter is reconstituted with an intact symmetrical commissure, muscular modiolus, and upper and lower lip symmetry. Spontaneous reinnervation by appropriate segmental facial branches occurs within 1 year. Four patients are presented.     

The temporal island scalp flap for management of facial burn scars

Facial burn scars are difficult to conceal and often preclude an aesthetic rehabilitation of the patient. Multistaged scalp and neck flaps have been described to provide hair-bearing skin to resurface burn scars in men. We have been resurfacing the upper lip and cheek in a one-stage procedure using a temporal artery island scalp flap. The temporoparietal fascia has been well described in recent years, and the understanding of this anatomy has facilitated the use of the island scalp flap for more distal transfers.     

Results of surgical lengthening of the short nose in the bilateral cleft lip patient

Some children with bilateral cleft lips do not grow a long enough nose and require surgical lengthening of the nose. We review our 12-year experience with a one-stage slide operation to achieve this. Seven males and 5 females had this operation at ages 7 through 13 years, and we have followed them from 6 months to 12 years. The results, and the subsequent growth effects are described. In general, good long-term improvement has been achieved and the external scars have not proved to be a major drawback. Subsequent procedures upon the columella, alae, and upper lip are often required to establish an unobtrusive nasal appearance.     

Aesthetic subunits of the breast

Surgery for breast cancer has traditionally addressed the breast as if it were a geometric circle with associated quadrants. Cosmetic reconstruction should not follow geometric patterns but should emphasize perceived contour and normal clothing lines. Similar to nasal reconstruction, a subunit principle in breast reconstruction planning may significantly improve the appearance of the result. To better identify the most aesthetic subunits for breast reconstruction, 10 years of autogenous reconstruction in 264 patients was reviewed. Various patterns of breast subunits were identified. The more favorable subunits of the breast in terms of postoperative appearance and camouflage of scars included the nipple, areola, and expanded areola subunits. For larger skin defects, the best subunits were the inferolateral, lower half, and a total breast subunits. Dividing the breast into reconstructive subunits that are to be replaced as a whole rather than as a patch gives superior results. Photographed examples of aesthetic subunits illustrate the placement of scars along natural lines that maximize the advantages of camouflage afforded by clothing.     

Columellar elongation in bilateral cleft lip repair: early results.

Flattening of the nasal tip and shortness of the columella are two of the deformities that remain following successful repair of a bilateral cleft of the lip. Until now, correction has not been possible without producing undesirable scars on the surface of the nose or lip. A three-dimensional Z-plasty on the alar rim achieves columellar lengthening and forward projection of the tip, but it does not have these disadvantages.     

The morphology of the upper lip of Cypridoidea ostracods: taxonomic and phylogenetic significance

This paper represents the first study of the morphology of the upper lip (labrum) and hypostome of ostracods using scanning electron microscopy (S.E.M.). There is considerable variation in the upper lip morphology of the 23 species of Cypridoidea (Podocopina) ostracods used in this study. The detail of the upper lip morphology of each species is very distinctive, so that species determination can be made on this feature alone, but it is not useful in diagnosing genera or subfamilies. The hypostome is not readily studied due to the large amounts of dense pseudochaetae (small, setae-like projections) protruding from it and hence is considered not to be a useful taxonomic feature. Several features of the upper lip and mouth region are documented for the first time. Comparisons of the general morphology of the upper lips of Recent ostracods with the upper lip of the fossil ostracod Pattersoncypris micropapillosa Bate, 1972, indicate that there has been very conservative evolution in these features since the Cretaceous.     

Lifting of the upper lip: personal technique

The authors illustrate a personal technique for lifting of the upper lip with augmentation of the lower lip. With this procedure, a shortening of the "prolabium," an increase of the vermilion, and a natural, nicer mouth are obtained, with the possibility of increasing the volume of the lower lip simultaneously. The operation is carried out as outpatient surgery using local anesthesia, with intravenous sedation if requested. Incisions are made bilaterally beginning at the alar fold of the nose; they then enter the nostrils and rise medially on the skin below the lower margin of the medial crura of the alar cartilage. In this way, the columella is safe, and there are no scars. Then, the two pieces of excess skin and a small, whole strip of orbicular muscle can be cut away, just under the nose. If the goal is to better extrude the vermilion, the skin as far as the Cupid's bow also has to be undermined; if the goal is to shorten the prolabium, a slightly wider amount of orbicular muscle can be removed. The muscle is suspended to the base of the nose with interrupted stitches (absorbable 4-0 suture), the subcutaneous tissue is sutured, and finally the skin is closed with a running suture. The removed muscle is a good graft for increasing the size of the lower lip.     

Reconstruction of the superior labial sulcus in secondary bilateral cleft lip deformities: an inverted U-shaped flap.

A shallow buccal sulcus deformity following bilateral cleft lip repair is not rare. A variety of techniques are described for the secondary reconstruction of a deficient sulcus. Most of these are associated with a variable amount of contraction with subsequent obliteration of the sulcus. In this article, an inverted U-shaped flap is described for the secondary reconstruction of the deficient sublabial sulcus. In these patients, mobility of the upper lip was severely restricted, so orthodontic treatment was not possible. This technique was used in nine patients whose primary cleft lip repairs were performed in different institutions. The amount of re-adhesion or contraction was negligible, because a bare surface was not left behind and skin or mucosal grafts were not used. By advancing the lateral segments of the lip medially, projection of the upper lip was increased. The procedure resulted in adequate upper lip mobility for all patients, and sufficient sulcus was maintained during 1 to 6 years of follow-up. The patients experienced no difficulty with orthodontic appliances after this reconstruction.     

Signaling through Tgf-beta type I receptor Alk5 is required for upper lip fusion

Cleft lip with or without cleft palate is one of the most common congenital malformations in newborns. While numerous studies on secondary palatogenesis exist, data regarding normal upper lip formation and cleft lip is limited. We previously showed that conditional inactivation of Tgf-beta type I receptor Alk5 in the ectomesenchyme resulted in total facial clefting. While the role of Tgf-beta signaling in palatal fusion is relatively well understood, its role in upper lip fusion remains unknown. In order to investigate a role for Tgf-beta signaling in upper lip formation, we used the Nes-Cre transgenic mouse line to delete the Alk5 gene in developing facial prominences. We show that Alk5/Nes-Cre mutants display incompletely penetrant unilateral or bilateral cleft lip. Increased cell death seen in the medial nasal process and the maxillary process may explain the hypoplastic maxillary process observed in mutants. The resultant reduced contact is insufficient for normal lip fusion leading to cleft lip. These mice also display retarded development of palatal shelves and die at E15. Our findings support a role for Alk5 in normal upper lip formation not previously reported.     

Botulinum Toxin to Improve Results in Cleft Lip Repair: A Double-Blinded,Randomized, Vehicle-Controlled Clinical Trial

Background

Most patients with facial scarring would value even a slight improvement in scar quality. Botulinum toxin A is widely used to alleviate facial dynamic rhytides but is also believed to improve scar quality by reducing wound tension during healing. The main objective was to assess the effect of Botulinum toxin on scars resultant from standardized upper lip wounds.

Methods

In this double-blinded, randomized, vehicle-controlled, prospective clinical trial, 60 consecutive consenting adults undergoing cleft lip scar revision (CLSR) surgery between July 2010 and March 2012 were randomized to receive botulinum toxin A (n = 30) or vehicle (normal saline; n = 30) injections into the subjacent orbicularis oris muscle immediately after wound closure. Scars were independently assessed at 6-months follow-up in blinded fashion using: Vancouver Scar Scale (VSS), Visual Analogue Scale (VAS) and photographic plus ultrasound measurements of scar widths.

Results

58 patients completed the trial. All scar assessment modalities revealed statistically significantly better scars in the experimental than the vehicle-control group.

Conclusion

Quality of surgical upper lip scars, which are oriented perpendicular to the direction of pull of the underlying orbicularis oris muscle, is significantly improved by its temporary paralysis during wound healing.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01429402","term_id":"NCT01429402"}}NCT01429402     

Bilateral vermilion flaps for lower lip repair

A more natural reconstructive procedure of the lower lip using bilateral vermilion flaps was applied in five patients with excellent results. The vermilion defects were about two-fifths to three-fifths. In three patients, the vermilion defect was repaired using bilateral vermilion flaps alone. In the remaining two patients, a narrow horizontal lip defect was repaired by bilateral vermilion flaps and a subcutaneous V-Y advancement flap of the lower lip. A single vermilion flap or bilateral vermilion flaps are considered to be of great value for vermilion reconstruction because of the inherent elasticity and common anatomic unit. The postoperative scars are not remarkable at all. A long and narrow horizontal lip defect (perhaps within 1.5 cm downward from the vermilion border) may be effectively repaired by the combination of vermilion flap(s) and a V-Y advancement flap without sacrificing any additional healthy tissue.     

Qianlabeo Striatus, a New Genus and Species of Labeoninae from Guizhou Province, China (Teleostei: Cyprinidae)

Qianlabeo striatus gen. et sp. nov. is described from a stream tributary to the Beipan Jiang of the upper Zhu Jiang (Pearl River) drainage in Matou, Anshun County, Guizhou Province, China. This monotypic genus is mainly characterized by its oromadibular morphology, namely an upper lip only present in and fully adnate to the side of the upper jaw, not covered by the pendulous rostral fold; the median portion of the upper jaw lacking an upper lip but bearing a thin, flexible and cornified cutting edge that is fully covered by the pendulous rostral fold; a postlabial groove prolonged, extended anteromedially close to the anteromost point of the midline of the lower lip but not to meet with its counterpart. The type species of this genus, Q. striatus has a longitudinal dark stripe along the side of the body.     

Lip service for the stiff upper lip

Lip augmentation procedures can restore volume and shape to the aging, thin upper lip, but some patients may develop problematic lip tightness. This stiff upper lip is manifested by a restricted smile and an adynamic central upper lip. We have had success in treating postreconstruction and postaugmentation stiff upper lip with a therapeutic device and treatment regimen. This therapy alleviated tightness and inability to smile. Also, the change in lip commissure-to-commissure distance in repose and when smiling improved after treatment.