The zygomatic flap: a further possibility in reconstructing soft-tissue defects of the nose and upper lip

Through the dissection and localization of the cutaneous zygomatic branch, as previously described by the authors, a vessel is available that plays an important role in reconstructive surgery. The performance of this anatomical study has enabled designing of the so-called zygomatic flap, which can be considered as a further possibility in the reconstruction of soft-tissue defects of the upper lip and nose. This new island axial pattern flap provides a reliable source of skin, with color match for facial resurfacing, and leaves a well-hidden donor site similar to that of the nasolabial flap. The flap must be carefully raised, and when properly designed, it can follow naturally existing contour lines, thus respecting and preserving the normal facial topography and leaving the patient with minimal surgical deformity. In this article, the authors report the clinical application of the zygomatic flap and the outcome of 10 cases. In a follow-up period from 1998 to the end of 2002, there was no flap loss, and in all cases, the aesthetic results were excellent and highly acceptable to the patients. The authors' experience with this new island axial pattern flap has been good, and they recommend this technique.     

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.     

Arterial anatomy of the lower lip: a cadaveric study

The aim of the study was to investigate the arterial anatomy of the lower lip. The location, course, length, and diameter of the inferior labial artery and the sublabial artery were revealed by bilateral meticulous anatomic dissections in 14 adult male preserved cadaver heads. Another cadaver head was used for silicone rubber injection to fill the regional arterial tree. The inferior labial artery was the main artery of the lower lip and in all cases branched off the facial artery. The mean length of the inferior labial artery was found to be 52.3 mm (range, 16 to 98 mm). The mean distance of the origin of the inferior labial artery from the labial commissura was 23.9 mm. The mean external diameter of the inferior labial artery at the origin was 1.2 mm. The sublabial artery was present in 10 (71 percent) of the cadavers. Mean measurements of this artery were 1 mm for diameter, 23.4 mm for length, and 27.6 mm for distance from the labial commissura. The sublabial artery may originate from the facial artery or the inferior labial artery. This study found that this region does not have a constant arterial distribution, the inferior labial artery and the sublabial artery (if it exists) can be in different locations unilaterally or bilaterally, and the diameter and the length may vary.     

Correction of the unilateral cleft lip nose

The cleft lip nasal deformity is best repaired secondarily in teenagers. Some more severe cases may be repaired during childhood. Optimal repair requires adequate exposure, best obtained with transcolumellar flying-bird incisions. The major anatomic defect, the misplaced lateral crus, needs to be advanced to a normal position. The vestibular lining of the lateral crus should remain attached to add circulation and support, especially when scoring of the cartilage is needed. The lateral defect left after advancement of the lateral crus should be closed with sutures. Accessory procedures, including septoplasty, augmentation or reshifting of the alar base attachment, and occasionally, cartilage grafts, are critical to achieving an aesthetic result. Fifty-three patients operated on using the technique described are reviewed.     

Primary correction of the unilateral cleft lip nose: a 15-year experience

This paper reviews a 15-year personal experience based on 400 unilateral cleft nasal deformities that were reconstructed using a method that repositions the alar cartilage by freeing it from the skin and lining and shifts it to a new position. The rotation-advancement lip procedure facilitates the exposure and approach to the nasal reconstruction. The nasal soft tissues are transected from the skeletal base, reshaped, repositioned, and secured by using temporary stent sutures that readapt the alar cartilage, skin, and lining. The nasal floor is closed and the ala base is positioned to match the normal side. Good subsequent growth with maintenance of the reconstruction has been noted in this series. The repair does not directly expose or suture the alar cartilage. Improvement in the cleft nasal deformity is noted in 80 percent of the cases. Twenty percent require additional techniques to achieve the desired symmetry. This method has been used by the author as his primary unilateral cleft nasal repair and has been taught to residents and fellows under his direction with good results. This technique eliminates the severe cleft nasal deformity seen in many secondary cases.     

Primary repair of the unilateral cleft lip nose in the Oriental: a 20-year follow-up

The unilateral cleft lip nasal deformity is corrected as a primary procedure with the lip repair. The abnormal attachment of the alar base is first released by an incision along the superior buccal sulcus and piriform margin. There is no intercartilaginous incision. Basically, we use the Brown-McDowell technique with the addition of an alar rim incision. Undermining of the ala between the two incisions is carefully and adequately done, splitting it into two layers. The first is a skin and the second, a chondrocutaneous (vestibular skin) layer, which is handled as a single unit, thus enhancing its vascularity. This second layer is a bipedicle flap with a broad medial pedicle and a narrow lateral pedicle at the alar base. When the alar base is rolled into its normal position, the chondrocutaneous unit hinging on its two pedicles counterrotates, correcting the subluxation of the ala, a major component of the cleft lip nasal deformity. We depend on the normal position of the alar base, the postoperative scar tissue, and the inherently thick nostril wall in the Oriental to keep the alar dome up. No transfixion sutures are used. Ten consecutive patients are shown 20 years after surgery. All had one operation only. None showed any disturbance of nasal growth.     

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.     

Treatment of the unilateral cleft lip nose.

Unilateral nasal shortening is an essential step in both the primary and the secondary treatment of the unilateral cleft lip nose. Procedures for this are described.     

Cartilaginous histology of the cleft lip nose: proving the extrinsic etiology

In an effort to prove the etiology of the cleft lip nasal deformity, 23 patients with unilateral cleft lip underwent biopsy through the midportion of the columella from mucosa to mucosa. This tissue "sandwich" contained an internal control of cleft and noncleft medial crus cartilage. With the use of special stains and examination under the microscope at low, medium, and high powers, sections were evaluated on the basis of presence of abnormal chondrocytes, number of binucleate chondrocytes, number of nucleated chondrocytes, number of lacunae, perichondrial thickness, and cartilage thickness. In each specimen examined, there were no significant differences between cleft and noncleft sides, proving histologically the previous subjective observation that the deformity is extrinsic, due to distortion of the lower lateral cartilage by abnormal vectors of force.     

Primary repair of the bilateral cleft lip nose: a 15-year review and a new treatment plan

For 15 years a forked flap has been used for columella reconstruction in primary repair of the bilateral cleft lip nose. With the adolescent growth spurt, three unfavorable features have become apparent: (1) the columella may grow too long and the nostrils too large, (2) often the nasal tip remains broad, and (3) there is a drift of the columellar base and the lip-columellar angle is transgressed by scar. This procedure has therefore been discontinued. A new treatment plan is presented in which the columella is reconstructed from tissues in the splayed-out nasal tip.