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.     

Total reconstruction of the "end-stage" cleft lip and palate deformity

The purpose of this paper is to present a 5-year experience using a comprehensive surgical approach to reconstruct what we have chosen to call the "end-stage cleft lip and palate deformity." The deformity consists of varying degrees of midface retrusion, malocclusion, nasal deformity, and lip deformity. Most of the patients afflicted had unacceptable upper lip anatomy characterized by tightness and lack of cupid's bow and bulk. All had severe palatal scarring with resulting arch collapse and severe malocclusion. Most had had multiple surgical attempts to improve nasal aesthetics using standard rhinoplasty techniques with little or no improvement. The procedure involves splitting the upper lip with incisions extending into the upper buccal sulcus and rim of the nose allowing wide skeletalization of the maxilla and osteocartilagenous nasal skeleton. LeFort I or II maxillary advancement, nasal reconstruction, and upper lip modification (with Abbé flap if indicated) are done. The jaws are placed in intermaxillary fixation for 6 to 8 weeks. This comprehensive approach has been used in 16 patients, aged 15 to 29 years, with follow-up of up to 5 years. Excellent functional and aesthetic improvement has occurred in all patients, and complications have been minimal.     

New approach to the gummy smile

The authors present a multidisciplinary approach to the gingival smile in which its three components are evaluated. These components are the dynamic component of the lip (repose versus smiling) and the two static elements of the gum and maxilla. Once an appropriate diagnosis has been made, the authors act on the gingiva for delayed passive eruption, on the maxilla for long face syndrome, and on the lip with lip-elongation techniques. When delayed passive eruption is associated with hyperfunction of the lip elevators, an intraoral approach with an incision at the level of the upper labial frenulum and dissection from the anterior nasal spine to the anterior maxillary fossae, in addition to gingival remodeling, is recommended to reduce gingival exposure.     

Morphology of chemosensory organs required for feeding in the leech Hirudo medicinalis

Sensilla that line the upper edge of the lip in the leech Hirudo medicinalis and that contain chemoreceptors required for feeding were examined in the scanning and transmission electron microscopes. The sensilla include two size-classes of ciliated button-like mounds--one about 35 microns in diameter and another about 10 microns in diameter. The larger sensilla are at the center of unpigmented patches of skin which are visible in the light microscope, while the smaller sensilla have not been previously described as distinct structures. Electron microscopy, though not light microscopy, shows that the lip sensilla differ markedly from the segmental sensilla of the leech, which have been shown to mediate mechanoreception and photoreception. In particular, the chemosensory lip sensilla contain multiciliated cells with cilia of a uniform length, whereas the segmental sensilla contain uniciliated cells with long, whip-like cilia, as well as multiciliated cells with short, stiff cilia. Thus, the two types of sensilla differ morphologically as well as functionally. In addition to the ciliated sensilla along the upper lip, structures consisting of a short, club-like process surrounded by granular material were observed inside the mouth. These structures may also be chemosensory organs.     

Functional asymmetry in the face.

The possible existence of one-sided dominance in the face, similar to the phenomena of handedness and footedness, has been investigated by studying smiling pattern, movements of the angles of mouth, winking, platysma contraction, raising and everting the upper lip with dilatation of the nostril, and vertical wrinkling of the forehead, on 300 right-handed and 30 left-handed persons. The conclusions are as follows: 1. The large majority of persons investigated do not use the two sides of face equally. 2. Facial ambilaterality is a rare feature. 3. There is no clear-cut correlation between handedness and the dominant side of the face. 4. The greater percentage (58.66%) of right-handed persons show a left-sided smile and find it more convenient to perform almost all exercises with the left side of the face. A still greater percentage (73.33%) of left-handed persons shows a right-sided smile and a better performance of all exercises with the right side of the face. The contralateral relationship of handedness to the dominant side of the face is significant in the right-handed and more so, in the left-handed persons.     

Neurovascular free-muscle transfer to treat facial paralysis associated with hemifacial microsomia

Despite the wide spectrum of hemifacial microsomia manifestations, treatment mainly focuses on mandible and ear abnormalities, rather than on facial paralysis. In fact, the surgical treatment of facial paralysis associated with hemifacial microsomia is quite underdeveloped, because the degree of paralysis is frequently incomplete or partial. Timing and type of surgery are also difficult to determine. Neurovascular free-muscle transfer is now a standard procedure for the dynamic smile reconstruction of longstanding facial paralysis. This type of strategy has considerable potential in the treatment of facial paralysis in patients with hemifacial microsomia. We present here our experience with neurovascular free-muscle transfer for smile reconstruction in eight patients with facial paralysis associated with hemifacial microsomia. The age of the patients at the time of surgery ranged from 7 to 28 years old, (average, 13.9 years). Six were male patients and two were female patients. The two-stage method combining gracilis muscle transfer with cross-face nerve grafting was performed in three patients, whereas the one-stage transfer of the latissimus dorsi muscle was performed in five. To construct a natural or near-natural smile, the muscles were transferred into the paralyzed cheek in all except one patient, in whom the latissimus dorsi muscle was transferred into the sublabial area to reconstruct a paralyzed lower lip. A dermal flap segment vascularized with perforating vessels from the latissimus dorsi muscle was simultaneously inserted into the underdeveloped cheek for soft-tissue augmentation in this patient. Muscle contraction was evident in all patients between 4 and 8 months after muscle transfer. Our present series revealed that neurovascular free-muscle transfer is a good option not only for smile reconstruction but also for restoration of the facial contours of patients with hemifacial microsomia. Compared with the two-stage method combining gracilis muscle transfer with cross-face nerve grafting, the one-stage method using the latissimus dorsi muscle has some advantages, including a one-stage operation, a shorter recovery period, and the absence of sequelae that occur after harvesting a sural nerve.     

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.     

Upper labial deficiency in Mobius syndrome: a previously unreported feature and its correction

Bilateral facial palsy in M?bius syndrome remains one of the greatest challenges in reconstructive plastic surgery. Facial reanimation is an invaluable aid to such patients because it allows for greater social interaction by means of the ability to smile. In performing facial reanimation surgery on patients with M?bius syndrome, it is the observation of the senior author (Harrison) that upper labial deficiency is a consistent and previously unreported feature of the syndrome. It has been the practice of the senior author to perform upper labial augmentation on M?bius syndrome patients by insertion of a lipodermal autograft, in addition to facial reanimation. Nine patients with M?bius syndrome who presented to the Department of Plastic Surgery during an 8-year period were reviewed. All nine possessed bilateral facial palsy and upper labial deficiency in addition to other abnormalities consistent with M?bius syndrome. Six patients underwent bilateral facial reanimation and upper labial augmentation alone. One patient refused facial reanimation surgery but consented to upper labial augmentation. One patient, with concomitant micrognathia, underwent bilateral facial reanimation, upper labial augmentation, and insertion of a Silastic chin implant. In one patient, a child who also exhibited micrognathia, bilateral facial reanimation alone was carried out, with further procedures for upper labial and chin cosmesis being postponed until adulthood. The indication for performing upper labial augmentation was cosmetic. The procedure improved upper labial appearance and restored balance to the mouth. Patients also expressed higher satisfaction with eating and drinking, which they related to the improved fullness of the upper lip. This was before the facial reanimation had become functional. Upper labial deficiency warrants addition to the list of facial features of M?bius syndrome and is something that must be assessed in the context of facial reanimation surgery.     

Advanced squamous cell carcinoma involving both upper and lower lips and oral commissure with simultaneous reconstruction by local flap: a case report

Introduction

Squamous cell carcinoma is one of the most common malignant tumors of the skin and oral mucosa. However, squamous cell carcinoma involving near total upper and lower lip and oral commissure is rarely seen in the English literature. Simultaneous reconstruction of the upper and lower lips has been inconclusive and presents a challenge to the surgeon. We report such a case and outline our simultaneous reconstruction with local flaps. To the best of our knowledge this has never been reported.

Case presentation

A 73-year-old Thai woman presented with a large rapidly growing squamous cell carcinoma involving the upper lip, lower lip, left oral commissure and left cheek. En bloc resection of upper lip, lower lip, left oral commissure and buccal region was performed. Left radical neck dissection and right modified neck dissection were performed. Reconstruction of the upper lip with a left nasolabial-cheek cervicofacial rotational-advancement flap and right cheek advancement with perialar crescent flap was performed. The lower lip was reconstructed with bilateral labiomental advancement flaps.

Conclusions

Squamous cell carcinoma can grow rapidly and spread along the orbicularis oris muscle and across the oral commissure to the opposite lip. In advanced cancer, multimodal treatment is necessary. No gold standard in the reconstruction of both upper and lower lips has been established. We report the case of an advanced squamous cell carcinoma involving both the upper lip, lower lip, left oral commissure and buccal area and simultaneous reconstruction with local flap coverage that, to the best of our knowledge, has never been reported.     

Forms and Social Signal Value of Smiles Associated with Pleasant and Unpleasant Sensory Experience

Episodes of facial displays involving the zygomatic action (AU12: lip corner pulling or smiling) were selected from a large sample of children (n = 95) exposed to pleasant and unpleasant odours in the presence of an unfamiliar person in order to investigate potential differences in morphological, temporal patterning and social signal value of smiling. In a first experiment, using the facial action coding system (FACS: Ekman & Friesen 1978), a considerable morphological flexibility of smiles was observed in relation to the subjects' hedonic experience. The facial configurations of smiling were formed by a number of actions in the upper (AU 4: brow lowering), middle (AU 9: nose wrinkling) and lower face (AU 14: dimpling, AU 15: lip comer depressing, AU 17: chin raising, AU 23: lip tightening) and the mouth was more often ‘closed’ in response to unpleasant odours. When exposed to pleasant odours, zygomatic action co-occurred more frequently with an opening of the mouth (AUs 25, 26, 27) or with a raising of the cheeks (AU 6). An analysis of the temporal patterning of zygomatic actions showed that they occurred more rapidly, dropped off the face less abruptly with a stepped decrease, were less smooth, and were often associated with shorter gazes directed toward the examiner in response only to unpleasant odours. These findings suggested that a number of subjects might exert some control on their smiling while confronted with a presumed social constraint, namely the smelling of unpleasant odours in the presence of an unfamiliar person. In a second experiment, the communicative value of smiling was investigated in a real-time projection of 10 variants of smiling to a panel of receivers (n = 52). The Duchenne smile (AU 6 + 12 + 25) and smile with lips opening (12 + 25) provided more accurate information about the hedonic valence of the inhaled odour than did the other types of smiling. In contrast, the perceived valence of the facial displays simultaneously combining zygomatic action with muscular actions of the lower face (AUs 15, 17, 23) appeared more difficult to discriminate by untrained receivers. It was hypothesized that the senders displayed some forms of smiling possibly to mask their responsiveness to unpleasant odours in signalling ambiguous or incorrect information about their internal state to a recipient.     

Reduction cheiloplasty for upper lip hemangioma

A technique for reconstruction of the upper lip following excision of a cavernous hemangioma is presented. An apron-vermilion flap from the inner third of buccal side is elevated, allowing good exposure of the hemangioma. Following removal of the hemangioma, the excessive mucosa-vermilion flap is reduced to form an accurate upper lip shape. This method achieves a pleasing contour of the upper lip.     

Median facial clefts in Xenopus laevis: roles of retinoic acid signaling and homeobox genes

The upper lip and primary palate form an essential separation between the brain, nasal structures and the oral cavity. Surprisingly little is known about the development of these structures, despite the fact that abnormalities can result in various forms of orofacial clefts. We have uncovered that retinoic acid is a critical regulator of upper lip and primary palate development in Xenopus laevis. Retinoic acid synthesis enzyme, RALDH2, and retinoic acid receptor gamma (RARγ) are expressed in complementary and partially overlapping regions of the orofacial prominences that fate mapping revealed contribute to the upper lip and primary palate. Decreased RALDH2 and RARγ result in a median cleft in the upper lip and primary palate. To further understand how retinoic acid regulates upper lip and palate morphogenesis we searched for genes downregulated in response to RARγ inhibition in orofacial tissue, and uncovered homeobox genes lhx8 and msx2. These genes are both expressed in overlapping domains with RARγ, and together their loss of function also results in a median cleft in the upper lip and primary palate. Inhibition of RARγ and decreased Lhx8/Msx2 function result in decreased cell proliferation and failure of dorsal anterior cartilages to form. These results suggest a model whereby retinoic acid signaling regulates Lhx8 and Msx2, which together direct the tissue growth and differentiation necessary for the upper lip and primary palate morphogenesis. This work has the potential to better understand the complex nature of the upper lip and primary palate development which will lead to important insights into the etiology of human orofacial clefts.     

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.     

安氏Ⅰ类错合拔牙与非拔牙矫治对口唇形态影响的研究

目的：研究安氏Ⅰ类错合拔牙与非拔牙矫治对口唇形态的影响。方法：从直丝弓矫治的AngleⅠ类错合患者治疗前后的X线侧位片中随机选取拔除4个第一前磨牙患者15例（A组）,非拔牙矫治患者15例（B组）,经X线头影软组织测量分析比较矫治前后拔牙组与非拔牙组口唇形态的变化,对所得数据进行统计学处理。结果：拔牙矫治后上下唇的突度有明显改善,平均减少1.42和2.03mm;上下唇的长度也平均增加0.51和1.58mm;非拔牙矫治患者治疗后鼻唇角、下唇突度、上下唇长度均有增加,但矫治前后无统计学差异。结论：拔牙矫治有利于减小上下唇突度从而改善软组织侧貌。     

安氏I类错合拔牙与非拔牙矫治对口唇形态影响的研究

目的:研究安氏Ⅰ类错合拔牙与非拔牙矫治对口唇形态的影响.方法:从直丝弓矫治的Angle Ⅰ类错合患者治疗前后的X线侧位片中随机选取拔除4个第一前磨牙患者15例(A组),非拔牙矫治患者15例(B组),经X线头影软组织测量分析比较矫治前后拔牙组与非拔牙组口唇形态的变化,对所得数据进行统计学处理.结果:拔牙矫治后上下唇的突度有明显改善,平均减少1.42和2.03 mm;上下唇的长度也平均增加0.51和1.58 mm;非拔牙矫治患者治疗后鼻唇角、下唇突度、上下唇长度均有增加,但矫治前后无统计学差异.结论:拔牙矫治有利于减小上下唇突度从而改善软组织侧貌.

Abstract：

Objictive: To investigate the effect of Angle Class Ⅰ malocclusion after orthodontic treatment, with and without extractions on lip position changes. Methods: 30 patients with Angle Class Ⅰ malocclusion were chosen. 15 patients were treated by 4 first-premolars extraction (Group A) and 15 patients were treated without extraction (Group B). The soft tissue X-ray cephalometric of the patients were measured before and after the treatment and compared statistically. Results: After the extraction treatment, the upper and lower projecting lip reduced by 1.42 mm and 2.03, mmrespectively. The length of the upper and lower lips increased by 0.51mm and 1.58mm, respectively. For the group B, the nasolabial angle, the lower lip protrusion, the length of upper and lower lips had been increased, though there had no statistical significance before and after treatment. Conclusions: After extraction treatment the upper and lower projecting lips decreased. The patients with extractment treatment had the facial aesthelics.     

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.     

Congenital double lip: a review of seven cases

Congenital double-lip deformity is an infrequent developmental abnormality affecting the lips, more commonly the upper lip. We report seven cases of double lip, all in males, of which six were in the upper lip and one in the lower lip. It was quite interesting to observe that in the upper lip, the buccal portion of the double lip appeared on either side with a midline constriction; in the lower lip, it was prominent in the midline without any central constriction. Surgical excision under regional nerve block anesthesia gives good results. The embryology, clinical appearances, and histopathology are discussed with a review of the literature.     

Three-dimensional lip morphometry in adults operated on for cleft lip and palate

Measurements were taken from 18 patients operated on for cleft lip and palate, aged 19 to 27 years, and 162 control subjects matched for sex, age, and ethnic group. Nine soft-tissue landmarks on the lips were digitized by a three-dimensional electromagnetic instrument. From the landmarks, several linear distances (mouth width, philtrum width, vermilion height of upper and lower lip, total vermilion height, total lip height), the interlabial angle, and some areas (vermilion of upper lip, vermilion of lower lip, total vermilion) and volumes (upper lip volume, lower lip volume, total lip volume) were calculated. Patient and reference data were compared by t tests and Watson-Williams tests. In the men, significant differences (p < 0.05) were found in width of the philtrum, height and area of the vermilion part of the upper lip, and total vermilion height and area (all larger in male patients than in controls). In the women, significant differences were found in the height and area of the vermilion part of the upper lip (larger in female patients than in controls), and in the height and area of the vermilion part of the lower lip (smaller in patients than in controls). In both sexes, the interlabial angle was smaller than in the reference population. In conclusion, the upper lip of adult patients operated on for cleft lip and palate differed from that of healthy controls of the same age, sex, and ethnic group. Surgical correction of cleft lip and palate failed to provide a completely normal appearance. The analysis pointed out those parts of the lips and mouth (in particular, the vermilion part of the upper lip) that differed the most from the norm. The method may be used to indicate to the surgeon and patient where additional procedures might be performed to approximate the morphologic characteristics of a reference population.     

Chin surgery III: revelations

This article is a logical extension of previous articles written on the topic of aesthetic chin surgery. In it, the authors expand on previously published surgical techniques and provide specific updates to increase success in some unusual situations. They review the indications for and uses of reduced-height implants, discuss the validity of centralized chin incisions in both reconstruction and revisions, show the diversity of mentalis muscle anatomy and chin pad variations, reveal the importance of the lip-to-labiomental crease inclination in cases of macrogenia, note a key update on reefing the mentalis muscle to a higher position for permanent sulcus position, discuss the issues of lower lip position and lower incisor show, and expound on the horizontal smile/chin ptosis phenomenon.     

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.