Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: a clinical series

Large, full-thickness lip defects after head and neck surgery continue to be a challenge for reconstructive surgeons. The reconstructive aims are to restore the oral lining, the external cheek, oral competence, and function (i.e., articulation, speech, and mastication). The authors' refinement of the composite radial forearm-palmaris longus free flap technique meets these criteria and allows a functional reconstruction of extensive lip and cheek defects in one stage. A composite radial forearm flap including the palmaris longus tendon was designed. The skin flap for the reconstruction of the intraoral lining and the skin defect was folded over the palmaris longus tendon. Both ends of the vascularized tendon were laid through the bilateral modiolus and anchored with adequate tension to the intact orbicularis muscle of the upper lip. This procedure was used in 12 patients. Six patients had cancer of the lower lip, five patients had a buccal cancer involving the lip, and one patient had a primary gum cancer that extended to the lower lip. Total to near-total resection (more than 80 percent) of the lower lip was indicated in six patients. In two other patients, the cancer ablation included more than 80 percent of the lower lip and up to 40 percent of the upper lip. A radial forearm palmaris longus free flap was used in all cases for reconstruction of the defect. Free flap survival was 100 percent. At the time of final evaluation, which was 1 year after the operation, all patients had good oral continence at rest (static suspension) and had achieved sufficient oral competence when eating. Ten patients were able to resume a regular diet, and two patients could eat a soft diet. All patients regained normal or near-normal speech and had an acceptable appearance. The described refinement of the composite radial palmaris longus free flap technique allows the reconstruction of the lower lip with a functioning oral sphincter; the technique can be recommended for patients who need large lower lip resection. It provides functional recovery of the reconstructed lower lip synchronizing with the remaining upper lip.     

Validity of architectural properties of the hamstring muscles: Correlation of ultrasound findings with cadaveric dissection

The purpose of this study was to compare the architectural parameters of the long head of biceps femoris (BFlh) and semitendinosus (ST) muscles by comparing measurements from ultrasound (US) with those obtained from direct dissection. The BFlh and ST architectures were examined bilaterally in 6 legs from 3 male cadavers. The fascicle length, pennation angle, muscle thickness and muscle and tendon length were obtained from direct measurement and US scans along each muscle. Intraclass correlation coefficients between the two methods ranged from 0.905 to 0.913 for the BFlh variables and from 0.774 to 0.974 for the ST parameters. Compared with the direct measurements, the US method showed a mean typical error of 0.09–0.14 cm for muscle thickness, 1.01–1.31° for the pennation angle, 0.92–1.71 cm for fascicle length and muscle–tendon length measurements. The US method is a valid alternative tool for assessing basic architectural parameters of ST and BFlh components of the hamstring muscles.     

Radial half of extensor carpi radialis longus tendon as graft to elongate muscle tendon unit for correction of finger clawing

In 12 patients, the extensor carpi radialis longus muscle tendon unit was elongated using the radial half of the parent tendon so that it could reach the site of new insertion, the A1-A2 pulley of flexor sheath or lateral bands, after routing the transfer through the carpal tunnel. The tendon was of appropriate thickness and could be split into two halves to be used as a graft. Further splitting of the tendon into four tails was possible. The transferred slips retained adequate strength to activate the fingers after the operation. It is suggested that splitting of the extensor carpi radialis longus tendon to use one half as a tendon graft be considered in patients in whom extensor carpi radialis longus transfer is planned to correct finger clawing. This technique is simple, needs minor modification in the sequence of operative steps, reduces operating time, and saves the patient from postoperative discomfort, muscle herniation, and scarring at the donor site (usually the thigh).     

Evolution of Skin Temperature after the Application of Compressive Forces on Tendon,Muscle and Myofascial Trigger Point

Some assessment and diagnosis methods require palpation or the application of certain forces on the skin, which affects the structures beneath, we highlight the importance of defining possible influences on skin temperature as a result of this physical contact. Thus, the aim of the present study is to determine the ideal time for performing thermographic examination after palpation based on the assessment of skin temperature evolution. Randomized and crossover study carried out with 15 computer-user volunteers of both genders, between 18 and 45 years of age, who were submitted to compressive forces of 0, 1, 2 and 3 kg/cm² for 30 seconds with a washout period of 48 hours using a portable digital dynamometer. Compressive forces were applied on the following spots on the dominant upper limb: myofascial trigger point in the levator scapulae, biceps brachii muscle and palmaris longus tendon. Volunteers were examined by means of infrared thermography before and after the application of compressive forces (15, 30, 45 and 60 minutes). In most comparisons made over time, a significant decrease was observed 30, 45 and 60 minutes after the application of compressive forces (p < 0.05) on the palmaris longus tendon and biceps brachii muscle. However, no difference was observed when comparing the different compressive forces (p > 0.05). In conclusion, infrared thermography can be used after assessment or diagnosis methods focused on the application of forces on tendons and muscles, provided the procedure is performed 15 minutes after contact with the skin. Regarding to the myofascial trigger point, the thermographic examination can be performed within 60 minutes after the contact with the skin.     

Comparative assessment of the acute ankle injury by ultrasound and magnetic resonance

We compared ultrasound (US) with magnetic resonance (MR) findings of muscle tendon and ligaments (mt&l) of 17 men and 13 women, 16-66 years old, who suffered from acute ankle injury without bone fracture visible on conventional radiographs. Joint effusion (JE), and injury of the Tibials anterior muscle tendon (TAmt), Calcaneofibular ligament (CFl), Long flexor of the great toe muscle tendon (LFGTmt), Short peroneus muscle tendon (SPmt), Long peroneus muscle tendon (LPmt), and Anterior talofibular ligament (ATFl) were assessed by the US, at seven days, and MR, at seventeenth day. Grading of ligament and muscle tendon injury as stretching (Grade 1), partially ruptured (Grade 2), and complete rupture (Grade 3); no lesion was considered to be Grade 0. Joint effusion and ATFl were the most common lesions whereas the TAmt lesion was the least frequent: JE approximately ATFl > SPmt approximately LPmt > LFGTmt approximately CFl approximately TAmt. Both US and MR were equally sensitive in detecting the presence (or absence) of the mt&l ankle injury, whereas US was less specific than MR in detecting G3 injury.     

Geometrical changes of knee ligaments and patellar tendon during passive flexion

Patterns of fibre elongation and orientation for the cruciate and collateral ligaments of the human knee joint and for the patellar tendon have not yet been established in three-dimensions. These patterns are essential for understanding thoroughly the contribution of these soft tissues to joint function and of value in surgical treatments for a more conscious assessment of the knee status. Measurements from 10 normal cadaver knees are here reported using an accurate surgical navigation system and consistent anatomical references, over a large flexion arc, and according to current recommended conventions. The contours of relevant sub-bundles were digitised over the corresponding origins and insertions on the bones. Representative fibres were calculated as the straight line segments joining the centroids of these attachment areas. The most isometric fibre was also taken as that whose attachment points were at the minimum change in length over the flexion arc. Changes in length and orientation of these fibres were reported versus the flexion angle. A good general repeatability of intra- and inter-specimens was found. Isometric fibres were found in the locations reported in the literature. During knee flexion, ligament sub-bundles slacken in the anterior cruciate ligament, and in the medial and lateral collateral ligaments, whereas they tighten in the posterior cruciate ligament. In each cruciate ligament the two compounding sub-bundles have different extents for the change in fibre length, and also bend differently from each other on both tibial planes. In the collateral ligaments and patellar tendon all fibres bend posteriorly. Patellar tendon underwent complex changes in length and orientation, on both the tibial sagittal and frontal planes. For the first time thorough and consistent patterns of geometrical changes are provided for the main knee ligaments and tendons after careful fibre mapping.     

Comparative anatomy of rabbit and human achilles tendons with magnetic resonance and ultrasound imaging

We sought to describe the comparative anatomy of the Achilles tendon in rabbits and humans by using macroscopic observation, magnetic resonance imaging, and ultrasonography. The calcaneus-Achilles tendon-gastrocnemius-soleus complexes from 18 New Zealand white rabbits underwent ultrasound (US) and magnetic resonance (MR) imaging and gross anatomic sectioning; these results were compared with those from a cadaveric gastrocnemius-soleus-Achilles tendon-calcaneus specimen from a 68-y-old human male. The medial and lateral gastrocnemius muscle tendons merged 5.2 +/- 0.6 mm proximal to the calcaneal insertion macroscopically, at 93% of their course, different from the gastrocnemius human tendons, which merged at 23% of their overall course. The rabbit flexor digitorum superficialis tendon, corresponding to the flexor digitorum longus tendon in human and comparable in size with the gastrocnemius tendons, was located medial and anterior to the medial gastrocnemius tendon proximally and rotated dorsally and laterally to run posterior to the Achilles tendon-calcaneus insertion. In humans, the flexor digitorum longus tendon tracks posteriorly to the medial malleolus. The soleus muscle and tendon are negligible in the rabbit; these particular comparative anatomic features in the rabbit were confirmed on the MR images. Therefore the rabbit Achilles tendon shows distinctive gross anatomical and MR imaging features that must be considered when using the rabbit as a research model, especially for mechanical testing, or when generalizing results from rabbits to humans.     

Myofascial force transmission: muscle relative position and length determine agonist and synergist muscle force.

Equal proximal and distal lengthening of rat extensor digitorum longus (EDL) were studied. Tibialis anterior, extensor hallucis longus, and EDL were active maximally. The connective tissues around these muscle bellies were left intact. Proximal EDL forces differed from distal forces, indicating myofascial force transmission to structures other than the tendons. Higher EDL distal force was exerted (ratio approximately 118%) after distal than after equal proximal lengthening. For proximal force, the reverse occurred (ratio approximately 157%). Passive EDL force exerted at the lengthened end was 7-10 times the force exerted at the nonlengthened end. While kept at constant length, synergists (tibialis anterior + extensor hallucis longus: active muscle force difference approximately -10%) significantly decreased in force by distal EDL lengthening, but not by proximal EDL lengthening. We conclude that force exerted at the tendon at the lengthened end of a muscle is higher because of the extra load imposed by myofascial force transmission on parts of the muscle belly. This is mediated by changes of the relative position of most parts of the lengthened muscle with respect to neighboring muscles and to compartment connective tissues. As a consequence, muscle relative position is a major codeterminant of muscle force for muscle with connectivity of its belly close to in vivo conditions.     

Studies on the tendinous compartments of the extensor muscles on the back of the human hand and their tendon sheaths. I

In 47 dissected right and left hands of adults of both sexes, kept in a moist condition, significant practical-clinical investigations of the transitional zone between forearm and hand were undertaken. In particular it was sought to determine the characteristic sizes of the extensor retinaculum, the osteofibrous tunnels, the insertion tendons of the hand and finger extensor muscles, and their tendon sheaths. Together with the palmar carpal ligament, the 2 to 3 cm wide extensor retinaculum annularly surrounds the whole circumference of the carpus. It extends obliquely from radial-proximal to ulnar-distal and conducts the extensor tendons over the carpal articulations. According to recent studies, it is divided into a superficial and a deep fibrous layer. From the undermost surface, vertical and oblique septa run to the plane of the forearm and carpal bones. They separate the fibrous portion of the 6 tendinous compartments of the dorsum manus. In 8.5% of cases, an accessory and completely independent tunnel of the extensor pollicis brevis muscle exists in the material investigated, and in 2.2% of cases, there is an additional tunnel for the extensor carpi radialis muscle. Hence, one occasionally finds 8 separate osteofibrous gliding compartments for the extensor muscles in the dorsal hand region. The longest tunnel belongs, as a rule, to the extensor digiti minimi muscle, whilst the widest pertains to the extensor digitorum muscle. Within the tunnel and also proximal and distal to it, the extensor tendons are surrounded by synovial sheaths. Because of its wide encroachment on the dorsum of the hand, the insertion tendon of the extensor digiti minimi muscle possesses the longest tendon sheath, measuring 68.8 mm. The next longest sheath, that of the extensor pollicis longus muscle, which measures 56.2 mm, begins further proximal to the gap of the radiocarpal articulation. In 12.8% of cases, there are divided sheaths of the abductor pollicis longus and of the extensor pollicis brevis muscle. The tendon sheath of both extensor carpi radiales muscles is frequently divided into 2 compartments which, in 2/3 of cases, communicate. The compartment of the extensor carpi radialis brevis muscle, in 91.5% of cases, shares a window-like opening with the roof of the synovial vagina of the extensor pollicis longus muscle. The tendon sheath of the long extensor muscles of the fingers originates 5 mm proximal to the forearm border of the extensor retinaculum and has a communal recess. The IVth tendon sheath opens distally and splays out in a glove-like manner to some distal recesses.(ABSTRACT TRUNCATED AT 400 WORDS)     

Mechanical effect of rat flexor carpi ulnaris muscle after tendon transfer: does it generate a wrist extension moment?

The mechanical effect of a muscle following agonist-to-antagonist tendon transfers does not always meet the surgeon's expectations. We tested the hypothesis that after flexor carpi ulnaris (FCU) to extensor carpi radialis (ECR) tendon transfer in the rat, the direction (flexion or extension) of the muscle's joint moment is dependent on joint angle. Five weeks after recovery from surgery (tendon transfer group) and in a control group, wrist angle-moment characteristics of selectively activated FCU muscle were assessed for progressive stages of dissection: 1) with minimally disrupted connective tissues, 2) after distal tenotomy, and 3) after maximal tendon and muscle belly dissection, but leaving blood supply and innervations intact. In addition, force transmission from active FCU onto the distal tendon of passive palmaris longus (PL) muscle (a wrist flexor) was assessed. Excitation of control FCU yielded flexion moments at all wrist angles tested. Tenotomy decreased peak FCU moment substantially (by 93%) but not fully. Only after maximal dissection, FCU wrist moment became negligible. The mechanical effect of transferred FCU was bidirectional: extension moments in flexed wrist positions and flexion moments in extended wrist positions. Tenotomy decreased peak extension moment (by 33%) and increased peak flexion moment of transferred FCU (by 41%). Following subsequent maximal FCU dissection, FCU moments decreased to near zero at all wrist angles tested. We confirmed that, after transfer of FCU towards a wrist extensor insertion, force can be transmitted from active FCU to the distal tendon of passive PL. We conclude that mechanical effects of a muscle after tendon transfer to an antagonistic site can be quite different from those predicted based solely on the sign of the new moment arm at the joint.     

Functional properties of palmaris longus muscles of rhesus monkeys transplanted as index finger flexors

This experiment with skeletal muscle autografts in monkeys was designed to retest previous findings that transplanted skeletal muscle can regenerate to a functional degree in primates without predenervation and to test a new hypothesis that increased functional demands on regenerated muscle grafts in monkeys may result in improved functional capacity of the grafts. Rhesus monkey index flexors were replaced with free palmaris longus muscle autografts with microneural anastomoses between the graft motor nerve and the severed profundus motor nerve. One monkey was taught selective index flexion before grafting and continued with this program after grafting to test the effect of training on the graft. Mature grafts were evaluated for in vivo contractile properties and by histology and histochemistry and were compared with a group of normal Rhesus palmaris longus muscles. The results reconfirm the capacity of nonpredenervated monkey skeletal muscle grafts to regenerate and to achieve some contractile ability and suggest that training of free muscle grafts may enhance recovery of their functional and structural properties.     

Mechanical properties of aponeurosis and tendon of the cat soleus muscle during whole-muscle isometric contractions

Recent studies have suggested that the mechanical properties of aponeurosis are not similar to the properties of external tendon. In the present study, the lengths of aponeurosis, tendon, and muscle fascicles were recorded individually, using piezoelectric crystals attached to the surface of each structure during isometric contractions in the cat soleus muscle. We used a surgical microscope to observe the surface of the aponeurosis, which revealed a confounding effect on measures of aponeurosis length due to sliding of a thin layer of epimysium over the proximal aponeurosis. After correcting for this artifact, the stiffness computed for aponeurosis was similar to tendon, with both increasing from around 8 F₀/L_c (F₀ is maximum isometric force and L_c is tissue length) at 0.1 F₀ to 30 F₀/L_c at forces greater than 0.4 F₀. At low force levels only (0.1 F₀), aponeurotic stiffness increased somewhat as fascicle length increased. There was a gradient in the thickness of the aponeurosis along its length: its thickness was minimal at the proximal end and maximal at the distal end, where it converged to form the external tendon. This gradient in thickness appeared to match the gradient in tension transmitted along this structure. We conclude that the specific mechanical properties of aponeurosis are similar to those of tendon. © 1995 Wiley-Liss, Inc.     

Free flap from the flexor aspect of the wrist for resurfacing defects of the hand and fingers

The distal portion of the flexor aspect of the forearm has been used as the donor site of full-thickness skin grafts, venous skin grafts, and Chinese forearm flaps. This article describes the use of a free flap harvested from the flexor aspect of the wrist and based on the superficial palmar branch of the radial artery to repair skin defects of the hand and fingers. The advantages of this flap are as follows: (1) the operative field is the same; (2) the radial artery is preserved; (3) it is thin, pliable, and hairless and thus can supply a gliding surface for tendons beneath it; (4) when it involves a palmaris longus tendon and/or the palmar cutaneous branch of the median nerve, it can be used as a vascularized tendon or nerve graft; and (5) in view of the flow-through type of the pedicle of the flap, the digital artery can be reconstructed simultaneously. However, it should be noted that a hypesthesia in the proximal central carpal area remains when the palmar cutaneous branch of the median nerve is harvested as a vascularized nerve graft. The scar of the donor site should be left in the distal wrist crease. If it is not lying in the distal wrist crease, it may suggest that the patient has tried to commit suicide.     

The influence of specimen length on the tensile failure properties of tendon collagen

Connective tissues such as ligament, tendon and skin are composites of strength-bearing collagen fibers embedded in a hydrated matrix. The tensile response and failure properties of rat-tail tendon are thought to represent those of the collagen fiber itself. In this study, the tensile failure properties of rat-tail tendon (tendon collagen) were determined for specimens of various test length. The experimental results indicated that failure strain, based on the test grip-to-grip dimension, and failure strain energy density decreased as specimen length increased. The failure stress, on the other hand, did not change appreciably with specimen length. Thus, tensile failure data cannot simply be normalized by the grip-to-grip length of the test specimen. Experimental data from various laboratories must clearly document the length of the test specimen.     

Why are mammalian tendons so thick?

The maximum stresses to which a wide range of mammalian limb tendons could be subjected in life were estimated by considering the relative cross-sectional areas of each tendon and of the fibres of its muscle. These cross-sectional areas were derived from mass and length measurements on tendons and muscles assuming published values for the respective densities. The majority of the stresses are low. The distribution has a broad peak with maximum frequency at a stress of about 13 MPa, whereas the fracture stress for tendon in tension is about 100 MPa. Thus, the majority of tendons are far thicker than is necessary for adequate strength. Much higher stresses are found among those tendons which act as springs to store energy during locomotion. The acceptability of low safety factors in these tendons has been explained previously (Alexander, 1981). A new theory explains the thickness of the majority of tendons. The muscle with its tendon is considered as a combined system which delivers mechanical energy: the thickness of the tendon is optimized by minimizing the combined mass. A thinner tendon would stretch more. To take up this stretch, the muscle would require longer muscle fibres, which would increase the combined mass. The predicted maximum stress in a tendon of optimum thickness is about 10 MPa, which is within the main peak of the observed stress distribution. Individual variations from this value are to be expected and can be understood in terms of the functions of the various muscles.     

Myofascial force transmission between a single muscle head and adjacent tissues: length effects of head III of rat EDL.

Force transmission from muscle fibers via the connective tissue network (i.e., myofascial force transmission) is an important determinant of muscle function. This study investigates the role of myofascial pathways for force transmission from multitendoned extensor digitorum longus (EDL) muscle within an intact anterior crural compartment. Effects of length changes exclusively of head III of rat EDL muscle (EDL III) on myofascial force transmission were assessed. EDL III was lengthened at the distal tendon. For different lengths of EDL III, isometric forces were measured at the distal tendon of EDL III, as well as at the proximal tendon of whole EDL and at the distal tendons of tibialis anterior and extensor hallucis longus (TA+EHL) muscles. Lengthening of EDL III caused high changes in force exerted at the distal tendon of EDL III (from 0 to 1.03 +/- 0.07 N). In contrast, only minor changes were found in force exerted at the proximal EDL tendon (from 2.37 +/- 0.09 to 2.53 +/- 0.10 N). Increasing the length of EDL III decreased TA+EHL force significantly (by 7%, i.e., from 5.62 +/- 0.27 to 5.22 +/- 0.32 N). These results show that force is transmitted between EDL III and adjacent tissues via myofascial pathways. Optimal force exerted at the distal tendon of EDL III (1.03 +/- 0.07 N) was more than twice the force expected on the basis of the physiological cross-sectional area of EDL III muscle fibers (0.42 N). Therefore, a substantial fraction of this force must originate from sources other than EDL III. It is concluded that myofascial pathways play an important role in force transmission from multitendoned muscles.     

Extensor carpi radialis longus muscle and the evolution of the first intermetacarpal ligament

The morphology and function of tendinous connections between the bases of the first and second metacarpal bone was studied in dissected specimens. The sample comprises 28 hands from eight species of cercopithecidae and pongidae and 23 human hands. Four types were identified: (1) No intermetacarpal connections were present. (2) The extensor carpi radialis longus tendon was divided at the carpus and the side branch inserted on the ulnar side of the base of the first metacarpal bone. (3) Part of the fibers of the extensor carpi radialis longus bypassed the insertion on the second metacarpal bone and continued to the base of the first metacarpal bone. A few proper intermetacarpal fibers were included. (4) An extracapsular, intermetacarpal ligament was present. Its fibers were mainly separated from the extensor carpi radialis longus. Type 1 is a general mammalian form. Type 2 is common in higher, non-human primates. Type 3 was found in 2 of the 23 human hands and otherwise among the anthropoid apes only. Type 4 is apomorph in man. Individual variations exist though. Type 3 and especially type 4 could check ab- and adductions and guide a circumduction in the first carpometacarpal joint.     

Frequency of the musculus palmaris longus studied in vivo in some Amazon indians

The frequency of the Musclus palmaris longus was studied by observing its tendon in vivo in 379 Amazon Indians belonging to the following tribes: Tucano, Tariana, Tiriyo, Desana, Piratapuya, Macu and Arapaso. The muscle was not observed in 14 individuals (3.7% ± 1.0) either unilaterally or bilaterally and in 24 of 758 limbs (3.1% ± 0.6). No statistically significant difference was observed in the frequency of the muscle among the different tribes. Bilateral absence was significantly more frequent than the unilateral one; absence in females was more frequent than in males. The frequency of palmaris longus agenesis in Amazon Indians agrees with reported values for Negroids and Mongoloids and is considerably lower than that generally reported for the Caucasoids.     

Correlation between semitendinosus and gracilis tendon cross-sectional area determined using ultrasound,magnetic resonance imaging and intraoperative tendon measurements

The purpose of this study was to examine the correlation in semitendinosus (ST) and gracilis (GT) tendon cross-sectional area (CSA) evaluated directly during anterior cruciate ligament (ACL) surgery and pre-operatively using ultrasound (US) and magnetic resonance imaging (MRI). A total of 14 patients undergoing ACL reconstruction with a quadruple ST–GT graft by the same orthopaedic surgeon participated in this study. Pre-operative evaluation included determination of ST and GT CSA area using US and MRI. Intraoperative measurement of the diameters of the ST, GT and the final ACL graft using a closed-hole sizing block with 0.5-mm increments was made and this diameter was used to estimate tendon CSA. The correlation between graft diameter and CSA were 0.563 (GT) and 0.807 (ST) for MRI and 0.498 (GT) and 0.612 (ST) for US. The final ACL graft diameter displayed a correlation coefficient of 0.813 with MRI CSA and 0.518 with US CSA. No differences in CSA were observed between intraoperative, MRI and US methods (p > 0.05). The intraclass correlation coefficients between the US, MRI and intraoperative graft methods for the ST and GT data ranged from 0.502 to 0.903 with an estimation error ranging from 1.41% to 2.26%. These results indicate that in clinical situations where MRI is contra-indicated or not accessible, US can provide measurable values which could predict sufficient diameter of the ACL graft. In addition, determination of tendon CSA using US displays errors less than 2% which is similar to that observed using MRI. This suggests that the application of US can be applied to in vivo examination of the ST and GT CSA.     

Reconstruction of the lower lip and chin with the composite radial forearm-palmaris longus free flap

Four cases of total lip and chin reconstruction are presented. In three, the composite radial forearm-palmaris longus free flap was used for reconstruction. In the fourth case, the palmaris longus was separated from the flap but still used as a lower lip sling. In all cases, the entire lower lip and the soft tissue of the chin were reconstructed in one stage. All patients healed primarily, and the three who underwent radiotherapy tolerated it without complications. Lip seal and speech were good, and there was no problem with drooling. Postoperative results emphasize the importance of respecting the aesthetic unit of the lower lip and chin.