Lateral Lip Research Articles

Improved Black procedure in microsurgical repair of bilateralcomplete cleft lip

Objective To discuss the effect of cheiloplasty we designed an improved Black procedure that with microsurgical technique the tissue from lateral lips on the bilateral cleft lip were used to reconstruct the skin of anterior lip and the vermilion tubercle. Methods 36 cases of congenital bilateral complete cleft lip deformity were repaired through improved Black procedure and microsurgical method, including 19 patients with very short prolabium tissue, repairing insufficient skin and vermilion tubercle tissue by fissure lateral lip tissue. Results Following-up for 3 months to 3 years after treatment showed that 36 patients were with normal and symmetrical high of anterior lips, the chubby vermilion tubercles, the natural morphous of labial archs, the appropriate strength of labrums and the vermilion tubercles and lips without color difference, and the effects were satisfactory. Conclusion The improved Black procedure redeems the shortages of traditional Black procedure for the case with bilateralcomplete cleft lip and smaller anterior lip, such as the deficient height of anterior lips, eclabium and inadequate vermilion tubercles. By applying microsurgical technique, the procedure gives better upper lip function and aesthetic effect, and therefore it is worthy to be recommended in clinic. Key words: Bilateralcomplete cleft lip; Improved Black procedure; Repair

Presurgical Unilateral Cleft Lip Anthropometrics: Implications for the Choice of Repair Technique

It has been stated that height of the lateral lip is difficult to obtain with the rotation advancement repair only when the lateral lip is short in both its vertical and horizontal dimensions. The authors studied preoperative cleft lip anthropometry to determine the frequency of the "geometrically unfavorable lateral lip"--short in both vertical and transverse dimensions. Direct caliper measurements were taken by a single observer of the heights and of the transverse lengths in 100 consecutive patients (age ≥3 months and <6 months) with unilateral cleft lip (51 complete and 49 incomplete) who were under general anesthesia just before cleft lip repair. In 75 patients, the height of the lateral lip was less than that of the noncleft side; on average, 2.1 mm less than (or 82 percent of) the noncleft side (range, 50 to 133 percent). In 86 patients, the lateral lip transverse length was less than on the noncleft side; on average, 2.7 mm less than (or 86 percent of) the noncleft side (range, 66 to 114 percent). Of the 75 patients with height deficiency, 63 patients also had transverse length deficiency. There were 19 patients who exhibited vertical height deficiency of 4 mm or more (>1 SD from the mean), and 79 percent of these patients with extreme height deficiency also exhibited transverse length deficiency. The lateral lip is frequently short in both vertical and transverse dimensions. These findings warrant consideration for the use of repairs other than rotation advancement (and its variations) in the setting of lateral lip deficiency.

Two New Species of Labiostrongylinea (Nematoda: Cloacininae) from Salawati Island, Indonesia

Two new species of Labiostrongylinea (Nematoda: Cloacininae), Labiosimplex papuensis n.sp and Labiomultiplex sagawinensis n.sp, are described from the stomach of the macropodid marsupial, Dorcopsis muelleri (Lesson, 1827) (Mammalia :Macropodidae) in Papua, Indonesia. Labiosimplex papuensis n. sp. is most similar to Ls. redmondi Smales, 1982 in having the lateral lips of similar shape to the submedians and can be distinguished from it by the form of the cephalic papillae and the much shorter spicules. Labiomultiplex sagawinensis n. sp. falls between two groups of species, in regard to spicule length, including Lm. novaeguineae Smales, 1994 also found only in New Guinea. It can be distinguished from all congeners by a suite of characters including the shape of the lateral lips, spicule length, the form of the genital cone, gubernaculum, branches of the dorsal ray and egg size. The finding of these two new species may be indicative of scenarios of coevolution with the host, D. muelleri (Ls. papuensis) and host switching from Dendrolagus sp., (Lm. sagawinensis) after isolation from Australia.

New species and new locality records of the nematode genus Labiosimplex (Strongylida: Chabertiidae) from macropodid marsupials in Western Australia

Labiosimplex mawsonae sp. nov. is described from the stomach of Macropus irma (Jourdan) (type host) from north of Williams, Western Australia. The new species is distinguished from all congeners by a combination of characters including the proportions of the lateral lip, the form of the bursa and dorsal ray, the length of the spicules and the length of the vagina vera. Labiosimplex camporum sp. nov. from the stomach of M. rufus (Desmarest) (type host) and M. robustus Gould from the Karratha region, is distinguished from all congeners by a combination of characters including the shape of the submedian lips and the form and size of the oesophageo-intestinal diverticula and the length of the spicules. Labiosimplex kungi Mawson is reported from Western Australia for the fi rst time and new locality records are reported for L. irma Smales, L. occidentalis Smales, L. longispicularis Smales and L. thomasae Smales. The patterns of occurrence of species of Labiosimplex within species of Macropus suggest both colonization and co speciation may have occurred.

Poikilolaimus carsiops n. sp. (Rhabditida: Rhabditidae) associated with Neotermes koshunensis (Kalotermitidae) in Kenting National Park, Taiwan

Abstract During a survey of termite-associated nematodes in southern Taiwan (Kenting National Park), two species of Poikilolaimus, Poikilolaimus cf. floridensis and an undescribed species, were isolated from termites in the family Kalotermitidae. The undescribed species is morphologically observed, described and figured herein as P. carsiops n. sp. The new species is characterised by an unusual cross-shaped stomatal opening formed by two well developed dorsal and two subventral lip sectors, each with a triangular flap and two vestigial lateral lip sectors lacking a flap, and several other morphological characters. Based upon morphology and molecular phylogenetic analysis, P. carsiops n. sp. is closest to P. floridensis; i. e., these two species share a plesiomorphic regular cuticle and short tail in both males and females, and a lack of metastegostomatal teeth or denticle. In the molecular phylogenetic analysis, P. carsiops n. sp. and P. floridensis formed a well-supported clade which was clearly separated from, but monophyletic with, a clade that includes the other Poikilolaimus species. Because both P. carsiops n. sp. and P. floridensis have been isolated only from the kalotermitid termites, the P. floridensis/P. carsiops n. sp. clade is considered to be specialised with dry wood and damp wood termites (Kalotermitidae).

Morphology of the infective larval stage of the equid parasite Habronema muscae (Spirurida: Habronematidae), from houseflies (Musca domestica)

The infective larva of the spirurid nematode Habronema muscae, a parasite of houseflies, was measured and specimens fixed in Karnovsky's fluid were examined by scanning electron microscopy. The oral opening contains six teeth and is surrounded by large bilobed dorsal and ventral lips and smaller lateral lips. A pair of amphids lie behind the lateral lips. There are two rows of four cephalic papillae. The body is deeply ridged, both transversely and longitudinally. The caudal end of the worm is studded by small papillae. The position of the anal opening is somewhat ambiguous. These larval morphological features are discussed, as well as the changes which must have occurred in the metamorphosis of the infective larva to the adult in the stomach of horses.

Comparative morphology and ultrastructure of the mouthparts in unfed larvae of Platytrombidium fasciatum and Camerotrombidium pexatum (Acariformes: Microtrombidiidae)

The mouthparts of unfed larvae of Platytrombidium fasciatum (C. L. Koch, 1836) and Camerotrombidium pexatum (C. L. Koch, 1837) (Acariformes: Microtrombidiidae) were studied using both light optical (whole-mounted specimens, toluidine blue stained semi-thin sections) and electron microscope (TEM, SEM) methods. The mouth apparatus incorporated within the gnathosoma occupies an axial position and is covered from above by the arched dorsal shield, or scutum. The chelicerae are comparatively long and separated, and the lateral lips form a permanent apomorphic sucker provided with an internal cuticular sclerite. The pharynx is extremely wide and totally fused with the bottom of the infracapitulum. The pharyngeal dilators originate on the posterior portions of the cervix (epistome) and on the capitular apodemes and run nearly parallel to the cervix to the dorsal pharyngeal wall. Comparatively short sigmoid pieces serve as origin of the muscles--cheliceral levators inserting on the posterior wall of the basal cheliceral segments. There are two sets of the extrinsic gnathosomal muscles originating on the posterior portion of the scutum: retractors of chelicerae inserting on the posterior portions of the basal cheliceral segments, and retractors of the gnathosoma inserting on the very posterior parts of the capitular apodemes. The labrum and the cervix delimit the pharynx and the subcheliceral space. The labrum and the cervix for the most part are weakly sclerotized cuticular plates and do not have own muscles. The larval mouth apparatus, in comparison with that of adult microtrombidiid mites, is simply organized and more specialized for ingestion of large masses of liquid food.

Definition of the Lateral Bulge Deformity After Primary Cleft Lip Repair Using Real-Time High-Resolution Ultrasound

The lateral bulge is a common secondary deformity after primary cleft lip repair; however, its underlying anatomy remains undefined. The purpose of this study was to use real-time high-resolution ultrasound to better understand the anatomy underlying the lateral bulge deformity. Twenty-three patients with a lateral bulge were included in addition to 12 patients without clefts to validate ultrasound measurements. Muscle and connective tissue dimensions were recorded at standardized landmarks using ultrasound, both at rest and with movement. The cleft and noncleft sides (right and left in noncleft patients) were compared within groups, and ratios between sides were compared across groups using parametric and nonparametric tests. Repeat measurements were recorded to calculate intrarater reliability. Orbicularis oris thickness was greater on the cleft side in the lateral bulge group at rest, both at the philtral column and alar crease (P < 0.001), and with facial movement at the corresponding landmarks (alar crease: smile P < 0.001 and pucker P = 0.003; philtral column: smile P < 0.001 and pucker P = 0.001). The ratio for levator width was also greater in the lateral bulge group (P < 0.001). No differences were identified between sides at the corresponding landmarks in the noncleft group. Ultrasound enabled real-time high-resolution evaluation of anatomic differences underlying the lateral bulge deformity. It was associated with greater orbicularis oris thickness and levator width on the cleft side. Findings from this study may guide future surgical correction of the lateral lip bulge.

Report of Unilateral Cleft Lip Repaired with the Skin-Vermilion Flap Method

Sir: Between January and December of 2008, this technique has been used in 96 consecutive unilateral cleft lip repairs. Forty-nine were of male and 47 of female patients, and 50 were incomplete unilateral cleft lip and 46 were complete unilateral cleft lip repairs. The patients' ages ranged between 3 months and 15 years, with a mean of 6.5 months. The operative markings are shown in Figure 1. The problem deserving of our attention is the marking of point 12; point 12 is marked just above the cutaneous roll, and then line 12-11 and line 4-6 are of equal length and will meet, line 13-12 and line 3-6 are of equal length and will meet too, and the line 13-12 plus line 12-10 is equal to that of the non–cleft-side philtral column (line 2-5).Fig. 1.: (Above, left) Preoperative sketch of unilateral incomplete cleft lip showing marking points and incision design. (Above, right, and below, left) Preoperative sketch of unilateral complete cleft lip showing marking points and incision design. (Below, right) Postoperative sketch of unilateral cleft lip repaired with the skin-vermilion method.All lines in Figure 1 are operative incisions. A skin-vermilion triangle flap is designed on the affected side of the lateral lip and inserted into the medial lip (line 6-4) to reconstruct a vermilion tubercle and lengthen the vertical height of the affected lip. The affected orbicularis is freed from its upturned insertion in the region of the columellar base, alveolar cleft margin, and alar base, and then the normal anatomical structure of the upper lip is reconstructed by resetting and fixing orbicularis, nasal columella, and nasal alae, and constructing the nasal base (Fig. 1). All of the patients presented good contour of the vermilion tubercle and chubby nasal base. The vertical height of their upper lip, nasal alae, and vermilion were symmetrical between affected and unaffected lateral lips. The technique can be applied to all degrees of unilateral cleft lip (Fig. 2).Fig. 2.: (Above, left) Preoperative markings of unilateral complete cleft lip. (Above, right) The operating incisions have been completed; a skin-vermilion triangle flap with skin, vermilion, and orbicularis has been formed on the affected side of the lateral lip and will be inserted into the medial lip to reconstruct a vermilion tubercle and lengthen the vertical height of the affected lip. Patient is shown preoperatively (below, left) and 7 days postoperatively (below, right).In patients with cleft lip, surgeons are constantly striving for the ultimate goal of achieving a lip and nose of normal form and function by operative repair. Even though we cannot achieve the ultimate goal at present, some achievements have been gained.1–3 For obtaining a normal upper lip and nose, we consider that we must solve two problems. The first is to recover the normal anatomical structure and tissue tension of the upper lip and nose with cleft lip, and the second is to provide an operative design with a minimal scar in the upper lip and a minimal impact on growing maxillae after cleft lip repair. This formed the basis of the described repair. The strengths of this described technique, then, are (1) effective completion of the problem about the affected medial lip deficient in vertical height without an increased incision in the nasal base; (2) application of lateral lip tissue in reconstructing the nasal agger and filling the nasal base; (3) maximum reservation of vermilion tissue, effective prevention of “whistle deformity,” and formation of a fluent red line; (4) minimal scar; and (5) an obvious vermilion tubercle and minimal tension of the upper lip for scarcely abandoning any tissue. The short-term effect of a cleft lip repair with the described technique is very satisfactory, but the long-term result after surgery should be observed by longer term follow-up of more cases. PATIENT CONSENT Parents or guardians provided written consent for use of patient images. Haisheng Yu, M.D. Qian Wei, M.D. Plastic Surgery Nan Ning, China

Insertional Footprint Anatomy of the Pectoralis Major Tendon

Correct anatomical repair of pectoralis major tendon injuries requires accurate identification of the humeral insertion site. In the absence of residual fibers at the insertion, proper placement requires knowledge of the anatomic relationships in the proximal humerus. This anatomic study attempts to measure these relationships and the dimensions of the insertional footprint to assist in surgical repair and reconstruction. Six matched pairs of cadaver proximal humeri were examined. All specimens were found to be in good condition and none were excluded. The proximal to distal length and maximum width of the pectoralis major tendon were measured at the humeral insertion with a digital caliper. The distance from the superomedial corner of the greater tuberosity to the superior aspect of the tendon insertion was also measured. The mean proximal to distal dimension of the pectoralis major insertion was 72.3+/-12.3 mm. The mean maximal thickness at the humeral insertion was 1.4+/-.2 mm. The distance from the superomedial corner of the greater tuberosity to the bony tendon insertion was 42.2+/-8.5 mm. The anatomic location of the humeral insertion of the pectoralis major tendon can be located in repair of pectoralis tendon injuries by referencing the superomedial corner of the greater tuberosity and the lateral lip of the bicipital groove. Findings in the present study will improve knowledge of the surgical anatomy relevant to repair and reconstruction of the pectoralis major tendon.

Morphological, ultrastructural and functional adaptations of the mouthparts in cheyletid mites (Acari: Actinedida: Cheyletidae)

ABSTRACT The cheyletid family includes more than 370 predatory and parasitic species. According to their feeding habit, some are involved in the integrated pest management of stored food, while other species are parasitic both of men and domestic animals. They all suck up liquid food after piercing tissues with their mouthparts showing peculiar adaptations to this feeding behavior. Like in other taxa of mites, the movable digits have been transformed into stylets that reach the tip of the gnathosoma, enclosed into the malapophyses and lateral lips, and enable the mite to pierce the animal tissues. Since the stylets are short, they serve merely for superficial penetration. Reduced fixed digits cover dorsally the infracapitulum and keep in place the stylets with a peculiar overlapping system. The cheliceral bases are proximally completely fused to each other but also fused with the infracapitulum, thus forming a “stylophore capsule.” Food intake is realized through the preoral groove and the food channel thanks to the pumping action of the pharyngeal chamber. Feeding activity is regulated by several sense organs. A three-dimensional reconstruction is provided with dynamic evidences of the functioning.

Chin IX: Unusual Soft Tissue Problems of the Lower Face

When the editor asked me to write something related to the chin, I (B.M.Z.) told him I would like to concentrate on the soft tissue of the perioral and chin region, something previously not presented before in this Journal specifically or anywhere. Dr. Flores and I have chosen certain soft tissue cases of the lower face, each of which presents certain dilemmas. The reconstructive methods in each case are unique, previously not shown, and represent salvage from prior failures. Case 1 shows how an interior Abbe flap can be used for ipsilateral lip reconstruction. Case 2 shows how a large upper lateral lip elemental loss can be regained from cheek and not the lower lip. Cases 3 and 4 show how to regain proper white roll bulge and symmetry by overcorrection, then exact adjustment in a second stage. Case 5 shows how a failed chin/lip reconstruction can be salvaged to regain sulcus height and aesthetic unit reconstruction. Each case depicts unique reconstructive designs to produce an aesthetic final result.

A technique for defogging intra tympanic mirrors

The sinus tympani in the middle ear have been the focus of clinical interest because of its tendency to be invaded by a cholesteatoma. Due to its visual obscurity, and the lack of a straightforward surgical approach, it can be diYcult to address [1]. Most residual cholesteatoma present in the sinus tympani [2]. It can be visualised by intra tympanic mirrors, Oto-endoscopes, or with techniques like, removal of the lateral lip of bone and tilting the patient’s head and/or microscope. Removal of the disease from sinus tympani is also inXuenced by surgical approaches, which include the anterior to posterior and the retro facial approach [3]. While using the intra tympanic mirror to visualise the sinus tympani, the mirror tends to fogs up. To prevent this from occurring, anti-fogging solutions or warming up the mirror are techniques that are readily used. We describe the following simple method to prevent fogging. A microsuction tip could be kept intermittently 2–3 mm away from the mirror. The turbulence of the air Xow generated by the suction would prevent the fogging. Microsuction is readily available on the operating table (Fig. 1). References

Upper-Lip Augmentation by Graft of Preseptal Orbicularis Oculi Muscle Through Blepharoplasty

Upper-lip augmentation is used to enhance a thin upper lip or correct lip deficiencies or senile hypotrophy. We describe an easy, effective, and reproducible technique. We use two preseptal orbicularis oculi muscle grafts that provide a reliable option for soft-tissue upper-lip augmentation, with improved vertical lip height and lateral lip projection and reappearance of the Cupid's bow. Muscle grafts are harvested from a blepharoplasty done at the same time. The advantages of this procedure include the creation of an anatomically natural upper lip through preserving the continuity and function of the labial structure, good augmentation, no donor-site morbidity, no visible scars on the vermilion, and successful rejuvenation with the associated blepharoplasty. Both patients and surgeons were satisfied with the results because the muscle grafts produce a youthful appearance by adding natural, soft roundness and fullness to the upper lip without an artificial look or the use of synthetic material, providing long-term augmentation.

Analysis of unilateral complete cleft lip repaired with skin-vermilion flap method

To introduce the skin-vermilion flap method repairing unilateral cleft lip and analyze the curative effect. We repaired 45 cases with unilateral complete cleft lip by designing a skin-vermilion triangle flap in affected lateral lip to reconstruct the vermilion tubercle, solution, resetting and fixing orbicularis oris muscle, columella nasi and lateral angle of alae nasi, constructing basis nasi, and forming agger nasi between April and December of 2008. All the cases obtained primitively satisfactory effect. The average of follow-up was 3.5 months (rang from 1 to 6 months). All the patients presented obvious agger nasi, good contour of vermilion tubercle and chubby basis nasi. their high-lip, alae nasi and vermilion border were symmetrical between affected and unaffected lateral lip. Simple design, less expected tissue dose, little scar and good contour of vermilion tubercle are the characteristic of unilateral complete cleft lip cheiloplasty repaired with skin-vermilion flap method.

Lifting Lips: 28 Years of Experience Using the Direct Excision Approach to Rejuvenating the Aging Mouth

The mouth ages along with the face, but it is frequently ignored when performing facial rejuvenation. The authors have addressed the mouth area with direct surgical options and excisions since 1980. In using the direct approach, the tradeoff for an improved appearance at a conversational distance is a scar that is barely visible from inches away. In more than 3000 procedures, the results have been consistently good, with very few minor scar irregularities that required revision. The authors advocate performing a lip lift to elevate the central lip and a corner mouth lift to elevate the lateral lip. Although the lip and corner lift are important in shortening the long lip of aging, one of the most useful perioral procedures is the direct excision of loose skin at the lower nasolabial/marionette foldover area. The authors conclude that results of facial rejuvenation are greatly enhanced by appropriate procedures of the mouth.

Mechanodependent cell movements in the axial rudiments of Xenopus gastrulae

Sandwich explants of the suprablastoporal area of Xenopus early-mid gastrula and same stages of entire embryos were stretched with two needles perpendicular to the direction of natural elongation of the axial rudiments. The changes in the embryonic shape and histological structure were monitored as well as the arrangement of descendants of one of dorsal blastomers labeled with fluorescein-dextran at the 16-cell stage. A substantial fraction of stretched explants reoriented along the applied stretch direction. The arrangement dynamics of fluorescein-dextran-labeled cells and explant shape demonstrate that this is an active response based on convergent intercalation of cells induced by stretching. Stretched gastrulae demonstrated arrested gastrulation, dorsoventral extension of the blastopore, and ventral flow of labeled cells towards the lateral lips of the blastopore, which was also mediated by convergent intercalation and tensotaxis. The obtained data are discussed in terms of the hypothesis of mechanical stress hyper-restoration.

Relocations of cell convergence sites and formation of pharyngula-like shapes in mechanically relaxed Xenopus embryos

Influence of the relaxation of mechanical tensions upon collective cell movements, shape formation, and expression patterns of tissue-specific genes has been studied in Xenopus laevis embryos. We show that the local relaxation of tensile stresses within the suprablastoporal area (SBA) performed at the early-midgastrula stage leads to a complete arrest of normal convergent cell intercalation towards the dorsal midline. As a result, SBA either remains nondeformed or protrudes a strip of cells migrating ventralwards along one of the lateral lips of the opened blastopore. Already, few minutes later, the tissues in the ventral lip vicinity undergo abnormal transversal contraction/longitudinal extension resulting in the abnormal cell convergence toward ventral (rather than dorsal) embryo midline. Within a day, the dorsally relaxed embryos acquire pharyngula-like shapes and often possess tail-like protrusions. Their antero-posterior and dorso-ventral polarity, as well as expression patterns of pan-neural (Sox3), muscular cardiac actin, and forebrain (Otx2) genes substantially deviate from the normal ones. We suggest that normal gastrulation is permanently controlled by mechanical stresses within the blastopore circumference. The role of tissue tensions in regulating collective cell movements and creating pharyngula-like shapes are discussed.

Bilateral Cleft Lip and Nasal Repair

The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.

Upper Lip Augmentation: Palmaris Longus Tendon as an Autologous Filler

Lip augmentation is used to enhance a thin upper lip or correct lip deficiencies. The palmaris longus tendon, an accessory tendon of the wrist, has been used successfully for upper extremity reconstruction and was used in this case series for upper lip augmentation. Patients underwent upper lip augmentation using palmaris longus tendon grafts at the University of California, Los Angeles from 1998 to 2005 (n = 38). Vertical lip height, lateral lip projection, and dynamic smile length were measured preoperatively, at 6 weeks, and at 1-year follow-up, and complications, lip mobility, and physician/patient outcome surveys were recorded. Palmaris graft lip augmentation was performed for cosmetic (n = 21) and reconstructive (n = 17) indications. There were two infections and two graft exposures, with no long-term sequelae. The vertical height of the upper lip had a mean increase of 204 percent and a mean relapse of 9 percent (change from postoperative period to follow-up). Lateral projection of the upper lip showed a mean increase of 180 percent and a relapse rate of 7 percent. Dynamic lip mobility had a mean grade of 4.7 of 5 at 1 year, and the postoperative smile length was close to the preoperative length (mean postoperative length was 96 percent of preoperative length). One patient developed a stiff upper lip and required reoperation and therapy for a good final outcome. The authors' case series shows that the palmaris longus tendon provides a reliable option for soft-tissue upper lip augmentation, with improved vertical height and lateral projection and maintenance of lip mobility.