Orbicularis Oris Research Articles

Repairing whole facial nerve defects with xenogeneic acellular nerve grafts in rhesus monkeys.

Acellular nerve allografts conducted via chemical extraction have achieved satisfactory results in bridging whole facial nerve defects clinically, both in terms of branching a single trunk and in connecting multiple branches of an extratemporal segment. However, in the clinical treatment of facial nerve defects, allogeneic donors are limited. In this experiment, we exposed the left trunk and multiple branches of the extratemporal segment in six rhesus monkeys and dissected a gap of 25 mm to construct a monkey model of a whole left nerve defect. Six monkeys were randomly assigned to an autograft group or a xenogeneic acellular nerve graft group. In the autograft group, the 25-mm whole facial nerve defect was immediately bridged using an autogenous ipsilateral great auricular nerve, and in the xenogeneic acellular nerve graft group, this was done using a xenogeneic acellular nerve graft with trunk-branches. Examinations of facial symmetry, nerve-muscle electrophysiology, retrograde transport of labeled neuronal tracers, and morphology of the regenerated nerve and target muscle at 8 months postoperatively showed that the faces of the monkey appeared to be symmetrical in the static state and slightly asymmetrical during facial movement, and that they could actively close their eyelids completely. The degree of recovery from facial paralysis reached House-Brackmann grade II in both groups. Compound muscle action potentials were recorded and orbicularis oris muscles responded to electro-stimuli on the surgical side in each monkey. FluoroGold-labeled neurons could be detected in the facial nuclei on the injured side. Immunohistochemical staining showed abundant neurofilament-200-positive axons and soluble protein-100-positive Schwann cells in the regenerated nerves. A large number of mid-graft myelinated axons were observed via methylene blue staining and a transmission electron microscope. Taken together, our data indicate that xenogeneic acellular nerve grafts from minipigs are safe and effective for repairing whole facial nerve defects in rhesus monkeys, with an effect similar to that of autologous nerve transplantation. Thus, a xenogeneic acellular nerve graft may be a suitable choice for bridging a whole facial nerve defect if no other method is available. The study was approved by the Laboratory Animal Management Committee and the Ethics Review Committee of the Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, China (approval No. 2018-D-1) on March 15, 2018.

Comparative morphometric study of the mimic facial muscles of brachycephalic and dolichocephalic dogs.

Excessive breeding of dogs has led to a disadvantageous morphology in some breeds, for example extreme brachycephaly, which is responsible for many health issues. We hypothesize that alterations of the mimic muscular system are present in brachycephalic dogs and could contribute to behavioural problems due to a restricted mimic display. Therefore, the purpose of this paper was to compare the mimic muscular systems of brachycephalic with dolichocephalic dogs. Mimic muscles were measured and set in ratio to measurements of the head and calculated indices. When bringing the length of the muscles m(x) in proportion to the length of the head, highly significant differences (p<.0001) and significant difference (p<.05) were found in all but two of the examined muscles. Calculations of the m(x) divided by the cranial index and the square index showed significant differences for all muscles. For example, the musculus (m.) levator nasolabialis was morphologically different from the one of dolichocephalic dogs. Muscle fibres of the m. levator nasolabialis were localized in the fold over the nasal bridge of brachycephalic dogs. The raphe of the m. orbicularis oris was not always apparent in brachycephalic dogs. The proportions of the muscle lengths and the length of the eye slots to the size of the skull have shifted considerably in brachycephalic dogs. We conclude that many alterations contribute to the strong shift in the proportions of the head of brachycephalic dogs versus that of dolichocephalic dogs. Our findings suggest that brachycephalic dogs have reduced mimic skills that can lead to ambiguous communication.

Anatomy of eyelids muscles

Objective of the research was to study up-to-date literary data concerning anatomical peculiarities of palpebral muscles and their supporting and retaining apparatus. Eye diseases have become common nowadays. Very fast development of computer technology and deterioration of ecological conditions are one of the most important factors affecting visual organ impairment. Age physiological changes of the eye and adjacent tissues aggravate the quality of human life as well. Meanwhile, the majority of changes can be corrected. Modern ophthalmology possesses a plenty of surgical techniques, and development of skills in cosmetology and new pharmacological agents ensure a desirable delay of aging and deterioration of the visual organ functions. All the above factors are unlikely to become achievements in medicine without comprehensive awareness of the visual organ anatomy and its auxiliary apparatus. A lot of diseases are associated with eyelids, and ectropion and ptosis of the lower or upper eyelid are the commonest of them. Hypertrophy of the upper part of the orbicular muscle causes ectropion. It is a condition in which the upper eyelid is turned outwards. Isolation of the upper tarsal muscle from the tarsal plate leads to the development of aponeurotic ptosis. Strain of the lower retaining ligament, palpebral fissure septum and capsular-palpebral ligament result in ectropion of the lower eyelid. The presented literary review contains up-to-date information concerning the structure of the muscles of the eyelids and adjacent and auxiliary structures, their functions and possible functional disorders are described. Conclusions. Еhe review of scientific literature dealing with anatomical studies of palpebral muscles and their main adjacent structures is indicative of great interest of scientists in this issue. Though our study has found certain disembodied data and unsystematized fragments in the literature available. In our opinion, compiling an appropriate handbook dealing with the data base available concerning anatomy of the eyelids will considerably improve the quality of numerous surgical operations in cosmetology and ophthalmology.

Lateral spread response of different facial muscles during microvascular decompression in hemifacial spasm

ObjectiveInterpreting lateral spread response (LSR) during microvascular decompression (MVD) for hemifacial spasm (HFS) is difficult when LSRs observed in different muscles do not match. We aimed to analyze LSR patterns recorded in both the orbicularis oris (oris) and mentalis muscles and their relationships with clinical outcomes. MethodsThe data of 1288 HFS patients who underwent MVD between 2015 and 2018 were retrospectively reviewed. LSR was recorded in the oris and mentalis muscles through centrifugal stimulation of the temporal branch of the facial nerve after preoperative mapping. The disappearance of LSR following surgery, clinical outcomes, and the characteristics of LSR in oris were analyzed. ResultsAfter surgery, LSR remained in 100 (7.7%) and 279 (21.6%) of the mentalis and oris muscles, respectively. The postoperative outcome correlated with LSR disappearance in the mentalis, not with that in the oris. ConclusionLSR patterns differed in each muscle and may not be correlated with clinical outcomes. LSR in the mentalis and oris muscles should be interpreted differently. SignificanceWe describe a monitoring protocol characterized by preoperative facial nerve mapping, antidromic stimulation, and recording from multiple muscles. We analyze differences in LSRs in the mentalis and oris muscles and suggest technical points for interpretation.

Clinical Validation of Superficial Lip Injections Utilizing Cohesive Polydensified Matrix Hyaluronic Acid-Based Soft Tissue Fillers.

A combination of optimal injection technique and dermal filler choice is key for improving lip architecture with natural and long-lasting results. To investigate the positioning of Cohesive Polydensified Matrix&trade; (CPM) hyaluronic acid (HA) fillers after superficial lip injections and document their tissue integration and effects on lip architecture and shape. Eligible patients underwent lip contouring and volumization using a superficial direct tissue action technique. All injections were performed with CPM-HA lip fillers using a 30G needle and retrograde microthreading. Total injected volume was 0.8-1.2 mL. High-resolution ultrasound (US) imaging, 3D surface scanning, and Global Aesthetic Improvement Scale (GAIS) assessments were performed before, and 1, 3 and 6 months post-injection to define the anatomy, positioning, longevity and patient satisfaction. Sixteen patients were injected (mean age, 33.2 years). US measurements revealed an increased skin&ndash;orbicularis oris muscle distance up to 1 month post-injection after which measurements returned to baseline values. This observation correlated with complete product integration into the surrounding tissue visualized by US at 3 months. An increased dry mucosa thickness (vermilion body) remained at 6 months, and GAIS scores revealed 70% of patients continued to experience visible lip improvements. 3D analyses revealed significantly increased total lip surface area at 3 months with increased Cupid&rsquo;s bow distance, philtral height, and anterior upper lip projection. Superficial injection of CPM-HA fillers offers an effective and safe tool for improving lip architecture and volume. Results showed homogeneous dermal integration of the product and aesthetic outcomes maintained up to 6 months. J Drugs Dermatol. 2021;20(9):940-945. doi:10.36849/JDD.6011.

Superior labial artery and vein anastomosis configuration to be considered in lip augmentation

The treatment of cleft lip and palate is performed over a long period, starting immediately after birth. However, esthetic problems remain after lip augmentation. Endothelial cells of new capillaries are important for wound healing. Thus, the reconstruction of vascular networks is key to postoperative wound healing during lip augmentation. However, studies describing the superior labial artery (SLA) and superior labial vein (SLV) are rare, and their mutual positional relationship thus remains unclear. We procured 29 adult cadavers and ten fetuses. Macroscopic and histological examinations were performed on adult cadavers. We extracted soft tissues and blood vessels after micro-computed tomography (CT) and 3D tissue reconstruction. We performed histological investigations of vascular networks within the cleft lip in fetal samples. In adults, the SLV was distributed throughout the cutaneous side of the orbicularis oris muscle and the SLA, throughout the mucosal side. The SLV and SLA were separated by this muscle. Micro-CT images revealed that the SLA on the mucosal side transversed the orbicularis oris muscle to the SLV (55％). Histological analysis of fetuses revealed that the SLA was on the mucosal side, similar to that in adults, and traversed the orbicularis oris muscle in continuity with the SLV of the cutaneous side (100%). In lip augmentation, the reconstruction of the vascular structure, which involves the anastomosis of SLA and SLV passing through the orbicularis oris muscle, is an important factor when considering esthetic repair.

Pediatric Miller Fisher Syndrome and Ocular Myasthenia Gravis (A Reminder of Clinical Mimicry): A Case Report

AbstractMiller Fisher syndrome (MFS) is a rare immune-mediated neuropathy that often presents with diplopia and bilateral external ophthalmoplegia. Other neurological deficits may occur such as ataxia and areflexia but not in all cases. Although MFS is a clinical diagnosis, serological confirmation is possible by identifying the anti-GQ1b antibody found in the majority of patients. Myasthenia gravis is an autoimmune disorder of the availability of acetylcholine receptors in the neuromuscular junction. Ocular myasthenia gravis is a disease subtype characterized by variable patterns of weakness of extraocular muscles, eyelid elevator, and orbicular muscle in which the initial sign in most adults and children is ptosis. We report a child with MFS who presented with clinical signs suggestive of ocular myasthenia gravis, but in whom the correct diagnosis was made on the basis of serological testing for the anti-GQ1b antibody. We aim to highlight the similarity between the two rare conditions and address the importance of early liaison with neurologists and ophthalmologists in reaching to the proper diagnosis.

Blood Perfusion of Human Upper Eyelid Skin Flaps Is Better in Myocutaneous than in Cutaneous Flaps.

The aim of this study was to monitor blood perfusion in human upper eyelid skin flaps and examine how the perfusion is affected by the thickness of the flap. Twenty upper eyelids were dissected as part of a blepharoplasty procedure in patients. The medial end of the blepharoplasty flap remained attached to mimic a flap design often used in reconstruction in the periocular area, a myocutaneous flap in which the blood supply follows the fibers of the orbicularis muscle and is thus parallel to the long axis of the flap. The muscle was thereafter dissected from the flap to create a cutaneous flap. Blood perfusion in the 2 types of flaps was compared using laser speckle contrast imaging. Blood perfusion decreased gradually from the base to the tip of all the flaps. Perfusion was significantly higher in the myocutaneous flaps than in the cutaneous flaps (p < 0.0004): 69% in the myocutaneous flaps and 43% in the cutaneous flaps, measured 5 mm from the base. Blood perfusion was preserved to a greater extent distally in the myocutaneous flaps (minimum value seen at 25 mm) than in the cutaneous flaps (minimum seen at 11 mm). Blood perfusion was better preserved in myocutaneous flaps, including both skin and the orbicularis oculi muscle, than in cutaneous flaps. This may be of clinical interest in patients with poor microcirculation in which a long flap is required for reconstructive surgery.

Botulinum Toxin for a Better Scar in Cleft Lip Surgery: A Prospective Randomized Control Trial.

An unsightly scar following cleft repair can undo the good work of even an experienced surgeon. A functioning orbicularis oris muscle beneath the lip scar maintains a zone of dynamic tension resulting in a stretched scar. Botulinum toxin type A (BTA) can be used to create a temporary paralysis of the orbicularis muscle during the healing phase. This may lead to better scar formation after a cleft lip repair. The present prospective randomized control trial enrolled 28 infants with unilateral cleft lip undergoing primary lip repair. They were randomized to receive injection of either BTA (botox group) or normal saline (control group) intraoperatively into adjacent orbicularis oris muscle immediately after completion of cleft lip repair. Blinded experts reassessed the scar after 6 months. Objective assessment was undertaken employing Visual Analogue Scale (VAS), Vancouver Scar Scale (VSS), and photographic scar width measurements. Twenty-two subjects were able to complete a follow-up duration of 6 months. Children in the BTA (Botox Group) had a statistically significantly better VAS score and lesser scar width compared to the control group. However, the difference in the VSS score between both groups was not statistically significant. On comparing patients with cleft lip alone with cleft lip and palate, no statistically significant difference was found in VAS, VSS, and scar width. There were no complications associated with the use of botulinum toxin A. Botulinum toxin type A injection is a safe and effective addition to improve scar appearance following cleft lip repair. There was improvement in appearance of the scar in terms of width, but no improvement was seen in the scar pigmentation. The scar outcome is independent of cleft lip classification.

Age Related Changes of Superior Orbicularis Oris Muscle in Terms of Tone and Viscoelastic Properties.

To examine the age-related changes in the viscoelastic properties and tone of the superior orbicularis oris muscle by a portablehand-held myotonometer. A total of 128 individuals (65 female, 63 male) who met the inclusion criteria were evaluated. Individuals were divided into 2 groups as under 40 years old (Group 1), and above (Group 2). The viscoelastic properties and muscle tone of orbicularis oris muscle were evaluated bilaterally in supine position with the Myoton PRO (Myoton AS, Estonia) device from the skin overlying the orbicularis oris. The reference point is accepted as the right and left paramedial philtrum dimple. The statistical analysis was performed. There was no statistically significant difference in the elasticity values of the right and left orbicularis oris muscles of the Group 1 and Group 2 individuals. There was a difference between the groups when the tone and stiffness values of both groups were compared. It was determined that individuals over the age of 40 had higher muscle tone and stiffness. All mechanical properties of the superior orbicularis oris muscle between the male and female individuals in Group 1 were different. The values are higher in the female gender. The elasticity values in both genders in Group 2 were similar. Tone and stiffness parameters were different between genders. Myoton PRO can be recommended as an alternative device in the quantitative evaluations of post-operative follow-ups, and pre/post rehabilitation in terms of viscoelastic parameters of the muscle.

P-MD014. Long term repeated use of botulinum toxin injection for hemifacial spasms in sri lanka

Introduction. Hemifacial spasm is a common indication for botulinum toxin use. Aim of this study was to find out the efficacy and safety of long-term use of botulinum toxin for hemifacial spasms in Sri Lanka. Methods. A group of 28 patients with hemifacial spasms who had been given botulinum toxin for more than 7 years were included in the study. Botulinum toxin was given at multiple sites including over the eyelid, at the ipsilateral orbicularis oculi, nasalis, orbicularis oris, mentalis and contralateral orbicularis oris sites on a dilution of 2 ml/100 units. Patients were then followed up every 3 months. Degree of improvement, side effects if any, the total number of units used and the information regarding the last injection used were collected. Results. There were 24 females with a female preponderance of 86%. Mean age (SD) at first injection of the patients was 58.7 (9.1) years. Mean (SD) duration of the repeated use was 10.5 (2.2) years. Range of the duration of treatment was from 7 to 15 years. During this duration, mean (SD) number of injections given was 25.2 (8). Average number of units given for each patient during these multiple injections was 20.3 (2.6). Improvement was seen in 96.5% of the times and side effects were seen only in 2.7% of the time and included heaviness of the eye, mild lower facial weakness and pain at the site of injection which did not last long. Patient compliance was good even after repeated long term use. There were no systemic side effects and drug resistance to botulinum toxin was not seen in these patients. Conclusion. These findings show that the long-term use of botulinum toxin for more than 10 years seems to be safe and efficacious for hemifacial spasm.

Contralateral orbicularis oculi muscle transposition in facial paralysis: functional, aesthetic and electromyographic outcomes. A case report and literature update

ABSTRACT Purpose Many surgical approaches have been described for achieving satisfactory functionality in patients with facial paralysis, to ensure the protection of the cornea and the highest degree of physiological blinking. Out of all those available, dynamic techniques are indicated when motion recovery and synchrony are the goals pursued. Orbicularis oculi transposition (OOT) allows a genuine restoration of blinking by means of contralateral reinnervation, with minimal insult for the donor site. Methods We present the case of a 64-year-old man with unilateral facial paralysis. A physical examination revealed a lagophthalmos of more than 5 mm. A neurophysiological study showed a mild-to-moderate axonal injury of the left facial nerve. Contralateral OOT was indicated as the first therapy option since it can restore involuntary blinking. The orbicularis muscle flap was not divided into branches, as described previously by other authors; the whole flap was transposed to the paralysed upper eyelid to achieve the highest level of potential reinnervation. Results Lagophthalmos was fully corrected after the surgery. The patient reported subjective improvement of symptoms, less frequent instillation of artificial tear drops and, especially, synchronous blinking with significant improvement in involuntarity. These improvements were maintained after 1 year of follow-up. Postoperative electromyographic studies confirmed the improvement in neural function. Conclusions OOT can be a safe and effective option for the treatment of patients with peripheral facial paralysis, as it achieves a good restoration of blinking function with minimal morbidity in the healthy donor eye.

Repair of Asymmetric Bilateral Cleft lip: 1 Stage or 2 Stage.

To verify the advantages and indications of 1-stage and 2-stage repair for asymmetric bilateral cleft lip (BCL). Retrospective study. From January 2004 to December 2016 in our department. Patients with BCL. Over 6 months after the operation, the surgery outcomes were evaluated and graded by 2 experienced surgeons. The result of surgery was evaluated using the scoring method of Mortier et al and Anastassov and Chipkov. Among 133 patients with asymmetric BCL, 61 (45.9%) had 1-stage repair and 72 (54.1%) had 2-stage repair. Sixty-eight (51.1%) patients had complete-incomplete cleft lip (CL), and those who underwent 1-stage repair showed a trend of better outcome (P = .028). Fifty (37.6%) patients with incomplete-microform CL showed no significant difference between the outcomes of 2 surgery plans (P = .253). In 15 (11.3%) patients with complete-microform CL, only one had 1-stage repair with a score of 8.5. The other 14 patients with 2-stage repair were scored 3.68 ± 1.28. Two-stage repair was preferable when the deformity degree was very different on 2 sides, as it could reduce unnecessary scar tissue and extend the nasal columella. One-stage repair could help to achieve the anatomical reduction of the orbicularis oris and a better contour of the vermilion tubercle. One-stage repair is recommended for patients with complete-incomplete CL and incomplete-microform CL. Two-stage repair for patients with complete-microform CL is preferred in our center, but more studies are required to support this conclusion.

New method of recording the functional activity pattern of the buccinator from the mucosal surface

ObjectivesThe buccinator (BUC) is an important muscle for oral function. Since it lies deep in the facial skin, recording its activity is difficult; thus, studies on its function are limited. We developed a method to access the deep facial muscles from the mucosal side. The aim of this study was to test the reliability of the new recording method for the BUC and to investigate the BUC behavior in typical facial functions. MethodsTo evaluate the new method, BUC activities were recorded simultaneously with a gel-type electrode on the skin and the newly developed surface electrode on the buccal mucosa. Electromyographic (EMG) activities in function, such as chewing and swallowing, along with the activities of the lower orbicularis oris (OO), zygomaticus major, masseter, and digastric muscles, were compared using the two recording methods. EMG activities among various tasks were compared using normalized values based on those obtained during maximum lip closure (MaxLC). ResultsThe new surface electrode was made of gold plates on a thin plastic fixed to a stainless-steel wire frame and weighed less than 1 g. The BUC activity recorded from the mucosa was the highest during a corner-pulling task and was low during clenching. The BUC was active during MaxLC, similar to the OO, and the BUC activity pattern among tasks recorded from the mucosa was identical to that reported by previous studies using intramuscular electrodes. The new electrode evaluated the BUC activities quantitatively, and the recordings by the new electrode were free from contamination. ConclusionsThe findings of this study confirmed the reliability of the new BUC recording method. It could be easily placed correctly within seconds, without the need for cleansing or sterilizing the skin. The BUC and OO were active during a MaxLC task, indicating that the BUC assists lip closure by pulling the corners of the mouth. The basic facial functions evaluated, including chewing, were similar to those studied by intramuscular electrodes.

Revisional Techniques for Secondary Cleft Lip Deformities.

Secondary deformities of repaired cleft lips are an unfortunate complication despite the meticulous approach of modern primary procedures. Most of these surgeries take place in the patient's early life and must be strategically planned to provide optimal cosmesis with minimal interventions. Depending on the level of severity, treatment of the secondary deformities ranges from noninvasive or minimally invasive techniques to complete revision cheiloplasty. Many novel topical, injectable, and laser therapies have allotted physicians more technical flexibility in treating superficial distortions. Nonetheless, surgical techniques such as diamond excision and adjacent tissue transfer remain popular and useful reconstructive modalities. Deformities involving the orbicularis oris must be completely taken down to allow full access to the muscle. Complete revision cheiloplasty requires recreation of the cleft defect and reconstruction similar to the primary repair. Due to the myriad of presentations of these secondary deformities, familiarity with the various treatments available is imperative for any cleft surgeon.

The Performance of Secondary Nasal Alar Base Revision for Unilateral Cleft Lip by Single YV-Plasty (the Importance of Overcorrection During Surgery).

Although primary surgery for cleft lip has improved over time, the degree of secondary cleft or nasal deformity reportedly varies from a minimum degree to a remarkable degree. Patients with cleft often worry about residual nose deformity, such as a displaced columella, a broad nasal floor, and a deviation of the alar base on the cleft side. Some of the factors that occur in association with secondary cleft or nasal deformity include a deviation of the anterior nasal spine, a deflected septum, a deficiency of the orbicularis muscle, and a lack of bone underlying the nose. Secondary cleft and nasal deformity can result from incomplete muscle repair at the primary cleft operation. Therefore, surgeons should manage patients individually and deal with various deformities by performing appropriate surgery on a case-by-case basis. In this report, we applied the simple method of single VY-plasty on the nasal floor to a patient with unilateral cleft to revise the alar base on the cleft side. We adopted this approach to achieve overcorrection on the cleft side during surgery, which helped maintain the appropriate position of the alar base and ultimately balanced the nose foramen at 13 months after the operation. It was also possible to complement the height of the nasal floor without a bone graft. We believe that this approach will prove useful for managing cases with a broad and low nasal floor, thereby enabling the reconstruction of a well-balanced nose.

Ideal esthetic and functional full-thickness lower eyelid “like with like” reconstruction using a combined Hughes flap and swing skin flap technique

A goal in ideal lower eyelid reconstruction is to achieve not only an esthetic recovery of the shape of the eyelid but also to obtain satisfactory eyelid function without damage to the corneal surface. In this report, we introduce our "Like with Like" reconstruction technique using a combined Hughes flap and swing skin flap. The Hughes flap is a tarsoconjunctival pedicled flap from the upper eyelid, and the swing skin flap is a kind of transposition flap based on the orbicularis muscle pedicle. Eight patients who had more than 25% of the lower eyelid affected by a full-thickness defect were included. There were five men and three women, and the average age was 68.4years old. All patients had undergone wide tumor excision of the lower eyelid due to a malignant tumor and had also had primary two-stage eyelid reconstruction with a combined Hughes flap and swing skin flap. The average reconstructive time was 1:20, and no postoperative severe complications such as flap necrosis or wound dehiscence were observed. The follow-up period was an average of one year, and there were no functional problems such as ectropion, lower eyelid retraction, lid margin hypertrophy, lacrimation disorder, or corneal problems observed in any cases. Esthetically, no reconstructed eyelid bulging or asymmetry in the lid margin was observed in any of the cases. Combining the Hughes flap and skin swing flap technique might be the best choice for a full-thickness lower eyelid defect with regard to the esthetic and functional results.

A 45-degree Upward Tension-Releasing Epicanthoplasty Performed in 712 Consecutive Cases

Medial epicanthoplasty is commonly used to enhance the aesthetic outcomes of double-eyelid operations in Asia. However, epicanthoplasty can cause problems such as scarring and excessive exposure of the lacrimal lakes. To resolve the problems associated with epicanthoplasty and to create more natural and long-lasting double-eyelid fold lines while minimizing incisions, we performed a 45-degree upward tension-releasing epicanthoplasty. A total of 712 patients underwent 45-degree upward tension-releasing epicanthoplasty, with or without double eyelidplasty. A triangular skin flap was elevated at a 45-degree angle from the epicanthal fold. The surrounding area was dissected to eliminate the rigid connective tissue between the orbicularis muscle and the skin, which creates skin tension. The incisions were sutured, and a small incision toward the medial canthus was added to further decrease tension and create space for the triangular flap to be transposed. A total of 707 patients underwent 45-degree upward tension-releasing epicanthoplasty with the double-eyelid procedure, and 5 patients underwent 45-degree upward tension-releasing epicanthoplasty alone. No complications were observed for any patients, and 95% of patients were satisfied with this technique. The 45-degree upward tension-releasing epicanthoplasty can release the tension in the epicanthal fold, minimize scarring, and control lacrimal lake exposure. In particular, this method was effective for creating an in-out double-fold line starting from the epicanthus and for maintaining the double-eyelid line, which can reduce unnecessary incisional double-eyelid surgery.

Superior Orbicularis Oris Muscle Activity in Children Surgically Treated for Bilateral Complete Cleft Lip and Palate.

The aim of this cross-sectional study was to evaluate the electromyographic activity of the superior orbicularis oris muscle both in children surgically treated for bilateral complete cleft lip and palate (BCCLP) as well as in subjects without BCCLP. The study comprised 77 children aged 6.6 to 12.5 years. All the patients with clefts had previously undergone lip and palate surgery. The upper lip electromyographic (EMG) assessments were made with a DAB-Bluetooth device (Zebris Medical GmbH, Germany) at rest, while swallowing saliva, protruding lips and compressing lips. EMG measurements were also made when the subjects produced phonemes /p/, /b/, and /m/ with the vowel /a/. The Mann-Whitney U test was applied to statistically analyze the EMG values. Significantly higher median upper lip EMG activity under working conditions such as swallowing saliva, lip compression, and production of the phoneme /p/ with the vowel /a/ was observed in patients with BCCLP compared to those without a cleft. The results of the study showed that the upper lip muscle activity increases in children with BCCLP when swallowing saliva, compressing lips and during some speech movement tasks. This may be important in the aspect of the effect of surgical lip repair on the craniofacial growth.

Unmasking the entity of 'drug-resistant' perioral myoclonia with absences: the twitches, darts and domes!

Perioral myoclonia with absences (POMA) is not recognized as a unique electro-clinical syndrome and studies suggest its inclusion under the genetic generalized epilepsy (GGE) spectrum. The aim of this study was to explore the prevalence and electro-clinical homogeneity of this disorder in an epilepsy monitoring unit. Between 2013 and 2019, among drug-resistant epilepsy patients who were referred for video-telemetry, those diagnosed with POMA based on the presence of documented absences with prominently observed peri-oral muscular contractions accompanied by generalized EEG features were included. Among 62 patients who were diagnosed with absence epilepsy, five finally met the criteria for POMA (8.1%) with late childhood or adolescent onset of epilepsy. Four (80%) had a referral diagnosis of focal epilepsy based on historical focal features with exacerbation of seizures on oxcarbazepine. All five patients demonstrated brief absences with orbicularis oris muscle contractions accompanied by subtle focal phenomenology. One patient had concurrent axial-appendicular myoclonic jerks precipitated by hyperventilation. While four patients had strikingly identical interictal and ictal characteristics of typical absence epilepsy, one patient demonstrated additional atypical generalized polyspike discharges without a "dart-dome" morphology. Therapeutic response to introduction of sodium valproate was noted in all five patients. Features that were not consistent with the diagnosis were apparent in one patient who was re-classified with combined focal and generalized epilepsy. Differentiating aspects in this patient included multifocal discharges, background slowing, fast-recruiting ictal rhythms and valproate resistance. This is one of the largest case series of POMA. This entity, which falls under the spectrum of GGE, remains under-diagnosed and its distinctive electro-clinical features need to be recorded in order to prevent misclassification as focal epilepsy of probable opercular origin. Background-slowing, atypical ictal rhythms and valproate unresponsiveness are not consistent with the diagnosis of this unique absence epilepsy. [Published with video sequences].