• Archives of Plastic Surgery
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• v.35 no.5
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• pp.574-580
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• 2008

Purpose: Philtral deformity is a stigma of secondary cleft lip nose. It occurs from the false arrangement of orbicularis oris muscle and the scar of previous operation. Various methods have been used to correct this deformity. We successfully corrected philtral deformity using overlapping of orbicularis oris muscle flap. Methods: From November 2000 to August 2007, we performed 39 cases of correction of philtral deformity in secondary cleft lip nose with overlapping of orbicularis oris muscle flap. Their age ranged from 5 to 53 years old. Existing scar tissue of previous operation was deepithelialized and preserved as scar flap. Lateral orbicularis oris muscle flap was elevated, advanced and overlapped upon medial muscle flap after dissection of orbicularis oris muscle of both sides. Reconstruction of philtral column was made from overlapping area by fixation of end part of lateral muscle flap to the point between philtral dimple and column. The degree of muscle flap advancement was decided by correction state of lateral muscle bulging. Correction of nostril floor depression or whistle deformity was also performed with preserved scar flap, if necessary. Results: Realignments of orbicularis oris muscle were possible in the majority of the patients and final results of philtral reconstruction were satisfactory mostly. Correction of nostril floor depression and whistle deformity was also achieved. Additional correction was performed later to 4 patients in whom insufficient reconstruction was noted. No significant complication was observed. Conclusion: More natural and symmetric philtrum was acquired with overlapping of orbicularis oris muscle flap. To the authors' knowledge, it is an easy and effective method for correction of philtral deformity through anatomical rearrangement of distorted orbicularis oris muscle with relatively simple procedure.

• Archives of Plastic Surgery
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• v.37 no.4
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• pp.427-432
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• 2010

Purpose: The purpose of this study is to estimate muscle defect by ultrasonography in the patients with secondary deformities of the lip. We investigated the association between the muscle defect in the repaired cleft lip and the philtral appearance not only at resting state but also maximal puckering. Methods: From December 2006 to November 2007, 52 children were evaluated after primary or secondary cheiloplasty. Digital photographs were taken both from the front and both three quarter views in repose and at maximal pucker. Video clips were also taken in repose and at maximal pucker. A panel of four, scored the philtral ridge and dimple seen on these photographs and videos by using two visual analog scales. Eminence of the philtral ridge was scored by a 5 point grading scale, from "conspicuous groove" to "normal philtral ridge" and the philtral dimple was scored by 3 point grading scale, from "no dimple" to "prominent dimple". Ultrasound images of the upper lip were made using a linear array transducer at the resting position of the lip and evaluated by a single radiologist. Results: The philtral ridge eminence scored $2.79{\pm}0.54$ and $1.40{\pm}0.53$ at resting and maximal pucker, correlating with "flat" and "conspicous groove". The philtral dimpling scored $1.44{\pm}0.53$ and $2.27{\pm}0.66$ at resting and maximal pucker, correlating with "no dimple" and "slight dimple". Ultrasound imaging showed the average muscle dehiscence to be $3.78{\pm}2.14$ mm at resting position. Correlation between the muscle defect in ultrasound imaging and philtral ridge eminence at rest was statistically significant (p<0.050), but was not significant (p=0.756) at maximal pucker using Spearman's rank correlation. Correlation between the muscle defect in ultrasound imaging and philtral dimpling was not statistically significant both at rest (p=0.920) and at maximal pucker (p=0.815) using Spearman's rank correlation. Conclusion: Quantitative assessment of the muscle defect using ultrasonography correlates with the static philtral appearance, but does not correlate with the dynamic appearance. Also, the size of the muscle defect does not show any correlation with the philtral dimpling. Our findings reveal that ultrasound imaging partially reflect static appearance of philtrum but cannot reflect dynamic appearance and suggest the need for further research to evaluate dynamic appearance.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.31 no.4
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• pp.353-360
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• 2009

The principles for repair of bilateral cleft lip and nasal deformity are 1) symmetry, 2) primary muscular continuity, 3) proper philtral size and shape, 4) formation of the median tubercle and vermilion-cutaneous ridge from lateral labial elements, and 5) primary positioning of the alar cartilages to construct the nasal tip and columella. The authors underscore the essential role of preoperative premaxillary positioning for the synchronous closure of the cleft lip and primary palate, and describe Mulliken's operative technique. We discuss three-dimensional adjustments based on predicted fourth-dimensional changes. In a consecutive series of 50 patients, no revisions were necessary for philtral size or columellar length. Preoperative premaxillary positioning and primary repair of bilateral cleft lip and nasal deformity may impair maxillary growth. Nevertheless, a symmetric nasolabial appearance, rather than emphasis on maxillary growth, is the priority for the child with bilateral cleft lip.

• Korean Journal of Cleft Lip And Palate
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• v.10 no.1
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• pp.39-56
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• 2007

The bilateral cleft lip, a more severe form of clefting than unilateral cleft lip, involves separation of the lip along philtral lines, isolating the central segment (prolabium). Bilateral cleft lip may be either symmetrical or asymmetrical, in which case the cleft lip is split more on one side than on the other. The cleft affects the obvious facial form as an anatomic deformity and has functional consequences, affecting the child's ability to eat, speak, hear, and breathe. Although there would seem to be quite a variance in reported figures, ratios of cleft lip with or without cleft palate have gone as high as 1:500 and as low as 1:1000. It is known that less than 10% of cleft lips are bilateral. Although bilateral cleft lip is less common than unilateral cleft lip, the deformity is more severe, and the reconstructive technique is more complex. Surgery is the only treatment necessary for patients with bilateral cleft lip. Accompanying the evolution of surgical repair is the increasingly important role of orthodontic support with early presurgical alveolar and nasal molding. Repositioning the maxillary and alveolar segments into a more anatomic position allows the surgeon to repair the lip and associated nasal deformity under more optimal conditions. The purpose of this article is to review the related anatomy, presurgical management, and surgical management of bilateral cleft lip.

• Archives of Plastic Surgery
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• v.44 no.3
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• pp.210-216
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• 2017

Background In treating minor-form or microform cleft lip, obtaining an optimal result is a challenge because of the visible scarring caused by traditional surgery. We present a refined method using muscle overlapping with a minimal skin incision in patients younger than 3 years, a group characterized by thin muscle. Methods The surgical technique involves restoration of the notched vermillion using Z-plasty, formation of the philtral column using overlapping of an orbicularis oris muscle flap through an intraoral incision, and correction of the cleft lip nasal deformity using a reverse-U incision and V-Y plasty. A single radiologist evaluated ultrasonographic images of the upper lip. Results Sixty patients were treated between September 2008 and June 2014. The age at the time of operation ranged from 6 to 36 months (mean, 26 months). The follow-up period ranged from 8 to 38 months (mean, 20 months) in minor-form cases and from 14 to 64 months (mean, 37 months) in microform cases. A notched cupid's bow was corrected in 10 minor-form cases and 50 microform cases. Ultrasonographic images were obtained from 3 patients with minor-form cleft lip and 9 patients with microform cleft lip 12 months after surgery. The average muscle thickness was 4.5 mm on the affected side and 4.1 mm on the unaffected side. Conclusions The advantages of the proposed procedure include the creation of an anatomically natural philtrum with minimal scarring. This method also preserves the continuity and function of the muscle and provides sufficient augmentation of the philtral column and nostril sill.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.34 no.2
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• pp.133-139
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• 2012

This is a review regarding Mulliken's Modification using the Millard rotation-advancement principle for the repair of unilateral complete cleft lip and nasal deformity. All patients underwent prior labionasal adhesion and dentofacial orthopedics with a pin-retained (Latham) appliance used for infants with a cleft of the lip and palate. Technical variations concerning the operation are described. A high rotation and releasing incision in the columella lengthens the medial labial element and produces a symmetric prolabium with minimal transgression of the upper philtral column through the advancement flap. The orbicularis oris muscle is everted, from caudad to cephalad, to form the philtral ridge. A minor variation of unilimb Z-plasty is used to level the cleft side of Cupid's bow handle, and cutaneous closure proceeds superiorly from this junction. The dislocated alar cartilage is visualized though a nostril rim incision and suspended to the ipsilateral upper lateral cartilage. Symmetry of the alar base is addressed in three dimensions, including maneuvers to position the deviated anterior-caudal septum, configure the sill, and efface the lateral vestibular web. The authors believe the technical refinements described herein contribute favorably to the outcome of repair regarding unilateral cleft lip and nasal distortion.

• Korean Journal of Cleft Lip And Palate
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• v.3 no.2
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• pp.41-50
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• 2000

The alar base on the cleft side in unilateral complete cleft lip, alveolus and palate is markedly displaced laterally, caudally and dorsally, By incising the pyriform margin from the cleft margin of the alveolar process, including mucosa of the anterior part of the inferior turbinate, to the upper end of the postnasal vestibular fold, the alar base is released from the maxilla, A physiological correction of nasal deformity can be accomplished by careful reconstruction of nasolabial muscle integrity, functional repair of the orbicular muscle, raising and rotating the displaced alar cartilage, and finally by lining the lateral nasal vestibule, The inferior maxillary head of the nasal muscle complex is identified as the deeper muscle just below the web of the nostril, The muscle is repositioned inframedially, so that it is sutured to the periosteum that overlies the facial aspect of the premaxilla in the region of the developing lateral incisor tooth, And then, the deep superior part of the orbicular muscle is sutured to the periosteum and the fibrous tissue at the base of the septum, just in front of the anterior nasal spine, The nasal floor is surgically created by insertions of the nasal muscle complex in deep plane and of the orbicular muscle in superficial one, The upper part of the lateral nasal vestibular defect is sutured by shifting the alar flap cephalically, The middle and lower parts of this defect are closed by use of cleft margin flaps of the philtral and lateral segments, respectively, Authors stress the importance of nasal floor reconstruction at primary surgery and report the technique and postoperative results.