Correction of Minor-Form and Microform Cleft Lip Using Modified Muscle Overlapping with a Minimal Skin Incision

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.

Repair of Unilateral Incomplete Lesser Form Cleft Lip

Analysis of Procedures for Correction of Microform Cleft Lip through Strategic Approaches

BACKGROUND: Even though degrees of deformation of microform cleft lip are not high, it has to be corrected with various procedures upon conditions and areas since it has various expressions. Many studies have focused on the classifications and procedures, but there are only a few studies on how much these procedures are performed in the actual field. This study aims to analyze the utilization of various procedures upon major correction points. METHODS: A total of 52 patients who had been corrected by one surgeon from 1995 to 2011 were enrolled as subjects. Based on the medical records, it was checked whether the incision was made or not along with the correction procedures for alar base and philtral column, Cupid's bow, and vermillion free margin. RESULTS: In case of an incision, full incision (42 times) was conducted most frequently. For alar base and philtral column, muscle re-approximation (25 times) was performed most frequently. However, recently, it was shown that excision on only the affected area and correction with dermis were more likely to be used. For Cupid's bow and vermilion free margin, elliptical excision on the only affected area followed by re-approximation was performed most frequently for 46 times (Cupid's bow) and 44 times (vermilion free margin), respectively. CONCLUSION: For the correction of microform cleft lip, less invasive procedures are preferred. However, in the actual field, if needed, aggressive procedures consisting of incisions have been conducted to correction. These trends are somewhat changed to utilization of a simple procedure, such as excision on the modified area, followed by a re-approximation rather than complicated procedures using the muscle.

Assinatura e certificação digital: sua aplicação na Odontologia / Digital signature and certification: application in Dentistry

A digitalização de documentos odontológicos com a assinatura digital e correspondente certificação é assegurada pela criptografia de arquivos, preservando-se o sigilo e a autoria da informação apresentada em prontuários. Os contratos, registros de tratamento e demais documentos que devem ser mantidos por longos prazos são substituídos por cópias certificadas, eliminando a necessidade de espaço físico e outras precauções necessárias para a conservação do material nos consultórios. Profissionais da área da saúde e, particularmente, o Cirurgião Dentista devem conhecer as possibilidades de emprego de técnicas, envolvendo o reconhecimento de arquivos, imagens e documentos digitalizados

Correction of Upper Lip Depression Using Conchal Cartilage Graft in Unilateral Cleft Lip Deformity

PURPOSE: To correct the upper lip depression after the correction of unilateral cleft lip, autologous grafts such as bone, dermal, fascial grafts and fat injections or alloplastic implants are used. Transplanted bones, dermis and fascia have a tendency to be absorbed and have donor morbidity. Fat injections are absorbed inconsistently and alloplastic implants have problems such as foreign body reactions, protrusions and infections. Authors corrected the upper lip depression using conchal cartilage graft in unilateral cleft lip deformity and the results was analysed with photos. METHODS: 26-unilateral cleft lip and 2-microform cleft lip cases, totally 28 cases were performed. Their mean age was 21.89 years. The male and female cases were 12 and 16, respectivley. Under anesthesia (general: 18 cases and local: 10 cases), cavum conchae (n=8), cymba conchae (n=16) and whole conchae (n=4) were harvested. Transversely cut the margin of the obtained cartilage, we cut out the most bent portion and put a partial-thickness incision on concave surface in cases of excessive convexity. Then, we performed the onlay graft of the conchal cartilage via scar revision site in unilateral cleft lip and via the reconstruction site of the cupid bow in microform cleft lip. The augmentation of the upper lip was evaluated with photos. Adapting the baseline connecting between the both cheilions as a horizontal standard line, we measured the highest point among the tangents between the upper lip and nose (point a), the lowest point (point c), the middle point between a and c (point b) and the vertical line from the alare (point d) to the horizontal standard line. To assess the postoperative symmetry, we compared cleft side upper lip contour index (%) A,B,C,D=(a,b,c,d)-ch x 100/(ch-ch) and non-cleft side upper lip contour index (%) A',B',C',D'= (a',b',c',d')-ch x 100 / (ch-ch).h) RESULTS: After the surgery, no complication was found except in one case which double layers graft performed in the cleft lip deformity, the lateral portion was protruded. The upper lip contour index, the difference of A and A' were-0.83%, and thus the mild depression was persisted. Difference of B and B', C and C', D and D' were 0.83%, 1.07%, 0.90%. There were statistically significant difference, and thus the depression of upper lip were improved generally. CONCLUSION: Authors performed the onlay graft of the conchal cartilage in unilateral cleft lip deformity and found that the depression of the upper lip was well corrected except the uppermost part when photogrammetrically analyzed.

Ultrastructural Characteristics of the Orbicularis Oris Muscle in the Microform Cleft Lip

RecentIy, increasing emphasis has been placed on the histochemical and ultrastructural characteristics of the muscle in the cleft lip. Schendelet al and Cho et al demonstrated a non-neurogenic muscle atrophy and mitochondrial myopathy, and Raposio examined an increased inflammatory reaction, but no mitochondrial abnormalities of the cleft lip muscle. However, no study has focused on the ultrastructure of the microform cleft lip muscle. Eleven muscle specimens were obtained from the microform cleft lip patients at the time of primary repair from Jun.1997 to Aug.1998 and they were submitted to histologic and histochemical examinations as well as electron microscopy. A non-neurogenic muscle atrophy was seen on HE stain. Modified Gomori trichrome stain revealed red granularity of the muscle fibers, suggesting an increase in mitochondrial activity, however, no ragged-red fibers, a typical sign of mitochondrial myopathy, was found. Electron microscopy revealed atrophy, disarray, and focal loss of myofibrils, dilated sarcoplasmic reticulum with glycogen deposit, and interstitial fibrosis. However, the mitochondrial morphology was well preserved with an increase of the number of the mitochondria which might be secondary change to muscle degeneration. In conclusion, ultrastructural characteristics of the orbicularis oris muscle in the microform cleft lip is non-neurogenic muscle atrophy without mitochondrial myopathy which is controversial in the complete cleft lip.

Philtrum Formation in Secondary Unilateral Cleft Lip and Microform Cleft Lip Using Vertical Interdigitation of the Orbicularis Oris Muscle

For patients who have undergone cleft lip surgery, the construction of the philtrum is crucial for restoring a normal appearance of the upper lip. Thirteen patients with unilateral secondary cleft lip deformity and 12 patients with microform cleft lip were treated for the creation of a philtral column between January of 1998 and October of 2002. Fifteen patients were male and 10 patients were female with an age ranges from 6 months to 43 years old. In patients with the depressed philtral column in secondary cleft lip deformity, external approach was used. The scar on the philtral column is excised and a full-thickness incision is made down to the orbicularis oris muscle and mucosa. The medial and lateral muscle flaps are exposed and split into two leaves. The two leaves of each muscle flap are sutured together to create a vertical interdigitation. Any excess skin is not excised but rather closed with 6-0 nylon. In patients with microform cleft lip, vertical interdigitation of the orbicularis oris was performed through the intraoral incision to avoid external scarring. The follow-up period ranged from 6 months to three years, with an average of 14 months. Among the 13 patients with secondary cleft lip deformity, 10 patients were satisfied with their surgical results. Two had fair results. One patient experienced a widening of the scar and no improvement in the philtral column. A possible cause for the lack of improvement in one patient was a partial disruption of the interdigitated muscle before wound healing. On the other hand, all patients with microform cleft lip were satisfied with their surgical results. In conclusion, the advantage of this procedure includes the creation of an anatomically natural philtrum through preserving the continuity and function of the muscle, sufficient augmentation of the philtral column by the vertical interdigitation of the muscle, relief of skin tension, and no donor-site morbidity. In addition, in microform cleft lip, the external visible scar was avoidable through the intraoral incision.

Dovetail Cheiloplasty

The widely prevailing Millard's rotation-advancement flap method is characterizes with the upper lip scar on a philtral column and that it is less conspicuous than LeMesurier's or Tennison's metheds. Nowadays, straight line closure methods are employed together with the Millard's. However there are still some problems which are a straight line closure that goes against the principle of plastic surgery, a noticeable scar, tenting of the peak of Cupid's bow, a short lip tendency, and depression of the lip when the muscle contracts. In this respect, we designed two or three small trapezoid skin flaps on the cleft side and the same number of releasing incision lines on the non-cleft side and then let them interdigitate one another. We called it dovetail cheiloplasty. The muscle work was done by suturing one third of the cleft side muscle to the dissected dermis of the non-cleft side skin flap just under the philtral dimple. Our patients had a primary incomplete, a microform type cleft lip or a secondary cleft lip deformity. The result of employing this method showed an inconspicuous scar, a shorter lip, and a natural formation of the philtrum. We believe this method induces the improvement of straight line closure with respect to the quality of scars and the morphology of an upper lip.

Surgical Correction of Microform Cleft Lip by Small Triangular Flap

Cleft lip is one of the most common major facial malformation. The defect of the midline tissue on the upper lip is due to failure of the contact and fusion between mesenchymal tissues of the lip. Microform cleft lip is defined as the cleft of the lip with the minor degree of the deformity on the lip and the nose. The hallmarks of the microform cleft lip are a small notching of the vermilion, a vertical congenital fibrous band extending from the vermilion to the nostril floor, and a displaced alar cartilage on the cleft side. The surgical methods of microform cleft lip include Rose-Thomson straight line closure and Millard Rotation- advancement repair. Although those methods repaired the functional impairment effectively, they failed to achieve the cosmetic improvement because of the long incision scar on the upper lip. The authors applied Tennison's small triangular flap to the microform cleft lips of the 10 patients from July 1998 to January 2001. We excised the scar on the notch of the vermilion with minimal incision using Tennison's small triangular flap and repaired the discontinuity of orbicularis oris musculture. The asymmetric nostrils were also corrected appropriately. We followed up each case with constant intervals and could get good results esthetically without shortening of the upper lip and the contracture of the scar band.

Classification and Operation of Microform Cleft Lip

Microform cleft lip is a mild expression of cleft lip. Downward depression of the nostril rim, skin striae of the upper lip, notching of the Cupid`s bow, and deformity of the vermilion border are characteristic findings. The definition is very important to aid in selection of the operative methods. Based on our operative experiences of cleft lip, we classified microform cleft lip according to our new definition.. According to author`s classification, class I(1 case) has cleft lip nose deformity without lip deformity or with slight short lip of cleft side, class IIa(5 cases) has minimal lip deformity with blurring of cupid`s bow, vermilion notching, and skin striae with intact of orbicularis oris muscle, class IIb(12 cases) has discontinuity of the orbicularis oris muscle, class III(5 cases) has mild lip nose deformity with discontinuity of orbicularis oris muscle including Cupid`s bow deviation. In class IIb and class III, reconstruction of orbicularis oris muscle is important and we repaired it with radical operation by rotation-advancement method. A total of 23 microform cleft lip result was reviewed. We treated the clefts following the above principles according to the classification and obtained satisfactory results.

A Case of Recurrent Holoprosencephaly / 대한산부인과학회잡지

Holoprosencephaly(HPE), a common developmental defect affecting the forebrain and cranioface, is etiologically heterogenous. Teratogen, chromosomal anomalies, genetic syndrome, or genetic disorder of non-syndromic HPE are usually accepted as etiology. But the severity of brain and craniofacial malformation are not associated with etiology. Individuals with microform of HPE, who usually have normal cognition and brain imaging, are at the risk of having children with HPE. Several studies on the basis of HPE gene have been performed, which shed valuable insight on normal brain development. As additional HPE genes are identified, more accurate recurrent risk counseling can be given. We experienced a case of recurrent HPE diagnosed by transabdominal ultrasound examinations at 22 weeks' gestation.

The Treatment of Microform Cleft Lip Patients According to the Classification

The microform cleft lip is the mildest expression of cleft lip and nose deformity, but it has no specific definition, classification, and few methods have been reported for its correction. It is characterized by deformity of the nostril, skin striae of the upper lip, notching of peaked Cupid's bow, deformity of the vermilion, and anomaly of the upper lateral incisior and alveolar ridge on the affected region. Sixty-three microform cleft lip patients were operated on between Dec. 1993 and Sep. 1998 in our department(29 males and 34 females). The age of the patients ranged from 5 months to 30 years(Mean 9 years). We classified and treated the microform cleft lip as follows: Class I: Cleft lip nose with very slight lip deformity Class II: Minimal lip deformity without vermilion notching Class III: Mild lip deformity with slight vermilion notching. The goals in the correction of a microform cleft lip are to obtain an esthetically pleasing upper lip and nose, and to reestablish muscle continuity for improved function. To attain these goals, we used the above classification and satisfactory results were obtained by treating the microform cleft according to the classification.

Repair of Microform Cleft Lip with Minimal Incision

Microform cleft lip is a mild form of incomplete cleft lip, also known as a minimal occult, abortive, forme fruste cleft lip. However, it has no definition and few methods have been reported for its correction. A microform cleft lip is characterized as the incomplete union of the superficial portion of the orbicularis oris muscle. It is more prominent during facial expression than in a resting state. We confined microform cleft lip in our study to the absence of philtral skin change and a contracted position on the top of cupid's bow. During the past 5 years, 17 patients of microform cleft lip were operated on. We corrected the defect of the upper vermilion border and nostril sill with minimal incision, and repaired the underlying lip musculature in superficial discontinuity. Reduction of the widened alar base was performed. Deformed alar cartilage was dissected via rim incision, and suspended in a medial and upper direction with pull-out sutures. The most important thing is precise repair of the superficial portion of the separated orbicularis oris muscle via minimal incision, and it is best to operate after 1-year of age for accurate repair. The results were satisfactory and the parents were also satisfied. The advantages of this procedure are as follows: 1. Less visible, minimal scar on upper lip 2. Simultaneous correction of vermillion notching, deformed cupid's bow and nasal deformity. 3. Eversion of philtral ridge due to tenting effect of horizontal mattress suture 4. Philtral elongation effect by reduction of alar base and Z-plasty of cupid's bow.

Avaliaçäo ambiental de amônia empresa Macrodata-Processamento de Dados Ltda / Ammonia environmental evaluation Macrodata-Processamento de Dados Ltda

A avaliaçäo ambiental realizada teve como objetivo conhecer o nível de concentraçäo de amônia no setor de duplicaçäo de micro-fichas. Após este trabalho, medidas de controle seräo adotadas pela empresa de modo a eliminar ou minimizar a emanaçäo de vapores de amônia para o ambiente de trabalho.