Novel classification system for adult Asian secondary bilateral cleft lip with nasal deformity that guides surgical strategy.

BACKGROUND: Bilateral cleft lip is a congenital defect often accompanied by secondary lip and nose deformity. The current classification system for secondary cleft lip deformity has limitations in guiding surgical planning. In this article, we report a method for secondary bilateral cleft lip classification that can guide surgery on the basis of the pathological anatomy of the columellar and upper lip. METHODS: Photographs of patients were retrospectively classified into four types on the basis of the ratio of columellar height to alar base width (CH/AW) and upper lip protrusion (UP) to lower lip, as follows: type I - with CH/AW ≥ 0.2 and UP ≥ 0; type II - with CH/AW ≥ 0.2 and UP <0; type III - with CH/AW < 0.2 and UP ≥0; type IV - with CH/AW < 0.2 and UP < 0. Surgical treatments and the change of the nasal profile were documented. RESULTS: A total of 105 patients from January 2008 to December 2018 were included in this study. The nasal profile was significantly improved in type III and IV patients with postoperative CH/AW values close to normal. The upper lip was distinctively retruded in type II and IV patients before treatment, and the postoperative view revealed improved upper lip protrusion with UP values close to normal. Ninety-eight patients reported satisfactory outcomes after treatment. CONCLUSIONS: The new classification method described provides key information regarding the deformity of different types of secondary bilateral cleft lip patients and provides clear guidance for surgical planning on the basis of the anatomical defect of each type.

Forearm Deformities in Birth Brachial Plexus Palsy - Patient Profile and Management Algorithm.

Forearm deformities are often seen in children with severe birth brachial plexus palsy (BBPP). They may be either a supination or a pronation deformity and both hinder normal use of the hand and parents often request for corrective surgery. However, the correction of these deformities can be challenging due to a paucity of options. Also, there is less information in literature on the management of forearm deformities in BBPP compared to the information with regard to nerve surgery or correction of shoulder deformities. This article presents a synopsis of incidence, pathogenesis, clinical presentation and parental concerns related to these deformities. The decision-making considerations, management strategies and outcome expectations are also discussed. Patient selection is very crucial, and the treatment plan must be individualised depending on the disability, parental expectations and existing motor power in the involved limb. Correction of both the deformities have different considerations; however, effective correction of these deformities is immensely satisfactory to the patient/parents in terms of improved function and appearance of the limb. Level of Evidence: Level V (Therapeutic).

Aesthetic evaluation of nasolabial reconstruction using abbe flap in bilateral cleft lip patients with secondary deformities.

BACKGROUND: The Abbe flap is a common technique frequently utilized in secondary surgery for bilateral cleft lip deformities, but objective indications for the Abbe flap remain unclear, and postoperative aesthetic evaluations are limited. METHODS: The study group consisted of 92 bilateral cleft lip patients with secondary deformities aged 7-39 years, and the control group consisted of 33 people aged 19-35 years. Thirteen objective nasolabial aesthetic parameters were selected to evaluate patients' nasolabial aesthetics. RESULTS: Minor secondary deformities were characterized by a smaller lip height index than severe deformities, as well as a smaller columellar angle compared with moderate and severe deformities (P < 0.05). For all patients, significant differences were found between preoperative and postoperative values of intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, lip vermilion height index, lip protrusion angle, columellar-labial angle, and nasal tip angle (P < 0.05). For patients with minor deformity, intercanthal distance/philtrum width ratio and intercanthal distance/medial cutaneous upper lip height ratio showed no significant change postoperatively (P > 0.05), and labial protrusion angle was smaller than the control group (P < 0.05). CONCLUSIONS: Patients undergoing secondary surgery using an Abbe flap achieved good nasolabial aesthetics. Intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, columellar-labial angle, nasolabial angle, nasal tip angle, and columellar angle are the objective aesthetic indicators for Abbe flap selection. Intercanthal distance/philtrum width ratio, intercanthal distance/medial cutaneous upper lip height ratio, and labial protrusion angle are reference parameters for choosing an Abbe flap for secondary bilateral cleft lip revision.

Longitudinal Morphological Changes in the Mucosal Free Margin After Unilateral Cleft Lip Repair.

Weakness of the mucosal free margin is common in secondary cleft lip deformities. However, the incidence is rarely reported after a long-term follow-up. We evaluated the evolution of patient mucosal free margin after primary repair and until the end of growth.Blinded retrospective study (photography and chart reviews).Tertiary care hospital; private practice.Forty-eight patients with unilateral cleft lip with or without cleft palate who underwent primary nasolabial repair between 1996 and 2004 were followed up until their end of growth marked at 18 and 16 years of age for male and female patients, respectively.Primary nasolabial repair using a straight-line closure without a triangular flap on the vermilion was performed; if needed, a revision surgery was performed at 5 years of age (85%).The contour of the mucosal free margin was classified into nodular, smooth, and recessed types at 1, 5, and 10 years and at the end of growth.At 1 year of age, the nodular type was more common (58%). However, the recessed type was more common (75%) at the end of growth. The mucosal free margin continued to change after 10 years of age. At the end of growth, half of the patients with incomplete cleft experienced center weakness, and the others had cleft-side weaknesses.Patients with incomplete clefts showed favorable results at early ages. However, two-thirds of the patients with complete and incomplete clefts showed focal weakness at the end of growth.

Patient-Specific Implants (PSI) in Maxillary Hypoplasia Secondary to Cleft Lip and Palate Deformity.

Maxillary hypoplasia is often evident in cleft patients due to impaired growth and dense scarring from previous cleft surgeries. For these patients, treatment scenario has taken many turns over ages, evolved from orthognathic correction to distraction osteogenesis, with mixed prognosis and outcome depending on severity of the case and other several factors. We are reporting a case of 24-year-old female with maxillary hypoplasia secondary to bilateral cleft lip and palate with hypoplastic prolabium, who has been treated with two patient-specific implants in bilateral maxillary region for facial profile enhancement.

Short-term nasal symmetry repaired by force-balanced muscular reconstruction technique.

OBJECTIVES: This study aimed to compare the postoperative outcome of the new and classical muscular reconstruction technique combined with nasal internal-fixation method for secondary deformity post unilateral cleft lip repair. A rationale is provided for the further surgical improvement of secondary deformities. METHODS: Sixty patients aged 4-18 years with secondary unilateral cleft lip-nose deformity were involved in this research. The deformities of 28 patients were repaired using the muscular force balance technique through nasal internal fixation method, and 32 were repaired using classical muscular reconstruction technique. Two-dimensional analysis was used to evaluate the nose-lip morphology of pre- and post-operative patients through standardized photographs seven days after surgery. RESULTS: Compared with preoperative nasal morphology in the muscular force balance technique group, the 7-days postoperative results of this group showed the significantly improved short-term outcomes in the correction of columellar deflection, alar rim angle, nasal shape, and the symmetry of alar base width, nostril width, nostril height, alar rim angle (P<0.05). CONCLUSIONS: The new muscular reconstruction technique with nasal internal-fixation method has a significant effect on nasal repair.

Correction of Post-Cleft Lip Nostril Floor Stenosis: Para-Alar Flap Combined With Lip Revision.

Post-cheiloplasty nostril floor stenosis is a scarcely reported secondary deformity. The aim of the current study was to assess the outcome of para-alar flap for management of nostril floor stenosis post-unilateral cleft lip repair. This is a retrospective case series study reviewing consecutive patients presenting with nostril floor stenosis following repair of unilateral cleft lip who were managed by the inferiorly based para-alar flap and lip revision. Differential nostril width was measured preoperative, immediate, and late postoperative. We reported 8 patients (3 boys and 5 girls) with an average age of 9.8 years (range: 4.5-19). Satisfactory results with good nostril symmetry measures were achieved, and no restenosis has been observed during the follow-up periods. The donor site scars were negligible. There was no reported partial or total flap loss. Para-alar flap was found to be an effective reconstructive option for patients with nostril floor stenosis post-unilateral cleft lip repair and can be combined safely with cleft lip revision.

Surgical treatment of neglected C2 odontoid process fracture with anterior atlantoaxial dislocation.

We report a case of the atlantoaxial (C1-2) deformity secondary to a neglected C2 odontoid fracture that was successfully treated with 3-stage operation performed in one session.

Short-term nasal symmetry repaired by force-balanced muscular reconstruction technique / 华西口腔医学杂志

OBJECTIVES@#This study aimed to compare the postoperative outcome of the new and classical muscular reconstruction technique combined with nasal internal-fixation method for secondary deformity post unilateral cleft lip repair. A rationale is provided for the further surgical improvement of secondary deformities.@*METHODS@#Sixty patients aged 4-18 years with secondary unilateral cleft lip-nose deformity were involved in this research. The deformities of 28 patients were repaired using the muscular force balance technique through nasal internal fixation method, and 32 were repaired using classical muscular reconstruction technique. Two-dimensional analysis was used to evaluate the nose-lip morphology of pre- and post-operative patients through standardized photographs seven days after surgery.@*RESULTS@#Compared with preoperative nasal morphology in the muscular force balance technique group, the 7-days postoperative results of this group showed the significantly improved short-term outcomes in the correction of columellar deflection, alar rim angle, nasal shape, and the symmetry of alar base width, nostril width, nostril height, alar rim angle (@*CONCLUSIONS@#The new muscular reconstruction technique with nasal internal-fixation method has a significant effect on nasal repair.

Progress in evaluating the postoperative effect of cleft lip / 口腔疾病防治

@#The postoperative evaluation of cleft lip is an important means to improve the operation method and the effect of the restoration. In recent years, the methods of cleft lip repair, such as Chinese western rotary propulsion, reconstruction of labial and nasal muscle tension band+trefoil flap, etc., have been developed. However, at present, there are still many secondary deformities, such as obvious scars and alar collapse. In this paper, in a review of the previous literature, the existing methods, advantages and disadvantages, and the application of the evaluation of the postoperative effect of cleft lip were reviewed. To date, there are many methods that can be used to evaluate the effect of cleft lip surgery. These research methods can be divided into subjective evaluation and objective evaluation, such as subjective evaluation, direct measurement, photo measurement, and three-dimensional scanning measurement. Among them, the subjective evaluation is simple, but the reliability is poor, and this method is suitable for all patients with cleft lip. The direct measurement has a low cost and is only suitable for one-dimensional information measurement, but the accuracy is poor, so it is difficult to determine the endpoints. The time of the photo measurement method is short, which can avoid tissue deformation, but it is easy to produce errors; this method is suitable for patients with cleft lip who can cooperate. The three-dimensional scanning measurement has a high accuracy, is time consuming and is a simple method but has a high cost and is suitable for areas with appropriate equipment conditions. Overall, the evaluation of the postoperative effect of cleft lip surgery should combine subjective evaluation with objective evaluation, dynamic evaluation with static evaluation, and utilize long-term follow-up to obtain comprehensive and accurate information and provide a reference for clinicians to carry out cleft lip surgery.

Secondary Correction of the Midline Defect of Upper Lip: A Report of Five Cases.

INTRODUCTION: Primary surgery of cleft lip and palate has dramatically improved with technical and material advances. Some adults who previously underwent surgery still have upper lip deformities or extensive scar, and they are occasionally seen for secondary treatment. CASES: In our study, a total of five patients with secondary deformity of the upper lip with the scarred tissue with paucity of the muscle in the midline were operated using the modified Abbe flap. CONCLUSION: With this technique, we were able to achieve the bulk in the midline over the upper lip and the functional integrity of the muscle was maintained.

Assessing Attentional Bias in Secondary Cleft Lip Deformities: An Eye-Tracking Study.

OBJECTIVE: Using a well-established measure of attention, we aimed to objectively identify differences in severity between types of simulated secondary cleft lip deformities. DESIGN: Volunteer participants viewed a series of images of a child digitally modified to simulate different secondary unilateral cleft lip deformities (long lip, short lip, white roll/vermilion disjunction, and vermilion excess), a lip scar with no secondary deformity, or a normal lip. Eye movements were recorded using a table-mounted eye-tracking device. Dwell times for 7 facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face) were compared. PARTICIPANTS: Forty-six naive adults (25 male; mean age 25.5 years) were recruited from our local university community. MAIN OUTCOME: The primary outcome of the study was cumulative dwell time between facial regions (eyes, nose, mouth, left ear, right ear, scar, and entire face). RESULTS: Participants spent significantly more time focused on the upper lip regions in patients with simulated secondary deformities relative to those who did not ( P < .01). Severe short lip deformities resulted in longer fixation times than severe long lips ( P < .05). Participants spent less time focused on the eye region in the presence of a secondary lip deformity ( P < .05). When total facial fixation time was assessed, short lip deformities resulted in the greatest duration dwell time ( P < .001). CONCLUSIONS: This study presents objective data to support the concept that observers show varying degrees of attentional bias to the lip region depending on the type and severity of the simulated secondary cleft lip deformity.

First auxiliary muscle tension line group reconstruction for nostril sill repair in cleft lip patients / 中华整形外科杂志

Objective@#This study is to repair nostril sill deformity in the cleft lip patients by reconstructing the first auxiliary muscle tension line group and to assess the therapeutic outcome.@*Methods@#437 cleft lip patients with nostril sill deformity underwent the surgery from January 1, 2012 to November 1, 2016.They were treated using the technique of first auxiliary muscle tension line group reconstruction to repair the deformity. Aesthetic correction evaluations were rated by the GAIS. Random digit was used to randomly select 24 patients during the follow-up for three-dimensional measurement and analysis. The preoperative and postoperative symmetry of the nostril sills were evaluated by paired t test.@*Results@#Mucosal ischemia or wound infection occurred in 11 cases, left obvious scar on the nostril floor. Surgical incisions of the other patients were primary healing. After 6 months to 3 years follow up, GAIS questionnaires of 378 patients demonstrated that 84% patients reported great or moderate improvement of nostril sills. Three-dimensional measurements of 24 patients suggested that there were no significant differences of the nostril sill and the nasal ala between the cleft side and the normal side.@*Conclusions@#First auxiliary tension line group reconstruction, which is to restore biomechanical balance rather than merely increase muscle volume, is an effective method of nostril sill repair in the cleft lip patients. Post-operatively, the patients achieved a stable and natural nostril sill, a middle columella, as well as a narrowed nasal ala.

Secondary deformity of postoperation of hypospadias and its treatment / 中华整形外科杂志

Objective@#To sum up the clinical manifestations and the method for repairing of secondary deformities of postoperation of hypospadias.@*Methods@#Applying balanus tissue flaps and urethral meatus plastic could correct the flat balanus and prevent urethral meatus from falling back. Resecting scar completely in penis and rebuilding urethral tissues could treat secondary curved penis. Applying modified penile augmentation which involved girth enhancement by a free dermal-fat graft and penile elongation (suprapubic skin advancement-ligamentolysis) could correct shorter and much smaller penis.@*Results@#Among January 1st 2007 to December 31st 2016, 62 cases were treated.All of them were male. Their ages were from 14 to 34 years old.55 cases were followed up from 6 months to 9 years after operations, but 7 cases could not be followed up because of the change of addresses and phone numbers.All patients achieved excellent cosmetic result. None of them had complications like urethral fistula.@*Conclusions@#After operations of hypospadias, the secondary deformities may happen when the children grow up.And these deformities always need to be corrected with operations. Balanoplasty, correction of penis and the penile augmentation are good methods for secondary deformities.Consequently, a good penis appearance and function can be acquired.

The anatomy of Wassel type IV-D thumb duplication.

We describe Wassel type IV-D thumb duplication anatomy after surgery on 11 affected children (12 hands, seven boys (eight hands) and four girls). We studied the structure and course of the flexor pollicis longus tendon and its action at the joint. Four patients had secondary deformity associated with an absent A2 pulley and a tendon that clung to the radial side of a small thumb. In patients with primary deformity, the flexor tendon sheath became membranous in the A2 area and attached to neighbouring sites on the opposite side of the proximal phalanx. In the proximal A2 area, the tendon divided - one division attached on the ulnar side of the distal phalanx base; the other, the base of the radial side. There was slight ulnar angulation of the distal phalanx on the radial portion of the duplication and slight ulnar angulation on the radial portion. LEVEL OF EVIDENCE: V.

A novel technique using a subcutaneously pedicled islanded prolabial flap for the secondary correction of bilateral cleft lip and nasal deformity.

CONTEXT: The bilateral cleft lip and nose deformity frequently requires lip revision surgery at the time of secondary rhinoplasty. The goal is to achieve an adequate philtrum with a well-shaped Cupid's bow, white roll alignment and a central vermilion tubercle. AIMS: We have devised a new technique of using prolabial tissue tailored as an island of skin based on a subcutaneous pedicle for the secondary reconstruction of the philtral aesthetic unit in patients with bilateral cleft lip nasal deformity. SETTINGS AND DESIGN: This technique was used in 21 patients from March 2012 to August 2015. All patients had undergone primary lip repair at other institutions and required lip revision with simultaneous rhinoplasty. SUBJECTS AND METHODS: The objective criteria considered in the post-operative evaluation by the authors included improvement of philtral ridge projection, symmetry of philtral column and nasal sill and white roll continuity. The ten individual parameters were given a score from 1 to 4 (with 1 = lowest and 4 = highest for each individual parameter) and the total score was rated as 31-40 = excellent, 21-30 = good, 11-20 = fair and 0-10 = Poor. The patients' overall satisfaction was assessed at 6 months postoperatively to record their impression of the aesthetic improvement after our procedure. RESULTS: The follow-up period ranged from 6 months to 3 years. The prolabial flap had no post-operative complications. The authors' assessment judged 15 (71.4%) patients as having an excellent outcome and 6 (28.5%) patients as having a good outcome. All patients expressed subjective satisfaction with the post-operative appearance of their upper lip and rated their results as improved and overall satisfaction scoring was high. CONCLUSIONS: This technique is a new addition to the repertoire of procedures which already exist for the correction of bilateral cleft lip nose deformity. It is safe, reliable and has a good aesthetic outcome with no significant morbidity.

Causes of secondary deformity after surgery to correct Wassel type IV-D thumb duplication.

UNLABELLED: This study was undertaken to document the causes of secondary deformities after surgery for correction of Wassel type IV-D thumb duplication. We carefully dissected and observed the flexor pollicis longus, and bone and joint anatomy in eight patients with secondary deformities after surgical correction. We transferred the flexor pollicis longus and thenar muscle attachments, reconstructed the A2 pulley, released and tightened the joint capsule, and performed osteotomies to correct skeletal malalignment. Kirschner wire fixation was used for 4-5 weeks, followed by brace fixation for 3 months. Patients were followed up for 13-34 months (mean 20 months). According to the Tada scores, the outcomes were good in six patients, and fair and poor in one patient each. The main causes of the secondary deformities were failure to reconstruct the A2 pulley, to transfer the flexor pollicis longus and thenar muscles, and incomplete resection of the radial metacarpal head. Brace fixation after Kirschner wire removal is crucial in preventing secondary deformities. LEVEL OF EVIDENCE: IV.

Correcting the secondary bilateral cleft lip deformities using an innovative partial-thickness musculomucosal pedicle cross-lip flap / 中华医学美学美容杂志

Objective According to the fine artery anatomy of the lower lip, we developed an innovative partial-thickness myocutaneous flap based on the vascular network of the submucosal and subcutaneous layers of the lower lip.We attempted to treat the secondary bilateral cleft lip deformities using this innovative cross-lip flap.Methods From July 2009 to June 2015, this new technique was used in 98 patients with secondary bilateral cleft lip deformities.The central defects usually occurred in these patients.The defects were reconstructed partially or completely according to the severities of the defects.The operative procedures were as follows: The split flap was elevated from the posterior portion of the oris orbicularis muscle after the inferior labial arteries were divided.Then the partial-thickness flap was rotated 180 degrees horizontally and inverted 180 degrees upward to the upper lip defect.Results All 98 musculomucosal pedicle flaps were viable.The upper lips were reconstructed according to the severities.Conclusions This myocutaneous cross-lip flap with musculomucosal-pedicle has a more reliable blood supply, better flexibility and plasticity.It is an effective method for aesthetic reconstruction for the secondary bilateral cleft lip deformities.

Outcome of double-cut correction on secondary deformity after unilateral cleft lip repair with nasolabial muscle reconstruction / 中华医学美学美容杂志

Objective To investigate the surgical methods and effect of double-cut nasolabial muscle directional three-dimensional reconstruction on the secondary deformity of unilateral cleft lip repair.Methods We first increased a contralateral vermilion secondary incision based on the nasolabial muscle directional three-dimensional reconstruction, without damaging the contralateral white lip skin, via suturing both sides of nose wings bundle of nose outside corner under the columella muscle, and overlapping suturing both sides of the orbicularis muscle flap, and then rebuilt and took shape of the nest and the crest.Results All incisions healed well in 18 patients, all nasal deformities were corrected better than the traditional methods, with the nasal base plump, the nasal sill formed close to the contralateral side, and rebuild the philtrumdimple and philtrum crest, with clear appearance and symmetrical form.A good appearance was obtained on the both sides of nostril, nasal base and the nasal sill, and the effect of preoperative design achieved.Conclusions Both sides of the nostrils size, nasal sill and shape are almost perfectly symmetrical, and the double-cut nasolabial muscle directional three-dimensional reconstruction is suitable for repairing the secondary deformity after unilateral cleft lip repair.

Reconstruction of secondary breast deformity after breast conservative therapy / 中华医学美学美容杂志

Objective To explore the causes of secondary breast deformity after breast conservative therapy and its preventive methods.Methods 30 cases were selected from the patients with secondary breast deformity of more than 1 year after breast conservative therapy,and more than half a year after radiotherapy and chemotherapy,and no local recurrence and distant metastasis occurred.After cicatrectomy and contracture loose solution,different methods were used according to varying degrees of the secondary breast deformity to reconstruct and repair the deformity.Results Three reconstructive methods were conducted.Local mammary flaps were used in 7 patients,latissimus dorsi myocutaneous flap in 21 patients,and transverse rectus abdominal musculocutaneous flaps in 2 patients.The shape and feeling were satisfactory in 30 patients with reconstructive breasts,in which 23were excellent (76.7 ％),and 7 were good (23.3 ％).All the patients were followed-up for average 2.5 years,and they were survived without tumor recurrence.Conclusions The secondary breast deformity after breast conservative therapy could be effectively prevented,and successfully reconstructed and repaired with different procedure according to varying degrees of the secondary breast deformity.As a result,the shape and feeling of reconstructive breasts are satisfactory.