The philtrum in cleft lip: review of anatomy and techniques for construction.

The philtrum is imperfectly formed in both unilateral and bilateral cleft lip. Surgical construction of this exquisite feature in the upper lip is challenging and often takes a back seat to construction of Cupid's bow and the nose. However, the philtrum is one of the defining features of a normal lip. The purpose of this review is to compile information on philtral anatomy and techniques for construction to guide the reader on his or her own quest to optimize cleft lip repair. In this article, we review the normal anatomy of the philtral dimple and ridges, with particular attention to pars peripheralis configuration. We also review methods for philtral construction during primary labial repair and secondary labial revision. For unilateral cleft lip, eversion of orbicularis oris muscle is necessary to build a philtral ridge. For bilateral cleft lip, emphasis is on proper design of the philtral flap and efforts to simulate a dimple and ridges. For secondary philtral correction, techniques include complete labial revision with various types of muscular re-repair and autologous philtral ridge augmentation. Objective methods are needed to document the efficacy of the many techniques for philtral construction and reconstruction.

An evidence-based approach to the treatment of nonmelanoma facial skin malignancies.

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

Integrated plastic surgery residency applicant survey: characteristics of successful applicants and feedback about the interview process.

BACKGROUND: Integrated plastic surgery residency training is growing in popularity, bringing new challenges to program directors and applicants. The purpose of this study was to identify characteristics of successful applicants and to obtain feedback from applicants to improve the integrated plastic surgery residency training application and interview process. METHODS: An anonymous survey assessing applicant academic qualifications, number of interviews offered and attended, and opinions about the application and interview process was distributed electronically to the 2006 integrated plastic surgery residency training applicant class. The number of interviews offered was used as an indicator of potential applicant success. RESULTS: A 38 percent survey participation rate (139 of 367) was achieved. United States Medical Licensing Examination Step 1 score correlated with number of interview invitations (p < or = 0.001). Successful Alpha Omega Alpha designation (p < or = 0.001), high class rank (p = 0.034), presence of a plastic surgery residency program at the participant's school (p = 0.026), and authorship of one or more publications (p < or = 0.001) were associated with receiving greater number of interview invitations. Geographic location was an important consideration for applicants when applying to and ranking programs. Applicants desired interviews on weekdays and geographic coordination of interviews. CONCLUSIONS: Integrated plastic surgery residency training is highly competitive, with the number of interview invitations correlating with academic performance and, to a lesser extent, research. Applicant feedback from this survey can be used to improve the application and interview process.

Comparative microanatomy of the orbicularis oris muscle between chimpanzees and humans: evolutionary divergence of lip function.

The orbicularis oris muscle plays a role in the production of primate facial expressions and vocalizations, nutrient intake, and in some non-human primates it is used as a prehensile, manipulative tool. As the chimpanzee (Pan troglodytes) is the closest living relative of humans, a comparison of the orbicularis oris muscle between these species may increase our understanding of the morphological specializations related to the differing functional demands of their lips and the factors responsible for their divergent evolution. To this end, this study compares the microanatomy of the mid-line upper fibers of the orbicularis oris muscle between chimpanzees and humans. A mid-line portion of the orbicularis oris muscle was harvested from the upper lips of three chimpanzee and five human cadavers. The sampled blocks included the area between the lateral borders of the nasal alar cartilages in both species. Each sample was processed for paraffin histology, sectioned and stained with a variety of protocols. Sections were examined for fiber direction and relative thickness of muscle layers. Ratios of cross-sectional connective tissue area vs. cross-sectional muscle tissue area, muscle fiber diameter and relative dermal thickness were calculated for each species. In both species, a clear pars marginalis layer was recognized, contrary to previous reports that only humans possess this layer. In chimpanzees, the relative fiber diameter and relative amount of muscle tissue (i.e. based on ratio of connective tissue area : muscle tissue area) were significantly (P < 0.05) greater than in humans. In contrast, measurements of relative dermal thickness showed that humans have a greater average dermal thickness of the upper lip than chimpanzees. Taken together, these results suggest that both human and chimpanzee orbicularis oris muscle upper fibers meet the specific functional demands associated with their divergent vocal and facial display repertoires, the development of human speech, and the use of the upper lip as a prehensile tool in chimpanzees.

Anatomical basis for apparent subepithelial cleft lip: a histological and ultrasonographic survey of the orbicularis oris muscle.

OBJECTIVE: To determine if there is an anatomic basis for subepithelial orbicularis oris muscle defects by directly comparing ultrasonographic images of the upper lip with corresponding histological sections obtained from cadavers. METHODS: Ultrasound was performed on the upper lips of previously frozen, unpreserved cadaver heads (n = 32), followed by dissection and sectioning of the upper lips. The ultrasound sequences were scored by a panel of raters, classifying the orbicularis oris muscle as negative, positive, or unknown for the presence of an orbicularis oris discontinuity (subepithelial defect). Based on ultrasound, six lip specimens were chosen for histological sectioning, were stained with hematoxylin-eosin and Gomori trichrome stain, and were evaluated with light microscopy at low (8x) and intermediate (100x) magnification. RESULTS: One cadaver was scored positive for an orbicularis oris muscle discontinuity based on ultrasound; whereas, the remaining cadavers were scored negative. Of the cadavers with negative ultrasound scores, two were noted to have orbicularis oris muscles with "irregular" features (e.g., excessive localized thinning or asymmetry). From histology, the area of discontinuity as visualized on the positively scored ultrasound was characterized by both disorganized orbicularis oris muscle fibers and excess connective tissue within the muscle belly. In contrast, the localized thinning observed on some of the negatively scored ultrasounds was not confirmed by histology. CONCLUSIONS: Abnormalities of the orbicularis oris muscle visualized by ultrasound have an anatomic basis as revealed through histology. Ultrasound is a useful tool for noninvasively identifying discontinuities of the orbicularis oris muscle.

Orbicularis oris muscle defects as an expanded phenotypic feature in nonsyndromic cleft lip with or without cleft palate.

Nonsyndromic cleft lip+/-cleft palate is a complex disease with a wide phenotypic spectrum; occult defects of the superior orbicularis oris muscle may represent the mildest subclinical form of the lip portion of the phenotype. This study used high-resolution ultrasonography to compare the frequency of discontinuities in the OO muscle in 525 unaffected relatives of individuals with nonsyndromic cleft lip+/-cleft palate versus 257 unaffected controls. OO muscle discontinuities were observed in 54 (10.3%) of the non-cleft relatives, compared to 15 (5.8%) of the controls-a statistically significant increase (P=0.04). Male relatives had a significantly higher rate of discontinuities than male controls (12.0% vs. 3.2%; P=0.01); female relatives also had a higher rate of discontinuities than female controls, but the increase was not statistically significant (8.9% vs. 7.4%; P=0.56). These data confirm the hypothesis that subepithelial OO muscle defects are a mild manifestation of the cleft lip phenotype. Identification of subepithelial OO muscle defects may be important in a clinical setting, as a means of providing more accurate recurrence risk estimates to relatives in cleft families. Furthermore, the expansion of the cleft lip+/-cleft palate phenotypic spectrum should improve the power of genetic studies.

Automated facial image analysis: detecting improvement in abnormal facial movement after treatment with botulinum toxin A.

The purpose of this study was to evaluate the ability of Automated Facial Image Analysis (AFA) to detect changes in facial motion after Botox injections in patients with facial nerve disorders accompanied by abnormal muscle activity. Eight subjects received Botox for oral to ocular synkinesis (n = 6), ocular to oral synkinesis (n = 1), and/or depressor anguli oris overactivity (n = 3). Subjects were video-recorded during 2 directed facial action tasks before and after Botox treatment. AFA measurement and Facial Grading System (FGS) scores were used to evaluate the effects of Botox. After Botox, AFA detected a decrease in abnormal movements of the eyelids in all patients with oral to ocular synkinesis, a decrease in oral commissure movement for the patients with ocular to oral synkinesis, and an increase in oral commissure movement in all patients with depressor overactivity. The FGS scores failed to demonstrate any change in facial movement for the case of ocular to oral synkinesis and for 2 cases of depressor overactivity. AFA enables recognition of subtle changes in facial movement that may not be adequately measured by observer based ratings of facial function.

Dinoflagellate expressed sequence tag data indicate massive transfer of chloroplast genes to the nuclear genome.

The peridinin-pigmented plastids of dinoflagellates are very poorly understood, in part because of the paucity of molecular data available from these endosymbiotic organelles. To identify additional gene sequences that would carry information about the biology of the peridinin-type dinoflagellate plastid and its evolutionary history, an analysis was undertaken of arbitrarily selected sequences from cDNA libraries constructed from Lingulodinium polyedrum (1012 non-redundant sequences) and Amphidinium carterae (2143). Among the two libraries 118 unique plastid-associated sequences were identified, including 30 (most from A. carterae) that are encoded in the plastid genome of the red alga Porphyra. These sequences probably represent bona fide nuclear genes, and suggest that there has been massive transfer of genes from the plastid to the nuclear genome in dinoflagellates. These data support the hypothesis that the peridinin-type plastid has a minimal genome, and provide data that contradict the hypothesis that there is an unidentified canonical genome in the peridinin-type plastid. Sequences were also identified that were probably transferred directly from the nuclear genome of the red algal endosymbiont, as well as others that are distinctive to the Alveolata. A preliminary report of these data was presented at the Botany 2002 meeting in Madison, WI.