Reconstruction of the upper lip using the mucosal eversion technic

A one-stage reconstruction technique for upper lip defects is presented. This technique uses everted mucosal advancement flaps for the reconstruction of the vermilion border of the lip. It is an extension of Meyer's method employed in the reconstruction of the lower lip (1973) and differs from Camille Bernard's procedure in that horizontal incisions with bilateral triangular skin excisions are used instead of the more unaesthetic perpendicular incisions in the nasolabial fold, leaving a scar along the vermilion border. The method is suitable for reconstructing the upper lip after excision of up to 80% of its substance, and is superior to traditional methods in terms of both the functional and aesthetic results obtained.     

A systematic algorithm for the management of lower lip asymmetry

Purpose

An asymmetric smile, caused by loss of function of the lip depressors, can be functionally and cosmetically debilitating. Although some surgeons report excellent results with muscle transfer to the lower lip, many facial reanimation surgeons find that dynamic techniques do not consistently address the lower lip. Our objectives were to retrospectively review our outcomes after treatment of the asymmetric lower lip, and to propose a progressive, stepwise algorithm for the management of lower lip asymmetry in facial paralysis.

Material/Methods

Retrospective chart review was performed on all patients treated in a multidisciplinary facial nerve center with lower lip asymmetry over an eighteen month period. Treatment ranged from a temporary trial of lidocaine, to chemodenervation with botulinum toxin, to pedicled digastric muscle transfer, and/or resection of the nonparetic depressor labii inferioris (DLI).

Results

Fifty-seven patients were treated with chemodenervation with botulinum toxin, four with anterior belly of the digastric transfer, and 3 with DLI resection. All patients with DLI resection had undergone chemodenervation to the contralateral lower lip with botulinum toxin and were pleased with the appearance of their smile.

Conclusions

We have found that lower lip asymmetry is optimally managed by adherence to a standardized protocol that offers patients insight into the likely outcome of chemodenervation or surgery and progresses systematically from the reversible to the irreversible. We present our algorithm for the management of the asymmetric lower lip, which reflects this graduated approach and has resulted in high patient satisfaction.     

Die funktionell und ästhetisch orientierte Rekonstruktion von Lippendefekten

Reconstruction of lip defects presents a challenge to the surgeon. Apart from attaining a good aesthetic result, preserving the function of the oral sphincter is an essential objective. A variety of techniques and modifications of procedures for reconstructing lip defects have been reported in the literature. It is up to the surgeon to select the reconstruction procedure ensuring optimum functional and cosmetic results, depending on the location, size, and depth of the defect. The division of the lips into aesthetic subunits can prove very beneficial in designing lip reconstruction procedures. The upper lip is divided into three aesthetic subunits: two lateral subunits and a median subunit, the philtrum. The lower lip constitutes a single subunit. In this study, established reconstruction techniques are discussed and a concept serving to facilitate the appropriate choice of technique is introduced. This concept differentiates between vermilion defects on the one hand, and partial-thickness and full-thickness lip defects on the other hand. For the lower lip, the full-thickness defects are classified as defects involving one-third, one-third to two-thirds of the lower lip width, and between two-thirds and complete loss of lip tissue. For the upper lip, a distinction is made between isolated defects of the central and lateral subunits and combined defects of the central and lateral subunits. Important principles of surgery and the advantages or disadvantages of different reconstruction techniques are discussed.     

Lip and perioral defects.

Reconstruction of the lip and perioral region presents a myriad of problems, as deformities of this region can produce both aesthetic deformation and functional difficulties. This article reviews basic principles of lip reconstruction, emphasizing the differences between defects of the upper and lower lip.     

Duplication of lower lip and mandible--a rare diprosopus

Diprosopus or duplication of the lower lip and mandible is a very rare congenital anomaly. We report this unusual case occurring in a girl who presented to our hospital at the age of 4 months. Surgery and problems related to this anomaly are discussed.     

Reconstruction after tumour's excision in lip's cancer: report of 100 cases

OBJECTIVE: Cancer of the lips is a frequent pathology, it represents 1/5 of cancers of the upper aerodigestive tract. Its objectives are to present the experience of the plastic and reconstructive surgery unit of the universitary hospital of Casablanca. MATERIAL AND METHOD: The authors present a retrospective study about 100 cases of lips cancer treated between January 1999 and December 2002. RESULTS: The average age is 59 years. The sex-ratio is 7.3. Eighty-five percent of our patients were smokers and 22% were alcoholics, the association alcoholic and smoker was found in 20%. In our study 71% were classified T1-T2 and 29% as T3-T4. The tumoral location was the lower lip in 82% and the upper lip in 10%. The histological study showed a squamous cell carcinoma type in 85% and a basal-cell carcinoma type in 14% of cases. After the tumour's excision, the reparation was done by cross-lip flap in 25%, the naso-lateral flap in 16% and the Gillies flap in 8%. The functional result was good in 92% of cases and the aesthetic result was excellent in 60% of cases and good in 30% of cases. The survival rate at 2 year was 90%. CONCLUSION: Actually, lip's cancer treatment is essentially surgical. The reconstructive techniques are various, depending on the size and location of the loss of substance.     

Vibratory patterns of normal and microscopically operated larynges. Observation of lower surface of vocal fold in dogs

The authors investigated the effect of microsurgical intervention involving the canine larynx on vocal fold vibration. In normal cases both lower lips and free edges vibrated symmetrically. The lower lip coincided with the free edge and collided with that of the other side at the midline. Immediately after the collision, the lower lip rapidly retracted laterally at the beginning of a closed phase. It stayed in the most lateral position for the rest of the closed phase until the free edge started to move away laterally. The lower lip then began to move medially to occlude again with the other side. In cases subjected to microsurgery, a part of the mucosal layer of either the upper or the lower surface of the vocal fold was removed. Several weeks after the procedure, vibration was observed. In either case, vibration of the free edge of the operated vocal fold diminished in amplitude and often became earlier in phase than that of the contralateral fold. Usually the lower lip of the operated vocal fold moved away more slowly. In addition, when the extent of epithelial removal was large, the lower lip itself was not elicited.     

EMG recording in human lip muscles: can single muscles be isolated?

Electromyography, recording the electrical activity of muscles, is an electrophysiological method that has been used widely in the study of movement performance by human subjects. Borrowing from the tradition of electromyographic studies of limb muscles, investigators interested in speech production have used the method to address many important experimental questions. Unfortunately, data recorded from craniofacial muscles generally have been discussed without reference to problems of interpretation that could arise due to the unique anatomical features of the muscles, particularly the lip muscles. Anatomical data show that the fibers of different muscles of the lips are interdigitated so that fibers with differing spatial orientation typically are found within a small section of lower lip tissue. The anatomical data are consistent with results of physiological studies of the lower lip muscles that have suggested that motor units with different physiological characteristics are found within a single recording site. Together, the anatomical and electrophysiological data suggest that, even with intramuscular electrodes, the probability of recording from a single muscle of the lip in isolation is extremely low. The fact that the activity of more than one muscle is likely to be sampled critically determines the nature of the conclusions that can be drawn from the data.     

Differential fine force control of the upper and lower lips

From a review of the literature, it was hypothesized that the upper lip and lower lip are differentially controlled by separate, but interacting, neuronal connectivities. A normal data base was developed for select measures of fine force control occurring within physiologic levels presumably involved in speech production. Fine force control in the lower lip was found to be significantly more stable, and recruited at higher rates than the upper lip. Explanations are presented for the lower lip superiority on these measures and observations are made concerning the use of these rudimentary physiologic measures in studies of the dysarthrias.     

Reconstruction of small- and medium-sized defects of the lower lip.

Defects of up to one third of the lower lip can usually be closed primarily, using one of the excision shapes described above. Defects of 30% to 50% of the lower lip can be closed with a stair-step or lip-switch flap. In most circumstances, stair-step reconstruction attains good function more quickly than the lip switch flap and has a better aesthetic result. Defects of 50% to 75% of the lower lip can be closed with a fan flap or a Karapandzic flap; the Karapandzic flap generally provides a better functional result. Both of these flaps cause rounding of the corner of the mouth that compromise the aesthetic result.     

Incidence and outcome of middle ear disease in cleft lip and/or cleft palate

OBJECTIVE: Otitis media with effusion is known to be very common among children with cleft palate, however, less is known regarding the natural history and outcome in this group. The purpose of the present study was to examine the incidence, natural history, treatment, and outcome of middle ear disease in children with clefts. METHODS: A questionnaire was sent to the parents of all children registered on the cleft lip and palate database at our institution. The medical records of all respondents were also reviewed. Statistical analysis of the results was performed using Fisher's exact test in contingency tables and binary logistic regression analyses, where appropriate. RESULTS: 397 fully completed questionnaires were returned. Ear disease was much more common in children with cleft palate, or cleft lip and palate, than in children with cleft lip. Among children with cleft palate, ear problems (infections and/or hearing loss) were most prevalent in the 4-6-year-old age group. However, ear problems persisted at a substantial level for many years after this; only after the age of 12 years did problems appear to settle. The incidence of below normal current hearing and of surgery for chronic otitis media was significantly related to history of ear infections (P=0.000 and 0.000, respectively), and to increased number of ventilation tube insertions (P=0.000 and 0.000, respectively). CONCLUSIONS: Middle ear disease is common in children with cleft palate, and, unlike the case for children without clefts, has a prolonged recovery, and a substantial incidence of late sequelae. The higher incidence of below normal hearing and surgery for chronic otitis media in children undergoing a greater number of ventilation tube insertions, although most likely reflecting an increased underlying severity of otitis media in these children, also underlines the lack of long-term benefits of ventilation tubes in this group.     

An Otorhinological study of patients with cleft lip and palate

32 patients of cleft palate with or without cleft lip were subjected to otorhinological study from January 1998 to September 2000, with special attention to the rhinological anomalies, ear pathology, any deafness, discharge or any other findings relevant to the middle ear. Hearing loss and ear changes were not seen in any patient with cleft lip alone, hence these patients were not included in this study. These changes were confined to the patients with cleft palate only, with or without cleft lip. High incidence of otological anomalies (75%) and rhinological anomalies (deviated nasal septum in 40.6%) were seen in patients with cleft palate with or without cleft lip. Hearing loss has been seen (37.5%) in patients with cleft palate and was purely conductive in nature.     

A novel fixed-target task to determine articulatory speed constraints in persons with amyotrophic lateral sclerosis

PurposeThe goal of this study was to determine if talkers with ALS are limited in their ability to increase lower lip and jaw speed at an early stage of the disease when their speaking rate and intelligibility are only minimally or not affected.MethodA novel metronome paced fixed-target task was used to assess movement speed capacities during lower lip and jaw oscillations in seven talkers with ALS and seven age and gender matched controls.ResultsLower lip peak speeds were significantly lower in talkers with mild ALS than in healthy talkers suggesting a lower lip speed constraint in talkers with mild ALS. Jaw peak speeds tended to be lower, but jaw displacements tended to be larger in talkers with mild ALS than in healthy talkers. Because greater speeds are typically expected for larger displacements, outcomes also suggest a jaw speed constraint in talkers with mild ALS.ConclusionsLower lip and jaw peak speeds may be sensitive measures to identify bulbar motor performance decline at an early stage of the disease when speaking rate and intelligibility are only minimally affected.Learning Outcomes: The reader will be able to explain two different articulatory strategies to increase speaking rate and understand why fast speech tasks and diadochokinetic pseudo-speech tasks are not suited to assess articulatory speed capacity in healthy and impaired talkers. The reader will also be able to explain how orofacial movement speed capacity can be tested using a fixed-target task and how ALS affects lower lip and jaw speed capacities during the early stages of the disease.     

Phonetic and otological results after early palate closure in 18 consecutive children presenting with cleft lip and palate

OBJECTIVE: First, to analyze the speech and hearing results at 3.5 years of age when early palate closure has been performed. Second to assess at 7 years of age the need for speech therapy and/or additional surgery in the form of cranial-based pharyngeal flap for obtaining normal speech. METHODS: Retrospective study in a tertiary teaching hospital concerning 18 consecutive cases presenting cleft lip and palate with no associated abnormalities. Interventions included early palatine closure (velum at 3 months, hard palate and lip at 6 months). Speech therapy was initiated at 3.5 years of age when needed. Cranial-based pharyngeal flap was performed when normal nasal emission was not obtained by speech therapy at 7 years of age. Phonetic and otological assessment were performed in all cases. RESULTS: Good to excellent speech in the majority (95%) of children, with only 3/18 undergoing pharyngoplasty to obtain type I or I/II speech by the age of 7 (range: 6.5-8.0). 6/18 children had drain insertion, and 2/18 had hearing loss of 20-40 dB in all frequencies. CONCLUSION: Most children (95%) start school with good or excellent speech. However, the high incidence of middle ear problems shows that more effective screening and treatment are warranted.     

Post-irradiation sarcoma of the lower lip

This report records the occurrence of an irradiation induced fibrosarcoma of the lower lip which appears to be the first case documented in this site. The problems associated with the histopathological diagnosis of such lesions are discussed and the value of electronmicroscopical examination of spindle cell sarcomas stressed.     

Intraoral nasolabial flap for lower lip augmentation following post-radiation contracture

The nasolabial flap (NLF) has been reported extensively for reconstruction of various intraoral and extraoral defects resulting from trauma or ablative surgery. However, it has not been described for post-radiation lip augmentation. Herein, we present the case of a 74-year-old female who previously underwent a subtotal glossectomy and free flap reconstruction followed by radiotherapy. While oncologically the patient did well, she developed a significant lower lip contracture which compromised oral intake, denture placement, lip excursion, and psychosocial well-being. The patient underwent release of the scar contracture and a NLF was utilized intraorally to act as a spacer between the gingiva and inner lip mucosa to augment the soft tissue deficit. The patient went on to regain oral intake and placement of her dentures, while reporting significant satisfaction with the post-procedural benefits.     

Comparison of upper and lower lip muscle activity between stutterers and fluent speakers

OBJECTIVE: There is a widespread clinical view that stuttering is associated with high levels of muscles activity. The proposal of this research was to compare stutterers and fluent speakers with respect to the electromyographic activity of the upper and lower lip muscles. METHODS: Ten individuals who stutter and 10 fluent speakers (control group) paired by gender and age were studied (mean age: 13.4 years). Groups were defined by the speech sample analysis of the ABFW-Language Test. A K6-I EMG (Myo-tronics Co., Seattle, WA, USA) with double disposable silver electrodes (Duotrodes, Myo-tronics Co., Seattle, WA) being used in order to analyze lip muscle activity. The clinical conditions investigated were movements during speech, orofacial non-speech tasks, and rest. Electromyographic data were normalized by lip pursing activity. The non-parametric Mann-Whitney test was used for the comparison of speech fluency profile, and the Student t-test for independent samples for group comparison regarding electromyographic data. RESULTS: There was a statistically significant difference between groups regarding speech fluency profile and upper lip activity in the following conditions: lip lateralization to the right and to the left and rest before exercises (P<0.05). There was no significant difference between groups regarding lower lip activity (P>0.05). CONCLUSION: The EMG activity of the upper lip muscle in the group with stuttering was significantly lower than in the control group in some of the clinical conditions analyzed. There was no significant difference between groups regarding the lower lip muscle. The subjects who stutter did not present higher levels of muscle activity in lip muscles than fluent speakers.     

Fascial sling suspension of the chin following resection of the anterior mandible

One of the most vexing problems in oncologic surgery of the head and neck is the morbidity imposed by resection of the anterior portion of the mandible. Reconstruction of this area most commonly involves the use of autogenous bone grafts. This technique is not universally applicable and is sometimes met with failure. This is especially true where the patient has received prior radiation therapy and where resection of bone and soft tissue has been extensive. The authors have found that a continuous sling of fascia lata suspended from the zygomatic arches and threaded subcutaneously through the lower lip provides adequate support for the chin in cases where osseous reconstruction is not feasible. This technique has been used successfully in three patients.     

Surgical rehabilitation following anterior resection for oral cavity carcinoma

Resection of large tumors located in the anterior aspect of the oral cavity is commonly complicated by problems of functional disturbance and esthetic aberration. Oral incompetence with defects in swallowing and inadvertant drooling are often major hurdles to overcome. The cosmetic deformity produced by the loss of support of the anterior floor of mouth and tongue due to the resected mandibular arch provides one of the most challenging reconstructive exercises facing the head and neck surgeon. Surgical rehabilitation is most adequately achieved by a consideration of each physiological defect produced by the surgical alteration of each anatomical entity in the lower third of the face. Reestablishment of mandibular arch continuity is the keystone of the reconstructive effort; however, procedures that improve lip support, lingual mobility, and alveolar ridge enhancement are vital features in the rehabilitation of a functioning esthetically acceptable oral and perioral region.