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Objective We have used micro-computed tomography (CT) to elucidate the relationship between the muscle fibers in specimens with cleft palate. These findings could be useful for muscle reconstruction in cleft palate repair and to better understand cleft palate speech.Design Cadaveric anatomical study.Participants This study included three specimens with cleft palateIntervention The specimens were stained with phosphomolybdic acid and scanned by Micro-CT.Main Outcome Measure(s) The anatomy of the muscles.Results Using 2D projection images and 3D reconstruction models, subtle anatomical structures could be observed in the muscles. The attachment of the levator veli palatini (LVP) was not at the posterior edge of the hard palate or palatine aponeurosis (PA), but at the anterior 21.71-44.2% of the cleft edge. The palatopharyngeal (PP) was composed of two bundles: inferior and superior heads, which clasped the LVP. The uvularis was unevenly distributed, and located on both sides of the cleft edge, originating at the edge. The palatoglossus, superior constrictor of pharynx and anatomical structure around the pterygoid hamulus, were normal. The PA, PP and LVP were attached to the cleft edge from front to back, in that order. The position of the uvularis was not fixed.Conclusions With the help of Micro-CT technology, detailed anatomical features and the relationship between muscles could be visualized. In the specimen with cleft palate, muscles in the soft palate were associated with the pharyngeal muscles, which formed the 3D “velopharyngeal muscles complex.” These findings provide anatomical evidence for muscle reconstruction in cleft palate repair.

Deep learning algorithms based on automatic 3D cephalometric marking points about people without craniomaxillofacial deformities have achieved good results. However, there has been no previous report about hemifacial microsomia (HFM). The purpose of this study is to apply a new deep learning method based on a 3D point cloud graph convolutional neural network to predict and locate landmarks in patients with HFM based on the relationships between points. The authors used a PointNet++ model to investigate the automatic 3D cephalometry. And the mean distance error (MDE) of the center coordinate position and the success detection rate (SDR) were used to evaluate the accuracy of systematic labeling. A total of 135 patients were enrolled. The MDE for all 32 landmarks was 1.46 ± 1.308 mm, and 10 landmarks showed SDRs at 2 mm over 90%, and only 4 landmarks showed SDRs at 2 mm under 60%. Compared with the manual reproducibility, the standard distance deviation and coefficient of variation values for the MDE of the artificial intelligence system was 0.67 and 0.43, respectively. In summary, our training sets were derived from HFM computed tomography to achieve accurate results. The 3D cephalometry system based on the graph convolutional network algorithm may be suitable for the 3D cephalometry system in HFM cases. More accurate results may be obtained if the HFM training set is expanded in the future.

Deep learning algorithms based on automatic 3-dimensional (D) cephalometric marking points about people without craniomaxillofacial deformities has achieved good results. However, there has been no previous report about cleft lip and palate. The purpose of this study is to apply a new deep learning method based on a 3D point cloud graph convolutional neural network to predict and locate landmarks in patients with cleft lip and palate based on the relationships between points. The authors used the PointNet++ model to investigate the automatic 3D cephalometric marking points. And the mean distance error of the center coordinate position and the success detection rate (SDR) were used to evaluate the accuracy of systematic labeling. A total of 150 patients were enrolled. The mean distance error for all 27 landmarks was 1.33 mm, and 9 landmarks (30%) showed SDRs at 2 mm over 90%, and 3 landmarks (35%) showed SDRs at 2 mm under 70%. The automatic 3D cephalometric marking points take 16 seconds per dataset. In summary, our training sets were derived from the cleft lip with/without palate computed tomography to achieve accurate results. The 3D cephalometry system based on the graph convolutional neural network algorithm may be suitable for 3D cephalometry system in cleft lip and palate cases. More accurate results may be obtained if the cleft lip and palate training set is expanded in the future.

The authors retrospectively analyzed the effects of Le Fort I advancement with distraction osteogenesis on skeletal and airway variables in patients with midfacial hypoplasia induced by cleft lip and/or palate using 3-dimensional computed tomography reconstructions.The authors enrolled 23 subjects with moderate-to-severe midface hypoplasia induced by cleft lip and palate who were treated with Le Fort I distraction osteogenesis (mean age, 19.22±3.48 y; male/female ratio, 20/3); computed tomography images (1 before distraction and another at completion of distraction) were acquired. A 3-dimensional craniometric findings and airway volumes for the nasal cavity, nasopharynx, velopharynx, and upper and lower oropharynx were compared before and after distraction. The relationships between craniofacial morphology and changes in airway volume were also assessed (P<0.05 was considered significant).Significant increases were observed in airway volumes for the nasal cavity (13.85%), nasopharynx (50.82%), velopharynx (29.57%), and upper oropharynx (36.92%) (P=0.007, P<0.001, P=0.023, and P<0.001, respectively), whereas no significant changes were observed for the lower oropharynx (P=0.117). Maxillary horizontal advancement was positively correlated with the airway volumes of the nasopharynx and upper oropharynx after distraction osteogenesis (rs=+0.451, P=0.031; rs=+0.548, P=0.007); however, no significant correlations were observed for the nasal cavity and velopharynx.The authors’ finding indicate that despite rotation of the mandible along with the maxilla, this change does not impact airway volume at the mandibular level. Le Fort I distraction osteogenesis can be feasible for patients with cleft lip and palate-induced midface hypoplasia, with satisfactory appearance and occlusion. Long-term detailed follow-up of the patients postdistraction osteogenesis is warranted.

Objective There have been few studies on the anatomy of palatine aponeurosis (PA). Herein, we elucidated the relationship between the PA and soft palate muscles and pharyngeal muscles.Design Two cadaveric specimens were dissected to observe the gross anatomy of the PA. Six cadaveric specimens were processed and scanned by micro-computed tomography to determine the elaborate anatomy. Images were exported to Mimics software to reconstruct a three-dimensional model.Results The PA covered the anterior (32.1%-38.8%) of the soft palate, extending from the tensor veli palatini (TVP) and connecting to 3 muscles: palatopharyngeus (PP), uvula muscle, and superior pharyngeal constrictor (SC). The SC and PP are attached to the PA on the medial side of the pterygoid hamulus. SC muscle fibers were attached to the hamulus, forming a distinct gap between the hamulus. Some muscle fibers of the PP and uvula originated from the PA. The PA extended from the TVP to the midline and the posterior edge of the hard palate. The PA was not uniformly distributed, which was complementary to the attached muscles in thickness.Conclusions PA, as a flexible fibrous membrane, maintains the shape of the soft palate. It extends from the TVP and covers anteriorly about one-third of the soft palate. The PA provides a platform for the soft palate muscles and pharyngeal muscles, connecting to the PP, uvula muscle, and SC. These muscles are important for palatopharyngeal closure and middle-ear function. It is necessary to minimize the damage to the PA during surgical interventions.

Objective Palatoplasty would involve the structures around the pterygoid hamulus. However, clinicians hold different opinions on the optimal approach for the muscles and palatine aponeurosis around the pterygoid hamulus. The absence of a consensus regarding this point can be attributed to the lack of investigations on the exact anatomy of this region. Therefore, we used micro-computed tomography to examine the anatomical structure of the region surrounding the pterygoid hamulus.Design Cadaveric specimens were stained with iodine–potassium iodide and scanned by micro-computed tomography to study the structures of the tissues, particularly the muscle fibers. We imported Digital Imaging and Communications in Medicine images to Mimics to reconstruct a 3-dimensional model and simplified the model.Results Three muscles were present around the pterygoid hamulus, namely the palatopharyngeus (PP), superior constrictor (SC), and tensor veli palatini (TVP). The hamulus connects these muscles as a key pivot. The TVP extended to the palatine aponeurosis, which bypassed the pterygoid hamulus, and linked the PP and SC. Some muscle fibers of the SC originated from the hamulus, the aponeurosis of which was wrapped around the hamulus. There was a distinct gap between the pterygoid hamulus and the palatine aponeurosis. This formed a pulley-like structure around the pterygoid hamulus.Conclusions Transection or fracture of the palatine aponeurosis or pterygoid hamulus, respectively, may have detrimental effects on the muscles around the pterygoid hamulus, which play essential roles in the velopharyngeal function and middle ear ventilation. Currently, cleft palate repair has limited treatment options with proven successful outcomes.

The TP63 gene is essential for epithelial proliferation, differentiation, and maintenance during embryogenesis. Despite considerable clinical variability, TP63-related symptoms are characterized by ectodermal dysplasia, distal limb malformations, and orofacial clefts. We identified a novel TP63variant (c.619A > G, p.K207E) in a seven-month-old Chinese patient with orofacial clefts and ectrodactyly but no evident signs of ectodermal dysplasia. This phenotype was rarely reported before. We summarized the presence of the three main TP63-related manifestations in the literature and noted different distributions of CP- and CL/P-related variants regarding p63 structural domains.

IMPORTANCE: The blood supply pattern of the partial-thickness musculomucosal pedicle flaps is different from the traditional Abbe flap. The arterial blood supply and venous drainage are highly reliable during clinical practice. OBJECTIVE: To describe the reconstruction of the philtrum in the cross-lip flap transfer using nasolabial muscle tension line group reconstruction. DESIGN, SETTING, AND PARTICIPANTS: From January 1, 2014, through June 31, 2015, a total of 6 patients with upper lip defect were treated with philtrum reconstruction in the same stage of the split cross-lip flap transfer at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. These patients underwent reconstruction of the philtrum by nasolabial muscle tension line group reconstruction. The patients were compared with a randomly chosen group of 5 individuals without upper lip defects by measuring the 3-dimensional scans. INTERVENTIONS: In the patient group, 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° horizontally and inverted 180° upward to the upper lip defect. The philtrum was reconstructed using the nasolabial muscle tension line group reconstruction. MAIN OUTCOMES AND MEASURES: Three-dimensional scans were performed from the 2-month to 28-month revisits. RESULTS: A total of 11 individuals were included in the study: 6 in the patient group (mean [SD] age, 17.0 [4.8] years; 2 [33.3%] female and 4 [66.7%] male) and 5 in the control group (mean [SD] age, 15.2 [6.0] years; 2 [40.0%] female and 3 [60.0%] male). In the patient group, 5 of 6 musculomucosal pedicle flaps were viable. A stable philtrum with philtral ridge and philtral dimple was reconstructed on the 5 flaps. The shape of the philtrum was natural according to the 3-dimensional scan measurement. One flap partially necrosed, and the scar retraction was severe postoperatively. CONCLUSIONS AND RELEVANCE: The blood supply of the partial-thickness cross-lip flap was from the small vascular network of the lower lip. It is reliable to reconstruct a philtrum in this stage of flap transfer. A complete philtrum structure can be reconstructed by applying muscle tension on the flap. LEVEL OF EVIDENCE: 4.

Nonsyndromic cleft lip with or without cleft palate (NSCLP) is a common congenital deformity, often associated with folate deficiency. The genes MTHFR, MTR, MTRR, and TCN2 play key roles in folate metabolism. The risk of NSCLP associated with particular variants in the folic acid pathway differs among ethnic groups. The goal of this study was to explore whether genetic variations in these four genes, as well as gene-gene interactions, are associated with NSCLP. We investigated 7 tagSNPs for MTHFR, 18 tagSNPs for MTR, 15 tagSNPs for MTRR, and 7 tagSNPs for TCN2 selected from HapMap data in a Chinese population. These single nucleotide polymorphisms (SNPs) were examined for associations with NSCLP in 204 patients and 226 controls. We then performed a meta-analysis of association between rs1801133 and NSCLP. There was a significant difference in the allele frequency and haplotype analysis of rs4077829 and rs10802565 in MTR between the NSCLP and control groups but not a significant difference after correction with 10,000 times permutations. The allele frequency, haplotype analysis, and gene-gene interactions of other SNPs did not show a significant difference. The meta-analysis results showed that no significant differences were found for allele comparison, heterozygote comparison, homozygote comparison, dominant model comparison, or recessive model comparison. The alterations of folate metabolism related to these polymorphisms are not involved in NSCLP in the Chinese population.

Supplemental Digital Content is available in the text.

Plastic surgeons have attempted various ways to rebuild the aesthetic subunits of the upper lip in patients with cleft lip with less than perfect results in most cases. We propose that repairing the 3 muscle tension line groups in the nasolabial complex will have improved aesthetic results.

The purposes of this study were to evaluate the effects of transsutural distraction osteogenesis applied to the maxillary complex with a new internalized distraction device and to analyze the long-term osteogenesis outcome.

In microform cleft lip repair, reconstructing the elaborate structures is difficult. We describe a new technique of unilateral microform cleft lip repair that is based on the muscle tension line group theory.

A thorough knowledge of the anatomic structure of the orbicularis oris of the upper lip and the nasalis in fetus with cleft lip is the key for the success of cleft lip repair. To understand the anatomic structure of the muscles of nasolabial region in fetus with cleft lip, the nasolabial tissues in 4 aborted fetuses with cleft lip were soaked for 7 days with iodine solution (Lugol solution of 3.75) and were given micro-computed tomography. After the iodine solution permeated into the soft tissues, a good contrast was showed between muscle fibers and other fibrillar connective tissues. Through the observation of the obtained images, we found that most orbicularis oris fibers gathered into bundles with clear outline and only had slight deformation and displacement on the health side of the cleft of the unilateral incomplete cleft lip; however, in the lateral cleft, the muscle fibers not only had deformation and displacement but also were immature, disorganized, and not gathered into bundles. After being restored in Digital Imaging and Communications in Medicine format, the obtained images were then transferred into Materialise’s interactive medical image control system, edited, and reconstructed into three-dimensional models. The models clearly showed the spatial relationship between the muscular tissues of the nasolabial region and the nasolabial outline in fetus with cleft lip.

This retrospective study describes various buccinator musculomucosal flaps for the repair of palatal fistulae. Twenty-two palatal fistulae were repaired at our institution between 2002 and 2012 by buccinator musculomucosal flaps with superior-anterior or posterior pedicles. Seventeen patients were treated with posteriorly pedicled flaps, 7 of whom had lengthening of the soft palate and 10 of whom had simultaneously repaired severe lateral palatal scarring. Five patients with anterior or midpalatal fistulae were treated with superior-anteriorly pedicled flaps. All but 4 of the 22 patients had satisfactory results. Four patients had recurrent fistulae, 2 resulting from flap tip necrosis and 2 from wound dehiscence. Follow-up was from 5 to 72 months. None of the patients had facial nerve injury, limited mouth opening, or difficulty chewing. We evaluated the factors that could cause complications, such as flap pattern, location of fistula, and size of palate defect. No statistically significant differences were found in the complication rates among different groups. In conclusion, the buccinator musculomucosal flap is reliable and versatile, with rich vascularity and flexible design. The flap is a good option for fistula repair, especially for larger fistulae at the anterior portion of the hard palate or at the junction of hard and soft palate, where surrounding soft tissues are stiff, scarred, and difficult to mobilize.

Autologous fat grafting has been successfully used in lip cosmetic surgery. However, little supportive evidence exists for its use in lip reconstruction following hemangioma treatment.

The Abbe flap has been used for full-thickness defects of the upper lip with the inferior labial artery as the pedicle. Using the fine artery anatomy of the lower lip, the authors developed an innovative partial-thickness myocutaneous flap based on the vascular network of the submucosal and subcutaneous layers, which derived mainly from the horizontal labiomental artery or the vertical labiomental artery. From 2010 to 2011, this new technique was used in 33 patients with upper lip defects. The split flap was elevated from the posterior portion of the oris orbicularis muscle after the inferior labial artery was divided. All 33 cases of musculomucosal pedicle flaps were viable. The flap was perfectly symmetrical after the first-stage operation, and the operative time was reduced significantly.

Seasonality of the incidence of congenital anomalies has provided useful clues in etiological research. However, seasonality of oral-facial clefts is inconsistent in many countries, including native China. The aim of this study was to determine whether births of patients with oral-facial clefts follow a seasonal pattern in a native Chinese population.

The purpose of this study was to observe bony healing in the hard palate after cleft palate repair and to discuss the factors affecting it.