Keywords
Lip - Surgical flaps - Reconstructive surgical procedure
INTRODUCTION
The philtrum, which derives from the Greek word philtron meaning "love potion," is
the most characteristic feature of the upper lip, helping to create a natural appearance
of the lip [[1]]. During lip motion, the philtral column and dimple are highlighted, helping a viewer
form an impression of the speaker [[2]]. Morphological philtral disorders occur in patients with cleft lip, secondary cleft
lip-nose deformity, and deformity after tumor resection or traumatic injury. A smooth
philtrum is also a characteristic feature of fetal alcohol syndrome [[3]]. Herein, we report a simple and effective method for creating a philtrum by flipping
myoplasty of the orbicularis oris muscle for a patient with a flat philtrum of unknown
etiology.
CASE
A 35-year-old female patient presented to our department with the complaint of a flat
upper lip. The patient had an ambiguous philtral column and philtral dimple, creating
the appearance of an overall flat upper lip ([Fig. 1]). A faint scar was also observed 20 mm along the white roll of the central upper
lip.
Fig. 1 Preoperative view
(A) Preoperative front view. Central angle of the Cupid's bow was 146°. (B) Preoperative
oblique view in which the flatness of the upper lip can be observed. cphR, crista
philtri right; cphL, crista philtri left; ls, labiale superius.
The patient was born normally at term, denied any history of trauma, and did not disclose
any maternal alcohol use. In an attempt to correct the flat philtrum, triamcinolone
had been injected in the midline of her upper lip three separate times 10 years earlier.
Furthermore, the patient also underwent an operation 5 years earlier to achieve a
definite philtrum. However, we were not able to determine the exact surgical procedure
used based on observation.
Based on a previously published anthropometric analysis of the mouths of Koreans,
a philtral reconstruction was designed so that the postoperative philtral width would
be 12 mm at the peaks of the Cupid's bow and 10 mm at the columellar base [[4]]. Under local anesthesia, a 26 gauge needle dipped in gentian violet was used to
puncture the area along the designated line, thus marking the orbicularis oris muscle
at the area where a philtral column would be created. A linear incision was made.
The subcutaneous dissection was done to the columellar base, so that this skin flap
could be elevated. After dissection, a vertical incision was made on a superficial
layer of the orbicularis oris muscle of the central upper lip, and an orbicularis
oris muscle flap about 2 mm thick was elevated to the area marked with gentian violet.
Both sides of the elevated muscle flap were then folded to the lateral side. The incisional
margin of the muscle flap was sutured using a horizontal mattress stitch onto the
lateral portion of the orbicularis oris using an absorbable suture. In the area of
the folded orbicularis oris muscle, the upper lip was allowed to thicken, forming
a philtral column. A dermal quilting suture was also used in the area of the central
upper lip where the muscular flap was elevated to make the philtral dimple more definite
([Figs. 2]
[3]). The skin was then sutured using a non-absorbable suture. We tied an external central
bolster to the new philtrum with a through-and-through nylon suture to provide additional
external pressure and to accentuate the new philtrum formation. Five days later, these
materials were removed from the surgical site. The patient was observed for one year
postoperatively. Her philtrum deepened by 1.25 mm, with the central angle of her Cupid’s
bow improving from a preoperative measurement of 146º to 128º postoperatively. Thus,
philtral reconstruction, which enabled the patient to naturally move her upper lip,
was achieved to her satisfaction ([Fig. 4]).
Fig. 2 Schematic illustration of the surgical technique
(A) Vertical incision of the orbicularis oris muscle flaps was performed. Dissection
of the muscle flap was performed at the gentian violet markings. (B) Flipping of the
bilateral muscle flaps was performed on the lateral sides. A quilting suture was placed
on the skin flap of the upper central lip at the site where the muscular flap was
elevated, creating a distinctive philtral dimple depression.
Fig. 3 Surgical technique
(A) The muscle flaps were completely exposed and split into two leaves. (B) Each muscle
flap was flipped over and sutured to the lateral side.
Fig. 4 View 1 year postoperatively
(A) Postoperative front view. Central angle of the Cupid's bow was 128°. (B) Postoperative
oblique view. Elevation of the philtral column and depression of the philtral dimple
were achieved by flipping myoplasty. cphR, crista philtri right; cphL, crista philtri
left; ls, labiale superius.
DISCUSSION
Physiologically, the upper lip protrudes slightly beyond the lower lip, with the philtral
dimple, philtral column, and Cupid's bow defining part of the particular appearance
of each individual. Although the functional significance of the philtrum is not obvious,
it remains an important aspect of subjective beauty, contributing to a symmetric and
natural-looking upper lip.
Morphological philtral defects are associated with many diseases, including holoprosencephaly
and fetal alcohol syndrome [[3]]. However, indistinct philtrum also occurs idiopathically. In a study analyzing
the philtral shapes of 55 Japanese adults without craniofacial disorders using the
Uemura method, Kishi et al. [[5]] reported that 6 out of 30 females had an indistinct philtrum and that the philtral
depth and the angle of the central Cupid's bow are objective parameters for determining
the visual clarity of the philtrum. In that study, the average angle of the central
Cupid's bow was 130.45° among 25 males and 136.24° among 30 females, while the philtral
depths were 1.23 mm and 0.88 mm, respectively. Another anthropometric analysis of
the mouth in the Korean population by Kim et al. [[4]] reported that the average phitral width was 11.8 mm for males and 10.2 mm for females.
Based on these studies, we planned phitral reconstruction to correspond to anthropometric
analysis of the East Asian mouth.
A variety of methods have been proposed for philtral reconstruction, including cutaneous
upsweep, auricular cartilaginous composite grafts, and overlap and vertical interdigitation
of the orbicularis oris [[6]
[7]
[8]]. Though many cases of philtral reconstruction have been reported in patients with
cleft lip or other secondary cleft lip-nose deformities, philtral reconstruction in
an individual with an indistinct philtrum has never been described.
The reconstruction method described here using flipping myoplasty of the orbicularis
oris muscle dissects only the superficial layer of the orbicularis oris muscle. It
allows muscular continuity and does not create any obstacle in upper lip movement.
It also allows the depression of the central tubercle and the elevation of both Cupid's
bow points, and as a result, the central Cupid's angle is improved. Compared to existing
surgical methods, our method has many advantages. By avoiding the use of implants,
allografts, or cartilage from other areas, the method described here is able to create
a natural upper lip and reduce associated costs without graft absorption or donor
site morbidity. As the white roll of the upper lip is incised, no linear vertical
scars are created. Moreover, there is no mucosal dissection, reducing the loss of
the reconstructed philtral column into the oral cavity.
We used an approach through the scar on the white roll which was left from the previous
operation. However, generally, the vermilion border, the distinct convex white roll,
and the precise relation between these two structures are absolutely critical in lip
repair. Therefore, in patients without a history of previous surgery, an approach
between the wet and dry vermilion is recommended for the conservation of the integrity
of the white roll and minimization of the scar.
A natural and definite philtrum was constructed in a patient with an indistinct philtrum
through a flipping orbicularis oris myoplasty, and is an easy and effective method
for reconstruction of the philtrum through anatomical rearrangement of the orbicularis
oris muscle. Furthermore, as natural upper lip movement was maintained, an aesthetically
and functionally satisfactory reconstruction was achieved.
