Facial Artery Perforator Flap for Perioral and Perinasal Oncologic Defect Reconstruction: Surgical Technique and Postoperative Outcomes.

INTRODUCTION: Facial artery perforator (FAP) flap is a versatile and reliable one-step facial reconstruction technique. However, its full potential remains underutilized due to a lack of clear guidelines and rigorous technique requirements. This study report the use of FAP flaps in our centre for the management of perioral and nasal oncologic defects, focusing on surgical technique performed and post-operative management. METHODS: We conducted a retrospective review of all patients who underwent reconstruction with a perioral or perinasal FAP flap only following tumor resection over a 4-year period (n = 29). Parameters measured included flap survival, complication rates, surgical technique performed, and the need for touch-up procedures. Patients were grouped based on age, defect size, and location and outcomes were compared across these groups. RESULTS: The mean histological tumor defect area was 331 mm2. During at least 6 months of follow-up, no local recurrence was observed. Twenty-seven (93.1%) flaps survived completely. Major postsurgical complications occurred in seven (23.8%) patients, including complete flap necrosis (1), partial flap necrosis (1), flap collapse (1), venous congestion (1), wound dehiscence (1), and local infection (2). A higher complication rate was associated with nose tip defects (80.0% vs. 12.5%, p = 0.007). Touch-up procedures were more frequently required for reconstructions involving the nasal sidewall and dorsum (53.8% vs. 13.3%, p = 0.04). CONCLUSION: Based on our experience, the FAP flap is highly effective for the reconstruction of the upper lip, nasolabial fold, and certain oncologic nasal defects. However, specific defect locations, such as the nose tip, may be associated with higher complication rates, necessitating careful patient selection and surgical planning.

Fabrication of Apparatus Specialized for Measuring the Elasticity of Perioral Tissues.

On the human face, the lips are one of the most important anatomical elements, both morphologically and functionally. Morphologically, they have a significant impact on aesthetics, and abnormal lip morphology causes sociopsychological problems. Functionally, they play a crucial role in breathing, articulation, feeding, and swallowing. An apparatus that can accurately and easily measure the elastic modulus of perioral tissues in clinical tests was developed, and its measurement sensitivity was evaluated. The apparatus is basically a uniaxial compression apparatus consisting of a force sensor and a displacement sensor. The displacement sensor works by enhancing the restoring force due to the deformation of soft materials. Using the apparatus, the force and the displacement were measured for polyurethane elastomers with various levels of softness, which are a model material of human tissues. The stress measured by the developed apparatus increased in proportion to Young's modulus, and was measured by the compression apparatus at the whole region of Young's modulus, indicating that the relation can be used for calibration. Clinical tests using the developed apparatus revealed that Young's moduli for upper lip, left cheek, and right cheek were evaluated to be 45, 4.0, and 9.9 kPa, respectively. In this paper, the advantages of this apparatus and the interpretation of the data obtained are discussed from the perspective of orthodontics.

Aesthetic management of lips and perioral region with Hylacross® and Vycross® hyaluronic-acid based fillers: A document of recommendations.

BACKGROUND: Lip volumization and perioral rejuvenation with hyaluronic-acid (HA) based dermal fillers are generating increasing interest and demand. However, this topic is still having many unmet needs nowadays. This document aimed to provide tips and recommendations that may help clinicians to achieve optimal and more predictable aesthetic outcomes. METHODS: A multidisciplinary group of aesthetic medicine doctors from Spain and Portugal reviewed the tools used for assessing the patient and aesthetic outcomes, as well as the different techniques and products used in lips/perioral rejuvenation. RESULTS: The consensus panel provided specific recommendations focusing on the basic information to collect before performing the aesthetic procedure; comprehensive approach to lips/perioral region rejuvenation; clinical and aesthetic assessment tools; product and technique selection; patient profile and needs; and safety issues (complications/adverse-events). CONCLUSIONS: The rapid evolution of techniques and tools for assessing the patient and aesthetic outcomes, as well as the development of new HA-based fillers makes it necessary to update the clinical recommendations that guide the daily practice of clinicians, particularly those who have less experience with these procedures. This document addressed relevant subjects related to lip/perioral-region rejuvenation to perform the correct procedure, with the appropriate HA-based, on the right patient; to help specialists to obtain optimal and predictable aesthetic outcomes.

Perioral Filler Augmentation.

Perioral tissues are among the first areas to show signs of facial aging, leading many patients to seek perioral fillers as their initial cosmetic treatment. These fillers offer a temporary solution by enhancing volume and reducing common facial lines. Various regions within the perioral area can be targeted, including the lips, nasolabial folds, philtral columns, vertical lip rhytids, oral commissures, melomental folds, mentolabial folds, and nasolabial folds. The technique for injecting perioral fillers depends on the specific region, chosen product, and the desired outcome of augmentation.

A Comparative Electromyographic Analysis of Masticatory Muscles Between Skeletal Class II and Skeletal Class I Malocclusion: A Cross-Sectional Study on a Syrian Population.

OBJECTIVES: This study aimed to investigate whether there was a difference in the muscular activity of the masticatory muscles between patients with skeletal Class II and skeletal Class I malocclusion. MATERIALS AND METHODS: A cross-sectional study was conducted using a sample of 56 selected patients referred to the Department of Orthodontics and Dentofacial Orthodontics, Faculty of Dentistry at the University of Damascus, Damascus, Syria. An electromyographic device measured the myoelectric activity of the perioral muscles on patients in the two created groups: the skeletal Class I malocclusion group (n=28 patients) and the skeletal Class II malocclusion group (n=28 patients). RESULTS: The study found a similarity in the muscular activity between the right and left sides within the same group, without significant differences between both sides for each muscle (P>0.05). The Class II group had significantly greater activity in the buccinator and digastric muscles than the Class I group (p<0.05). On the other hand, the Class I group had significantly greater activity in the orbicularis and mentalis muscles than the Class II group (P<0.05). CONCLUSION: Patients with skeletal Class II malocclusion and skeletal Class I showed differences in muscular activity. The buccinator and digastric muscles were more active in skeletal Class II patients, while orbicularis oris and mentalis were less active. The temporalis and masseter muscles showed similar activity in both groups.

Masseter and digastric muscle activity evaluation using a novel electromyogram that utilizes elastic sheet electrodes.

PURPOSE: To evaluate the reproducibility and reliability of a novel electromyogram (EMG) device with a flexible sheet sensor for measuring muscle activity related to mastication and swallowing. METHODS: We developed a new EMG device made of elastic sheet electrodes to measure the masseter and digastric muscle activities for evaluating mastication and swallowing. To examine the measurement reproducibility of the new EMG device, masseter muscle activity was analyzed using the intraclass correlation coefficient (ICC). Further, we measured the maximum amplitude, duration, integrated value, and signal-to-noise ratio (SNR) using the new EMG device and conventional EMG devices and evaluated the reliability using ICC and Bland-Altman analysis. RESULTS: We confirmed high ICC (1,1) and ICC (2,1) scores (0.92 and 0.88, respectively) while measuring the reproducibility of the new EMG device. When compared to the active electrode EMG device, we found a high correlation for the maximum amplitude (0.90), duration (0.99), integrated values (0.90), and SNR (0.75), with no observation of significant fixed errors. Moreover, the regression coefficient was not significant for any of the evaluation items and no proportional error was observed. Compared with the passive electrode EMG device, the maximum amplitude and duration were highly correlated (0.73 and 0.89). In addition, the SNR exhibited a significant fixed error. In contrast, the regression coefficient was not significant for any of the evaluation items and no proportional error was observed. CONCLUSIONS: Our results suggest that the new EMG device can be used to reliably and reproducibly evaluate muscle activity during mastication and swallowing.

Management of Post-Electric Burn Microstomia by Free Radial Artery Forearm Flap in a 1-Year-Old Child.

Management of post-electric burn microstomia is a challenging task, especially in children, as it causes difficulty in feeding and airway problems (secondary to nasal airway blockage). The recreated defect is often full thickness and requires full-thickness tissue for reconstruction. The free flap can provide adequate normal tissue for the restoration of functions and aesthesis of the perioral region. However, performing free flaps in children is equally demanding due to small-diameter vessel anastomosis and postoperative monitoring. We present a case of postburn microstomia that was managed by contracture release and reconstruction by free radial artery forearm flap in a 1-year-old child. Postoperatively, at 6 months of follow-up, the flap settled well and the child was able to open his mouth fully with good aesthetic outcome. The free flap can be considered a good and safe option for perioral contracture release and reconstruction for better functional and aesthetic outcomes.

Atypical extrapyramidal manifestation of a typical antipsychotic with serotonergic antidepressant.

INTRODUCTION: Typical antipsychotics are known to produce extrapyramidal side effects such as drug induced parkinsonism, acute dystonia, akathisia, tardive dyskinesias and rabbit syndrome. Rabbit syndrome is characterized by vertical rhythmic motion of the mouth and lips, resembling chewing movements of a rabbit. REASON FOR THE REPORT: Rabbit syndrome seen in patients on antidopaminergic therapies is characterized by vertical rhythmic movements of perioral region, has a late onset, and characteristically spares the tongue. The main aim of the report is to highlight atypical manifestation of antipsychotic associated Rabbit syndrome in the presence of a serotonergic antidepressant. An elderly patient presented with atypical rabbit syndrome with relatively acute onset, horizontal movements of jaw and marked tongue involvement after haloperidol-escitalopram initiation. OUTCOME: The patient improved with discontinuation of antipsychotic. The tongue involvement was believed to be secondary to escitalopram use.

Topical and Intralesional Immunotherapy for the Management of Skin Cancer in Special Locations: Lips and Eyelids.

The use of topical and intralesional immunotherapy in the treatment of cutaneous malignant neoplasia in sensitive areas such as the lips and eyelids is discussed. Surgery may not be feasible or may result in deformities in these areas, making alternative treatment options necessary. A narrative literature review was conducted using MEDLINE (PubMed) as the main literature database, collecting available evidence of experiences with various topical and intralesional therapies in the aforementioned anatomical locations, ranging from case reports to clinical trials. The clearance rates and potential adverse reactions of therapeutic options such as imiquimod 5%, 5-fluorouracil (5-FU), photodynamic therapy (PDT), ingenol mebutate (IM), diclofenac, intralesional methotrexate, and interferon are reviewed. Although limited by their heterogeneity and the scarcity of clinical trials, these studies point towards promising response rates and minimal adverse effects, making these treatments viable options in selected cases.

A Case of Perioral Dermatitis Successfully Treated with Abrocitinib.

Perioral dermatitis (POD) is a chronic inflammatory skin disease that primarily affects females between the ages of 16 and 45. Conventional therapies face the challenge of limited efficacy and a high recurrence rate. In this report, we present the case of a 26-year-old male patient with POD who was successfully treated using the Janus kinase (JAK) inhibitor, abrocitinib. This treatment exhibited both good efficacy and safety. Abrocitinib, as a JAK inhibitor, holds promise as a potential therapy for cases of POD that might be resistant to conventional therapies.

Knowledge and Awareness of Oral and Perioral Piercing and Its Complications Among the Population in Riyadh.

Background and objective Body piercing was a cultural custom associated with religious or ceremonial rites in antiquity. Currently, it has grown in popularity among teenagers and young people as a form of self-expression. Young adults are now frequently seen with body and oral piercings, which can cause several complications. Patients with intraoral piercing often present with poor dental and periodontal health, as well as various complications and side effects. The general public is often poorly informed about the risks they are exposed to after intraoral piercing and the strategies for minimizing them, and even healthcare professionals often have limited knowledge of the risks and complications that may arise after this procedure. To the best of our knowledge, no published data assessing the knowledge of oral and perioral piercing among the population living in Riyadh City, Saudi Arabia are currently available. In light of this, we conducted this study to assess the level of awareness and knowledge of oral piercing and its complications among the population living in Riyadh city and evaluate the correlation of nationality, sex, age, and socioeconomic status (educational level, area of residence, and income) with the level of individual knowledge. Methods This was a cross-sectional observational study with a sample size of 1,099. A confidence interval (CI) of 95%, a standard deviation of 0.5, and a margin of error of 5% were employed to determine the sample size. A structured questionnaire was used as the study tool and was distributed in several residential areas in Riyadh, such as North, South, Middle, Eastern, and Western Riyadh City. The data collection was performed using simple random sampling via electronic questionnaires distributed to participants living in Riyadh. Results A total of 1,054 individuals completed the survey. Of these, 95.6% were Saudi nationals. Approximately 85.5% of the participants (n = 901) were women, 52.4% were aged 20-29 years (n = 552), and most participants (62.9%, n = 663) had a low monthly income (<5,000 Saudi Riyals); in terms of residence, the highest number of participants were from the northern region of Riyadh (37.1%, n = 391). Most participants had heard of or seen an oral or perioral piercing (89.1%, n = 939). However, very few of them had received an oral piercing themselves (10.7%, n = 113) or had a family member with an oral piercing (18.7%, n = 197). Participants reported that the most commonly observed site for oral piercing was the lip (29.8%, n = 314), and teenagers were the most common age group with oral piercings (76.3%, n = 804). Regarding the adverse effects, most participants reported being aware of the negative consequences of oral piercing in the mouth (72.2%, n = 761). Sex and age were the only factors that showed a significant association with participants' level of knowledge. Women were significantly more knowledgeable and had higher scores (ß: 0.41; 95% CI: 0.13, 0.69) than men (p<0.05). Additionally, participants aged 20-29 years had significantly higher knowledge scores (ß: 0.39; 95% CI: 0.15, 0.63) than younger participants (p<0.05). Conclusions Based on our findings, participants' knowledge and awareness about oral piercing is adequate in general. However, there should be more efforts to educate the people of Riyadh about the complications of these piercings as well as raise awareness about proper oral hygiene methods.

Long-Term Efficacy and Tolerability of a Medium G' HA Filler with Tri-Hyal Technology on the Rejuvenation of the Mobile Facial Zone.

Purpose: Injectable hyaluronic acid-based fillers are commonly used for the correction of skin contour irregularities and to smooth skin depressions formed by volume loss during the aging process. These fillers are particularly efficient to restore perioral skin depressions/wrinkles or to correct topographical anomalies. The European directives require a continuous evaluation of the performance of these medical devices, particularly for CE marked products. Methods: An 18-month prospective randomized single-blind study for the efficacy and safety of ART FILLER Universal (AFU) was performed on the lips, the nasolabial folds, and the marionettes lines. The evaluations were performed on 153 subjects enrolled in this study. The efficacy, the longevity, and the safety were evaluated for the injected areas via area specific clinical scoring after a single injection with the filler and with no re-touch. Results: We showed here that filler injection induced potent improvements of volume restoration after a single injection on all the treated areas. These beneficial properties of the filler were significant 3 weeks after injection and during the whole study period. Moreover, injections of the filler were well tolerated by the subjects. The recorded adverse events are routinely seen with HA fillers for face volume corrections, and most of these local reactions resolved within 14 days. Conclusion: AFU was well tolerated and showed a continuous efficacy for at least 18 months, in exploratory analyses.

Atypical Presentation of Lip Nodules in Clinically Diagnosed Juvenile Hyaline Fibromatosis.

Juvenile hyaline fibromatosis (JHF) is a rare, hereditary disease characterized by abnormal hyaline deposits within the skin, soft tissues, joints, and bones. The condition itself is often debilitating, with no curative treatment available. A definitive diagnosis is established by genetic testing. However, the hallmarks of gingival hypertrophy, subcutaneous scalp nodules, and joint contractures can be used as a clinical guide when genetic testing is unavailable. Here, we report an unusual case of a five-year-old child clinically diagnosed with juvenile hyaline fibromatosis with atypical nodules exclusively confined to the perioral region.

Development and Validation of a Comprehensive Perioral Evaluation Method Using Three-Dimensional Stereophotogrammetry.

BACKGROUND: The non-invasive three-dimensional (3D) stereophotogrammetry is widely used in anthropometry for medical purpose. Yet, few studies have assessed its reliability on measuring the perioral region. OBJECTIVES: This study aimed to provide a standardized 3D anthropometric protocol for the perioral region. METHODS: 38 female and 12 male Asians were recruited (mean age 31.6 ± 9.6 years). Two sets of 3D images using the VECTRA 3D imaging system were acquired for each subject, and two measurement sessions for each image were performed independently by two raters. 25 landmarks were identified, and 28 linear, 2 curvilinear, 9 angular and 4 areal measurements were evaluated for intrarater, interrater, and intramethod reliability. RESULTS: Our results showed high reliability of 3D imaging-based perioral anthropometry by mean absolute difference (0.57 and 0.57 unit), technical error measurement (0.51 and 0.55 unit), relative error of measurement (2.18% and 2.44%), relative technical error of measurement (2.02% and 2.34%), and intraclass correlation coefficient (0.98 and 0.98) for intrarater 1 and intrarater 2 reliability; respectively 0.78 unit, 0.74 unit, 3.26%, 3.06% and 0.97 for interrater reliability; and respectively 1.01 unit, 0.97 unit, 4.74%, 4.57% and 0.95 for intramethod reliability. CONCLUSIONS: This standardized protocol utilizing 3D surface imaging technologies are feasible and highly reliable in perioral assessment. It could be further applied for diagnostic purpose, surgical planning and therapeutic effect evaluation in clinical practice in relation to perioral morphologies. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A technical approach for redefinition and volumization of lip area with hyaluronic acid: A case series.

BACKGROUND AND AIM: Non-surgical procedures using injectable filler products for perioral rejuvenation have emerged and evolved rapidly to become one of the most frequently performed aesthetic treatments. We report a case series describing the administration of two hyaluronic acid-based dermal fillers (HA filler) with excellent characteristics and formulation using a technique developed by the author. PATIENT/METHODS: We describe a series of nine female subjects who underwent perioral rejuvenation performed by a single physician in her private clinic. The HA filler (Alaxin® FL or Alaxin® LV) was injected into the lips using the specially developed Clodia technique. Patients were given post-treatment advice for optimal results. Patient- and investigator-perceived outcomes were rated using the Global Aesthetic Improvement Scale (GAIS) and adverse events (AEs) were collected. RESULTS: All subjects described the injection method as painless and well tolerated, as shown by the immediate post-treatment photographs. Mean GAIS scores for both the patients and the investigator were 4.8/5, indicating significant improvement 12 months after the treatment. No AEs were reported during follow-up. The HA filler showed a high degree of dermal integration in all subjects, and the investigator reported excellent handling and injection properties. CONCLUSION: Perioral rejuvenation with an HA filler administered using the developed injection technique gave highly satisfactory results in all subjects and was not associated with AEs.

Complications of fillers in the lips and perioral area: Prevention, assessment, and management focusing on ultrasound guidance.

An ever-increasing interest in perioral rejuvenation with dermal fillers reflects the esthetic importance of this region. However, filler injections in the lips and perioral area have been associated with various complications. Such complications are classified according to severity (mild, moderate, severe) or by the time of onset: immediate (within 24 h after injection), early (24 h to 4 weeks post-procedure), and late or delayed (>4 weeks after injection). While most complications are mild and manageable, vascular compromise, infections, and the development of delayed-onset nodules may significantly undermine the ultimate esthetic outcome and cause substantial morbidity. These more serious complications often require more invasive treatment modalities. This article details the prevention and management of such adverse events and discusses safe filler injection principles, including safety recommendations for the lips. Lastly, we highlight the use of ultrasound guidance in complication prevention (vascular mapping, filler identification, location, and extent), assessment (identification of intravascular embolus or external vascular compression by the filler implant), and management (real-time imaging of hyaluronidase or other drug injection in the affected area). Esthetic practitioners should be versed in injection anatomy, and the prevention, recognition, and management of filler complications in the perioral area.