A design for the repair of unilateral cleft lips

A Design

for the Repair Cleft Lips

of Unilateral

TORD SKOOG, M.D., Uppsala, Sweden From tbe Department of Plastic Hospital, Uppsala, Sweden.

Surgery,

University

side. In the literature it is found that closure of single cIeft lips using two flaps has previously been suggested by Trauner [f], who combined a modified Hagedorn-Le Mesurier technic with his original Z-plastic procedure for secondary

1952 Tennison [4] pubIished a modified design for repair of singIe harelips, which provided one triangular flap from each side of

I

N

t 2% 3

b a

\

b a

--X----J-

B

A FIG.

I.

For expIanation of diagrams see text.

the cIeft to restore symmetry and aIso preserved a full Cupid’s bow. Marcks and co-workers, in 1953, reported excehent resuIts using simiIar technics. In 1955 Millard [j] presented a new design for this type of repair. He employed curved incisions corresponding to the caIcuIated phiItrum Iine on the cleft side and added length to this side of the lip by extending the media1 incision underneath the coIumeIIa so that the entire central part of the Iip was brought down to the correct IeveI. I have used these two methods in cases of uniIatera1 cleft lips with varying degrees of deformity, and the operative results with both methods have been very satisfying, particuIarIy in incomplete cIefts. The former method, involved considerabIe sacrifice of however, tissue in complete cIefts, and using the Millard technic I found it diffxcult to avoid retraction of the scar line at the vermiIion border. Based upon this experience a repair was designed which used two flaps for eIongation of the cleft

correction of the nostril of the Iip. PLANNING

floor and upper

AND PROCEDURE

part

OF THE OPERATION*

On the media1 side of the cIeft the Cupid’s bow is identified and two points are marked (Fig. IA), first, the peak of the bow on the cIeft side (a) and, second, a point which is at the level of the base of the coIumeIIa and corresponds to the philtrum border on the normal side (b). An incision is made from (b) to (a). Right angle incisions to the philtrum from the marked points wiI1 eIongate the media1 side of the cIeft as much as required. The lower transverse incision is made first and generaIIy extends halfway into the phiItrum. If a pronounced Cupid’s bow is desired, this incision should be made * This method was first reported at the Twenty-Fifth AnnuaI Meetinn of the American Societv of PIastic and ReconstructiveYSurgery, Miami, FIoriia, October 27, w6.

223

American

Journal

oj Surgery.

Volume

pp. February,

1958

Skoog

E

F

G

FIG. 2. Mustrates the method described herein appIied to a compIete cleft in a chiId three months of age. A, lines of incision. B, incisions made. Note the increase in length obtained on the cIeft side and the preserved central part of the Cupid’s bow. C, the cleft closed by the technic described in the text. ,D, one week postoperativeIy. Note the restored symmetry of aIar bases. E, F and G, diagrams of the operation.

anguIar fIap is drawn to (~2) near the border of the mucous membrane caIcuIated to fiI1 the Iower defect on the media1 side. (Fig. IB.) When more Iength is required on the IateraI side, point (~2) is pIaced Iower. From (az) a line of incision is marked to (Q, the same Iength as from (a) to (b) and toward the inner side of the alar base. At this stage it is better not to outIine fIap (A) on Figure 2F, consisting of tissue near the cIeft on the IateraI side and designed to be rotated into the upper triangu-

longer. The incision beIow the coIumeIIa is then made, and extended far enough so that the centraI part of the Cupid’s bow can easiIy be puIIed down to the normal IeveI. (Figs. IB and zB.) By so doing two trianguIar tissue defects open on the media1 side and ffaps can be designed on the IateraI side of the cIeft to fit into these gaps. On the IateraI side, a point (al) is marked on the mucocutaneous ridge where the Iip stiI1 has the norma thickness. From this point a tri224

Repair

of’ l!niIateraI

CIeft

Lips

FIG. 2. A, a three month old bov with an incompIete cIeft. B, nine months after the operation performed as shown in Figure 2. ing. No bandages or appIiances have been used for reducing tension on the suture line. The skin sutures are removed in three to four days but the catgut sutures can be Ieft. The operations have been performed under general anesthesia with ether using endotracheal intubation. To minimise bIeeding, 5 ml. of 0.5 per cent with norepinephrine is injected xyIocaine@ IocaIIy before the operation. Figures 3A and 3B are photographs of a patient with an incompIete cIeft before and after operation which was performed as shown in Figure 2.

Iar defect on the media1 side. This is because the ffap is more easiIy shaped when the incisions so far described have already been made. It wiIl also be found that the tissue media1 to (a&) wiII retract after being freed. Furthermore, the degree of rotation of this flap is adjusted by excision on one side or the other, depending on the required eIevation of the alar base, and can be determined onIy at this stage of the operation. To achieve a niceIy curved aIar base, the aIar cartiIage need not be separated from the covering skin or lining in this procedure. In patients with considerabIe depression of the aIar base it might be advantageous, however, to perform a Z-plastic procedure on the retracted ridge between the upper and lower nasa1 cartiIages. If the medial crus of the aIar cartiIage is freed from the incision at the base of the columeIIa up to the tip of the nose, the deformity of the nasa1 tip wil1 in some cases be markedIy reduced. AI1 incisions of the lip are made verticaIIy through its entire thickness with a BardParker bIade No. I I. The Iip is we11 mobilised on both sides by undermining from incisions extending into the fornix of the vestibulum oris as recommended by Brown et al. in 1950. Special attention is paid to freeing the depressed alar base. CIosure of the lip is accomplished with one buried suture (catgut No. 3-o) just beIow the floor of the nostril, two mucocutaneous-muscuIar on-end mattress sutures (catgut No. 3-o), fine approximation sutures at the free border of the Iip (catgut No. 5-o) and simple interrupted skin sutures (nyIon monofiIament No. 5-o on an atraumatic@ needIe). The skin sutures have either been Ieft exposed to the air or covered with a smaI1 dress-

COMMENTS I. The procedure described herein preserves the maximum amount of tissue. 2. The cIeft side is eIongated quite easily; thus this design is particuIarIy usefu1 in complete cIefts. 3. A full Cupid’s bow is preserved and tissue is transferred to the media1 side of the cleft in such a way that norma eversion and protrusion of the lip is achieved. 4. The scar Iine is irreguIar with sharp angIes, which wiI1 prevent retraction and secondary deformity. The vertical part of the scar corresponds to the border of the philtrum. The transverse scars will act as Iocks to prevent widening of the Iongitudinal part of the scar Iine and being comparativeIy short will not disturb the appearance of the lip during emotiona1 expression. 5. By rotating the tissue near the cIeft toward the coIumeIIa, the orbicuIaris oris muscIe on the cIeft side wiI1 be we11 exposed and good muscuIar union achieved. 6. The upper trianguIar Aap, which is puIIed mediaIIy, wiIl exert pressure on the underIying bone at a IeveI at which I beIieve we can most

225

Skoog This design for repair of uniIatera1 cIeft Iips exempIifies some we11 known ruIes in Sir HaroId GiIIies’ teaching of pIastic surgery: (I) On the media1 side of the cIeft, the transverse incisions wiI1 “repIace” the Cupid’s bow “into normal position.” (2) On the IateraI side, flaps are designed to fiI1 the actua1 tissue defect in this deformity. (3) The anatomica cIosure wiII “restore norma function.”

effectiveIy redirect the growth of the premaxilla into the normal position. 7. The ffoor of the nostril is we11 eIevated by the tissue rotated from the cIeft side of the Iip. The mediaIIy pIaced obIique scar Iine in the nostri1 wiI1 not cause secondary depression of the floor. Tissue for the base of the coIumeIIa is aIso amply provided. 8. The Iaterai part of the aIa nasi is brought into position most satisfactoriIy by the rotation of the upper trianguIar hap, and a s&us is created at the aIar base without the aid of deep sutures. g. The pattern of the incisions is not based on a rigid geometrica formula but can be varied according to the individual case as we11 as to the esthetic feeIings of the surgeon. IO. The use of smaI1, narrowIy based flaps in this procedure stresses the need for an accurate and atraumatic operative technic. I I. The ffexibiIity in appIication of this design makes it highIy desirabIe that the surgeon be we11 familiar with the principles and practice of pIastic surgery.

REFERENCES

I. BROWN, J. B. and MCDOWELL, F. SimpIified design for repair of single cIeft Iips. Surg., Gynec. +Y Obst., 80: 12-26, x945. 2. MARCKS, K. M., TREVASKIS, A. E. and DACOSTA, A. Further observation in cIeft lip repair. Plast. CT Reconstruct. surg., 12: 392-402,~ 1953. 3. MILLARD, R., JR. Transactions of the InternationaI Society of Plastic Surgeons, vol. I. BaItimore, 1957. WiIIiams & Wilkins Co. 4. TENNISON, C. W. Repair of unilateral cIeft Iip by stenciI method. Ph. e Reconstruct. Surg., Q: 115-120, 1952. 5. TRAUNER, R. Die Operation der LippenspaIte. Fortscbr. d. Kiefer- u. Gesicbts-cbir., I: 16, 1955.

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