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A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip
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A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip Soyeon Jung , Kyung Hoon Chung , Shiaw-Yu Chang , ¨ Dorte Ohrmman , Elva Lim , Lun-Jou Lo PII: DOI: Reference:
S1748-6815(19)30501-7 https://doi.org/10.1016/j.bjps.2019.11.013 PRAS 6317
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
2 March 2019 22 November 2019
¨ Please cite this article as: Soyeon Jung , Kyung Hoon Chung , Shiaw-Yu Chang , Dorte Ohrmman , Elva Lim , Lun-Jou Lo , A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.11.013
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A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip
Soyeon Jung, Kyung Hoon Chung, Shiaw-Yu Chang, Dörte Ohrmman, Elva Lim, LunJou Lo
Running title: Muscle reconstruction in unilateral cleft lip repair
Affiliation: Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
Corresponding author: Lun-Jou Lo, M.D. Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital. 5 Fu-Shin Street, Kwei Shan, Taoyuan 333, Taiwan. Tel: (886)-3-3281200, ext. 2430. Fax: (886)-3-3273369. Email: [email protected]
Conflicts of interest statement: No conflicting relationship exists for all authors Financial disclosure: None of the authors have any sources of financial or other support or any financial or professional relationships that may pose a competing interest.
1
ABSTRACT Background: Adequate skin lengthening and symmetry may not be consistently obtained in unilateral cleft lip repair, especially in patients with complete cleft. The purpose of this study was to present the model of muscle dissection and approximation to facilitate the lip lengthening and symmetry. Methods: The design followed the rotation-advancement method without skin measurement. A curvilinear skin incision was made from subnasale to the Cupid‟s bow peak. Muscle dissection was continued to the contralateral nostril floor beneath the columella base to facilitate downward rotation in the medial lip. Wide muscle dissection was performed in the lateral lip segment from the nasal mucosa passing the alar base. The lateral lip muscle was advanced and sutured to the medial lip muscle in a Z-plasty fashion. A small skin backcut was made above the Cupid‟s bow peak. Primary nasal correction was performed. A series of 138 patients with complete unilateral cleft lip and palate were included in this study. Standard photographs were collected for measurement in the nasolabial region. Results: Adequate lengthening and symmetry of the lip was obtained. The ratio of vertical philtral height was 0.99±0.05 between the cleft and noncleft sides. The C flap was used for supplementary skin lengthening in 58% of cases. Postoperative lip retraction requiring massage occurred in 13%. Overall nasolabial appearance was satisfactory. Conclusion: The new technique of perioral muscle reconstruction facilitated to obtain lip lengthening and symmetry in the repair of complete unilateral cleft lip.
Keywords: Unilateral cleft lip repair, rotation-advancement, symmetry of lip, lengthening, muscle reconstruction
2
INTRODUCTION Since the original rotation-advancement (RA) technique was introduced by Millard, it has become a popular method for unilateral cleft lip repair. The majority of surgeons continue to practice this technique.1 Ideal results may not routinely be obtained, and there have been many modifications based on the RA method. The evolutions improve the surgical outcome in terms of symmetry of lip, reduction of lip scars, proper muscle function, appropriate philtrum and Cupid‟s bow, smooth vermilion, as well as reposition of lower lateral cartilage. Achieving symmetry is important in unilateral cleft lip repair. The repair is more difficult in the case of complete unilateral cleft lip and palate. There are separated alveolar segments, inferiorly and posteriorly displaced alar base, deviation of columella base to the noncleft side, and soft tissue discrepancy along the cleft.2 The structural deformities could be improved by preoperative nasoalveolar molding to facilitate the surgical repair.3 However, there is soft tissue discrepancy to cope with (Figure 1).4 To increase the downward rotation of medial lip segment, a backcut across the midpoint of columella base (of Millard)5, 6, incision extending upward to the columella (of Mohler)7, or a skin backcut above the Cupid‟s bow (of Fisher)8 were recommended (Table 1). To lengthen the lateral lip segment, the landmark for the designated Cupid’s bow peak could be moved laterally, a Z-plasty using the C flap in the nasal floor, or a skin backcut above the peak could be made from our experience.9 Lengthening of lip on both medical and lateral segments could also be achieved by the wave-line technique (of Pfeiffer) and the equal bows advancement method (of Hakim).10,11 In many
times, the
modifications for lengthening both medial and lateral lip segments could be successfully achieved. But the consistency on symmetry was a concern, and shortening of the lip with elevation of Cupid‟s bow peak on the cleft side could occur. Further disadvantages could 3
include unnatural scars, or narrowing of the lateral lip length from Cupid‟s bow to commissure with lateral shifting of philtrum caused by moving the Cupid‟s bow landmark laterally. To lengthen the lip in the unilateral cleft lip repair, we proposed a new technique of muscle reconstruction (Figure 2A to C). The aim of this study was to present the technique and the long-term outcome in a cohort of complete unilateral cleft lip and palate.
MATERIALS AND METHODS Patients The patients with complete type of unilateral cleft lip and palate (UCLP) between July 2000 and September 2016 were included in this study. Patients‟ data were collected from the medical records. All surgeries were performed by single senior surgeon (LJL) using the same surgical technique. As this group of patients had complete unilateral cleft lip and palate with wide separation of alveolar segments, presurgical nasoalveolar molding was employed. Patients‟ latest photos at age older than 3 years and before 9 yeaers were collected for evaluation and measurement.
Surgical procedures Marking on nasolabial region The skin design was simple and based on anatomic landmarks without measurement. The crucial differences from the established methods were the skin incision along the skinvermilion junction, no back cut in the upper lip or columella, and a small triangular flap above the Cupid‟s bow peak (Table 1). The design started with marking the subnasale and two lateral points of columella-lip junction (Figure 1, Figure 2A; Blue dotted and solid lines). 4
The Cupid‟s bow peak (CBP), the lowest point of Cupid‟s bow and the cleft-side CBP were determined on the white skin roll. The red line, junction between vermilion and mucosa, was marked. A curvilinear incision line of medial lip was drawn from subnasale to the CBP, creating the C-flap lateral to this line. Lateral border of C-flap was drawn along the skinvermilion border upward and behind the columella at the same level of contralateral nostril junction. Incision line of upper lip mucosa was marked from the CBP along the lateral frenulum to the sulcus. A backcut at the frenulum base was marked for release of buccal mucosa. Points of the alar bases were marked on the alar crest. On the lateral lip, Noordhoff‟s point was estimated and marked on the point where the vermilion just became the widest, a corresponding CBP point. A skin incision line was marked from this point upward along the skin border until the nasal floor. A triangular vermilion flap is designed between Noordhoff‟s point and red line. The width of this vermilion flap was the difference in the vermilion width at both CBP points in medial lip, and mostly was about 2mm.4 The design and marking were concluded by tattooing the landmarks with needle (Video 1).
Surgical technique Skin hooks were used to stretch the lip tissue for precise incision and control of bleeding. Under hook traction, a blunt tip scissors were used to cut skin, muscle and mucosa in the medial lip. Division of the muscle was continued upward passing the columella base to the contralateral nostril floor underneath the skin (Video 2; Figure 2A, red dotted line on medial lip; Figure 3). This allowed adequate downward rotation of the medial lip. A release of the base of frenulum was done for lengthening of buccal mucosa. Gentle undermining between 1 to 2mm in the medial lip was performed separating the mucosa, muscle, and skin (Video 2, Figure 4). The C-flap was divided from its mucosa (CM flap). A skin hook was used to lift 5
the cleft side dome lengthening the columella, and the CM flap was turned and sutured using Vicryl 5-0 (Ethicon, Somerville, NJ) to cover the defect behind the C-flap. This CM flap was later turned over and sutured with the inferior turbinate mucosa flap for nostril floor reconstruction. In the lateral lip, a limited dissection was performed to the piriform mucosa at supraperiosteal level, releasing the alar base. The dissection continued to the inferior turbinate, turned posteriorly to the inferior border of turbinate and cut the posterior part. A stab wound was performed on the nasal mucosa above the turbinate, and dissection continued to the superior border of the turbinate, separating the turbinate mucosa flap. An intranasal dissection was done to free the nasal skin. At this moment, the nasal ala was completely released from the piriform. The nasal mucosa was divided from the buccal mucosa, and the orbicularis muscle was freed from the nasal mucosa. No. 67 blade was used to cut along skin-vermilion junction from the Noordhoff‟s point to nostril sill. Extensive dissection in the lateral lip was performed to separate the mucosa, muscle, and skin layers (Video 2, Figure 5). Dissection of the muscle was done carefully close to the dermis level, beginning from nasal mucosa laterally passing the alar base. A fingertip was placed against the skin providing protection and accurate dissection (Figure 6; Blue arrow). Development of this long and intact muscle flap is important for lengthening of lip. The skin flap also became pliable and easy to be lengthened following the muscle repair. A triangular vermilion flap with the marginalis muscle was developed using no. 11 blade. A small backcut was made 1mm above the CBP in the medial lip, allowing adequate rotation and lengthening in the medial lip. This skin relaxing opening was typically between 1 and 2 mm in width. A small triangular skin flap with corresponding size and location was created from the lateral lip. Mobilization of the medial and lateral segments was performed to 6
judge the tissue laxity and symmetry on the levels of alar base, Cupid‟s bow and vermilion (Video 2). Placement of four muscle sutures was performed at this stage. The first suture approximated the marginalis muscle on both sides. Careful judgement was made to ensure smooth vermilion. The 2nd and 3rd sutures caught the posterior part of lateral muscle and anterior part (subdermal plane) of medial muscle in order to create median dimpling and lateral elevation simulating the philtrum (Figure 2C). The 4th suture brought the upper part of lateral muscle flap to the contralateral nostril floor, filling the space by downward rotation of the medial muscle (Figure 2C, Figure 7). The 5th suture was a cinching suture bringing together the alar base (AC point) and the contralateral columella base using a type of subcutaneous sustaining suture (SDC 1 and 2). All were used with 5-0 PDS sutures (Ethicon, Bridgewater, NJ). The cinching suture was tied first, followed by the muscle sutures from the first to the fourth. Upon the tying, small single hooks were used to lower the CBP points on both sides and the symmetry observed (Video 3). Key skin sutures with 7-0 Vicryl (Ethicon, Somerville, NJ) were placed at the small releasing Z-plasty, the triangular vermilion flap, subnasale and the skin-vermilion border. When elongation of the lateral lip was needed, the C-flap was used as Z-plasty at the nostril sill. Otherwise, the C-flap was trimmed (Video 4, Figure 8).12
Measurements in the nasolabial region (Figure 9-10) Measurements were performed to evaluate the symmetry on lip and nose. Standardized digital photographs of frontal and basal views were assessed using the ImageJ (National Institute of Health, Bethesda, Md).13 The photographs were selected from the follow-ups between age 3 and 9 years before alveolar bone grafting without previous intermediate revisional surgeries. Definitions of alar height and width (AH, AW), nostril height and width 7
(NH, NW), alar cheek angle (ACA), lateral philtral height (LPH), medial philtral height (MPH), vertical philtral height (VPH), and lateral lip height (LLH) were made. As the measurements were in pixel numbers, rather than absolute distances, ratios were obtained between the cleft and noncleft sides for possible dimensional discrepancies.
RESULTS A consecutive 138 patients with complete UCLP received the one-stage lip repair and primary nasal reconstruction. (Table 2) The skin backcut above the CBP point was performed in 98.6% of patients for adequate lengthening of lip. The C-flap was used in the nostril floor for further lip lengthening in 58.0% of patients. Revision surgery was requested by parents in 9 patients (6.5%). The revisions were combined with other planned procedures in 3 cases, 2 in palatoplasty and 1 in alveolar bone grating. Six of the revisions were performed in the early study period. Postoperative lip massage was advised in 13.0% of patients to correct the lip retraction. In the evaluation of patients‟ photos, the lip scars were acceptable and the nasal tip definition was good without separation of the lower lateral cartilages. Standard photos of frontal and basal views were available for measurement in 111 patients. The follow-up photos were taken at an average age of 5.0 years (standard deviation 2.2 years), ranging from 3 to 9 years. Table 3 showed the ratios of nasolabial dimension. Overall nasolabial appearance was satisfactory (SDC 3 and 4).
DISCUSSION The unilateral cleft lip repair, especially in the complete UCLP, possibly leaves noticeable scars with contracture and lip deformity.14,15 Rotation-advancement method with the multiple modifications aimed to improve the lip appearance. However, inconsistent 8
results with problems of scars, shortening and imbalance were concerned, and the lip repair remains a challenge.10,16-18 It might be the reason that Millard‟s RA method was recommended only for minor or narrow clefts.1,18,19 Noordhoff‟s triangular vermilion flap helped to improve the fullness and balance of the central red lip.20 Mohler avoided the back cut in the upper lip, and relocated the scars to the columella base.7 However, the size of Cflap might not be enough to fill the defect in the cases with wide cleft. The method was modified to obtain wider C-flap for more downward rotation.21,22 The back cut was added as upward incision into the columella for elongation.6,23 Another type for lip lengthening from curvilinear incision was reported. The curves resulted in sacrifice of tissue in the noncleft side of lip and possible scar contracture with unbalanced Cupid‟s bow.10,11,14,24 A subunit concept was proposed and incisions were located on the borders to conceal the scars.8,25 Fisher‟s technique was characterized by accurate measurement and calculation for the proper releasing incision, with skin incision away from the borders. In our method, no skin calculation was required, and our skin incision was performed on the skin-vermilion border keeping all the skin component. Any skin redundancy after muscle approximation could be trimmed at later stage. Although the various techniques are still currently practiced for repair of unilateral cleft lip (Table 1), common concerns remain on the scars, inconsistent results and some are cumbersome to perform.26 Satisfactory leveling of the Cupid‟s bow was achieved in our study, demonstrated by the ratio of the vertical philtral height (VPH) at 0.99 between the cleft and noncleft sides (Figure 10, Table 3). Certain skin release should be performed to follow the muscle lengthening, including the small incision above the CBP in the medial lip plus a small triangular skin flap in the lateral lip (98.6%), and the use of C-flap as Z-plasty in the nostril floor (58.0%). The small opening in the medial lip was about 1 to 2mm to accept the triangular skin flap from the 9
lateral lip. The tension in this skin flap was minimal and the scar was unnoticeable. This small skin flap appeared to be a normal depression superior to the white skin roll and served to prevent elevation of the CBP that could occur without using this flap.27 It is the reason we do not advocate lip massage following the repair. Once scar contracture or any sign of CBP elevation occurred in the postoperative period (13% in our series), lip massage effectively lengthened the lip. The upper muscle suture in the columella base served to fill the defect in the upper medial lip following muscle downward rotation, a Z-plasty fashion to prevent lip retraction. It also helps to correct the nasal deformity by pulling the columella base and cleft side alar base together (Figure 2C). The nasal over-correction was achieved by the cinching suture and the Tajima method of primary rhinoplasty (SDC 1).12 Several techniques for unilateral cleft lip repair relied on accurate skin measurement and the design to cope with discrepancy between the two lip segments. In some cases, it could be complicated because of the diverse variance on the shape and size across the cleft. On the other hand, using Millard‟s cut-as-you-go method, one might encounter unexpected or unsuccessful situation.28 We believe that the muscle reconstruction provides the frame and contribute to adequate skin lengthening. Therefore, the skin design is simplified (Figure 1). In the authors‟ center, a unilateral cleft lip repair focusing on skin lengthening was performed by another senior surgeon.29-31 The skin lengthening was achieved using Mohler‟s method and routine postoperative lip scar massage, without emphasizing extended muscle dissection and reconstruction. It would be interesting to compare the outcome between the two approaches by quantitative measurement and panels of evaluators in a future study. As lip lengthening and symmetry were the main goals in this study, quantitative assessment was performed using the digital photographs and ratios between the cleft and 10
noncleft sides.12,13 Hakim et al. reported an equal bows/straight line advancement technique and carried out anthropometric measurement using the t-test, and Cline et al. compared the rotation-advancement and philtral ridge techniques showing no difference between the two methods.10, 32 Knight and colleagues reported the changing nasolabial dimensions after cleft lip repair using an anthropometric study.33 It is anticipated that 3-dimensional photographic measurement will be more convenient and accurate in the outcome assessment. The extended dissection and lengthening of muscle for Z-plasty type of reconstruction in unilateral cleft lip repair have not been highlighted in the literature although correction of the abnormally positioned muscle was mentioned (Table 1). Basic concept of rotationadvancement of Millard5 was popularly applied with modifications. The skin and muscle were cut at the same plane, and therefore skin design was carefully planned to cope with the tissue deficiency for adequate lengthening. Calculation of skin dimension was mostly performed in the literature. For skin lengthening, a backcut was made across the midline,5 or the skin incision extending onto the columella,7,21,23 or a small backcut above the Cupid‟s bow peak.8,23 The opening space from the relaxing incision on the upper lip and columella is covered by the rotation of C flap, likely to create an unnatural scar. The C flap was not used in Fisher‟s subunit technique.8 We used C flap when there was tissue deficiency in the lateral lip segment requiring the skin in the nostril floor, and it occurred on 58% of cases. In our experience, tissue deficiency in the lateral lip segment was not infrequent from our previous study.4 This study was restricted to the patient type with complete unilateral cleft lip and palate. For the incomplete cleft lip, the lip tissue dimension was varied and the surgical design should be different, warranting another study. The limitation in this study was its retrospective nature, and the lack of a comparative group, i.e., with and without the extended 11
muscle reconstruction. It is difficult to have a control group when a technique was well established with consistent satisfactory results. An ideal outcome assessment would be using 3-dimensional photogrammetric images, and this would be the way in the future study. In conclusion, this study described a new method of extended muscle dissection and reconstruction in unilateral cleft lip repair. The skin design is simple and constant without measurement and calculation. The muscle reconstruction helped to lengthen the lip and symmetry was obtained. We believe this method is easy to use, even for the young surgeons.
ACKNOWLEDGEMENT We thank Dr. Samuel Noordhoff for establishing and supervising the cleft care in the past years. We would also thank our research assistants Lien-Shin Niu and Yi-Tan Hung for collection of patients‟ data.
Funding: None Conflicts of interest: None declared Ethical approval: By the Institutional Review Board of Chang Gung Foundation (IRB 201600309B0)
REFERENCES 1. Sitzman TJ, Girotto JA, Marcus JR. Current surgical practices in cleft care: unilateral cleft lip repair. Plast Reconstr Surg 2008; 121: 261e-70e. 2. Fisher DM, Lo LJ, Chen YR, Noordhoff MS. Three-dimensional computed tomographic analysis of the primary nasal deformity in 3-month-old infants with complete unilateral cleft lip and palate. Plast Reconstr Surg 1999; 103: 1826-34. 12
3. Liou EJ, Subramanian M, Chen PK, Huang CS. The progressive changes of nasal symmetry and growth after nasoalveolar molding: a three-year follow-up study. Plast Reconstr Surg 2004; 114: 858-64. 4. Chou PY, Luo CC, Chen PK, et al. Preoperative lip measurement in patients with complete unilateral cleft lip/palate and its comparison with norms. J Plast Reconstr Aesthet Surg 2013; 66: 513-7. 5. Millard DR, Refinements in rotation-advancement cleft lip technique. Plast Reconstr Surg 1964; 33: 26-38. 6. Stal S, Brown RH, Higuera S, et al. Fifty years of the Millard rotation-advancement: looking back and moving forward. Plast Reconstr Surg 2009; 123: 1364-77. 7. Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg 1987; 80: 511-7. 8. Fisher DM. Unilateral cleft lip repair: an anatomical subunit approximation technique. Plast Reconstr Surg 2005; 116: 61-71. 9. Noordhoff MS, Chen YR, Chen KT, Hong KF, Lo LJ. The surgical technique for the complete unilateral cleft lip-nasal deformity.
Operative Techniques in Plastic and
Reconstructive Surgery 2: 167-174, 1995. 10. Hakim SG, Aschoff HH, Jacobsen HC, Sieg P. Unilateral cleft lip/nose repair using an equal bows/straight line advancement technique - A preliminary report and postoperative symmetry-based anthropometry. J Craniomaxillofac Surg 2014; 42: e39-45. 11. Pfeifer G. Lip corrections following earlier cleft surgery by way of wave-line incisions. Dtsch Zahnarztl Z 1970; 25: 569-76. 12. Lonic D, Morris DE, Lo LJ. Primary overcorrection of the unilateral cleft nasal deformity: quantifying the results. Ann Plast Surg 2016; 77 Suppl 1: S25-9. 13. Chang SY, Lonic D, Pai BC, Lo LJ. Primary repair in patients with unilateral complete 13
cleft of lip and primary palate: assessment of outcomes. Ann Plast Surg 2018; 80: S2-s6. 14. Demke JC, Tatum SA. Analysis and evolution of rotation principles in unilateral cleft lip repair. J Plast Reconstr Aesthet Surg 2011; 64: 313-8. 15. Chait L, Kadwa A, Potgieter A, Christofides E. The ultimate straight line repair for unilateral cleft lips. J Plast Reconstr Aesthet Surg 2009; 62: 50-5. 16. Kaplan EN. Growth of the unilateral cleft lip. Cleft Palate J 1978; 15: 202-8. 17. Lazarus DD, Hudson DA, van Zyl JE, Fleming AN, Fernandes D. Repair of unilateral cleft lip: a comparison of five techniques. Ann Plast Surg 1998; 41: 587-94. 18. Meyer E, Seyfer A. Cleft lip repair: technical refinements for the wide cleft. Craniomaxillofac Trauma Reconstr 2010; 3: 81-6. 19. Burt JD, Byrd HS. Cleft lip: unilateral primary deformities. Plast Reconstr Surg 2000; 105: 1043-55 20. Noordhoff MS. Reconstruction of vermilion in unilateral and bilateral cleft lips. Plast Reconstr Surg 1984; 73: 52-61. 21. Cutting CB, Dayan JH. Lip height and lip width after extended Mohler unilateral cleft lip repair. Plast Reconstr Surg 2003; 111: 17-23 22. Li L, Liao L, Zhong Y, et al. A modified Mohler technique for patients with unilateral cleft lip based on geometric principles--A primary report. J Craniomaxillofac Surg 2015; 43: 663-70. 23. Mulliken JB, Martinez-Perez D. The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: technical variations and analysis of results. Plast Reconstr Surg 1999; 104: 1247-60. 24. Holtje WJ, Ehmann G. Wave-line procedure in the repair of cleft lip. J Maxillofac Surg 1973; 1: 198-202. 14
25. Tse R, Lien S. Unilateral cleft lip repair using the anatomical subunit approximation: modifications and analysis of early results in 100 consecutive cases. Plast Reconstr Surg 2015; 136: 119-30. 26. Marcus JR, Allori AC, Santiago PE. Principles of cleft lip repair: conventions, commonalities, and controversies. Plast Reconstr Surg 2017; 139: 764e-80e. 27. Kim HY, Park J, Chang MC, Song IS, Seo BM. Modified Fisher method for unilateral cleft lip-report of cases. Maxillofac Plast Reconstr Surg 2017; 39: 12. 28. Romero R. The Millard rotation-advancement lip repair using accurate measurements. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84: 335-8. 29. Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PK. Botulinum toxin to improve results in cleft lip repair: a double-blinded, randomized, vehicle-controlled clinical trial. PLoS One 2014; 9: e115690. 30. Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PK. Botulinum toxin to improve results in cleft lip repair. Plast Reconstr Surg 2014; 134: 511-6. 31. Chen PK, Noordhoff SM, Kane A. Repair of unilateral cleft lip. Plastic Surgery 3rd ed. Philadelphia: Elsevier Saunders, 2013. 32. Cline JM, Oyer SL, Javidnia H, et al. Comparison of the rotation-advancement and philtral ridge techniques for unilateral cleft lip repair. Plast Reconstr Surg 2014; 134: 1269-78. 33. Knight ZL, Ganske I, Deutsch CK, Mulliken JB. The changing nasolabial dimensions following repair of unilateral cleft lip: an anthropometric study in late childhood. Plast Reconstr Surg 2016; 138: 879e-86e.
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LEGENDS Figure 1. The basic design for cleft lip repair. Total 9 points indicate the anatomic landmarks. Subnasale and two points on columella-lip crease, both alar crest (AC) points, three points on Cupid‟s bow incluing the lowest point and Noordhoff‟s point on lateral lip.
Figure 2A. The design lines referring to the disoriented orbicularis muscle. (Blue dotted lines and solid lines) The directions of muscle dissection on both sides of lips (Red dotted lines)
16
Figure 2B. The completion of dissection. Note that both segments of lips including skin and muscle are dovetailed nicely.
17
Figure 2C. Muscle approximation. Note the superior part of lateral lip muscle filled the defect under the columella in a sort of Z-plasty.
18
19
Figure 3. The first part in dissection of the medial lip. Note the tip of the sharp scissors inserted under the columella for dissecting the muscle. Refer the small illustration on right-bottom part of the photo.
20
Figure 4. The second part in dissection of the medial lip. Note the depth of the dissection to the subdermal layer should not be over 1~2mm to create the central dimple.
21
Figure 5. The dissection of the lateral lip. In lateral lip, three-layer dissection was also performed but more extensive than the dissection of the medial lip.
22
Figure 6. The dissection to the subdermal layer in the lateral lip. The obtained muscle should be thick enough to reconstruct the anatomic lip muscle. Blue arrow is indicating the fingertip supporting the skin to prevent perforating it.
23
Figure 7. The approximation of the dissected muscles. Total four sutures are placed to reconstruct the muscles. The fourth one is sutured from the corner of the lateral lip muscle to the contralateral columella, which is filling up the defect under the columella.
24
Figure 8. The alar rim correction. It is also known as „Tajima inverted U method‟. The inverted U is designed 2mm over the height of nostril in non-cleft side.
25
Figure 9. The alar height and width (AH, AW) were the maximal distance from alar base line to upper border of ala, from subnasale to the projection of alar base, respectively. Nostril height and width (NH, NW) were maximal vertical distance and horizontal distance of the nostril aperture. Alar cheek angle (ACA) was the lateral angle between alar base line and the line joining the alar curvature point and the intersection point of the lateral nostril tangent line and the upper border of ala. Refer to Table 2.
26
Figure 10. Lateral philtral height (LPH) is the distance from the curvature point of alar base to crista philtra, and medial philtral height (MPH) is the distance from subnasale to crista philtra. Vertical philtral height (VPH) is the vertical distance from the level of crista philtra to alar base line. Lateral lip height (LLH) is the distance from the curvature point of alar base to cheilion. Refer to Table 2. 27
SDC 1. The cinch sutures. It not only decreases the width of nostril but also increases the height of nostril. In addition to this advantage, it brings the columella base toward the cleft side and the ala more medially. 28
SDC 2. Subcutaneous sustaining suture. To increase the traction and holding power, the dermal layer is caught by the suture. It creates traction force without cuttingthrough and is able to maintain the alar and columella bases in the desirable position.
SDC 3 and 4. The postoperative pictures. Note the symmetry of the upper lip and the balance between the anatomic landmarks on both sides.
Legends for video Video 1 is for the design based on the anatomic landmarks. Video 2 is for the dissection to the medial lip and lateral lip including harvesting turbinate 29
flap. Video 3 is the approximation after adequate dissection was performed. The temporary four sutures are placed between two sides of muscles. The fifth one is a cinch suture which is for reducing the nostril width and increasing the height. Video 4 is the Tajima reverse U method to approximate the lower lateral cartilage, correct the alar dome, and lengthen the columella.
30
Table 1. Comparisons among various techniques for unilateral cleft lip repairs. Rotation
Use of C-flap
Dissection
incision
Back cut
Vermilion
(releasing
flap
Presurgical Preosurgical Postoperative measureme
incision) Wide C-flap
Free C-flap
Add downward No
No
n by Millard fashion
C-flap could
from
incision from
“Cut as you
membranous
the base of the
go”
columella
of Cupid‟s
the defect of
septum
bow to the
back cut.
Free the alar
base of the
base and
columella
lateral element
result
nt
Modificatio Curvilinear
(1964, 1968) From the peak be used to fill
design
31
Noordhoff
Curvilinear
The same as
Dissect to the
A similar back
Yes
(1984)
Fashion
Millard‟s
base of
cut with
A
As Millard‟s
Modification
columella
Millard‟s
triangular
Dissect to the
modification
flap
Modification
alar base
Yes
between white skin roll and red line
Mohler
Straight line
Narrow C-flap Dissection
Add 90 degrees No
(1987)
Incision from
from medial
the peak of
alar crus to the incision onto
line closure
Cupid‟s bow
tip of the nose the columella
from
downturn
Yes
Straight
to the
columellar
columella
base to mucosa
32
Mulliken
Curvilinear
Narrow C-flap More
Add upward
Yes
(1999)
fashion
C-flap is
incision onto
Incision for
Incision from
retrograded up subdermal and the columella
Vermilion
the peak of
to the
submucosal
Additional
flap is on
Cupid‟s bow
columellar
planes
releasing
red line
to the
defect for
Dissect lateral incision can be
columella
hemi-
side up to the
on white skin
columellar
level of
roll
lengthening
infraorbital
and filling
foramen
extensive in
Yes
medial sill. Cutting
Curvilinear-
(2003)
Wide C flap
Free the alar
The back cut is
straight line
base and
more obtuse
fashion
lateral element angle than
Yes
Yes
Mohler‟s
33
Fisher
Straight line
(2005)
C-flap is not
Medial Lip:
No upper back
Yes
Incision line is created.
Free muscle
cut
A
designed along
from skin and
A small
triangular
the borders of
mucosa
releasing
flap as
anatomic
Preserving
incision is on
Noordhoff‟
subunits.
philtral dimple just above Lateral Lip:
white skin roll.
Dissection
Length of
between skin
vertical height
and muscle in
in cleft side can
lateral lip is
be adjusted by
more
the direction of
extensive.
a small
Free alar base
releasing
from
triangle
Yes
s method
34
underlying maxilla. This Study
Curvilinear
C-flap is
Medial Lip:
No upper back
Yes
fashion
trimmed, or
Dissection of
cut
Preserve
Incision from
adjusted and
muscle to the
the peak of
used in nostril contralateral
A small
marginalis
Cupid‟s bow
floor for
nostril floor
releasing
muscle
to the
lateral lip
Preserving the incision is
subnasale
lengthening.
philtral dimple created at 1mm triangular
No
the pars
with the
Lateral Lip:
above white
vermilion
Free alar base
skin roll
flap to
from piriform
augment
Extensive
medial
dissection
vermilion
among skin, 35
muscle and mucosa
Table 2. Demographics of the patients with complete unilateral cleft lip and palate Clinical presentation Male/female Age at surgery (months)
Patients, n=138
Percentage
83/55
60.1/39.9 %
3.2 ± 0.7
Releasing small skin z-plastyⅰ yes/no
136/2
98.6/1.4 %
Use of C-flapⅱ yes/no
80/58
58.0/42.0 %
Revision surgeryⅲ yes/no
9/129
6.5/93.5 %
36
Postoperative lip retraction requiring massage
18/138
13.0 %
Stitch inflammation
2/138
1.5 %
Dehiscenceiv
1/138
0.7 %
ⅰ Small z-plasty: Small relaxing incision just above the Cupid‟s bow peak on the white skin roll ⅱ Use of C-flap: yes for z-plasty at nostril floor, not to be trimmed ⅲ Revision surgery: Secondary procedures for vermilion trimming (5), lip lengthening (4), and revision of nose (6) ⅳ Partial skin dehiscence at cleft side nasal floor that healed secondarily
37
Table 3. Ratios of the nasolabial measurement in the patients with complete unilateral cleft lip and palate (n= 111) Cleft side/non-cleft side
Mean ± s.d.
Alar width
1.05±0.09
Alar height
0.97±0.06
Nostril width
1.17±0.18
Nostril height
0.93±0.13
Alar cheek angle
1.00±0.04
Lateral philtral height
0.92±0.12
Medial philtral height
1.14±0.26
Vertical philtral height
0.99±0.05
Lateral lip height
1.00±0.08
38
A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip Soyeon Jung , Kyung Hoon Chung , Shiaw-Yu Chang , ¨ Dorte Ohrmman , Elva Lim , Lun-Jou Lo PII: DOI: Reference:
S1748-6815(19)30501-7 https://doi.org/10.1016/j.bjps.2019.11.013 PRAS 6317
To appear in:
Journal of Plastic, Reconstructive & Aesthetic Surgery
Received date: Accepted date:
2 March 2019 22 November 2019
¨ Please cite this article as: Soyeon Jung , Kyung Hoon Chung , Shiaw-Yu Chang , Dorte Ohrmman , Elva Lim , Lun-Jou Lo , A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip, Journal of Plastic, Reconstructive & Aesthetic Surgery (2019), doi: https://doi.org/10.1016/j.bjps.2019.11.013
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip
Soyeon Jung, Kyung Hoon Chung, Shiaw-Yu Chang, Dörte Ohrmman, Elva Lim, LunJou Lo
Running title: Muscle reconstruction in unilateral cleft lip repair
Affiliation: Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
Corresponding author: Lun-Jou Lo, M.D. Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital. 5 Fu-Shin Street, Kwei Shan, Taoyuan 333, Taiwan. Tel: (886)-3-3281200, ext. 2430. Fax: (886)-3-3273369. Email: [email protected]
Conflicts of interest statement: No conflicting relationship exists for all authors Financial disclosure: None of the authors have any sources of financial or other support or any financial or professional relationships that may pose a competing interest.
1
ABSTRACT Background: Adequate skin lengthening and symmetry may not be consistently obtained in unilateral cleft lip repair, especially in patients with complete cleft. The purpose of this study was to present the model of muscle dissection and approximation to facilitate the lip lengthening and symmetry. Methods: The design followed the rotation-advancement method without skin measurement. A curvilinear skin incision was made from subnasale to the Cupid‟s bow peak. Muscle dissection was continued to the contralateral nostril floor beneath the columella base to facilitate downward rotation in the medial lip. Wide muscle dissection was performed in the lateral lip segment from the nasal mucosa passing the alar base. The lateral lip muscle was advanced and sutured to the medial lip muscle in a Z-plasty fashion. A small skin backcut was made above the Cupid‟s bow peak. Primary nasal correction was performed. A series of 138 patients with complete unilateral cleft lip and palate were included in this study. Standard photographs were collected for measurement in the nasolabial region. Results: Adequate lengthening and symmetry of the lip was obtained. The ratio of vertical philtral height was 0.99±0.05 between the cleft and noncleft sides. The C flap was used for supplementary skin lengthening in 58% of cases. Postoperative lip retraction requiring massage occurred in 13%. Overall nasolabial appearance was satisfactory. Conclusion: The new technique of perioral muscle reconstruction facilitated to obtain lip lengthening and symmetry in the repair of complete unilateral cleft lip.
Keywords: Unilateral cleft lip repair, rotation-advancement, symmetry of lip, lengthening, muscle reconstruction
2
INTRODUCTION Since the original rotation-advancement (RA) technique was introduced by Millard, it has become a popular method for unilateral cleft lip repair. The majority of surgeons continue to practice this technique.1 Ideal results may not routinely be obtained, and there have been many modifications based on the RA method. The evolutions improve the surgical outcome in terms of symmetry of lip, reduction of lip scars, proper muscle function, appropriate philtrum and Cupid‟s bow, smooth vermilion, as well as reposition of lower lateral cartilage. Achieving symmetry is important in unilateral cleft lip repair. The repair is more difficult in the case of complete unilateral cleft lip and palate. There are separated alveolar segments, inferiorly and posteriorly displaced alar base, deviation of columella base to the noncleft side, and soft tissue discrepancy along the cleft.2 The structural deformities could be improved by preoperative nasoalveolar molding to facilitate the surgical repair.3 However, there is soft tissue discrepancy to cope with (Figure 1).4 To increase the downward rotation of medial lip segment, a backcut across the midpoint of columella base (of Millard)5, 6, incision extending upward to the columella (of Mohler)7, or a skin backcut above the Cupid‟s bow (of Fisher)8 were recommended (Table 1). To lengthen the lateral lip segment, the landmark for the designated Cupid’s bow peak could be moved laterally, a Z-plasty using the C flap in the nasal floor, or a skin backcut above the peak could be made from our experience.9 Lengthening of lip on both medical and lateral segments could also be achieved by the wave-line technique (of Pfeiffer) and the equal bows advancement method (of Hakim).10,11 In many
times, the
modifications for lengthening both medial and lateral lip segments could be successfully achieved. But the consistency on symmetry was a concern, and shortening of the lip with elevation of Cupid‟s bow peak on the cleft side could occur. Further disadvantages could 3
include unnatural scars, or narrowing of the lateral lip length from Cupid‟s bow to commissure with lateral shifting of philtrum caused by moving the Cupid‟s bow landmark laterally. To lengthen the lip in the unilateral cleft lip repair, we proposed a new technique of muscle reconstruction (Figure 2A to C). The aim of this study was to present the technique and the long-term outcome in a cohort of complete unilateral cleft lip and palate.
MATERIALS AND METHODS Patients The patients with complete type of unilateral cleft lip and palate (UCLP) between July 2000 and September 2016 were included in this study. Patients‟ data were collected from the medical records. All surgeries were performed by single senior surgeon (LJL) using the same surgical technique. As this group of patients had complete unilateral cleft lip and palate with wide separation of alveolar segments, presurgical nasoalveolar molding was employed. Patients‟ latest photos at age older than 3 years and before 9 yeaers were collected for evaluation and measurement.
Surgical procedures Marking on nasolabial region The skin design was simple and based on anatomic landmarks without measurement. The crucial differences from the established methods were the skin incision along the skinvermilion junction, no back cut in the upper lip or columella, and a small triangular flap above the Cupid‟s bow peak (Table 1). The design started with marking the subnasale and two lateral points of columella-lip junction (Figure 1, Figure 2A; Blue dotted and solid lines). 4
The Cupid‟s bow peak (CBP), the lowest point of Cupid‟s bow and the cleft-side CBP were determined on the white skin roll. The red line, junction between vermilion and mucosa, was marked. A curvilinear incision line of medial lip was drawn from subnasale to the CBP, creating the C-flap lateral to this line. Lateral border of C-flap was drawn along the skinvermilion border upward and behind the columella at the same level of contralateral nostril junction. Incision line of upper lip mucosa was marked from the CBP along the lateral frenulum to the sulcus. A backcut at the frenulum base was marked for release of buccal mucosa. Points of the alar bases were marked on the alar crest. On the lateral lip, Noordhoff‟s point was estimated and marked on the point where the vermilion just became the widest, a corresponding CBP point. A skin incision line was marked from this point upward along the skin border until the nasal floor. A triangular vermilion flap is designed between Noordhoff‟s point and red line. The width of this vermilion flap was the difference in the vermilion width at both CBP points in medial lip, and mostly was about 2mm.4 The design and marking were concluded by tattooing the landmarks with needle (Video 1).
Surgical technique Skin hooks were used to stretch the lip tissue for precise incision and control of bleeding. Under hook traction, a blunt tip scissors were used to cut skin, muscle and mucosa in the medial lip. Division of the muscle was continued upward passing the columella base to the contralateral nostril floor underneath the skin (Video 2; Figure 2A, red dotted line on medial lip; Figure 3). This allowed adequate downward rotation of the medial lip. A release of the base of frenulum was done for lengthening of buccal mucosa. Gentle undermining between 1 to 2mm in the medial lip was performed separating the mucosa, muscle, and skin (Video 2, Figure 4). The C-flap was divided from its mucosa (CM flap). A skin hook was used to lift 5
the cleft side dome lengthening the columella, and the CM flap was turned and sutured using Vicryl 5-0 (Ethicon, Somerville, NJ) to cover the defect behind the C-flap. This CM flap was later turned over and sutured with the inferior turbinate mucosa flap for nostril floor reconstruction. In the lateral lip, a limited dissection was performed to the piriform mucosa at supraperiosteal level, releasing the alar base. The dissection continued to the inferior turbinate, turned posteriorly to the inferior border of turbinate and cut the posterior part. A stab wound was performed on the nasal mucosa above the turbinate, and dissection continued to the superior border of the turbinate, separating the turbinate mucosa flap. An intranasal dissection was done to free the nasal skin. At this moment, the nasal ala was completely released from the piriform. The nasal mucosa was divided from the buccal mucosa, and the orbicularis muscle was freed from the nasal mucosa. No. 67 blade was used to cut along skin-vermilion junction from the Noordhoff‟s point to nostril sill. Extensive dissection in the lateral lip was performed to separate the mucosa, muscle, and skin layers (Video 2, Figure 5). Dissection of the muscle was done carefully close to the dermis level, beginning from nasal mucosa laterally passing the alar base. A fingertip was placed against the skin providing protection and accurate dissection (Figure 6; Blue arrow). Development of this long and intact muscle flap is important for lengthening of lip. The skin flap also became pliable and easy to be lengthened following the muscle repair. A triangular vermilion flap with the marginalis muscle was developed using no. 11 blade. A small backcut was made 1mm above the CBP in the medial lip, allowing adequate rotation and lengthening in the medial lip. This skin relaxing opening was typically between 1 and 2 mm in width. A small triangular skin flap with corresponding size and location was created from the lateral lip. Mobilization of the medial and lateral segments was performed to 6
judge the tissue laxity and symmetry on the levels of alar base, Cupid‟s bow and vermilion (Video 2). Placement of four muscle sutures was performed at this stage. The first suture approximated the marginalis muscle on both sides. Careful judgement was made to ensure smooth vermilion. The 2nd and 3rd sutures caught the posterior part of lateral muscle and anterior part (subdermal plane) of medial muscle in order to create median dimpling and lateral elevation simulating the philtrum (Figure 2C). The 4th suture brought the upper part of lateral muscle flap to the contralateral nostril floor, filling the space by downward rotation of the medial muscle (Figure 2C, Figure 7). The 5th suture was a cinching suture bringing together the alar base (AC point) and the contralateral columella base using a type of subcutaneous sustaining suture (SDC 1 and 2). All were used with 5-0 PDS sutures (Ethicon, Bridgewater, NJ). The cinching suture was tied first, followed by the muscle sutures from the first to the fourth. Upon the tying, small single hooks were used to lower the CBP points on both sides and the symmetry observed (Video 3). Key skin sutures with 7-0 Vicryl (Ethicon, Somerville, NJ) were placed at the small releasing Z-plasty, the triangular vermilion flap, subnasale and the skin-vermilion border. When elongation of the lateral lip was needed, the C-flap was used as Z-plasty at the nostril sill. Otherwise, the C-flap was trimmed (Video 4, Figure 8).12
Measurements in the nasolabial region (Figure 9-10) Measurements were performed to evaluate the symmetry on lip and nose. Standardized digital photographs of frontal and basal views were assessed using the ImageJ (National Institute of Health, Bethesda, Md).13 The photographs were selected from the follow-ups between age 3 and 9 years before alveolar bone grafting without previous intermediate revisional surgeries. Definitions of alar height and width (AH, AW), nostril height and width 7
(NH, NW), alar cheek angle (ACA), lateral philtral height (LPH), medial philtral height (MPH), vertical philtral height (VPH), and lateral lip height (LLH) were made. As the measurements were in pixel numbers, rather than absolute distances, ratios were obtained between the cleft and noncleft sides for possible dimensional discrepancies.
RESULTS A consecutive 138 patients with complete UCLP received the one-stage lip repair and primary nasal reconstruction. (Table 2) The skin backcut above the CBP point was performed in 98.6% of patients for adequate lengthening of lip. The C-flap was used in the nostril floor for further lip lengthening in 58.0% of patients. Revision surgery was requested by parents in 9 patients (6.5%). The revisions were combined with other planned procedures in 3 cases, 2 in palatoplasty and 1 in alveolar bone grating. Six of the revisions were performed in the early study period. Postoperative lip massage was advised in 13.0% of patients to correct the lip retraction. In the evaluation of patients‟ photos, the lip scars were acceptable and the nasal tip definition was good without separation of the lower lateral cartilages. Standard photos of frontal and basal views were available for measurement in 111 patients. The follow-up photos were taken at an average age of 5.0 years (standard deviation 2.2 years), ranging from 3 to 9 years. Table 3 showed the ratios of nasolabial dimension. Overall nasolabial appearance was satisfactory (SDC 3 and 4).
DISCUSSION The unilateral cleft lip repair, especially in the complete UCLP, possibly leaves noticeable scars with contracture and lip deformity.14,15 Rotation-advancement method with the multiple modifications aimed to improve the lip appearance. However, inconsistent 8
results with problems of scars, shortening and imbalance were concerned, and the lip repair remains a challenge.10,16-18 It might be the reason that Millard‟s RA method was recommended only for minor or narrow clefts.1,18,19 Noordhoff‟s triangular vermilion flap helped to improve the fullness and balance of the central red lip.20 Mohler avoided the back cut in the upper lip, and relocated the scars to the columella base.7 However, the size of Cflap might not be enough to fill the defect in the cases with wide cleft. The method was modified to obtain wider C-flap for more downward rotation.21,22 The back cut was added as upward incision into the columella for elongation.6,23 Another type for lip lengthening from curvilinear incision was reported. The curves resulted in sacrifice of tissue in the noncleft side of lip and possible scar contracture with unbalanced Cupid‟s bow.10,11,14,24 A subunit concept was proposed and incisions were located on the borders to conceal the scars.8,25 Fisher‟s technique was characterized by accurate measurement and calculation for the proper releasing incision, with skin incision away from the borders. In our method, no skin calculation was required, and our skin incision was performed on the skin-vermilion border keeping all the skin component. Any skin redundancy after muscle approximation could be trimmed at later stage. Although the various techniques are still currently practiced for repair of unilateral cleft lip (Table 1), common concerns remain on the scars, inconsistent results and some are cumbersome to perform.26 Satisfactory leveling of the Cupid‟s bow was achieved in our study, demonstrated by the ratio of the vertical philtral height (VPH) at 0.99 between the cleft and noncleft sides (Figure 10, Table 3). Certain skin release should be performed to follow the muscle lengthening, including the small incision above the CBP in the medial lip plus a small triangular skin flap in the lateral lip (98.6%), and the use of C-flap as Z-plasty in the nostril floor (58.0%). The small opening in the medial lip was about 1 to 2mm to accept the triangular skin flap from the 9
lateral lip. The tension in this skin flap was minimal and the scar was unnoticeable. This small skin flap appeared to be a normal depression superior to the white skin roll and served to prevent elevation of the CBP that could occur without using this flap.27 It is the reason we do not advocate lip massage following the repair. Once scar contracture or any sign of CBP elevation occurred in the postoperative period (13% in our series), lip massage effectively lengthened the lip. The upper muscle suture in the columella base served to fill the defect in the upper medial lip following muscle downward rotation, a Z-plasty fashion to prevent lip retraction. It also helps to correct the nasal deformity by pulling the columella base and cleft side alar base together (Figure 2C). The nasal over-correction was achieved by the cinching suture and the Tajima method of primary rhinoplasty (SDC 1).12 Several techniques for unilateral cleft lip repair relied on accurate skin measurement and the design to cope with discrepancy between the two lip segments. In some cases, it could be complicated because of the diverse variance on the shape and size across the cleft. On the other hand, using Millard‟s cut-as-you-go method, one might encounter unexpected or unsuccessful situation.28 We believe that the muscle reconstruction provides the frame and contribute to adequate skin lengthening. Therefore, the skin design is simplified (Figure 1). In the authors‟ center, a unilateral cleft lip repair focusing on skin lengthening was performed by another senior surgeon.29-31 The skin lengthening was achieved using Mohler‟s method and routine postoperative lip scar massage, without emphasizing extended muscle dissection and reconstruction. It would be interesting to compare the outcome between the two approaches by quantitative measurement and panels of evaluators in a future study. As lip lengthening and symmetry were the main goals in this study, quantitative assessment was performed using the digital photographs and ratios between the cleft and 10
noncleft sides.12,13 Hakim et al. reported an equal bows/straight line advancement technique and carried out anthropometric measurement using the t-test, and Cline et al. compared the rotation-advancement and philtral ridge techniques showing no difference between the two methods.10, 32 Knight and colleagues reported the changing nasolabial dimensions after cleft lip repair using an anthropometric study.33 It is anticipated that 3-dimensional photographic measurement will be more convenient and accurate in the outcome assessment. The extended dissection and lengthening of muscle for Z-plasty type of reconstruction in unilateral cleft lip repair have not been highlighted in the literature although correction of the abnormally positioned muscle was mentioned (Table 1). Basic concept of rotationadvancement of Millard5 was popularly applied with modifications. The skin and muscle were cut at the same plane, and therefore skin design was carefully planned to cope with the tissue deficiency for adequate lengthening. Calculation of skin dimension was mostly performed in the literature. For skin lengthening, a backcut was made across the midline,5 or the skin incision extending onto the columella,7,21,23 or a small backcut above the Cupid‟s bow peak.8,23 The opening space from the relaxing incision on the upper lip and columella is covered by the rotation of C flap, likely to create an unnatural scar. The C flap was not used in Fisher‟s subunit technique.8 We used C flap when there was tissue deficiency in the lateral lip segment requiring the skin in the nostril floor, and it occurred on 58% of cases. In our experience, tissue deficiency in the lateral lip segment was not infrequent from our previous study.4 This study was restricted to the patient type with complete unilateral cleft lip and palate. For the incomplete cleft lip, the lip tissue dimension was varied and the surgical design should be different, warranting another study. The limitation in this study was its retrospective nature, and the lack of a comparative group, i.e., with and without the extended 11
muscle reconstruction. It is difficult to have a control group when a technique was well established with consistent satisfactory results. An ideal outcome assessment would be using 3-dimensional photogrammetric images, and this would be the way in the future study. In conclusion, this study described a new method of extended muscle dissection and reconstruction in unilateral cleft lip repair. The skin design is simple and constant without measurement and calculation. The muscle reconstruction helped to lengthen the lip and symmetry was obtained. We believe this method is easy to use, even for the young surgeons.
ACKNOWLEDGEMENT We thank Dr. Samuel Noordhoff for establishing and supervising the cleft care in the past years. We would also thank our research assistants Lien-Shin Niu and Yi-Tan Hung for collection of patients‟ data.
Funding: None Conflicts of interest: None declared Ethical approval: By the Institutional Review Board of Chang Gung Foundation (IRB 201600309B0)
REFERENCES 1. Sitzman TJ, Girotto JA, Marcus JR. Current surgical practices in cleft care: unilateral cleft lip repair. Plast Reconstr Surg 2008; 121: 261e-70e. 2. Fisher DM, Lo LJ, Chen YR, Noordhoff MS. Three-dimensional computed tomographic analysis of the primary nasal deformity in 3-month-old infants with complete unilateral cleft lip and palate. Plast Reconstr Surg 1999; 103: 1826-34. 12
3. Liou EJ, Subramanian M, Chen PK, Huang CS. The progressive changes of nasal symmetry and growth after nasoalveolar molding: a three-year follow-up study. Plast Reconstr Surg 2004; 114: 858-64. 4. Chou PY, Luo CC, Chen PK, et al. Preoperative lip measurement in patients with complete unilateral cleft lip/palate and its comparison with norms. J Plast Reconstr Aesthet Surg 2013; 66: 513-7. 5. Millard DR, Refinements in rotation-advancement cleft lip technique. Plast Reconstr Surg 1964; 33: 26-38. 6. Stal S, Brown RH, Higuera S, et al. Fifty years of the Millard rotation-advancement: looking back and moving forward. Plast Reconstr Surg 2009; 123: 1364-77. 7. Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg 1987; 80: 511-7. 8. Fisher DM. Unilateral cleft lip repair: an anatomical subunit approximation technique. Plast Reconstr Surg 2005; 116: 61-71. 9. Noordhoff MS, Chen YR, Chen KT, Hong KF, Lo LJ. The surgical technique for the complete unilateral cleft lip-nasal deformity.
Operative Techniques in Plastic and
Reconstructive Surgery 2: 167-174, 1995. 10. Hakim SG, Aschoff HH, Jacobsen HC, Sieg P. Unilateral cleft lip/nose repair using an equal bows/straight line advancement technique - A preliminary report and postoperative symmetry-based anthropometry. J Craniomaxillofac Surg 2014; 42: e39-45. 11. Pfeifer G. Lip corrections following earlier cleft surgery by way of wave-line incisions. Dtsch Zahnarztl Z 1970; 25: 569-76. 12. Lonic D, Morris DE, Lo LJ. Primary overcorrection of the unilateral cleft nasal deformity: quantifying the results. Ann Plast Surg 2016; 77 Suppl 1: S25-9. 13. Chang SY, Lonic D, Pai BC, Lo LJ. Primary repair in patients with unilateral complete 13
cleft of lip and primary palate: assessment of outcomes. Ann Plast Surg 2018; 80: S2-s6. 14. Demke JC, Tatum SA. Analysis and evolution of rotation principles in unilateral cleft lip repair. J Plast Reconstr Aesthet Surg 2011; 64: 313-8. 15. Chait L, Kadwa A, Potgieter A, Christofides E. The ultimate straight line repair for unilateral cleft lips. J Plast Reconstr Aesthet Surg 2009; 62: 50-5. 16. Kaplan EN. Growth of the unilateral cleft lip. Cleft Palate J 1978; 15: 202-8. 17. Lazarus DD, Hudson DA, van Zyl JE, Fleming AN, Fernandes D. Repair of unilateral cleft lip: a comparison of five techniques. Ann Plast Surg 1998; 41: 587-94. 18. Meyer E, Seyfer A. Cleft lip repair: technical refinements for the wide cleft. Craniomaxillofac Trauma Reconstr 2010; 3: 81-6. 19. Burt JD, Byrd HS. Cleft lip: unilateral primary deformities. Plast Reconstr Surg 2000; 105: 1043-55 20. Noordhoff MS. Reconstruction of vermilion in unilateral and bilateral cleft lips. Plast Reconstr Surg 1984; 73: 52-61. 21. Cutting CB, Dayan JH. Lip height and lip width after extended Mohler unilateral cleft lip repair. Plast Reconstr Surg 2003; 111: 17-23 22. Li L, Liao L, Zhong Y, et al. A modified Mohler technique for patients with unilateral cleft lip based on geometric principles--A primary report. J Craniomaxillofac Surg 2015; 43: 663-70. 23. Mulliken JB, Martinez-Perez D. The principle of rotation advancement for repair of unilateral complete cleft lip and nasal deformity: technical variations and analysis of results. Plast Reconstr Surg 1999; 104: 1247-60. 24. Holtje WJ, Ehmann G. Wave-line procedure in the repair of cleft lip. J Maxillofac Surg 1973; 1: 198-202. 14
25. Tse R, Lien S. Unilateral cleft lip repair using the anatomical subunit approximation: modifications and analysis of early results in 100 consecutive cases. Plast Reconstr Surg 2015; 136: 119-30. 26. Marcus JR, Allori AC, Santiago PE. Principles of cleft lip repair: conventions, commonalities, and controversies. Plast Reconstr Surg 2017; 139: 764e-80e. 27. Kim HY, Park J, Chang MC, Song IS, Seo BM. Modified Fisher method for unilateral cleft lip-report of cases. Maxillofac Plast Reconstr Surg 2017; 39: 12. 28. Romero R. The Millard rotation-advancement lip repair using accurate measurements. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 84: 335-8. 29. Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PK. Botulinum toxin to improve results in cleft lip repair: a double-blinded, randomized, vehicle-controlled clinical trial. PLoS One 2014; 9: e115690. 30. Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PK. Botulinum toxin to improve results in cleft lip repair. Plast Reconstr Surg 2014; 134: 511-6. 31. Chen PK, Noordhoff SM, Kane A. Repair of unilateral cleft lip. Plastic Surgery 3rd ed. Philadelphia: Elsevier Saunders, 2013. 32. Cline JM, Oyer SL, Javidnia H, et al. Comparison of the rotation-advancement and philtral ridge techniques for unilateral cleft lip repair. Plast Reconstr Surg 2014; 134: 1269-78. 33. Knight ZL, Ganske I, Deutsch CK, Mulliken JB. The changing nasolabial dimensions following repair of unilateral cleft lip: an anthropometric study in late childhood. Plast Reconstr Surg 2016; 138: 879e-86e.
15
LEGENDS Figure 1. The basic design for cleft lip repair. Total 9 points indicate the anatomic landmarks. Subnasale and two points on columella-lip crease, both alar crest (AC) points, three points on Cupid‟s bow incluing the lowest point and Noordhoff‟s point on lateral lip.
Figure 2A. The design lines referring to the disoriented orbicularis muscle. (Blue dotted lines and solid lines) The directions of muscle dissection on both sides of lips (Red dotted lines)
16
Figure 2B. The completion of dissection. Note that both segments of lips including skin and muscle are dovetailed nicely.
17
Figure 2C. Muscle approximation. Note the superior part of lateral lip muscle filled the defect under the columella in a sort of Z-plasty.
18
19
Figure 3. The first part in dissection of the medial lip. Note the tip of the sharp scissors inserted under the columella for dissecting the muscle. Refer the small illustration on right-bottom part of the photo.
20
Figure 4. The second part in dissection of the medial lip. Note the depth of the dissection to the subdermal layer should not be over 1~2mm to create the central dimple.
21
Figure 5. The dissection of the lateral lip. In lateral lip, three-layer dissection was also performed but more extensive than the dissection of the medial lip.
22
Figure 6. The dissection to the subdermal layer in the lateral lip. The obtained muscle should be thick enough to reconstruct the anatomic lip muscle. Blue arrow is indicating the fingertip supporting the skin to prevent perforating it.
23
Figure 7. The approximation of the dissected muscles. Total four sutures are placed to reconstruct the muscles. The fourth one is sutured from the corner of the lateral lip muscle to the contralateral columella, which is filling up the defect under the columella.
24
Figure 8. The alar rim correction. It is also known as „Tajima inverted U method‟. The inverted U is designed 2mm over the height of nostril in non-cleft side.
25
Figure 9. The alar height and width (AH, AW) were the maximal distance from alar base line to upper border of ala, from subnasale to the projection of alar base, respectively. Nostril height and width (NH, NW) were maximal vertical distance and horizontal distance of the nostril aperture. Alar cheek angle (ACA) was the lateral angle between alar base line and the line joining the alar curvature point and the intersection point of the lateral nostril tangent line and the upper border of ala. Refer to Table 2.
26
Figure 10. Lateral philtral height (LPH) is the distance from the curvature point of alar base to crista philtra, and medial philtral height (MPH) is the distance from subnasale to crista philtra. Vertical philtral height (VPH) is the vertical distance from the level of crista philtra to alar base line. Lateral lip height (LLH) is the distance from the curvature point of alar base to cheilion. Refer to Table 2. 27
SDC 1. The cinch sutures. It not only decreases the width of nostril but also increases the height of nostril. In addition to this advantage, it brings the columella base toward the cleft side and the ala more medially. 28
SDC 2. Subcutaneous sustaining suture. To increase the traction and holding power, the dermal layer is caught by the suture. It creates traction force without cuttingthrough and is able to maintain the alar and columella bases in the desirable position.
SDC 3 and 4. The postoperative pictures. Note the symmetry of the upper lip and the balance between the anatomic landmarks on both sides.
Legends for video Video 1 is for the design based on the anatomic landmarks. Video 2 is for the dissection to the medial lip and lateral lip including harvesting turbinate 29
flap. Video 3 is the approximation after adequate dissection was performed. The temporary four sutures are placed between two sides of muscles. The fifth one is a cinch suture which is for reducing the nostril width and increasing the height. Video 4 is the Tajima reverse U method to approximate the lower lateral cartilage, correct the alar dome, and lengthen the columella.
30
Table 1. Comparisons among various techniques for unilateral cleft lip repairs. Rotation
Use of C-flap
Dissection
incision
Back cut
Vermilion
(releasing
flap
Presurgical Preosurgical Postoperative measureme
incision) Wide C-flap
Free C-flap
Add downward No
No
n by Millard fashion
C-flap could
from
incision from
“Cut as you
membranous
the base of the
go”
columella
of Cupid‟s
the defect of
septum
bow to the
back cut.
Free the alar
base of the
base and
columella
lateral element
result
nt
Modificatio Curvilinear
(1964, 1968) From the peak be used to fill
design
31
Noordhoff
Curvilinear
The same as
Dissect to the
A similar back
Yes
(1984)
Fashion
Millard‟s
base of
cut with
A
As Millard‟s
Modification
columella
Millard‟s
triangular
Dissect to the
modification
flap
Modification
alar base
Yes
between white skin roll and red line
Mohler
Straight line
Narrow C-flap Dissection
Add 90 degrees No
(1987)
Incision from
from medial
the peak of
alar crus to the incision onto
line closure
Cupid‟s bow
tip of the nose the columella
from
downturn
Yes
Straight
to the
columellar
columella
base to mucosa
32
Mulliken
Curvilinear
Narrow C-flap More
Add upward
Yes
(1999)
fashion
C-flap is
incision onto
Incision for
Incision from
retrograded up subdermal and the columella
Vermilion
the peak of
to the
submucosal
Additional
flap is on
Cupid‟s bow
columellar
planes
releasing
red line
to the
defect for
Dissect lateral incision can be
columella
hemi-
side up to the
on white skin
columellar
level of
roll
lengthening
infraorbital
and filling
foramen
extensive in
Yes
medial sill. Cutting
Curvilinear-
(2003)
Wide C flap
Free the alar
The back cut is
straight line
base and
more obtuse
fashion
lateral element angle than
Yes
Yes
Mohler‟s
33
Fisher
Straight line
(2005)
C-flap is not
Medial Lip:
No upper back
Yes
Incision line is created.
Free muscle
cut
A
designed along
from skin and
A small
triangular
the borders of
mucosa
releasing
flap as
anatomic
Preserving
incision is on
Noordhoff‟
subunits.
philtral dimple just above Lateral Lip:
white skin roll.
Dissection
Length of
between skin
vertical height
and muscle in
in cleft side can
lateral lip is
be adjusted by
more
the direction of
extensive.
a small
Free alar base
releasing
from
triangle
Yes
s method
34
underlying maxilla. This Study
Curvilinear
C-flap is
Medial Lip:
No upper back
Yes
fashion
trimmed, or
Dissection of
cut
Preserve
Incision from
adjusted and
muscle to the
the peak of
used in nostril contralateral
A small
marginalis
Cupid‟s bow
floor for
nostril floor
releasing
muscle
to the
lateral lip
Preserving the incision is
subnasale
lengthening.
philtral dimple created at 1mm triangular
No
the pars
with the
Lateral Lip:
above white
vermilion
Free alar base
skin roll
flap to
from piriform
augment
Extensive
medial
dissection
vermilion
among skin, 35
muscle and mucosa
Table 2. Demographics of the patients with complete unilateral cleft lip and palate Clinical presentation Male/female Age at surgery (months)
Patients, n=138
Percentage
83/55
60.1/39.9 %
3.2 ± 0.7
Releasing small skin z-plastyⅰ yes/no
136/2
98.6/1.4 %
Use of C-flapⅱ yes/no
80/58
58.0/42.0 %
Revision surgeryⅲ yes/no
9/129
6.5/93.5 %
36
Postoperative lip retraction requiring massage
18/138
13.0 %
Stitch inflammation
2/138
1.5 %
Dehiscenceiv
1/138
0.7 %
ⅰ Small z-plasty: Small relaxing incision just above the Cupid‟s bow peak on the white skin roll ⅱ Use of C-flap: yes for z-plasty at nostril floor, not to be trimmed ⅲ Revision surgery: Secondary procedures for vermilion trimming (5), lip lengthening (4), and revision of nose (6) ⅳ Partial skin dehiscence at cleft side nasal floor that healed secondarily
37
Table 3. Ratios of the nasolabial measurement in the patients with complete unilateral cleft lip and palate (n= 111) Cleft side/non-cleft side
Mean ± s.d.
Alar width
1.05±0.09
Alar height
0.97±0.06
Nostril width
1.17±0.18
Nostril height
0.93±0.13
Alar cheek angle
1.00±0.04
Lateral philtral height
0.92±0.12
Medial philtral height
1.14±0.26
Vertical philtral height
0.99±0.05
Lateral lip height
1.00±0.08
38