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Conservative technique for treatment of unilateral cleft lip: Reconstruction of the midline tubercle of the vermilion
CONSERVATIVE TECHNIQUE FOR T R E A T M E N T OF UNILATERAL CLEFT L I P : RECONSTRUCTION OF T H E MIDLINE TUBERCLE OF T H E VERMILION 1 By VICTOR SPINA and ORLANDOLODOVICI From the Department of Surgery of the Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Brazil
IN restoring the continuity of a unilateral cleft lip there are very few surgical methods which take into account the Cupid's bow and the philtrum. The majority of techniques in current use involve the sacrifice of these natural structures ; however, it is known that their preservation offers a more rewarding msthetic result. Nevertheless it is necessary to consider that, in trying to camouflage the hare-lip look, attempts at saving these structures may encounter some difficulties. The problem is complex, and before studying some of its main aspects it would be useful to specify the conditions that are required for a technique of repairing unilateral cleft lip to be regarded as an ideal one. In our opinion, such an ideal technique should meet the following requirements : I. Simplicity in outlining and making the incisions. 2. Preservation of the anatomical details present in the lip, such as the philtrum and the Cupid's bow. 3. Saving of tissue, with the purpose of obtaining a tension-free lip, which is of primary importance for the msthetic aspect as well as the functional result and future development of the maxillary bone. 4. Re-establishment of the continuity of the lip in its cutaneous, muscular, and mucous components. 5. Zigzag-shaped cutaneous scar in order to prevent a possible scar contracture. By analysing the most commonly employed techniques for the correction of cleft lip we will see that, in spite of the benefits they provide, they are still far from ideal (Fig. I). Thompson-New technique (Fig. I, a), notwithstanding its simple execution, causes the loss of a great amount of tissue, resulting in a tight lip. Furthermore, it destroys the Cupid's bow and the philtrum columns, leaving a vertical scar subject to contraction. Depending on the gravity of the defect, Mirault-Blair's technique (Fig. I, b) has the merit of preserving one or both philtrum columns, leaving an irregular scar. It has the disadvantage of destroying the Cupid's bow and excising a reasonable amount of tissue thus resulting also in a tight lip. Brown and McDowell's (1945, 195 o) technique (Fig. I, c) reduces somewhat the disadvantages of Mirault-Blair's, mainly because it removes less tissue. Le Mesurier's technique (Fig. I, d), one of the most employed at present, gives a series of advantages over the others referred to. It actually provides more rewarding msthetic results. The vermilion protrudes, giving the lip a more elegant aspect. We must, however, realise that this interesting detail corresponds to a 1 Presented at the Second Brazilian Congress of Plastic Surgery, September IIO
1958.
CONSERVATIVE
TECHNIQUE
FOR
TREATMENT
OF
UNILATERAL
CLEFT
LIP
ili
considerable loss of tissue in the central part of the lip, which produces a certain tightness in the intermediate Zone. We may point out as advantages the irregular scar and the reconstruction of the Cupid's bow. This latter, in our opinion, is an advantage as long as the purpose is secured ; we believe that even the most expert surgeons do not obtain uniformity in the results. The destruction of the Cupid's bow and its reconstruction, according to the original technique, demand great precision in the measurements, as a tiny error may prevent achievement of the real objectives. It may be added that the inferior vertical scar ends at the culminative point of the Cupid's bow, which is far from being satisfactory.
FIG. i
Outlines of the techniques of a, Thompson-New ; b, Mirault-Blair; c, Brown and McDowell; and d, Le Mesurier. The dotted lines show the incisions, and the shaded areas the losses of tissue.
In conclusion, it is a technique in which the outlining of the incisions can vary according to different cases, but which demands, as we have already said, precise measurements. Its performance is not simple and the repair of secondary deformities is difficult to plan. Veau (1938) had already stated that every anatomical element of a normal lip is to be found in the cleft lip, and all there is to do is to put them in their proper places ; in fact, the muscles and all the other components exist. The Cupid's bow appears always complete and very obvious on its medial side, although directed obliquely upwards ; the two philtrum columns also exist, the one on the cleft side being always a short one, thus being responsible for the obliquity 0fthe Cupid's bow. Le Mesurier (1949) and Recamier (1955) have also emphasised this asymmetry.
112
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
According to these observations, we realise that in a unilateral cleft lip it is necessary to bring tissue to the medial side, thus lengthening the short philtrum column and consequently bringing the Cupid's bow to its true position. As a matter of fact this concept is regarded as the basis for the techniques more recently suggested as solutions for the problem (Cardoso, I952 ; Marcks et al., z953 ; Lemos, I956 ; Millard, I957 ; Hagerty, I958 ; Skoog, z958 ; Tennison, I958). We believe that the technique we are going to present fulfils more thoroughly the previously established conditions. It corresponds to the method of Lemos, together with changes of its own. It has, as advantages over all others, simplicity,
(; a
b
•
:t
FIG. 2 D i a g r a m s of t h e p r o p o s e d t e c h n i q u e : a, o u t l i n i n g o f incision in brilliant g r e e n ; b, the m u c o u s m e m b r a n e a n d m u s c u l a r c o m p o n e n t s already s u t u r e d ; c, r e m o v a l of t h e m u c o u s m e m b r a n e of t h e lateral flap of the vermilion for r e c o n s t r u c t i o n of t h e m e d i a n tubercle ; d, o n e n y l o n skin s u t u r e at t h e m u c o c u t a n e o u s junction, a n o t h e r i m m e d i a t e l y above it and a t h i r d in t h e nasal vestibule ; t h e s e last two s u t u r e s are h e l d b y hmmostats, a n d t h e distance b e t w e e n t h e m will f o r m t h e central line o f t h e Z-plasty ; e, outlining in ink of t h e Z ' s side arms ; f , c o m p l e t e d Z - p l a s t y a n d reconstruction o f t h e m e d i a n tubercle b y t h e b u r i e d lateral flap of the vermilion.
little loss of tissue, and partial sparing of the philtrum columns and the Cupid's bow. Finally, it satisfies all the requirements of the ideal technique. We add an attempt to restore the midline tubercle of the vermilion, when not well defined, as may be seen in Fig. 2, c, d, e, and f . Lemos, in order to avoid the inconveniences of Thompson-New technique, started by employing the same incisions, sparing, however, the Cupid's bow by lengthening the resuking line of suture by a Z-plasty. The incisions pertaining to this technique involve all the lip's anatomical components--mucous membrane, muscle, and skin.
CONSERVATIVE TECHNIQUE
FOR
TREATMENT
OF
UNILATERAL
CLEFT
LIP
I I3
The criticism which occurred to us is that the muscular component is repaired in the opposite direction to the fibres of the orbicularis muscle of the lip. We believe that it is unnecessary for the legs of the Z-incision to involve the mucous membrane and the orbicularis muscle. These must simply be sutured, restricting the Z-plasty to the skin, which will be sufficient to effect the required increase in lip height. The points of reference are marked by using a 2 per cent. solution of brilliant green on the sides of the cleft; on the medial side the points correspond to the base of the columella (a) and the beginning of the Cupid's bow (b) ; on the lateral side this distance is transposed, starting from the insertion of the ala (a', b') (Fig. 2, a). The incisions between these points are performed almost along the mucocutaneous line, wasting therefore a minimum of tissue, through all the lip planes and maintaining the flap of vermilion on each side. The incisions at the labial sulcus adjacent to the cleft are made, connecting with the incisions of the mucosa, thus freeing the lip and the cheek. Reconstruction is then done in layers ; initially the edges of the mucosa are sutured together at the vertical part of the lip with interrupted sutures of 4/0 atraumatic chromic catgut ; the edges of the incisions of the labial sulcus are sutured in the same manner and the skin is dissected away from the muscle layer. The latter is sutured with the same type of catgut, using two or three sutures (Fig. 2, b). The suturing of the skin is done with 5/0 interrupted nylon, the first suture being inserted at the level of the nasal vestibule and held by hmmostat. Proceeding, another suture is inserted at the mucocutaneous junction in order to re-establish its continuity ; immediately above this suture another one is put in and held by a second hmmostat (Fig. 2, d); the distance between the latter and the suture placed at the nasal vestibule will form the central line of the Z-plasty. In estimating the desirable lengthening, the remaining limbs of the Z are outlined in ink, the superior one being made medially (Fig. 2, e). The flaps are transposed, completing the cutaneous suture. Finally, the lateral mucous flaps of the vermilion are overlapped and sutured with interrupted 4/0 atraumatic .chromic catgut. Whenever the medial tubercle is not well defined we employ the vermilion .of the lateral side, in order to give more substance to the central part to correspond to the normal tubercle. It is necessary to remove the mucous membrane of the lateral vermilion flap. This flap is buried under the flap on the medial side after ~slight undermining of the latter. When a notch is expected at the vermilion line of suture, the same tactics may be adopted (Fig. 2, c, e, f). We have employed this technique in fifty-nine cases operated on during the period from December I956 to July I958. There were nineteen cases of unilateral partial cleft lip, with the following result : fourteen cases of good lip conformation with good healing and without any complications ; one case of hypertrophic scar ; one case of uneven flaps ; two cases of disruption of skin sutures with a fair end :result ; and one case of infection with a good outcome. Nine cases were observed over a period of eighteen months ; eight showed good results but in one the flaps were still uneven and required slight repair. In three cases the cleft lip was complete, with a good immediate result in each case ; two were re-examined after two and three months respectively, and the ,third after one year, and all maintained the same good results. 2B
114
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
T h e cleft was total unilateral in twenty-three patients, and the immediate results were good in nineteen cases. One presented a dehiscence of the skin. In three there were technical errors : in two cases misjudgment in outlining the reference point corresponding to the Cupid's bow which resulted in insufficient height of the lip ; in the other case a notching of the lip's vermilion occurred. T h e late results of this group were as follows : eleven cases were observed from one to sixteen months, with six patients presenting a good result, two with technical errors and three with hypertrophic scars; these five cases were easily corrected. Finally, fourteen cases were of secondary deformity of cleft lip : of these, immediate results were good in eleven ; suppuration occurred in one ; hypertrophic scar in one, and technical error (the lip having greater height than the normal side) in one. During a period which varied from five to fourteen months eight cases were observed, with the following results : good in five ; hypertrophic scar in two ; one case of technical error. These last three cases were adequately corrected by simple repair. Early and Late Results of Cleft Lip Cases treated by Z-plasty Technique E a r l y r e s u l t s (59 c a s e s ) Fair . Technical errors Hypertrophic scars i Disruption of sutures Suppuration .
47 5 2 3 2
cases cases cases cases cases
L a t e r e s u l t s (32 cases, z t o z8 m o n t h s ) Fair . Technical faults H y p e r t r o p h i c scars i
23 cases 4 cases 5 cases
Without consideration of the type of lip fissure and secondary deformity the immediate results of fifty-nine cases were good in forty-seven ; there was technical error in five cases ; hypertrophic scars in two ; disruption of the skin sutures in two cases, with a good final result ; disruption of the skin and muscle sutures in one case with a good end result ; and finally suppuration in two cases, which had also a good outcome. Among fifty-nine cases, thirty-two were observed from one to eighteen months, with twenty-three cases of good results ; four cases with technical error, two of them having been repaired with success ; and finally five cases of hypertrophic scars, which were corrected. Comparing the data of the different types of cleft lip, we concluded that there were no evident differences which could be ascribed to them. It has therefore proved advisable to treat cleft lips of any type by Z-plasty technique. In only one case, and this of secondary deformity, we had to modify the technique, for the lip already showed, on its deformed side, a height greater than that on the opposite side. To evaluate the efficiency of the technique now under study some remarks on the results we mentioned are in order : T h e results were not so good in twelve cases, for reasons not related to the method, such as defective healing, infection,
CONSERVATIVE
TECHNIQUE
FOR
TREATMENT
OF
UNILATERAL CLEFT
LIP
II
disruption of sutures, and technical faults. All these complications are present in greater or lesser degree in any method of cleft lip repair. Therefore, when it is correctly done, the Z-plasty for cleft lip produces a perfect lip appearance by conserving all normal anatomical components. As to late results, these too, when not satisfactory, were always influenced by factors not related to the method, such as hypertrophic scars and technical errors. That is so true that, out of nine cases with unsatisfactory results, seven were properly corrected by simple repair.
FIG. 3
FIG. 4
FIG. 5
FIG. 6
Figs. 3 to 6 . - - C l e f t lip treated b y the t e c h n i q u e described.
The results of some of our cases operated on with the proposed technique are showfi in Figs. 3 to Io. The methods of deft-lip repair that achieved a greater popularity--like those of Mirault-Blair, Brown and McDowell, Thompson-New, Le Mesurier--besides being rather complicated exhibit the characteristic of not sparing the normal structures. These techniques are liable to criticism when judged according to the principles of an ideal method. More recently, innumerable techniques have been proposed, among which are those of Tennison, Marcks and Col, Cardoso, Hagerty, Millard, Lemos, and Skoog. All of them are based on the following principles : the presence in the cleft lip of every element of the normal lip, and the appreciation that the philtrum
116
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
columns of the cleft side are shorter, thus causing an elevation of the Cupid's bow on that side. These techniques consist of lengthening the short phiitrum column, preserving all the normal structures, at the same time overlapping the lines of the skin suture, which take the shape of a Z. With the exception of Lemos' method, all the others seek the common objective of bringing tissue from the lateral dement of the lip to the medial, through complicated incisions which are difficult to outline. Since there is a perfectly standardised and well-known surgical technique, as the Z-plasty, with
Fro. 7
FIG. 8
FIG. 9 FIG. IO Figs. 7 to io.--Secondary cleft lip repaired by the same technique.
the basic property of producing length, it is obvious that it is easier to give the shorter philtrum column its normal dimensions by means of this technique, and consequently to bring the Cupid's bow into normal position. Furthermore, the increase in height to be added to the cleft lip is well calculated, because of the special characteristics of the Z-plasty. The suitability of this method is not affected by the varieties of cleft lip ; a good lip appearance is always obtained. The results, when unsatisfactory, are a consequence of factors not related to the technique. SUMMARY A technique for correction of cleft lip is described in which there is no sacrifice of tissue, the anatomical structures are preserved and the shorter philtrum
CONSERVATIVE TECHNIQUE FOR TREATMENT OF UNILATERAL CLEFT LIP
I 17"
column is lengthened by means of a Z-plasty applied only to the skin. The method is easy and the results are satisfactory. The writers present their experience in fifty-nine cases treated by this method.
REFERENCES BROWN, J. B., and McDOWELL, F. (I945). Surg. Gynec. Obstet., 80, I2. -(I95O). Plast. reconstr. Surg., 5, 392. CARDOSO, A. D. (I952). Plast. reconstr. Surg., IO, 92. HAGERTY, R. F. (r958). Surg. Gynec. Obstet., ro6, II9. LE MESURIER, A. t3. (I949). Plast. reconstr. Surg., 4, I. LEMOS, P. C. (I956). Hospital, Rio deft., 50, 607. MARCKS, K. M., TREVASKIS, A. E., and DA COSTA, A. (I953). Plast. reconstr. Surg., r2, 392. MILLARD, D. R. (I957). " Transactions of the International Society of Plastic Surgeons." First Congress. p. I6O. Baltimore : Williams & Wilkins Co. RECAMIER, J. (I955). Sere. H6p. Paris, Io, I. SKOOG, T. (I958). Amer. ft. Surg., 95, 223. TENNISON, C. W. (I958). Plast. reconstr. Surg., 9, It5. VEAU, V. (I938). " Bec de Li~vre." Paris : Masson et Cie.
IN restoring the continuity of a unilateral cleft lip there are very few surgical methods which take into account the Cupid's bow and the philtrum. The majority of techniques in current use involve the sacrifice of these natural structures ; however, it is known that their preservation offers a more rewarding msthetic result. Nevertheless it is necessary to consider that, in trying to camouflage the hare-lip look, attempts at saving these structures may encounter some difficulties. The problem is complex, and before studying some of its main aspects it would be useful to specify the conditions that are required for a technique of repairing unilateral cleft lip to be regarded as an ideal one. In our opinion, such an ideal technique should meet the following requirements : I. Simplicity in outlining and making the incisions. 2. Preservation of the anatomical details present in the lip, such as the philtrum and the Cupid's bow. 3. Saving of tissue, with the purpose of obtaining a tension-free lip, which is of primary importance for the msthetic aspect as well as the functional result and future development of the maxillary bone. 4. Re-establishment of the continuity of the lip in its cutaneous, muscular, and mucous components. 5. Zigzag-shaped cutaneous scar in order to prevent a possible scar contracture. By analysing the most commonly employed techniques for the correction of cleft lip we will see that, in spite of the benefits they provide, they are still far from ideal (Fig. I). Thompson-New technique (Fig. I, a), notwithstanding its simple execution, causes the loss of a great amount of tissue, resulting in a tight lip. Furthermore, it destroys the Cupid's bow and the philtrum columns, leaving a vertical scar subject to contraction. Depending on the gravity of the defect, Mirault-Blair's technique (Fig. I, b) has the merit of preserving one or both philtrum columns, leaving an irregular scar. It has the disadvantage of destroying the Cupid's bow and excising a reasonable amount of tissue thus resulting also in a tight lip. Brown and McDowell's (1945, 195 o) technique (Fig. I, c) reduces somewhat the disadvantages of Mirault-Blair's, mainly because it removes less tissue. Le Mesurier's technique (Fig. I, d), one of the most employed at present, gives a series of advantages over the others referred to. It actually provides more rewarding msthetic results. The vermilion protrudes, giving the lip a more elegant aspect. We must, however, realise that this interesting detail corresponds to a 1 Presented at the Second Brazilian Congress of Plastic Surgery, September IIO
1958.
CONSERVATIVE
TECHNIQUE
FOR
TREATMENT
OF
UNILATERAL
CLEFT
LIP
ili
considerable loss of tissue in the central part of the lip, which produces a certain tightness in the intermediate Zone. We may point out as advantages the irregular scar and the reconstruction of the Cupid's bow. This latter, in our opinion, is an advantage as long as the purpose is secured ; we believe that even the most expert surgeons do not obtain uniformity in the results. The destruction of the Cupid's bow and its reconstruction, according to the original technique, demand great precision in the measurements, as a tiny error may prevent achievement of the real objectives. It may be added that the inferior vertical scar ends at the culminative point of the Cupid's bow, which is far from being satisfactory.
FIG. i
Outlines of the techniques of a, Thompson-New ; b, Mirault-Blair; c, Brown and McDowell; and d, Le Mesurier. The dotted lines show the incisions, and the shaded areas the losses of tissue.
In conclusion, it is a technique in which the outlining of the incisions can vary according to different cases, but which demands, as we have already said, precise measurements. Its performance is not simple and the repair of secondary deformities is difficult to plan. Veau (1938) had already stated that every anatomical element of a normal lip is to be found in the cleft lip, and all there is to do is to put them in their proper places ; in fact, the muscles and all the other components exist. The Cupid's bow appears always complete and very obvious on its medial side, although directed obliquely upwards ; the two philtrum columns also exist, the one on the cleft side being always a short one, thus being responsible for the obliquity 0fthe Cupid's bow. Le Mesurier (1949) and Recamier (1955) have also emphasised this asymmetry.
112
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
According to these observations, we realise that in a unilateral cleft lip it is necessary to bring tissue to the medial side, thus lengthening the short philtrum column and consequently bringing the Cupid's bow to its true position. As a matter of fact this concept is regarded as the basis for the techniques more recently suggested as solutions for the problem (Cardoso, I952 ; Marcks et al., z953 ; Lemos, I956 ; Millard, I957 ; Hagerty, I958 ; Skoog, z958 ; Tennison, I958). We believe that the technique we are going to present fulfils more thoroughly the previously established conditions. It corresponds to the method of Lemos, together with changes of its own. It has, as advantages over all others, simplicity,
(; a
b
•
:t
FIG. 2 D i a g r a m s of t h e p r o p o s e d t e c h n i q u e : a, o u t l i n i n g o f incision in brilliant g r e e n ; b, the m u c o u s m e m b r a n e a n d m u s c u l a r c o m p o n e n t s already s u t u r e d ; c, r e m o v a l of t h e m u c o u s m e m b r a n e of t h e lateral flap of the vermilion for r e c o n s t r u c t i o n of t h e m e d i a n tubercle ; d, o n e n y l o n skin s u t u r e at t h e m u c o c u t a n e o u s junction, a n o t h e r i m m e d i a t e l y above it and a t h i r d in t h e nasal vestibule ; t h e s e last two s u t u r e s are h e l d b y hmmostats, a n d t h e distance b e t w e e n t h e m will f o r m t h e central line o f t h e Z-plasty ; e, outlining in ink of t h e Z ' s side arms ; f , c o m p l e t e d Z - p l a s t y a n d reconstruction o f t h e m e d i a n tubercle b y t h e b u r i e d lateral flap of the vermilion.
little loss of tissue, and partial sparing of the philtrum columns and the Cupid's bow. Finally, it satisfies all the requirements of the ideal technique. We add an attempt to restore the midline tubercle of the vermilion, when not well defined, as may be seen in Fig. 2, c, d, e, and f . Lemos, in order to avoid the inconveniences of Thompson-New technique, started by employing the same incisions, sparing, however, the Cupid's bow by lengthening the resuking line of suture by a Z-plasty. The incisions pertaining to this technique involve all the lip's anatomical components--mucous membrane, muscle, and skin.
CONSERVATIVE TECHNIQUE
FOR
TREATMENT
OF
UNILATERAL
CLEFT
LIP
I I3
The criticism which occurred to us is that the muscular component is repaired in the opposite direction to the fibres of the orbicularis muscle of the lip. We believe that it is unnecessary for the legs of the Z-incision to involve the mucous membrane and the orbicularis muscle. These must simply be sutured, restricting the Z-plasty to the skin, which will be sufficient to effect the required increase in lip height. The points of reference are marked by using a 2 per cent. solution of brilliant green on the sides of the cleft; on the medial side the points correspond to the base of the columella (a) and the beginning of the Cupid's bow (b) ; on the lateral side this distance is transposed, starting from the insertion of the ala (a', b') (Fig. 2, a). The incisions between these points are performed almost along the mucocutaneous line, wasting therefore a minimum of tissue, through all the lip planes and maintaining the flap of vermilion on each side. The incisions at the labial sulcus adjacent to the cleft are made, connecting with the incisions of the mucosa, thus freeing the lip and the cheek. Reconstruction is then done in layers ; initially the edges of the mucosa are sutured together at the vertical part of the lip with interrupted sutures of 4/0 atraumatic chromic catgut ; the edges of the incisions of the labial sulcus are sutured in the same manner and the skin is dissected away from the muscle layer. The latter is sutured with the same type of catgut, using two or three sutures (Fig. 2, b). The suturing of the skin is done with 5/0 interrupted nylon, the first suture being inserted at the level of the nasal vestibule and held by hmmostat. Proceeding, another suture is inserted at the mucocutaneous junction in order to re-establish its continuity ; immediately above this suture another one is put in and held by a second hmmostat (Fig. 2, d); the distance between the latter and the suture placed at the nasal vestibule will form the central line of the Z-plasty. In estimating the desirable lengthening, the remaining limbs of the Z are outlined in ink, the superior one being made medially (Fig. 2, e). The flaps are transposed, completing the cutaneous suture. Finally, the lateral mucous flaps of the vermilion are overlapped and sutured with interrupted 4/0 atraumatic .chromic catgut. Whenever the medial tubercle is not well defined we employ the vermilion .of the lateral side, in order to give more substance to the central part to correspond to the normal tubercle. It is necessary to remove the mucous membrane of the lateral vermilion flap. This flap is buried under the flap on the medial side after ~slight undermining of the latter. When a notch is expected at the vermilion line of suture, the same tactics may be adopted (Fig. 2, c, e, f). We have employed this technique in fifty-nine cases operated on during the period from December I956 to July I958. There were nineteen cases of unilateral partial cleft lip, with the following result : fourteen cases of good lip conformation with good healing and without any complications ; one case of hypertrophic scar ; one case of uneven flaps ; two cases of disruption of skin sutures with a fair end :result ; and one case of infection with a good outcome. Nine cases were observed over a period of eighteen months ; eight showed good results but in one the flaps were still uneven and required slight repair. In three cases the cleft lip was complete, with a good immediate result in each case ; two were re-examined after two and three months respectively, and the ,third after one year, and all maintained the same good results. 2B
114
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
T h e cleft was total unilateral in twenty-three patients, and the immediate results were good in nineteen cases. One presented a dehiscence of the skin. In three there were technical errors : in two cases misjudgment in outlining the reference point corresponding to the Cupid's bow which resulted in insufficient height of the lip ; in the other case a notching of the lip's vermilion occurred. T h e late results of this group were as follows : eleven cases were observed from one to sixteen months, with six patients presenting a good result, two with technical errors and three with hypertrophic scars; these five cases were easily corrected. Finally, fourteen cases were of secondary deformity of cleft lip : of these, immediate results were good in eleven ; suppuration occurred in one ; hypertrophic scar in one, and technical error (the lip having greater height than the normal side) in one. During a period which varied from five to fourteen months eight cases were observed, with the following results : good in five ; hypertrophic scar in two ; one case of technical error. These last three cases were adequately corrected by simple repair. Early and Late Results of Cleft Lip Cases treated by Z-plasty Technique E a r l y r e s u l t s (59 c a s e s ) Fair . Technical errors Hypertrophic scars i Disruption of sutures Suppuration .
47 5 2 3 2
cases cases cases cases cases
L a t e r e s u l t s (32 cases, z t o z8 m o n t h s ) Fair . Technical faults H y p e r t r o p h i c scars i
23 cases 4 cases 5 cases
Without consideration of the type of lip fissure and secondary deformity the immediate results of fifty-nine cases were good in forty-seven ; there was technical error in five cases ; hypertrophic scars in two ; disruption of the skin sutures in two cases, with a good final result ; disruption of the skin and muscle sutures in one case with a good end result ; and finally suppuration in two cases, which had also a good outcome. Among fifty-nine cases, thirty-two were observed from one to eighteen months, with twenty-three cases of good results ; four cases with technical error, two of them having been repaired with success ; and finally five cases of hypertrophic scars, which were corrected. Comparing the data of the different types of cleft lip, we concluded that there were no evident differences which could be ascribed to them. It has therefore proved advisable to treat cleft lips of any type by Z-plasty technique. In only one case, and this of secondary deformity, we had to modify the technique, for the lip already showed, on its deformed side, a height greater than that on the opposite side. To evaluate the efficiency of the technique now under study some remarks on the results we mentioned are in order : T h e results were not so good in twelve cases, for reasons not related to the method, such as defective healing, infection,
CONSERVATIVE
TECHNIQUE
FOR
TREATMENT
OF
UNILATERAL CLEFT
LIP
II
disruption of sutures, and technical faults. All these complications are present in greater or lesser degree in any method of cleft lip repair. Therefore, when it is correctly done, the Z-plasty for cleft lip produces a perfect lip appearance by conserving all normal anatomical components. As to late results, these too, when not satisfactory, were always influenced by factors not related to the method, such as hypertrophic scars and technical errors. That is so true that, out of nine cases with unsatisfactory results, seven were properly corrected by simple repair.
FIG. 3
FIG. 4
FIG. 5
FIG. 6
Figs. 3 to 6 . - - C l e f t lip treated b y the t e c h n i q u e described.
The results of some of our cases operated on with the proposed technique are showfi in Figs. 3 to Io. The methods of deft-lip repair that achieved a greater popularity--like those of Mirault-Blair, Brown and McDowell, Thompson-New, Le Mesurier--besides being rather complicated exhibit the characteristic of not sparing the normal structures. These techniques are liable to criticism when judged according to the principles of an ideal method. More recently, innumerable techniques have been proposed, among which are those of Tennison, Marcks and Col, Cardoso, Hagerty, Millard, Lemos, and Skoog. All of them are based on the following principles : the presence in the cleft lip of every element of the normal lip, and the appreciation that the philtrum
116
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
columns of the cleft side are shorter, thus causing an elevation of the Cupid's bow on that side. These techniques consist of lengthening the short phiitrum column, preserving all the normal structures, at the same time overlapping the lines of the skin suture, which take the shape of a Z. With the exception of Lemos' method, all the others seek the common objective of bringing tissue from the lateral dement of the lip to the medial, through complicated incisions which are difficult to outline. Since there is a perfectly standardised and well-known surgical technique, as the Z-plasty, with
Fro. 7
FIG. 8
FIG. 9 FIG. IO Figs. 7 to io.--Secondary cleft lip repaired by the same technique.
the basic property of producing length, it is obvious that it is easier to give the shorter philtrum column its normal dimensions by means of this technique, and consequently to bring the Cupid's bow into normal position. Furthermore, the increase in height to be added to the cleft lip is well calculated, because of the special characteristics of the Z-plasty. The suitability of this method is not affected by the varieties of cleft lip ; a good lip appearance is always obtained. The results, when unsatisfactory, are a consequence of factors not related to the technique. SUMMARY A technique for correction of cleft lip is described in which there is no sacrifice of tissue, the anatomical structures are preserved and the shorter philtrum
CONSERVATIVE TECHNIQUE FOR TREATMENT OF UNILATERAL CLEFT LIP
I 17"
column is lengthened by means of a Z-plasty applied only to the skin. The method is easy and the results are satisfactory. The writers present their experience in fifty-nine cases treated by this method.
REFERENCES BROWN, J. B., and McDOWELL, F. (I945). Surg. Gynec. Obstet., 80, I2. -(I95O). Plast. reconstr. Surg., 5, 392. CARDOSO, A. D. (I952). Plast. reconstr. Surg., IO, 92. HAGERTY, R. F. (r958). Surg. Gynec. Obstet., ro6, II9. LE MESURIER, A. t3. (I949). Plast. reconstr. Surg., 4, I. LEMOS, P. C. (I956). Hospital, Rio deft., 50, 607. MARCKS, K. M., TREVASKIS, A. E., and DA COSTA, A. (I953). Plast. reconstr. Surg., r2, 392. MILLARD, D. R. (I957). " Transactions of the International Society of Plastic Surgeons." First Congress. p. I6O. Baltimore : Williams & Wilkins Co. RECAMIER, J. (I955). Sere. H6p. Paris, Io, I. SKOOG, T. (I958). Amer. ft. Surg., 95, 223. TENNISON, C. W. (I958). Plast. reconstr. Surg., 9, It5. VEAU, V. (I938). " Bec de Li~vre." Paris : Masson et Cie.