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Correction of secondary vermilion notching deformity in unilateral cleft lip patients: Complete revision of two errors
Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 326e329
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Correction of secondary vermilion notching deformity in unilateral cleft lip patients: Complete revision of two errors Sang Woo Lee, Min Ho Kim, Rong-Min Baek* Department of Plastic and Reconstructive Surgery (Head: Rong-Min Baek, MD), Seoul National University Bundang Hospital, 166 Gumiro, Bundang, Seongnam, Gyeonggi 463-707, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 30 January 2010 Accepted 14 July 2010
Background: Vermilion notching deformity is one of the most common secondary deformities in unilateral cleft lip patients. Two errors during primary cheiloplasty seem to cause notching deformity. The first one is insufficiently lengthened oral lining of the medial lip compared to the cutaneous surface, and the other is medialized marking of the height of cupid’s bow on cleft side rather than marking it at the thickest portion of the vermilion. The authors were able to obtain satisfactory results after revising notching deformities by correcting these two errors. Methods: A total of 104 patients (median age: 13) with secondary notching deformity underwent revision surgery from 1987 to 2009. After the new height of cupid’s bow on the cleft side was marked on the white roll with the greatest vermilion fullness, the notched vermilion including the cutaneous scar was elevated. For sufficient lengthening of the oral lining, the elevated tissue was interposed as an inferior pedicled flap into a relaxing incision of the central portion of the oral sulcus. Results: The follow-up period ranged from 1 year to 12 years. The patients were satisfied with the aesthetic outcomes. Seven patients experienced lateral vermilion bulging which was easily corrected by an elliptical excision. Conclusion: Complete revision by lengthening the oral lining of the central lip portion, and lateralizing the height of cupid’s bow of cleft side to the region where vermilion is thickest, is an effective method for correction of secondary notching deformity. Ó 2010 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Unilateral cleft lip Secondary notching deformity Revision cheiloplasty
1. Introduction Secondary deformities in cleft lip patients who have undergone primary cheiloplasty are not uncommon. Recent advances in clinical research and surgical techniques have reduced the need for secondary revision procedures; however, secondary deformities of cleft lip are still prevalent (Mommaerts and Nagy, 2008; Schwenzer-Zimmerer et al., 2008). Notching deformity (whistle deformity) is one of the most common secondary deformities (Stal and Hollier, 2002) after primary cheiloplasty. Notching deformities are often thought to be confined to the vermilion, and surgeons tend to restrict their efforts by correcting them within the vermilion using a local mucosal flap. Dermofat grafts or fascia grafts on a notching area may also be attempted (Chen et al., 1995; Patel and Hall, 2004; Wakami et al., 2010). However, these procedures may cause unwanted scars or otherwise produce suboptimal outcomes. * Corresponding author: E-mail address: [email protected] (R.-M. Baek).
The authors assumed that notching deformities arise because of two errors during primary cheiloplasty, and that notching can be corrected by revision of these errors. First, vermilion notching may occur when the oral lining of the medial flap is lengthened insufficiently. This occurs when the symmetry of the cupid’s bow is achieved by rotation and sufficient lengthening of cutaneous side, but the lengthening of the oral lining is relatively shorter. This causes a tethering of the mucosal flap of the oral lining, creating a notch. The second error is medailly deflected marking of the height of cupid’s bow. When the height of cupid’s bow is determined on cleft side, the marking should be at the thickest point of the vermilion. If the location of marking of the height of cupid’s bow on the cleft side is determined by using the same length as measured between the oral commisure and the height of cupid’s bow on the noncleft side, the vermilion of the lateral flap usually becomes thinner than the medial flap, creating a notching deformity. The authors have obtained satisfactory results after complete revision of notching deformities in unilateral cleft lip patients by correcting the two errors.
1010-5182/$ e see front matter Ó 2010 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2010.07.001
S.W. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 326e329
327
Fig. 1. (A) Preoperative design of incision line. The height of cupid’s bow on the cleft side of the lip was realigned to the white roll (black arrow) perpendicular from the area of thickest vermilion (white arrow). (B) The notch and cutaneous scar tissue were excised and used as an inferior pedicle flap. (C) Inferior pedicle flap was interposed into the lengthened central oral sulcus after a relaxing incision. (D) Interposition of the flap was performed after trimming. (E) Immediate postoperative view.
2. Patients and methods From 1987 to 2009, a total of 104 patients with unilateral secondary notching deformities underwent surgery. Their ages ranged from 5 years to 64 years, and the median age was 13 years. Of these patients, 12 had undergone previous secondary deformity correction at other clinical facilities, but with suboptimal results. Most operations were performed under general anaesthesia, and in some adult patients monitored anaesthesia care (MAC) was used. First, the height of cupid’s bow on the cleft side was reassigned to the point just before the attenuation of vermilion fullness. In other words, a perpendicular line was drawn from the point where the thickness of vermilion is greatest to the white roll, and the point where this line meets the white roll was determined as the height of cupid’s bow on the cleft side lip (Fig. 1A). A flap was designed to include the notched portion and cutaneous scar tissue between the previous height of cupid’s bow and the point where the new height was intended (Fig. 1B). This flap was used as an inferior pedicled flap. The mucosa was incised at the central oral sulcus, and the flap was interposed so that sufficient lengthening of the central part of the oral lining would be made, correcting the notch and creating fullness of the central vermilion (Fig. 1CeE). The continuity of the orbicularis oris muscle was monitored intraoperatively. In case of discontinuity, overlapping of both ends of the muscle was performed after realignment. Patients were discharged on the day of, or the day after surgery, and sutures were removed on the 6th postoperative day.
cheiloplasty at 10 years of age at another hospital, but presented with a secondary notching deformity and peaking of the white roll. During surgery, we found and repaired discontinuity of the orbicularis oris muscle, and the notching deformity was revised using our method. The results were satisfactory, and the peaking of the white roll was corrected concomitantly (Fig. 2). 3.2. Case 2 A 22-year-old female patient with left unilateral cleft lip underwent primary cheiloplasty at 4 months of age. The patient underwent corrective rhinoplasty and revision cheiloplasty for secondary deformity at a different hospital at 20 years of age. The revision was inadequate, and she presented at our institution. She underwent revisional surgery using our method. Discontinuity and malalignment of the orbicularis oris muscle were corrected simultaneously by cutting and realigning during revision. Notching deformity was corrected and alar base depression was improved by muscle realignment (Fig. 3). 3.3. Case 3 A 23-year-old male patient with a left unilateral cleft lip underwent primary cheiloplasty at 4 months of age. He presented with a vermilion notching deformity. Intraoperative analysis showed that the lengthening of the central area of the oral lining was insufficient. After surgery, the result was satisfactory (Fig. 4).
3. Results 4. Discussion The follow-up period ranged from 1 year to 12 years. The patients were generally satisfied with the aesthetic outcome and there were no particular complications. Seven out of 104 patients (6.7%) experienced lateral vermilion bulging, which was easily corrected by an elliptical excision. 3.1. Case 1 A 20-year-old male patient with left unilateral complete cleft lip and palate underwent primary cheiloplasty at 2 months of age and palatoplasty at 12 months of age. The patient underwent revision
Focusing on the cutaneous aspect during primary cheiloplasty may attain cutaneous symmetry; however, lip tightening or vermilion notching deformity may develop (Baek and Lee, 2009). The lips are a three-dimensional structure, and cutaneous lengthening by rotation must be performed concurrently with lengthening of the oral lining. With our methods of primary cheiloplasty, transpositioning of the medial mucosal flap into the central oral lining allowed lengthening of the oral side, and vermilion notching deformity did not occur in most of the 400 cases who underwent our procedure (Baek and Lee, 2009). Although lateral vermilion
328
S.W. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 326e329
Fig. 2. (A) Vermilion notching and peaking of white roll are seen. (B) Photograph 1 year after operation.
Fig. 3. (A) Preoperative frontal view. Note the vermilion notching and depression of the left alar base. (B) Photograph 3 months after operation.
Fig. 4. (A) Preoperative frontal view. Note the vermilion notching deformity. (B) Postoperative result at 1-year follow-up. Notching deformity is corrected and philtral scar is improved.
bulging deformities may occasionally occur with this method, these can be easily revised by a simple elliptical excision. The location of the height of cupid’s bow on the cleft side can be determined by transposing the equal distance measured from the oral commisure to the height of cupid’s bow on the noncleft side, or by the point where the white roll disappears. Horizontal symmetry may be achieved using such procedures; however, notching deformities may occur as a result of vermilion thinning on the cleft side (Losee et al., 2003). Vertical asymmetry, which is much more conspicuous than horizontal asymmetry, may also occur because of the decreased vertical height from the alar base. Therefore the standard procedure for determining the location of the height of cupid’s bow on the cleft side should be a perpendicular line drawn from the point where the thickness of vermilion is greatest to the white roll, and the point at which the line meets the white roll is where the height of cupid’s bow should be located. Repair of the orbicularis oris muscle is essential in cheiloplasty (Seagle and Furlow, 2004). When muscle repair is poorly or inadequately executed during primary cheiloplasty, depression or grooving may occur, which becomes more obvious when the lips are moved or pursed. Our methods allow the evaluation of the state of the orbicularis oris muscle during surgery, and when discontinuity of the muscle is discovered, a realignment or overlap can be performed to correct depression or grooving. The operating time was not much longer than the time needed for conventional partial elliptical excision or VeYadvancement methods, and provided improvement in the overall aesthetic outcome of the lips. The mean operating time was approximately 1 h, and surgical methods allowed concurrent scar revision of the upper white lip. This surgical method has another advantage, in that it can correct mild cases of short lip by making an incision up to the base
S.W. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 326e329
of the columella and placing a backcut. It also allows simultaneous realignment of peaking of the white roll. In such cases, tattooing of the skin and vermilion junction with gentian violet is crucial, as the incision design is excised or erased during surgery, and the vermilion junction may be hard to distinguish because of the effects of epinephrine. 5. Conclusion The authors performed satisfactory revision cheiloplasty on patients with secondary vermilion notching deformities of unilateral cleft lip. This was accomplished by sufficient lengthening of the medial oral lining, and by taking the white roll with the greatest vermilion fullness as the standard point of the height of cupid’s bow on the cleft side. Conflict of interest The authors received no financial support from any company or sources, and have no commercial association or financial relationships to disclosure.
329
References Baek RM, Lee SW: Important aspects of oral lining in unilateral cleft lip repair. J Craniofac Surg 20: 1578e1582, 2009 Chen PK, Noordhoff MS, Chen YR, Bendor-Samuel R: Augmentation of the free border of the lip in cleft lip patients using temporoparietal fascia. Plast Reconstr Surg 95: 781e788, 1995 Losee JE, Selber JC, Arkoulakis N, Serletti JM: The cleft lateral lip element: do traditional markings result in secondary deformities? Ann Plast Surg 50: 594e600, 2003 Mommaerts MY, Nagy K: Analysis of the cleft lip-nose in the submental-vertical view. Part II. Panel study: which is the most important deformity? J Craniomaxillofac Surg 36: 315e320, 2008 Patel IA, Hall PN: Free dermis-fat graft to correct the whistle deformity in patients with cleft lip. Br J Plast Surg 57: 160e164, 2004 Schwenzer-Zimmerer K, Chaitidis D, Berg-Boerner I, Krol Z, Kovacs L, Schwenzer NF, Zimmerer S, Holberg C, Zeilhofer HF: Quantitative 3D soft tissue analysis of symmetry prior to and after unilateral cleft lip repair compared with non-cleft persons (performed in Cambodia). J Craniomaxillofac Surg 36: 431e438, 2008 Seagle MB, Furlow Jr LT: Muscle reconstruction in cleft lip repair. Plast Reconstr Surg 113: 1537e1547, 2004 Stal S, Hollier L: Correction of secondary cleft lip deformities. Plast Reconstr Surg 109: 1672e1681, 2002 Wakami S, Harada T, Muraoka M, Ishii M: Rectangular mucosal flap with artificial dermis grafting for vermilion deformity in cleft lips. J Plast Reconstr Aesthet Surg 63: 22e27, 2010
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Correction of secondary vermilion notching deformity in unilateral cleft lip patients: Complete revision of two errors Sang Woo Lee, Min Ho Kim, Rong-Min Baek* Department of Plastic and Reconstructive Surgery (Head: Rong-Min Baek, MD), Seoul National University Bundang Hospital, 166 Gumiro, Bundang, Seongnam, Gyeonggi 463-707, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 30 January 2010 Accepted 14 July 2010
Background: Vermilion notching deformity is one of the most common secondary deformities in unilateral cleft lip patients. Two errors during primary cheiloplasty seem to cause notching deformity. The first one is insufficiently lengthened oral lining of the medial lip compared to the cutaneous surface, and the other is medialized marking of the height of cupid’s bow on cleft side rather than marking it at the thickest portion of the vermilion. The authors were able to obtain satisfactory results after revising notching deformities by correcting these two errors. Methods: A total of 104 patients (median age: 13) with secondary notching deformity underwent revision surgery from 1987 to 2009. After the new height of cupid’s bow on the cleft side was marked on the white roll with the greatest vermilion fullness, the notched vermilion including the cutaneous scar was elevated. For sufficient lengthening of the oral lining, the elevated tissue was interposed as an inferior pedicled flap into a relaxing incision of the central portion of the oral sulcus. Results: The follow-up period ranged from 1 year to 12 years. The patients were satisfied with the aesthetic outcomes. Seven patients experienced lateral vermilion bulging which was easily corrected by an elliptical excision. Conclusion: Complete revision by lengthening the oral lining of the central lip portion, and lateralizing the height of cupid’s bow of cleft side to the region where vermilion is thickest, is an effective method for correction of secondary notching deformity. Ó 2010 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Unilateral cleft lip Secondary notching deformity Revision cheiloplasty
1. Introduction Secondary deformities in cleft lip patients who have undergone primary cheiloplasty are not uncommon. Recent advances in clinical research and surgical techniques have reduced the need for secondary revision procedures; however, secondary deformities of cleft lip are still prevalent (Mommaerts and Nagy, 2008; Schwenzer-Zimmerer et al., 2008). Notching deformity (whistle deformity) is one of the most common secondary deformities (Stal and Hollier, 2002) after primary cheiloplasty. Notching deformities are often thought to be confined to the vermilion, and surgeons tend to restrict their efforts by correcting them within the vermilion using a local mucosal flap. Dermofat grafts or fascia grafts on a notching area may also be attempted (Chen et al., 1995; Patel and Hall, 2004; Wakami et al., 2010). However, these procedures may cause unwanted scars or otherwise produce suboptimal outcomes. * Corresponding author: E-mail address: [email protected] (R.-M. Baek).
The authors assumed that notching deformities arise because of two errors during primary cheiloplasty, and that notching can be corrected by revision of these errors. First, vermilion notching may occur when the oral lining of the medial flap is lengthened insufficiently. This occurs when the symmetry of the cupid’s bow is achieved by rotation and sufficient lengthening of cutaneous side, but the lengthening of the oral lining is relatively shorter. This causes a tethering of the mucosal flap of the oral lining, creating a notch. The second error is medailly deflected marking of the height of cupid’s bow. When the height of cupid’s bow is determined on cleft side, the marking should be at the thickest point of the vermilion. If the location of marking of the height of cupid’s bow on the cleft side is determined by using the same length as measured between the oral commisure and the height of cupid’s bow on the noncleft side, the vermilion of the lateral flap usually becomes thinner than the medial flap, creating a notching deformity. The authors have obtained satisfactory results after complete revision of notching deformities in unilateral cleft lip patients by correcting the two errors.
1010-5182/$ e see front matter Ó 2010 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2010.07.001
S.W. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 326e329
327
Fig. 1. (A) Preoperative design of incision line. The height of cupid’s bow on the cleft side of the lip was realigned to the white roll (black arrow) perpendicular from the area of thickest vermilion (white arrow). (B) The notch and cutaneous scar tissue were excised and used as an inferior pedicle flap. (C) Inferior pedicle flap was interposed into the lengthened central oral sulcus after a relaxing incision. (D) Interposition of the flap was performed after trimming. (E) Immediate postoperative view.
2. Patients and methods From 1987 to 2009, a total of 104 patients with unilateral secondary notching deformities underwent surgery. Their ages ranged from 5 years to 64 years, and the median age was 13 years. Of these patients, 12 had undergone previous secondary deformity correction at other clinical facilities, but with suboptimal results. Most operations were performed under general anaesthesia, and in some adult patients monitored anaesthesia care (MAC) was used. First, the height of cupid’s bow on the cleft side was reassigned to the point just before the attenuation of vermilion fullness. In other words, a perpendicular line was drawn from the point where the thickness of vermilion is greatest to the white roll, and the point where this line meets the white roll was determined as the height of cupid’s bow on the cleft side lip (Fig. 1A). A flap was designed to include the notched portion and cutaneous scar tissue between the previous height of cupid’s bow and the point where the new height was intended (Fig. 1B). This flap was used as an inferior pedicled flap. The mucosa was incised at the central oral sulcus, and the flap was interposed so that sufficient lengthening of the central part of the oral lining would be made, correcting the notch and creating fullness of the central vermilion (Fig. 1CeE). The continuity of the orbicularis oris muscle was monitored intraoperatively. In case of discontinuity, overlapping of both ends of the muscle was performed after realignment. Patients were discharged on the day of, or the day after surgery, and sutures were removed on the 6th postoperative day.
cheiloplasty at 10 years of age at another hospital, but presented with a secondary notching deformity and peaking of the white roll. During surgery, we found and repaired discontinuity of the orbicularis oris muscle, and the notching deformity was revised using our method. The results were satisfactory, and the peaking of the white roll was corrected concomitantly (Fig. 2). 3.2. Case 2 A 22-year-old female patient with left unilateral cleft lip underwent primary cheiloplasty at 4 months of age. The patient underwent corrective rhinoplasty and revision cheiloplasty for secondary deformity at a different hospital at 20 years of age. The revision was inadequate, and she presented at our institution. She underwent revisional surgery using our method. Discontinuity and malalignment of the orbicularis oris muscle were corrected simultaneously by cutting and realigning during revision. Notching deformity was corrected and alar base depression was improved by muscle realignment (Fig. 3). 3.3. Case 3 A 23-year-old male patient with a left unilateral cleft lip underwent primary cheiloplasty at 4 months of age. He presented with a vermilion notching deformity. Intraoperative analysis showed that the lengthening of the central area of the oral lining was insufficient. After surgery, the result was satisfactory (Fig. 4).
3. Results 4. Discussion The follow-up period ranged from 1 year to 12 years. The patients were generally satisfied with the aesthetic outcome and there were no particular complications. Seven out of 104 patients (6.7%) experienced lateral vermilion bulging, which was easily corrected by an elliptical excision. 3.1. Case 1 A 20-year-old male patient with left unilateral complete cleft lip and palate underwent primary cheiloplasty at 2 months of age and palatoplasty at 12 months of age. The patient underwent revision
Focusing on the cutaneous aspect during primary cheiloplasty may attain cutaneous symmetry; however, lip tightening or vermilion notching deformity may develop (Baek and Lee, 2009). The lips are a three-dimensional structure, and cutaneous lengthening by rotation must be performed concurrently with lengthening of the oral lining. With our methods of primary cheiloplasty, transpositioning of the medial mucosal flap into the central oral lining allowed lengthening of the oral side, and vermilion notching deformity did not occur in most of the 400 cases who underwent our procedure (Baek and Lee, 2009). Although lateral vermilion
328
S.W. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 326e329
Fig. 2. (A) Vermilion notching and peaking of white roll are seen. (B) Photograph 1 year after operation.
Fig. 3. (A) Preoperative frontal view. Note the vermilion notching and depression of the left alar base. (B) Photograph 3 months after operation.
Fig. 4. (A) Preoperative frontal view. Note the vermilion notching deformity. (B) Postoperative result at 1-year follow-up. Notching deformity is corrected and philtral scar is improved.
bulging deformities may occasionally occur with this method, these can be easily revised by a simple elliptical excision. The location of the height of cupid’s bow on the cleft side can be determined by transposing the equal distance measured from the oral commisure to the height of cupid’s bow on the noncleft side, or by the point where the white roll disappears. Horizontal symmetry may be achieved using such procedures; however, notching deformities may occur as a result of vermilion thinning on the cleft side (Losee et al., 2003). Vertical asymmetry, which is much more conspicuous than horizontal asymmetry, may also occur because of the decreased vertical height from the alar base. Therefore the standard procedure for determining the location of the height of cupid’s bow on the cleft side should be a perpendicular line drawn from the point where the thickness of vermilion is greatest to the white roll, and the point at which the line meets the white roll is where the height of cupid’s bow should be located. Repair of the orbicularis oris muscle is essential in cheiloplasty (Seagle and Furlow, 2004). When muscle repair is poorly or inadequately executed during primary cheiloplasty, depression or grooving may occur, which becomes more obvious when the lips are moved or pursed. Our methods allow the evaluation of the state of the orbicularis oris muscle during surgery, and when discontinuity of the muscle is discovered, a realignment or overlap can be performed to correct depression or grooving. The operating time was not much longer than the time needed for conventional partial elliptical excision or VeYadvancement methods, and provided improvement in the overall aesthetic outcome of the lips. The mean operating time was approximately 1 h, and surgical methods allowed concurrent scar revision of the upper white lip. This surgical method has another advantage, in that it can correct mild cases of short lip by making an incision up to the base
S.W. Lee et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 326e329
of the columella and placing a backcut. It also allows simultaneous realignment of peaking of the white roll. In such cases, tattooing of the skin and vermilion junction with gentian violet is crucial, as the incision design is excised or erased during surgery, and the vermilion junction may be hard to distinguish because of the effects of epinephrine. 5. Conclusion The authors performed satisfactory revision cheiloplasty on patients with secondary vermilion notching deformities of unilateral cleft lip. This was accomplished by sufficient lengthening of the medial oral lining, and by taking the white roll with the greatest vermilion fullness as the standard point of the height of cupid’s bow on the cleft side. Conflict of interest The authors received no financial support from any company or sources, and have no commercial association or financial relationships to disclosure.
329
References Baek RM, Lee SW: Important aspects of oral lining in unilateral cleft lip repair. J Craniofac Surg 20: 1578e1582, 2009 Chen PK, Noordhoff MS, Chen YR, Bendor-Samuel R: Augmentation of the free border of the lip in cleft lip patients using temporoparietal fascia. Plast Reconstr Surg 95: 781e788, 1995 Losee JE, Selber JC, Arkoulakis N, Serletti JM: The cleft lateral lip element: do traditional markings result in secondary deformities? Ann Plast Surg 50: 594e600, 2003 Mommaerts MY, Nagy K: Analysis of the cleft lip-nose in the submental-vertical view. Part II. Panel study: which is the most important deformity? J Craniomaxillofac Surg 36: 315e320, 2008 Patel IA, Hall PN: Free dermis-fat graft to correct the whistle deformity in patients with cleft lip. Br J Plast Surg 57: 160e164, 2004 Schwenzer-Zimmerer K, Chaitidis D, Berg-Boerner I, Krol Z, Kovacs L, Schwenzer NF, Zimmerer S, Holberg C, Zeilhofer HF: Quantitative 3D soft tissue analysis of symmetry prior to and after unilateral cleft lip repair compared with non-cleft persons (performed in Cambodia). J Craniomaxillofac Surg 36: 431e438, 2008 Seagle MB, Furlow Jr LT: Muscle reconstruction in cleft lip repair. Plast Reconstr Surg 113: 1537e1547, 2004 Stal S, Hollier L: Correction of secondary cleft lip deformities. Plast Reconstr Surg 109: 1672e1681, 2002 Wakami S, Harada T, Muraoka M, Ishii M: Rectangular mucosal flap with artificial dermis grafting for vermilion deformity in cleft lips. J Plast Reconstr Aesthet Surg 63: 22e27, 2010