- Email: [email protected]
Detailed assessment of cleft lip scar following straight line repair
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 282e288
Detailed assessment of cleft lip scar following straight line repair I. Tamada*, T. Nakajima Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan Received 14 June 2008; accepted 1 November 2008
KEYWORDS Cleft lip; Scar; Straight line repair; Facial measurement instrument; Rotation advancement
Summary Minimizing upper lip skin scarring is one of the most important factors in cleft lip repair. Currently, Millard’s procedure or one of its modifications is the most commonly used surgical repair procedure, yet several surgeons continue to prefer a more natural-looking straight scar. Some publications concerning the resultant scarring after Millard’s procedure are available; on the other hand, those concerning that after straight line repair are limited. This study aimed to evaluate and analyse upper lip skin scarring following straight line repair in order to further refine our surgical procedure. Twenty-six patients with ages ranging from 4 years and 11 months to 6 years and 10 months (17 boys and nine girls) participated in this study. Each upper lip skin scar was divided into three portions and evaluated by three board-certified plastic surgeons who calculated the evaluation score. The score for each portion of the scar was analysed to determine the correlation of the score with the five following factors: type of cleft, age at operation, length of operation, skin texture regularity and skin brightness; the last two were determined using a facial-measurement instrument. Taking all the results into consideration together with practical experience, the quality of scars of the upper lip skin was thought to be correlated with the skin brightness and length of the operation, particularly in the case of the upper and middle third portions of the upper lip. In the lower third portion, the scar quality appeared to be more influenced by the age at operation. It is suggested that early surgical intervention may help minimize scarring because lip motion is weaker in younger babies than in older ones. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Minimizing upper lip skin scarring is one of the most important factors in cleft lip repair. Carefully designed
* Corresponding author. Tel.: þ81 3 3353 1211. E-mail address: [email protected] (I. Tamada).
incision lines, anatomically appropriate muscle reconstruction, and atraumatic suturing are essential for optimal scars. Nevertheless, despite these measures, conspicuous postoperative scars occasionally result. Currently, the most common procedure for primary cleft lip repair is undoubtedly Millard’s procedure,1 and many
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.11.005
Detailed assessment of cleft lip scar following straight line repair
283
Figure 1 Schemes of Nakajima’s straight line repair, utilized in the presented study. a. Skin incision for the complete cleft case. b. Skin incision for the incomplete cleft case. c. Reconstruction of the musculature. d. Resultant scar of the complete case. e. Resultant scar of the incomplete case.
surgeons have made revisions and modifications to optimize this procedure.2e5 The drawback of the original Millard’s procedure is that the procedure leaves a conspicuous scar at the alar base and across the philtrum. To make this scar less conspicuous, some surgeons have devised and published their own procedures, with the aim of obtaining a straighter and more natural-looking suture line.6e9 We also have devised a straight line repair procedure and have improved it.10e12 One of the advantages of this procedure is the resultant simple, straight scar which can be easily revised if required; this is reassuring to the child’s parents. However, while a number of reports regarding the longterm results of Millard’s procedure have been published, detailed reports that assess upper lip scars after straight line repair are limited. The features of postoperative scarring may differ depending on the procedure used. Hence, to better evaluate white lip scarring after straight line repair and to optimise the procedure of straight line repair, we assessed the scars of preschool children who had undergone straight line primary cleft lip repair, and investigated the factors which influence the resultant upper lip scar.
Patients and methods Procedures for primary lip repair In our department, patients are usually treated at the age of 1w2 months. Although we have developed a new modification of the straight-line repair procedure,12 we used straight line repair with small triangular or semicircular flap procedures in this study. In the case of patients with complete cleft lip (Figure 1-a), we performed straight line repair with a small triangle flap procedure; in the case of patients with incomplete cleft lip (Figure 1-b), we used straight line repair with a semicircular flap procedure. The reconstruction of the musculature is shown in Figure 1-c. One of the steps in this muscle reconstruction is the identification of the lump of the levator labii superior muscles and its reconstruction independent from the orbicularis oris muscle. The resultant suture lines are shown in Figure 1-d and e. A more detailed description of these procedures has already been published elsewhere.10e12
284
I. Tamada, T. Nakajima middle third, consisting of the main central part of the upper lip scar; and the lower third, consisting of the small triangle or round flap without the vermilion (Figure 2). The evaluation was made using pictures taken with a facial-measurement instrument (Robo Skin Analyzer, Inforward, Tokyo, Japan; Figure 3) and ordinary digital cameras. Four classifications (excellent, good, fair, and poor) were converted into a numerical score (minimum 0 to maximum 3), and the total score of each evaluator was defined as the evaluation score. The type of cleft (complete or incomplete), age at operation, and length of operation were retrospectively obtained from the treatment records and analysed as possible factors affecting the outcome. Skin brightness and skin texture regularitydpossible factors affecting the resultant scar qualitydwere calculated using the skinanalysing software of the facial-measurement instrument. Mann-Whitney’s U test was used to determine significant differences in the evaluation scores for the different types of cleft lips. Spearman’s rank correlation coefficient was used to evaluate the correlation between the remaining four factors and the evaluation score. All statistical analyses were performed using SPSS ver.15.0 (SPSS Japan Inc., Tokyo, Japan).
Results The upper third portion of the scar was not statistically analysed in nine of the 26 subjects, while the lower third portion was not statistically analysed in three subjects because these patients had undergone corrective surgery that extended into the lesion. In one patient, the operation time could not be clearly determined from the past medical records. All candidates are listed in Table 1, and all the results of statistical analysis are listed in Table 2. Figure 2 Photos utilized for evaluation. a. Evaluation of the upper third portion. (upper; ordinal camera, lower; facial measurement instrument). b. Evaluation of the middle and lower third portion. (The transverse line is the border of two portions).
Patients Among those cleft lip patients who were preschool children when this study was carried out, 26 patients and their families gave oral informed consent to participate in this study. The patients’ ages ranged from 4 years and 11 months to 6 years and 10 months. Seventeen patients were boys, and the remaining nine were girls. All patients underwent primary cleft lip repair at Keio University Hospital or at a hospital associated with the Keio University Hospital; all patients were operated on by the senior author (Nakajima T.) or by senior residents under the supervision of the senior author. The postoperative cleft lip scars were evaluated by three board-certified plastic surgeons. The scar on the upper lip skin was evaluated in detail by dividing it into three portions: the upper third, consisting of the nostril floor and a small superior part of the upper lip scar; the
Evaluation of the upper third portion A slight negative correlation was noted between the evaluation score and the length of the operation (correlation coefficient: 0.276), but this was not statistically significant. A considerable positive correlation existed between the evaluation score and skin brightness (correlation coefficient: 0.411), but this too was not statistically significant.
Evaluation of the middle third portion A statistically significant (p < 0.01) negative correlation between the evaluation score and the length of the surgery was observed (correlation coefficient: 0.519). A statistically significant positive (p < 0.05) correlation was present between the evaluation score and the skin brightness (correlation coefficient: 0.473).
Evaluation of the lower third portion A considerable negative correlation was seen between the evaluation score and the age at the time of operation (correlation coefficient: 0.404), but this was not statistically significant.
Detailed assessment of cleft lip scar following straight line repair
285
Figure 3 The facial measurement instrument. a. The body of the instrument. b. The full-face photo obtained with the instrument.
A slight negative correlation between the evaluation score and the length of operation was revealed (correlation coefficient: 0.217), but this was not statistically significant. Negligible correlation was observed between the evaluation score and skin brightness (correlation coefficient: 0.031).
Discussion The achievement of optimal results after primary cleft lip repair remains a challenging problem, and some reports have assessed the results of Millard’s procedure. In 2006, Christofides et al evaluated postoperative upper lip scars after Millard’s procedure by dividing the scar area into three portions; they concluded that more complications involved the upper and lower portions than the middle one.13 Among our patients, nine underwent revisional surgery for the upper third portion, and 10 underwent revisional surgery for the lower third portion before our study was conducted. Taking this into consideration, our results are consistent with Christofides’ report, though the procedures used were different. The main purpose of revisional surgery is to improve the labial and nasal contours, and the mean evaluation scores for each third were very similar (4.18, 4.19, and 4.30). Therefore, we believe that the area of the upper lip is not a decisive factor, at least with regard to scarring. In the present study, no statistically significant difference between the type of cleft (incomplete or complete) and the evaluation score was observed for any third of the scar. Thus, our results suggest that the postoperative upper lip scar is not affected by the type of cleft. Nevertheless, the type of cleft will affect the long-term stability of the nasal contour, the vermilion symmetry, and the maxillary profile, because of differences in the underlying bony structure, the compression force toward the maxilla, the required undermining area, etc. We usually reconstruct the orbicularis oris muscle appropriately to avoid the development of tension force against the skin; this can be achieved even in the case of wide unilateral complete cleft lip via sufficient muscle dissection, though not in the case of complete bilateral cleft lip and palate. We consider that
this is a probable explanation for our results. Reddy et al operated on 796 patients by using either modified Millard’s procedure or the Pfeifer wavy line incision technique. They concluded that one technique was essentially as good as the other and that the technique for the closure of the underlying tissues was probably of more importance than the actual procedure used for achieving a good result.14 Our present result seems to be in agreement with their conclusion. A statistically significant negative correlation was found between the evaluation score and the length of operation in the case of the middle third of the upper lip scar and a relatively negative correlation was found in the case of the upper and lower thirds of the upper lip scar. All cleft lip operations were performed by the senior author (Nakajima T.) or by senior residents under his instruction, but it was difficult to retrospectively determine which surgeon participated in each part of every operation. Therefore, in the present study, we did not analyse the differences among the results obtained by different surgeons, but it seems reasonable to assume that experienced surgeons perform the operation more quickly and successfully than younger surgeons. In the present study, skin brightness was also considered to be one of the possible factors that influence the resultant scar quality. A relatively high correlation between skin brightness and the evaluation score was found in the upper and middle thirds of the upper lip scar, and this is in agreement with the well-known fact that scars on darker skin are more conspicuous than those on lighter skin. In the case of the lower third, however, the scar quality was found to be correlated the age at the surgery rather than with the skin brightness. In the present study, the lower third of the upper lip was treated earlier and showed a tendency toward better results. Because the lower third portion of the upper lip is engaged in more active movements, such as oral motion or nipple-sucking, early operation, when the lip motion is less powerful, may result in better scars in this portion. From this perspective, appropriate reconstruction of the deep layer of the orbicularis oris (pars marginalis) is considered to be important not only for oral function but also for the scar quality in the lower third portion of the lip.
286
Table 1
The list of the patients
Patient No.
Age at the evaluation (years)
Type of cleft
Age at operation (days)
Length of operation (minutes)
Skin texture regularity
Skin brightness
Evaluation score of the upper third portion
Evaluation score of the middle third portion
Evaluation score of the lower third portion
Incised site at the revisional surgery
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
6.2 5.11 6.10 5.6 6.7 6.3 5.1 5.0 5.0 5.1 5.9 6.8 5.10 5.8 6.10 6.6 6.3 6.4 5.11 6.3 5.0 4.11 6.9 6.1 5.9 6.3
incomplete incomplete complete complete incomplete complete complete complete complete incomplete incomplete complete incomplete incomplete complete complete complete complete complete incomplete complete incomplete complete incomplete complete incomplete
62 56 46 81 45 38 29 73 33 45 49 96 45 54 41 33 52 66 35 51 65 62 49 31 52 93
100 113 133 161 95 unknown 145 144 113 126 120 86 163 123 199 155 120 125 150 185 175 165 148 170 110 195
72 68 80 51 76 35 73 69 55 40 39 54 39 67 49 73 69 60 62 44 65 37 54 57 65 99
183.8 177.5 167.5 173.7 179.8 170.1 174.6 181.6 177.8 188.4 188.3 178.9 178.8 168.9 172.5 169.3 178.2 178.0 167.1 182.4 175.3 184.3 174.8 171.3 153.8 175.9
5 2 2 5 8 4 1 5 3 5 1 3 6 5 0 0 3 8 5 7 4 5 4 1 1 0
6 5 2 2 7 5 7 7 8 6 4 6 4 3 2 5 3 8 1 4 2 4 0 0 4 4
3 3 7 4 8 4 6 3 6 5 5 4 4 1 0 4 3 8 0 5 3 5 3 4 6 0
none A, C none none none A, C none none none none A, B, C none A, C none A, B, C A, C A, C none A, B none A A, C none none C none
I. Tamada, T. Nakajima
A: vermilion. B: lower skin flap. C: nostril floor.
Detailed assessment of cleft lip scar following straight line repair Table 2
287
The results of the correlation analysis Type of the cleft
Upper third No significant portion difference p: 0.516 Middle third No significant portion difference p: 0.834 Lower third No significant portion difference p: 0.429
Age at operation
Length of operation
Skin texture regularity
Skin brightness
Little correlation
A bit correlation
A bit correlation
correlation coefficient: 0.148 Little correlation
correlation coefficient: 0.276 Significant correlation ** correlation coefficient: 0.519 A bit correlation
correlation coefficient: 0.261 Little correlation correlation coefficient: 0.140 Little correlation
Considerable correlation correlation coefficient: 0.411 Significant correlation * correlation coefficient: 0.473 Little correlation
correlation coefficient: 0.217
correlation coefficient: 0.111
correlation coefficient: 0.031
correlation coefficient: 0.056 Considerable correlation correlation coefficient: 0.404
*: p< 0.05. **: p< 0.01.
Concerning the age at primary lip repair, a recent study by Goodacre et al has found no significant differences in the attractiveness between patients operated on neonatally and those operated on at around the age of 3 months.15 In their study, however, evaluation was not limited to the scar quality as in our study, but was largely based on the gross appearance. In deciding the timing of the primary repair, surgeons must consider not only the overall success of the surgery but also the mother-infant relationship,16 social situation, etc. These factors continue to complicate the optimal timing of the primary repair. Although the determination of the advantages of early cleft lip repair was not the main purpose of this study, we consider our timing of primary surgery (usually at the age of 1 or 2 months) to be optimal both in terms of the surgical results and the mother-infant relationship, provided secure reconstruction of musculature is achieved. Taking all the results into consideration, our conclusions are as follows: The quality of scars of the upper lip skin is correlated with the skin brightness and length of the operation, especially in the case of scars of the upper and middle thirds. In the lower third portion of the upper lip skin, it is likely that scar quality is more influenced by the age at operation than the skin brightness and length of the operation. Early surgery may result in better scars because lip motion is weaker in younger babies than in older ones. Accordingly, meticulous and appropriate reconstruction of the deep layer of the orbicularis oris (pars marginalis) may optimise the surgical procedure.
Conflict of interest statement The facial-measurement instrument used in this study was leased from Inforward Corp., but this company did not fund this study.
References 1. Millard Jr DR. Refinements in rotation-advancement cleft lip technique. Plast Reconstr Surg 1964;33:26e38.
2. Mulliken JB, Martı´nez-Pe ´rez 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;104:1247e60. 3. Ray RM. Unilateral cleft lip repair by rotation/advancement: potential errors and how to avoid them. Facial Plast Surg 2007; 23:87e90. 4. Becker M, Svensson H, McWilliam J, et al. Millard repair of unilateral isolated cleft lip: a 25-year follow-up. Scand J Plast Reconstr Surg Hand Surg 1998;32:387e94. 5. Millard Jr DR. The voice of polite dissent: A variation of the rotation-advancement operation for repair of wide unilateral cleft lips. Commentary by Dr. D. Ralph Millard, Jr. Plast Reconstr Surg 1974;53:340e1. 6. Fisher DM. Unilateral cleft lip repair: an anatomical subunit approximation technique. Plast Reconstr Surg 2005;116: 61e71. 7. Chait L, Kadwa A, Potgieter A, et al. The ultimate straight line repair for unilateral cleft lips. J Plast Reconstr Aesthet Surg 2009;62:50e5. 8. Furnas DW. Straight-line closure: a preliminary to Millard closure in unilateral cleft lips (with a history of the straightline closure, including the Mirault misunderstanding). Clin Plast Surg 1984;11:701e37. 9. Song R, Liu C, Zhao Y. A new principle for unilateral complete cleft lip repair, the lateral columellar flap method. Plast Reconstr Surg 1998;102:1848e52. discussion 1853e4. 10. Nakajima T, Yoshimura Y. Early repair of unilateral cleft lip employing a small triangular flap method and primary nasal correction. Br J Plast Surg 1993;46:616e8. 11. Nakajima T, Yoshimura Y, Yoneda K, et al. Primary repair of an incomplete unilateral cleft lip: avoiding an elongated lip and achieving a straight suture line. Br J Plast Surg 1998;51: 511e6. 12. Nakajima T, Tamada I, Miyamoto J, et al. Straight line repair of unilateral cleft lip: new operative method based on 25 years experience. J Plast Reconstr Aesthet Surg 2008;61: 870e8. 13. Christofides E, Potgieter A, Chait L. A long term subjective and objective assessment of the scar in unilateral cleft lip repairs using the Millard technique without revisional surgery. J Plast Reconstr Aesthet Surg 2006;59:380e6. 14. Reddy GS, Webb RM, Reddy RR, et al. Choice of incision for primary repair of unilateral complete cleft lip: a comparative study of outcomes in 796 patients. Plast Reconstr Surg 2008; 121:932e40.
288 15. Goodacre TE, Hentges F, Moss TL, et al. Does repairing a cleft lip neonatally have any effect on the longer-term attractiveness of the repair? Cleft Palate Craniofac J 2004; 41:603e8.
I. Tamada, T. Nakajima 16. Murray L, Hentges F, Hill J, et al. Cleft Lip and Palate Study Team. The effect of cleft lip and palate, and the timing of lip repair on mother-infant interactions and infant development. J Child Psychol Psychiatry 2008;49:115e23.
Detailed assessment of cleft lip scar following straight line repair I. Tamada*, T. Nakajima Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo 160-8582, Japan Received 14 June 2008; accepted 1 November 2008
KEYWORDS Cleft lip; Scar; Straight line repair; Facial measurement instrument; Rotation advancement
Summary Minimizing upper lip skin scarring is one of the most important factors in cleft lip repair. Currently, Millard’s procedure or one of its modifications is the most commonly used surgical repair procedure, yet several surgeons continue to prefer a more natural-looking straight scar. Some publications concerning the resultant scarring after Millard’s procedure are available; on the other hand, those concerning that after straight line repair are limited. This study aimed to evaluate and analyse upper lip skin scarring following straight line repair in order to further refine our surgical procedure. Twenty-six patients with ages ranging from 4 years and 11 months to 6 years and 10 months (17 boys and nine girls) participated in this study. Each upper lip skin scar was divided into three portions and evaluated by three board-certified plastic surgeons who calculated the evaluation score. The score for each portion of the scar was analysed to determine the correlation of the score with the five following factors: type of cleft, age at operation, length of operation, skin texture regularity and skin brightness; the last two were determined using a facial-measurement instrument. Taking all the results into consideration together with practical experience, the quality of scars of the upper lip skin was thought to be correlated with the skin brightness and length of the operation, particularly in the case of the upper and middle third portions of the upper lip. In the lower third portion, the scar quality appeared to be more influenced by the age at operation. It is suggested that early surgical intervention may help minimize scarring because lip motion is weaker in younger babies than in older ones. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Minimizing upper lip skin scarring is one of the most important factors in cleft lip repair. Carefully designed
* Corresponding author. Tel.: þ81 3 3353 1211. E-mail address: [email protected] (I. Tamada).
incision lines, anatomically appropriate muscle reconstruction, and atraumatic suturing are essential for optimal scars. Nevertheless, despite these measures, conspicuous postoperative scars occasionally result. Currently, the most common procedure for primary cleft lip repair is undoubtedly Millard’s procedure,1 and many
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.11.005
Detailed assessment of cleft lip scar following straight line repair
283
Figure 1 Schemes of Nakajima’s straight line repair, utilized in the presented study. a. Skin incision for the complete cleft case. b. Skin incision for the incomplete cleft case. c. Reconstruction of the musculature. d. Resultant scar of the complete case. e. Resultant scar of the incomplete case.
surgeons have made revisions and modifications to optimize this procedure.2e5 The drawback of the original Millard’s procedure is that the procedure leaves a conspicuous scar at the alar base and across the philtrum. To make this scar less conspicuous, some surgeons have devised and published their own procedures, with the aim of obtaining a straighter and more natural-looking suture line.6e9 We also have devised a straight line repair procedure and have improved it.10e12 One of the advantages of this procedure is the resultant simple, straight scar which can be easily revised if required; this is reassuring to the child’s parents. However, while a number of reports regarding the longterm results of Millard’s procedure have been published, detailed reports that assess upper lip scars after straight line repair are limited. The features of postoperative scarring may differ depending on the procedure used. Hence, to better evaluate white lip scarring after straight line repair and to optimise the procedure of straight line repair, we assessed the scars of preschool children who had undergone straight line primary cleft lip repair, and investigated the factors which influence the resultant upper lip scar.
Patients and methods Procedures for primary lip repair In our department, patients are usually treated at the age of 1w2 months. Although we have developed a new modification of the straight-line repair procedure,12 we used straight line repair with small triangular or semicircular flap procedures in this study. In the case of patients with complete cleft lip (Figure 1-a), we performed straight line repair with a small triangle flap procedure; in the case of patients with incomplete cleft lip (Figure 1-b), we used straight line repair with a semicircular flap procedure. The reconstruction of the musculature is shown in Figure 1-c. One of the steps in this muscle reconstruction is the identification of the lump of the levator labii superior muscles and its reconstruction independent from the orbicularis oris muscle. The resultant suture lines are shown in Figure 1-d and e. A more detailed description of these procedures has already been published elsewhere.10e12
284
I. Tamada, T. Nakajima middle third, consisting of the main central part of the upper lip scar; and the lower third, consisting of the small triangle or round flap without the vermilion (Figure 2). The evaluation was made using pictures taken with a facial-measurement instrument (Robo Skin Analyzer, Inforward, Tokyo, Japan; Figure 3) and ordinary digital cameras. Four classifications (excellent, good, fair, and poor) were converted into a numerical score (minimum 0 to maximum 3), and the total score of each evaluator was defined as the evaluation score. The type of cleft (complete or incomplete), age at operation, and length of operation were retrospectively obtained from the treatment records and analysed as possible factors affecting the outcome. Skin brightness and skin texture regularitydpossible factors affecting the resultant scar qualitydwere calculated using the skinanalysing software of the facial-measurement instrument. Mann-Whitney’s U test was used to determine significant differences in the evaluation scores for the different types of cleft lips. Spearman’s rank correlation coefficient was used to evaluate the correlation between the remaining four factors and the evaluation score. All statistical analyses were performed using SPSS ver.15.0 (SPSS Japan Inc., Tokyo, Japan).
Results The upper third portion of the scar was not statistically analysed in nine of the 26 subjects, while the lower third portion was not statistically analysed in three subjects because these patients had undergone corrective surgery that extended into the lesion. In one patient, the operation time could not be clearly determined from the past medical records. All candidates are listed in Table 1, and all the results of statistical analysis are listed in Table 2. Figure 2 Photos utilized for evaluation. a. Evaluation of the upper third portion. (upper; ordinal camera, lower; facial measurement instrument). b. Evaluation of the middle and lower third portion. (The transverse line is the border of two portions).
Patients Among those cleft lip patients who were preschool children when this study was carried out, 26 patients and their families gave oral informed consent to participate in this study. The patients’ ages ranged from 4 years and 11 months to 6 years and 10 months. Seventeen patients were boys, and the remaining nine were girls. All patients underwent primary cleft lip repair at Keio University Hospital or at a hospital associated with the Keio University Hospital; all patients were operated on by the senior author (Nakajima T.) or by senior residents under the supervision of the senior author. The postoperative cleft lip scars were evaluated by three board-certified plastic surgeons. The scar on the upper lip skin was evaluated in detail by dividing it into three portions: the upper third, consisting of the nostril floor and a small superior part of the upper lip scar; the
Evaluation of the upper third portion A slight negative correlation was noted between the evaluation score and the length of the operation (correlation coefficient: 0.276), but this was not statistically significant. A considerable positive correlation existed between the evaluation score and skin brightness (correlation coefficient: 0.411), but this too was not statistically significant.
Evaluation of the middle third portion A statistically significant (p < 0.01) negative correlation between the evaluation score and the length of the surgery was observed (correlation coefficient: 0.519). A statistically significant positive (p < 0.05) correlation was present between the evaluation score and the skin brightness (correlation coefficient: 0.473).
Evaluation of the lower third portion A considerable negative correlation was seen between the evaluation score and the age at the time of operation (correlation coefficient: 0.404), but this was not statistically significant.
Detailed assessment of cleft lip scar following straight line repair
285
Figure 3 The facial measurement instrument. a. The body of the instrument. b. The full-face photo obtained with the instrument.
A slight negative correlation between the evaluation score and the length of operation was revealed (correlation coefficient: 0.217), but this was not statistically significant. Negligible correlation was observed between the evaluation score and skin brightness (correlation coefficient: 0.031).
Discussion The achievement of optimal results after primary cleft lip repair remains a challenging problem, and some reports have assessed the results of Millard’s procedure. In 2006, Christofides et al evaluated postoperative upper lip scars after Millard’s procedure by dividing the scar area into three portions; they concluded that more complications involved the upper and lower portions than the middle one.13 Among our patients, nine underwent revisional surgery for the upper third portion, and 10 underwent revisional surgery for the lower third portion before our study was conducted. Taking this into consideration, our results are consistent with Christofides’ report, though the procedures used were different. The main purpose of revisional surgery is to improve the labial and nasal contours, and the mean evaluation scores for each third were very similar (4.18, 4.19, and 4.30). Therefore, we believe that the area of the upper lip is not a decisive factor, at least with regard to scarring. In the present study, no statistically significant difference between the type of cleft (incomplete or complete) and the evaluation score was observed for any third of the scar. Thus, our results suggest that the postoperative upper lip scar is not affected by the type of cleft. Nevertheless, the type of cleft will affect the long-term stability of the nasal contour, the vermilion symmetry, and the maxillary profile, because of differences in the underlying bony structure, the compression force toward the maxilla, the required undermining area, etc. We usually reconstruct the orbicularis oris muscle appropriately to avoid the development of tension force against the skin; this can be achieved even in the case of wide unilateral complete cleft lip via sufficient muscle dissection, though not in the case of complete bilateral cleft lip and palate. We consider that
this is a probable explanation for our results. Reddy et al operated on 796 patients by using either modified Millard’s procedure or the Pfeifer wavy line incision technique. They concluded that one technique was essentially as good as the other and that the technique for the closure of the underlying tissues was probably of more importance than the actual procedure used for achieving a good result.14 Our present result seems to be in agreement with their conclusion. A statistically significant negative correlation was found between the evaluation score and the length of operation in the case of the middle third of the upper lip scar and a relatively negative correlation was found in the case of the upper and lower thirds of the upper lip scar. All cleft lip operations were performed by the senior author (Nakajima T.) or by senior residents under his instruction, but it was difficult to retrospectively determine which surgeon participated in each part of every operation. Therefore, in the present study, we did not analyse the differences among the results obtained by different surgeons, but it seems reasonable to assume that experienced surgeons perform the operation more quickly and successfully than younger surgeons. In the present study, skin brightness was also considered to be one of the possible factors that influence the resultant scar quality. A relatively high correlation between skin brightness and the evaluation score was found in the upper and middle thirds of the upper lip scar, and this is in agreement with the well-known fact that scars on darker skin are more conspicuous than those on lighter skin. In the case of the lower third, however, the scar quality was found to be correlated the age at the surgery rather than with the skin brightness. In the present study, the lower third of the upper lip was treated earlier and showed a tendency toward better results. Because the lower third portion of the upper lip is engaged in more active movements, such as oral motion or nipple-sucking, early operation, when the lip motion is less powerful, may result in better scars in this portion. From this perspective, appropriate reconstruction of the deep layer of the orbicularis oris (pars marginalis) is considered to be important not only for oral function but also for the scar quality in the lower third portion of the lip.
286
Table 1
The list of the patients
Patient No.
Age at the evaluation (years)
Type of cleft
Age at operation (days)
Length of operation (minutes)
Skin texture regularity
Skin brightness
Evaluation score of the upper third portion
Evaluation score of the middle third portion
Evaluation score of the lower third portion
Incised site at the revisional surgery
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
6.2 5.11 6.10 5.6 6.7 6.3 5.1 5.0 5.0 5.1 5.9 6.8 5.10 5.8 6.10 6.6 6.3 6.4 5.11 6.3 5.0 4.11 6.9 6.1 5.9 6.3
incomplete incomplete complete complete incomplete complete complete complete complete incomplete incomplete complete incomplete incomplete complete complete complete complete complete incomplete complete incomplete complete incomplete complete incomplete
62 56 46 81 45 38 29 73 33 45 49 96 45 54 41 33 52 66 35 51 65 62 49 31 52 93
100 113 133 161 95 unknown 145 144 113 126 120 86 163 123 199 155 120 125 150 185 175 165 148 170 110 195
72 68 80 51 76 35 73 69 55 40 39 54 39 67 49 73 69 60 62 44 65 37 54 57 65 99
183.8 177.5 167.5 173.7 179.8 170.1 174.6 181.6 177.8 188.4 188.3 178.9 178.8 168.9 172.5 169.3 178.2 178.0 167.1 182.4 175.3 184.3 174.8 171.3 153.8 175.9
5 2 2 5 8 4 1 5 3 5 1 3 6 5 0 0 3 8 5 7 4 5 4 1 1 0
6 5 2 2 7 5 7 7 8 6 4 6 4 3 2 5 3 8 1 4 2 4 0 0 4 4
3 3 7 4 8 4 6 3 6 5 5 4 4 1 0 4 3 8 0 5 3 5 3 4 6 0
none A, C none none none A, C none none none none A, B, C none A, C none A, B, C A, C A, C none A, B none A A, C none none C none
I. Tamada, T. Nakajima
A: vermilion. B: lower skin flap. C: nostril floor.
Detailed assessment of cleft lip scar following straight line repair Table 2
287
The results of the correlation analysis Type of the cleft
Upper third No significant portion difference p: 0.516 Middle third No significant portion difference p: 0.834 Lower third No significant portion difference p: 0.429
Age at operation
Length of operation
Skin texture regularity
Skin brightness
Little correlation
A bit correlation
A bit correlation
correlation coefficient: 0.148 Little correlation
correlation coefficient: 0.276 Significant correlation ** correlation coefficient: 0.519 A bit correlation
correlation coefficient: 0.261 Little correlation correlation coefficient: 0.140 Little correlation
Considerable correlation correlation coefficient: 0.411 Significant correlation * correlation coefficient: 0.473 Little correlation
correlation coefficient: 0.217
correlation coefficient: 0.111
correlation coefficient: 0.031
correlation coefficient: 0.056 Considerable correlation correlation coefficient: 0.404
*: p< 0.05. **: p< 0.01.
Concerning the age at primary lip repair, a recent study by Goodacre et al has found no significant differences in the attractiveness between patients operated on neonatally and those operated on at around the age of 3 months.15 In their study, however, evaluation was not limited to the scar quality as in our study, but was largely based on the gross appearance. In deciding the timing of the primary repair, surgeons must consider not only the overall success of the surgery but also the mother-infant relationship,16 social situation, etc. These factors continue to complicate the optimal timing of the primary repair. Although the determination of the advantages of early cleft lip repair was not the main purpose of this study, we consider our timing of primary surgery (usually at the age of 1 or 2 months) to be optimal both in terms of the surgical results and the mother-infant relationship, provided secure reconstruction of musculature is achieved. Taking all the results into consideration, our conclusions are as follows: The quality of scars of the upper lip skin is correlated with the skin brightness and length of the operation, especially in the case of scars of the upper and middle thirds. In the lower third portion of the upper lip skin, it is likely that scar quality is more influenced by the age at operation than the skin brightness and length of the operation. Early surgery may result in better scars because lip motion is weaker in younger babies than in older ones. Accordingly, meticulous and appropriate reconstruction of the deep layer of the orbicularis oris (pars marginalis) may optimise the surgical procedure.
Conflict of interest statement The facial-measurement instrument used in this study was leased from Inforward Corp., but this company did not fund this study.
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I. Tamada, T. Nakajima 16. Murray L, Hentges F, Hill J, et al. Cleft Lip and Palate Study Team. The effect of cleft lip and palate, and the timing of lip repair on mother-infant interactions and infant development. J Child Psychol Psychiatry 2008;49:115e23.