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Evaluation of the results of simultaneous open rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity
Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 751e757
Evaluation of the results of simultaneous open rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity* Muhitdin Eski*, Andac Aykan, Dogan Alhan, Fatih Zor, Selcuk Isik Gulhane Military Medical Academy, Department of Plastic and Reconstructive Surgery, 06010 Etlik, Ankara, Turkey Received 10 June 2014; accepted 2 February 2015
KEYWORDS Abbe flap; Secondary bilateral cleft and nasal deformity; Simultaneous rhinoplasty; Software-based method
Summary Aims: We aimed to evaluate the results of simultaneous rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity by means of a newly developed software-based method. Patients and Methods: A total of 16 patients with the bilateral cleft lip nasal deformity received Abbe flap and simultaneous open rhinoplasty between 2004 and 2010. The mean age of the patients was 21 years, and the average follow-up time was 2.4 years. After the open rhinoplasty procedure, the upper lip was reconstructed with the Abbe flap. Preoperative and postoperative photographs that had been taken laterally were evaluated by using Adobe Photoshop CS4 and Adobe InDesign software. The length of the columella and the relative changes of the most anterior point of the upper lip to the vertical plane tangent to the most anterior point of the lower lip were measured in pixels on standardized preoperative and postoperative images. The differences were calculated and compared as a percentage (%). Results: There was no flap loss and associated problems. The measurements of columellar length revealed an average increase of 51.8 11.3%, while the relative change of the most anterior point of the upper lip revealed an average increase of 68.6 11.2%. Conclusion: The results of the treatment modality were successfully evaluated by a newly developed software-based method. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
*
This paper was presented at The Aesthetic Meeting on 11e16 April 2013, New York, USA. * Corresponding author. Gulhane Military Medical Academy, Department of Plastic and Reconstructive Surgery, 06010 Etlik, Ankara, Turkey. Tel.: þ90 0312 304 54 13; fax: þ90 0312 304 54 04. E-mail address: [email protected] (M. Eski). http://dx.doi.org/10.1016/j.bjps.2015.02.007 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
752
Introduction Even the recent advances in primary repair of bilateral cleft lip nasal (BCLN) deformity have had limited success, because the outcome is less acceptable and the secondary deformities are inevitable.1e6 In patients with the secondary BCLN deformities, the most common lip deformities are the tight upper lip, short prolabium, lack of acceptable philtral column and Cupid’s bow definition, and central vermilion deficiency.7 In addition to these, the depressed nasal tip, wide nostril floor and short columella are the most important nasal deformities that need to be corrected in these patients.8 It is quite difficult to correct these deformities because there exists different degree of tissue deficiency in both lips and nose and asymmetry and tissue distortion. These deformities are required for the replacement of fullthickness lip elements and the alignment of anatomical landmarks such as philtral column and Cupid’s bow definition. The Abbe flap is a useful and well-defined and established reconstructive tool for the significant secondary deformities of the BCLN.7e12 Although both anatomical and aesthetic units of the upper lip are restored by the Abbe flap, it could not correct the columellar tissue deficiency. The upper lip, nasal structure, nasal skin, and prolabial skin are the sites that have been employed for the reconstruction of short columella.13 Basically, the VeY advancement technique is used for moving the prolabium into the columella. Brown and McDowell described the modification of VeY advancement for the reconstruction of short columella for the BCLN with their development of a philtral flap.14 Millard combined forked flaps developed from either side of the prolabium, along with vestibular-based flaps, to simultaneously elongate the columella and narrow the nasal floors.13,15 Cronin described the technique that uses nasal structure for elongation of the short columella.16,17 In this technique, a bipedicle flap is carried around the base of the ala to the base of nasolabial fold, with the entire floor of the nose undermined and lateral nasal components advanced medially. The technique usually combined suturing the medial crura of lower lateral cartilages together or an application of strut graft to provide additional stability and support to the columella as well as the nasal tip.13 There exist numerous operations that use nasal skin shifting by external incision with limited success.18e20 In this technique, part of the prolabial skin of the upper lip was preserved and marked as a nasal tip-based extended columellar flap, which was used for covering elongated columella during rhinoplasty. The remaining part of the upper lip was excised and released and the resultant defect of the upper lip was planned to reconstruct with the Abbe flap. In this study, the reconstruction of secondary deformities of BCLN with simultaneous rhinoplasty and Abbe flap was presented and the results were evaluated by means of a newly developed software-based method.
M. Eski et al. between 2004 and 2010. None of the patients had prior orthognathic operations. The mean age of the patients at the time of the operation was 21 years (range, 17e25) and the average follow-up period was 2.4 years.
Surgical procedure Before the operation, the Abbe flap, which was 12e14 mm in length and 10e12 mm in width, was designed and marked in the central lower lip with a slightly wider U-shaped caudal end (Figure 1). Part of the prolabial skin of the upper lip was preserved and marked for columellar elongation (extended columellar flap). The operations were carried out under general anesthesia. It is important to mark the vermilion-cutaneous line to prevent the distortion of the lower lip as well as the upper lip. The first step of the surgery was the incision of the extended columellar flap. Following the incision, superior pedicled extended columellar flap was elevated as a fullthickness skin flap. Next, the rim incision and regular open rhinoplasty was performed with tip reconstruction. In tip plasty, columellar strut graft was used to elongate the columella. The extended columellar flap enabled us to easily cover the elongated columella. The remaining part of the upper lip was excised and released and the resultant defect of the upper lip was planned to reconstruct with the Abbe flap. Following the rhinoplasty, the marked flap incision was performed and the Abbe flap containing fullthickness tissue from the central lower lip was elevated. The vertical and horizontal lengthening procedures of the upper lip segments were performed if any deficiency existed. The Abbe flap was rotated upward and inset to the defect in layers. The white skin and the vermilion lines between the Abbe flap and lateral lip segments were aligned by using preoperative vermillionecutaneous junction markings on the upper lip (Figure 2) (see video: supplemental digital content 1). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.02.007.
Patients and methods Patient demographics A total of 16 male patients with the BCLN deformity received Abbe flap and simultaneous open rhinoplasty
Figure 1 Preoperative planning of the patient. The Abbe and extended columellar flap lines and the site of the lower lip midlines are determined.
Evaluation of the results of simultaneous open rhinoplasty and Abbe flap
753
were used for nasal packing. The pedicle of the Abbe flap was divided under local anesthesia 14e17 days later.
Assessment
Figure 2 Surgical procedure. Procedure is performed under general anesthesia (upper-left). Marking of vermillioncutaneous line (upper-right). After rhinoplasty (bottom-left). The Abbe flap is in place (bottom-right).
Postoperative care The airway tube was inserted into the mouth to alleviate airway obstruction at the end of the surgery. Doyle splints
The patients who were followed at least 6 months and had standard pictures that can be used for assessment included for software-based preoperative and postoperative evaluation. Only one question was asked to capture the physical status of patient: How well do you like the appearance of your nose and lips following this surgery? Preoperative and postoperative (6 months) photographs that had been taken laterally were evaluated by using Adobe Photoshop CS4 and Adobe InDesign CS4 software. After the conversion of the lateral images to the gray scale pattern, nose, lip, and ear boundaries were marked (path drawing) (Figure 3). After the path drawing, images were standardized on the basis of the ear size (Figure 4). The length of the columella (sn-c; from subnasale sn to the most inferior line of the infralobular triangle c) (3) was measured in pixels on standardized preoperative and postoperative images (Figure 5). The distance between the vertical lines that were tangent to the most anterior point of the lower lip (Ll0 ) and the most anterior point of the upper lip (Ul0 , labiale superius) was measured in pixels on images (21). The differences between the preoperative and postoperative measurements were calculated and compared as a percentage (%).
Results All patients expressed their satisfaction and that the surgery satisfactorily improved their appearance. There was no flap loss and associated problems. No problem was encountered in terms of airway obstruction due to combined surgery. In five patients, minor revision (alignment of scars) was performed on the upper lip. The eight patients’
Figure 3 Initially, the preoperative and postoperative images were converted to the gray scale images. After the conversion, boundaries of the basic anatomical structures were marked with different color (pink for preoperative, blue for postoperative images) by using the Adobe Photoshop CS4 software.
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M. Eski et al.
Figure 4 The standardization of the preoperative and postoperative images on the basis of the ear dimensions (Adobe InDesign CS4) (pink for preoperative, blue for postoperative images).
standard photographs that were suitable for the evaluation were assessed with the software. An average increase of 51.8 11.3% was determined between the preoperative and postoperative columellar lengths. The relative change
of the most anterior point of upper lip compared to the lower lip (Ul0 Ll0 ) had an average increase of 68.6 11.2%. Simultaneously, the surgery corrected both the nasal and lip deformities and improved the facial profiles of the patients (Figures 6 and 7).
Discussion
Figure 5 The measurement methods of the length of the columella (from subnasale sn to the most inferior line of the infralobular triangle c) (upper left and right). The relative changes of the most anterior point of the upper lip (Ul0 ) to the vertical plane tangent to the most anterior point of the lower lip (Ll0 ) were measured in pixels on preoperative (pink) and postoperative (blue) images (lower left and right). Yellow lines indicate the measurements, white line indicates vertical line that is tangent to the most anterior point of the lower lip.
Simultaneous open rhinoplasty and Abbe flap successfully enabled us to correct the secondary deformities of BCLN, which include both central lip and nose. The upper lip includes important anatomical landmarks such as philtral columns, Cupid’s bow, and central tubercle, which are essential for ideal aesthetic appearance. The Abbe flap addresses reconstruction of all components of the secondary bilateral cleft lip deformities and provides both aesthetic and functional repair. It offers healthy tissue for reconstruction of the philtral landmarks, reconstitution of oral competence of the orbicularis oris muscle, and recreation of Cupid’s bow and the central pouts.7,8 However, in our cases, the most important advantage of Abbe flap was to allow us to use extended columellar skin flap to reconstruct the short columella. The Abbe flap also corrects the relatively protruding lower lip. However, the etiology of the sagging lower lip remains unknown; it is the prevalent feature of the bilateral cleft lip patients as mentioned by Cutting and Warren.8 Therefore, the correction of the lower lip provided a secondary benefit of Abbe flap reconstruction as seen in our cases. Millard used the “shield”-shaped Abbe flap design.10 Jackson described the “triangular”-shaped Abbe flap.12 In addition to these, various Abbe flap designs were used in the literature, such as square and M shape or W shape.7e11 All shapes are acceptable and have their own advantages. We used a U-shaped Abbe flap design in which vertical limbs tapered slightly toward the midline and then extended to the labiomental crease. This gives the flap a modified shield shape. This enabled us to use full-size extended columellar flap and restore donor defect of this flap accurately. In addition, this design creates the columellar base flare. The scar that results in the lower lip was located on the labiomental crease and aesthetically acceptable. The size of the flap was compatible with the craniofacial normative
Evaluation of the results of simultaneous open rhinoplasty and Abbe flap
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Figure 6 A 21-year-old patient who received Abbe flap and simultaneous open rhinoplasty. Preoperative (left) and postoperative (1 year) (right) views of the patient.
philtral measurements, which were presented as a table by Lo et al.22 The male Caucasian philtrum width and height was 10.9 1.7 and 14.8 2.4, respectively. We followed these measurements in our cases. Due to the characteristics of the related nasal deformities, the surgical correction of a BCLN deformity includes the repositioning of the lower lateral cartilage, achieving symmetry of alar domes and nasal floor.4 Parallel to other studies in the literature, an open rhinoplasty procedure was utilized for correction of the nasal deformities in our study.11e20,22e24 However, in our technique, part of the prolabium was included to the columella, and it was elevated as extended columellar flap. This approach allowed us to view directly both the cartilaginous and bony structure and made the corrective procedures easy and accurate and cover elongated columellar length with strut cartilage graft. The most important advantage of the extended columellar flap in BCLN patients was allowing the columellar elongation. The short columella is one of the most prominent features of the secondary BCLN.4,8 Consequently, the elongation of the columella is the main step for correction
Figure 7 A 20-year-old patient who received Abbe flap and simultaneous open rhinoplasty. Preoperative (left) and postoperative (6 months) (right) views of the patient.
of the nose deformities in this group of patients. Local tissue that can be employed for short columella was well described in the Introduction section. However, it is difficult to provide enough columellar length due to the scar and insufficient tissue on the upper lip. The extended columellar flap is an excellent choice for columellar elongation with simultaneous Abbe flap. The extended columellar flap is an axial-pattern skin flap in which blood supply flows from tip of the nose via a pair of columellar artery branches.23 This prolabial flap,
756 which is derived from the base of the columella, could be used safely for columella elongation. Elevation of the flap is straightforward, and easy. If there was a previous surgical incision scar on columella, extended columellar flap should not be used. In our patients, we did not observe any problems related to the extended columellar flap. The other most important advantage of extended columellar flap was tension-free closure of elongated columella. Otherwise, tension on columella may affect or distort the projected nasal tip. The combination with the Abbe flap provided the reconstruction of the upper lip defect, which was created by the elevation of columellar flap. Moreover, as mentioned by Cho BC et al., when the degloved nasal skin is redraped, any tension may affect or distort the projected nasal tip.25 Due to this fact, the other advantages of the columellar lengthening are structural support for the columella and reduction in the tension of redraped nasal skin. Successful results that had been obtained by using simultaneous Abbe flap and nasal repair exist in the literature.22,24,25 Yonehara Y et al. successfully corrected the secondary deformations of BCLN deformity of the five patients by using single-stage combined procedure.26 In their technique, the septal cartilage graft and cantilevered iliac bone graft had been utilized for nasal repair. Although the iliac bone graft may provide the nasal dorsum augmentation and tip elevation, the donor-site morbidity is important. It is the only cartilage graft that could be sufficient for nasal reconstruction in this group of patients. In all our patients, the nasal airway was obstructed by the deformed septal cartilage and removed. The removed septal cartilage was used as a cartilaginous strut in our patients. Although local anesthesia with or without sedation has been used for Abbe flap surgery,24,27,28 in our cases, general anesthesia was used because the simultaneous rhinoplasty was performed. This enables us to control every step of the surgery. Depending on the nature of the combined procedure, special precautions should be taken during awakening of the general anesthesia. It should be noted that simultaneous rhinoplasty and Abbe flap for the reconstruction of the secondary BCLN is not an outpatient procedure. First, the Doyle splint was used on all patients following the rhinoplasty procedure. This enables patients to breathe from the nose. Before awakening, a small-caliber airway tube can be inserted into the mouth to breathe well. One other measure is strong cooperation with anesthesiologist. As a result of the measures taken, neither airway obstruction nor respiratory difficulty developed in our patients. The secondary deformities of BCLN are frequently compounded by the presence of maxillary retrusion and related lower lip protrusion.8,22 The orthognathic surgery and orthodontic treatment are the best options before the soft tissue reconstruction to correct the dentoskeletal discrepancies.6,8,11 The proponents of this approach advocate that the final decision regarding the need for additional soft tissue to the upper lip can only be made after all other contours are made as near-normal as possible. Cutting and Warren successfully treated secondary correction of the bilateral cleft lip deformities by using three-stage procedure.8 Initially, they performed LeFort I osteotomy with or without distraction osteogenesis to correct the anatomic position of the midface.
M. Eski et al. Before the Abbe flap, the rhinoplasty had been performed as a secondary procedure. However, we used a one-stage operation involving the simultaneous placement of an Abbe flap and rhinoplasty. This procedure also improved the facial profile of our patients. However, if needed or the patient desired the orthognathic surgery, it should be performed in these cases. There are no standardized measures for assessing the aesthetic or functional outcomes following rhinoplasty.29 Several authors have described outcome measures to assess the patient satisfaction and have reported significant improvement in the quality of life for patients following rhinoplasty regardless of whether the indication was cosmetic or posttraumatic.29 For assessing the outcome from patients’ perspective, only one question was asked: whether the surgery improved their facial appearance or not and whether they are satisfied by the results or not? However, in order to qualify the improvement of the basic anatomic units that were intended to correct, we utilized objective methods that were based on measurements of pixel units. In terms of columellar length and upper lip projection, the amount of improvement was not evaluated objectively in previous studies.22,24,26 Subjective methods were used for evaluation of the results that were obtained by the different reconstructive tools for correction of related deformities of the secondary bilateral cleft lip patient. In this study, the evaluation of the columellar length and the subnasale and columella (sn-c) distance were selected for measurement following the Mulliken’s method.3,30,31 Unlike his method, the upper lip improvement was evaluated by measurement of the most anterior point of the upper lip (Ul0 , labiale superius) to the vertical plane tangent to the most anterior point of the lower lip (Ll0 ) in our study.3,21 However, because the Abbe flap is elevated from lower lip, alteration of the lower lip projection is possible during postoperative period. This situation implies a need for more stable reference point to obtain more accurate results. In addition, it should be noted that these patients had procumbent lower lip that needed to be corrected. After harvesting the Abbe flap from the lower lip, the protrusion of the lower lip was also corrected. The lower lip was located in the relatively natural position following flap elevation. The insertion of the Abbe flap to the released upper lip advanced the upper lip anteriorly. The end result of this surgery is the relative changes between the upper lip and the lower lip. For this reason, our results showed the relative changes to each other of the upper and the lower lip. Because of the compatibility, the lateral aspects were selected for measurement of these parameters. This measurement enabled us to assess the outcome objectively following this simultaneous surgery. This was the strength of the present study. However, the number of patients and duration of postoperative follow-up may have been the weakness of our study. Although 6 months is an adequate duration of postoperative follow-up, 4e18 months were used in previous studies for the assessment of postoperative results.32,33 It is reported that 6 months is required for the second stage of operation following the Abbe flap, and in this period, scars become inconspicuous.22 Further studies are needed to investigate the longterm results over 2 years.
Evaluation of the results of simultaneous open rhinoplasty and Abbe flap
Conclusion Based on our measurement method, postoperative changes of two important anatomical units have been determined successfully. These findings represent evidence in support of the success of the simultaneous rhinoplasty and Abbe flap for the reconstruction of the secondary BCLN deformity.
Ethical approval Not required.
Funding None.
Conflict of interest None declared.
Acknowledgment We thank Anil Aykan Barnbrook, Ph.D.c, Mimar Sinan Fine Arts University, Social Science Institute, Department of Graphic Design, for helping in the evaluation of the images.
References 1. Mulliken JB, Wu JK, Padwa BL. Repair of bilateral cleft lip: review, revisions, and reflections. J Craniofac Surg 2003;14(5):609e20. 2. Morovic CG, Cutting C. Combining the cutting and Mulliken methods for primary repair of the bilateral cleft lip nose. Plast Reconstr Surg 2005;116:1613e9. 3. Kim SK, Lee JH, Lee KC, et al. Mulliken method of bilateral cleft lip repair: anthropometric evaluation. Plast Reconstr Surg 2005;116:1243e51. 4. Van Beek AL, Hatfield AS, Schnepf E. Cleft rhinoplasty. Plast Reconstr Surg 2004;114:57e69. 5. Miyamoto J, Miyamoto S, Nagasao T, et al. Anthropometric evaluation of bilateral cleft lip nose with cone beam computed tomography in early childhood: estimation of nasal tip collapse. J Plast Reconstr Aesthet Surg 2012;65:169e74. 6. Mathes SJ, Hentz VR. Secondary deformities of the cleft lip, nose, and palate. In: Stal S, Hollier LH, editors. Plastic surgery. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2006. p. 339e63. 7. Koshy JC, Ellsworth WA, Sharabi SE, et al. Bilateral cleft lip revisions: the Abbe flap. Plast Reconstr Surg 2010;126(1):221e7. 8. Cutting CB, Warren SM. Extended Abbe flap for secondary correction of the bilateral cleft lip. J Craniofac Surg 2013;24: 75e8. 9. Agostini T. The Sabattini-Abbe ´ flap: a historical note. Plast Reconstr Surg 2009;123:767e8. 10. Jackson IT, Soutar DS. The sandwich Abbe flap in secondary cleft lip deformity. Plast Reconstr Surg 1980;66:38e45. 11. Erol OO, Pence M, Agaoglu G. The Abbe ´ island flap for the reconstruction of severe secondary cleft lip deformities. J Craniofac Surg 2007;18(4):766e72.
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12. Millard DR. Composite lip flaps and grafts in secondary cleft deformities. Br J Plast Surg 1964;17:22e9. 13. Serafin D, Georgiade NG. Secondary reconstructive procedures for patients with clefts. In: Pediatric plastic surgery, Princeton; 1984. p. 352e78. 14. Brown JB, McDowell F. Secondary repair of cleft lips and their nasal deformities. Ann Surg 1941;114:101. 15. Millard DR. Columellar lengthening by a forked flap. Plast Recontr Surg 1958;22:454. 16. Cronin TD. Lengthening columella by use of skin from the nasal floor and alae. Plast Reconstr Surg 1958;21:417. 17. Cronin TD, Upton J. Lengthening of the short columella associated with bilateral cleft lip. Ann Plast Surg 1978;1:75. 18. Brauer RO, Foerster DW. Another method to lengthen the columella in the bilateral cleft lip. Plast Reconstr Surg 1966; 38:27. 19. Edgerton MT, Carson MD, McKnelly LD. Lengthening of the short columella by skin flaps from the nasal tip and dorsum. Plast Reconstr Surg 1967;40:343. 20. Straith CL, Straith RE, Laeson JM. Reconstruction of the harelip nose. Plast Reconstr Surg 1957;20:455. 21. Shetye PR, Caterson EJ, Grayson BH, McCarthy JG. Soft-tissue profile changes following early Le Fort III distraction in growing children with syndromic craniosynostosis. Plast Reconstr Surg 2013;132(4):945e54. 22. Lo LJ, Kane AA, Chen YR. Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbe ´ flap revisited. Plast Reconstr Surg 2003;112(5):1219e27. 23. Daniel Rollin K. Nasal base. In: Daniel Rollin K, editor. Rhinoplasty, an atlas of surgical techniques. 1st ed. New York: Springer; 1999. p. 139e62. 24. Yoshimura Y, Nakajima T, Nakanishi Y, et al. Secondary correction of bilateral cleft lip deformity with simultaneous Abbe flap and nasal repair. J Cranio Maxillofac Surg 1998; 26(1):17e21. 25. Cho BC, Choi KY, Lee JH, et al. The correction of a secondary bilateral cleft lip nasal deformity using refined open rhinoplasty with reverse-U incision, VeY plasty, and selective combination with composite grafting: long-term results. Arch Plast Surg 2012;39(3):190e7. 26. Yonehara Y, Mori Y, Chikazu D, et al. Secondary correction of bilateral cleft lip and nasal deformity by simultaneous placement of an Abbe flap, septal cartilage graft, and cantilevered iliac bone graft. J Oral Maxillofac Surg 2008;66:581e8. 27. Millard DR, McLaughlin CA. Abbe ´ flap on mucosal pedicle. Ann Plast Surg 1979;3:544. 28. Holmstrom H. The Abbe ´ flap converted to an island flap. Scand J Plast Reconstr Surg 1986;20:51. 29. Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg 2011; 128(2):49e73. 30. Mulliken JB. Bilateral complete cleft lip and nasal deformity: an anthropometric analysis of staged to synchronous repair. Plast Reconstr Surg 1995;96:9e23. 31. Kohout MP, Aljaro LM, Farkas LG, et al. Photogrammetric comparison of two methods for synchronous repair of bilateral cleft lip and nasal deformity. Plast Reconstr Surg 1998;102(5): 1339e49. 32. Bonne OB, Wexler MR, De-Nour AK. Rhinoplasty patients’ critical self-evaluations of their noses. Plast Reconstr Surg 1996; 98(3):436e9. 33. Meningaud JP, Lantieri L, Bertrand JC. Rhinoplasty: an outcome research. Plast Reconstr Surg 2008;121(1):251e7.
Evaluation of the results of simultaneous open rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity* Muhitdin Eski*, Andac Aykan, Dogan Alhan, Fatih Zor, Selcuk Isik Gulhane Military Medical Academy, Department of Plastic and Reconstructive Surgery, 06010 Etlik, Ankara, Turkey Received 10 June 2014; accepted 2 February 2015
KEYWORDS Abbe flap; Secondary bilateral cleft and nasal deformity; Simultaneous rhinoplasty; Software-based method
Summary Aims: We aimed to evaluate the results of simultaneous rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity by means of a newly developed software-based method. Patients and Methods: A total of 16 patients with the bilateral cleft lip nasal deformity received Abbe flap and simultaneous open rhinoplasty between 2004 and 2010. The mean age of the patients was 21 years, and the average follow-up time was 2.4 years. After the open rhinoplasty procedure, the upper lip was reconstructed with the Abbe flap. Preoperative and postoperative photographs that had been taken laterally were evaluated by using Adobe Photoshop CS4 and Adobe InDesign software. The length of the columella and the relative changes of the most anterior point of the upper lip to the vertical plane tangent to the most anterior point of the lower lip were measured in pixels on standardized preoperative and postoperative images. The differences were calculated and compared as a percentage (%). Results: There was no flap loss and associated problems. The measurements of columellar length revealed an average increase of 51.8 11.3%, while the relative change of the most anterior point of the upper lip revealed an average increase of 68.6 11.2%. Conclusion: The results of the treatment modality were successfully evaluated by a newly developed software-based method. ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
*
This paper was presented at The Aesthetic Meeting on 11e16 April 2013, New York, USA. * Corresponding author. Gulhane Military Medical Academy, Department of Plastic and Reconstructive Surgery, 06010 Etlik, Ankara, Turkey. Tel.: þ90 0312 304 54 13; fax: þ90 0312 304 54 04. E-mail address: [email protected] (M. Eski). http://dx.doi.org/10.1016/j.bjps.2015.02.007 1748-6815/ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
752
Introduction Even the recent advances in primary repair of bilateral cleft lip nasal (BCLN) deformity have had limited success, because the outcome is less acceptable and the secondary deformities are inevitable.1e6 In patients with the secondary BCLN deformities, the most common lip deformities are the tight upper lip, short prolabium, lack of acceptable philtral column and Cupid’s bow definition, and central vermilion deficiency.7 In addition to these, the depressed nasal tip, wide nostril floor and short columella are the most important nasal deformities that need to be corrected in these patients.8 It is quite difficult to correct these deformities because there exists different degree of tissue deficiency in both lips and nose and asymmetry and tissue distortion. These deformities are required for the replacement of fullthickness lip elements and the alignment of anatomical landmarks such as philtral column and Cupid’s bow definition. The Abbe flap is a useful and well-defined and established reconstructive tool for the significant secondary deformities of the BCLN.7e12 Although both anatomical and aesthetic units of the upper lip are restored by the Abbe flap, it could not correct the columellar tissue deficiency. The upper lip, nasal structure, nasal skin, and prolabial skin are the sites that have been employed for the reconstruction of short columella.13 Basically, the VeY advancement technique is used for moving the prolabium into the columella. Brown and McDowell described the modification of VeY advancement for the reconstruction of short columella for the BCLN with their development of a philtral flap.14 Millard combined forked flaps developed from either side of the prolabium, along with vestibular-based flaps, to simultaneously elongate the columella and narrow the nasal floors.13,15 Cronin described the technique that uses nasal structure for elongation of the short columella.16,17 In this technique, a bipedicle flap is carried around the base of the ala to the base of nasolabial fold, with the entire floor of the nose undermined and lateral nasal components advanced medially. The technique usually combined suturing the medial crura of lower lateral cartilages together or an application of strut graft to provide additional stability and support to the columella as well as the nasal tip.13 There exist numerous operations that use nasal skin shifting by external incision with limited success.18e20 In this technique, part of the prolabial skin of the upper lip was preserved and marked as a nasal tip-based extended columellar flap, which was used for covering elongated columella during rhinoplasty. The remaining part of the upper lip was excised and released and the resultant defect of the upper lip was planned to reconstruct with the Abbe flap. In this study, the reconstruction of secondary deformities of BCLN with simultaneous rhinoplasty and Abbe flap was presented and the results were evaluated by means of a newly developed software-based method.
M. Eski et al. between 2004 and 2010. None of the patients had prior orthognathic operations. The mean age of the patients at the time of the operation was 21 years (range, 17e25) and the average follow-up period was 2.4 years.
Surgical procedure Before the operation, the Abbe flap, which was 12e14 mm in length and 10e12 mm in width, was designed and marked in the central lower lip with a slightly wider U-shaped caudal end (Figure 1). Part of the prolabial skin of the upper lip was preserved and marked for columellar elongation (extended columellar flap). The operations were carried out under general anesthesia. It is important to mark the vermilion-cutaneous line to prevent the distortion of the lower lip as well as the upper lip. The first step of the surgery was the incision of the extended columellar flap. Following the incision, superior pedicled extended columellar flap was elevated as a fullthickness skin flap. Next, the rim incision and regular open rhinoplasty was performed with tip reconstruction. In tip plasty, columellar strut graft was used to elongate the columella. The extended columellar flap enabled us to easily cover the elongated columella. The remaining part of the upper lip was excised and released and the resultant defect of the upper lip was planned to reconstruct with the Abbe flap. Following the rhinoplasty, the marked flap incision was performed and the Abbe flap containing fullthickness tissue from the central lower lip was elevated. The vertical and horizontal lengthening procedures of the upper lip segments were performed if any deficiency existed. The Abbe flap was rotated upward and inset to the defect in layers. The white skin and the vermilion lines between the Abbe flap and lateral lip segments were aligned by using preoperative vermillionecutaneous junction markings on the upper lip (Figure 2) (see video: supplemental digital content 1). Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2015.02.007.
Patients and methods Patient demographics A total of 16 male patients with the BCLN deformity received Abbe flap and simultaneous open rhinoplasty
Figure 1 Preoperative planning of the patient. The Abbe and extended columellar flap lines and the site of the lower lip midlines are determined.
Evaluation of the results of simultaneous open rhinoplasty and Abbe flap
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were used for nasal packing. The pedicle of the Abbe flap was divided under local anesthesia 14e17 days later.
Assessment
Figure 2 Surgical procedure. Procedure is performed under general anesthesia (upper-left). Marking of vermillioncutaneous line (upper-right). After rhinoplasty (bottom-left). The Abbe flap is in place (bottom-right).
Postoperative care The airway tube was inserted into the mouth to alleviate airway obstruction at the end of the surgery. Doyle splints
The patients who were followed at least 6 months and had standard pictures that can be used for assessment included for software-based preoperative and postoperative evaluation. Only one question was asked to capture the physical status of patient: How well do you like the appearance of your nose and lips following this surgery? Preoperative and postoperative (6 months) photographs that had been taken laterally were evaluated by using Adobe Photoshop CS4 and Adobe InDesign CS4 software. After the conversion of the lateral images to the gray scale pattern, nose, lip, and ear boundaries were marked (path drawing) (Figure 3). After the path drawing, images were standardized on the basis of the ear size (Figure 4). The length of the columella (sn-c; from subnasale sn to the most inferior line of the infralobular triangle c) (3) was measured in pixels on standardized preoperative and postoperative images (Figure 5). The distance between the vertical lines that were tangent to the most anterior point of the lower lip (Ll0 ) and the most anterior point of the upper lip (Ul0 , labiale superius) was measured in pixels on images (21). The differences between the preoperative and postoperative measurements were calculated and compared as a percentage (%).
Results All patients expressed their satisfaction and that the surgery satisfactorily improved their appearance. There was no flap loss and associated problems. No problem was encountered in terms of airway obstruction due to combined surgery. In five patients, minor revision (alignment of scars) was performed on the upper lip. The eight patients’
Figure 3 Initially, the preoperative and postoperative images were converted to the gray scale images. After the conversion, boundaries of the basic anatomical structures were marked with different color (pink for preoperative, blue for postoperative images) by using the Adobe Photoshop CS4 software.
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Figure 4 The standardization of the preoperative and postoperative images on the basis of the ear dimensions (Adobe InDesign CS4) (pink for preoperative, blue for postoperative images).
standard photographs that were suitable for the evaluation were assessed with the software. An average increase of 51.8 11.3% was determined between the preoperative and postoperative columellar lengths. The relative change
of the most anterior point of upper lip compared to the lower lip (Ul0 Ll0 ) had an average increase of 68.6 11.2%. Simultaneously, the surgery corrected both the nasal and lip deformities and improved the facial profiles of the patients (Figures 6 and 7).
Discussion
Figure 5 The measurement methods of the length of the columella (from subnasale sn to the most inferior line of the infralobular triangle c) (upper left and right). The relative changes of the most anterior point of the upper lip (Ul0 ) to the vertical plane tangent to the most anterior point of the lower lip (Ll0 ) were measured in pixels on preoperative (pink) and postoperative (blue) images (lower left and right). Yellow lines indicate the measurements, white line indicates vertical line that is tangent to the most anterior point of the lower lip.
Simultaneous open rhinoplasty and Abbe flap successfully enabled us to correct the secondary deformities of BCLN, which include both central lip and nose. The upper lip includes important anatomical landmarks such as philtral columns, Cupid’s bow, and central tubercle, which are essential for ideal aesthetic appearance. The Abbe flap addresses reconstruction of all components of the secondary bilateral cleft lip deformities and provides both aesthetic and functional repair. It offers healthy tissue for reconstruction of the philtral landmarks, reconstitution of oral competence of the orbicularis oris muscle, and recreation of Cupid’s bow and the central pouts.7,8 However, in our cases, the most important advantage of Abbe flap was to allow us to use extended columellar skin flap to reconstruct the short columella. The Abbe flap also corrects the relatively protruding lower lip. However, the etiology of the sagging lower lip remains unknown; it is the prevalent feature of the bilateral cleft lip patients as mentioned by Cutting and Warren.8 Therefore, the correction of the lower lip provided a secondary benefit of Abbe flap reconstruction as seen in our cases. Millard used the “shield”-shaped Abbe flap design.10 Jackson described the “triangular”-shaped Abbe flap.12 In addition to these, various Abbe flap designs were used in the literature, such as square and M shape or W shape.7e11 All shapes are acceptable and have their own advantages. We used a U-shaped Abbe flap design in which vertical limbs tapered slightly toward the midline and then extended to the labiomental crease. This gives the flap a modified shield shape. This enabled us to use full-size extended columellar flap and restore donor defect of this flap accurately. In addition, this design creates the columellar base flare. The scar that results in the lower lip was located on the labiomental crease and aesthetically acceptable. The size of the flap was compatible with the craniofacial normative
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Figure 6 A 21-year-old patient who received Abbe flap and simultaneous open rhinoplasty. Preoperative (left) and postoperative (1 year) (right) views of the patient.
philtral measurements, which were presented as a table by Lo et al.22 The male Caucasian philtrum width and height was 10.9 1.7 and 14.8 2.4, respectively. We followed these measurements in our cases. Due to the characteristics of the related nasal deformities, the surgical correction of a BCLN deformity includes the repositioning of the lower lateral cartilage, achieving symmetry of alar domes and nasal floor.4 Parallel to other studies in the literature, an open rhinoplasty procedure was utilized for correction of the nasal deformities in our study.11e20,22e24 However, in our technique, part of the prolabium was included to the columella, and it was elevated as extended columellar flap. This approach allowed us to view directly both the cartilaginous and bony structure and made the corrective procedures easy and accurate and cover elongated columellar length with strut cartilage graft. The most important advantage of the extended columellar flap in BCLN patients was allowing the columellar elongation. The short columella is one of the most prominent features of the secondary BCLN.4,8 Consequently, the elongation of the columella is the main step for correction
Figure 7 A 20-year-old patient who received Abbe flap and simultaneous open rhinoplasty. Preoperative (left) and postoperative (6 months) (right) views of the patient.
of the nose deformities in this group of patients. Local tissue that can be employed for short columella was well described in the Introduction section. However, it is difficult to provide enough columellar length due to the scar and insufficient tissue on the upper lip. The extended columellar flap is an excellent choice for columellar elongation with simultaneous Abbe flap. The extended columellar flap is an axial-pattern skin flap in which blood supply flows from tip of the nose via a pair of columellar artery branches.23 This prolabial flap,
756 which is derived from the base of the columella, could be used safely for columella elongation. Elevation of the flap is straightforward, and easy. If there was a previous surgical incision scar on columella, extended columellar flap should not be used. In our patients, we did not observe any problems related to the extended columellar flap. The other most important advantage of extended columellar flap was tension-free closure of elongated columella. Otherwise, tension on columella may affect or distort the projected nasal tip. The combination with the Abbe flap provided the reconstruction of the upper lip defect, which was created by the elevation of columellar flap. Moreover, as mentioned by Cho BC et al., when the degloved nasal skin is redraped, any tension may affect or distort the projected nasal tip.25 Due to this fact, the other advantages of the columellar lengthening are structural support for the columella and reduction in the tension of redraped nasal skin. Successful results that had been obtained by using simultaneous Abbe flap and nasal repair exist in the literature.22,24,25 Yonehara Y et al. successfully corrected the secondary deformations of BCLN deformity of the five patients by using single-stage combined procedure.26 In their technique, the septal cartilage graft and cantilevered iliac bone graft had been utilized for nasal repair. Although the iliac bone graft may provide the nasal dorsum augmentation and tip elevation, the donor-site morbidity is important. It is the only cartilage graft that could be sufficient for nasal reconstruction in this group of patients. In all our patients, the nasal airway was obstructed by the deformed septal cartilage and removed. The removed septal cartilage was used as a cartilaginous strut in our patients. Although local anesthesia with or without sedation has been used for Abbe flap surgery,24,27,28 in our cases, general anesthesia was used because the simultaneous rhinoplasty was performed. This enables us to control every step of the surgery. Depending on the nature of the combined procedure, special precautions should be taken during awakening of the general anesthesia. It should be noted that simultaneous rhinoplasty and Abbe flap for the reconstruction of the secondary BCLN is not an outpatient procedure. First, the Doyle splint was used on all patients following the rhinoplasty procedure. This enables patients to breathe from the nose. Before awakening, a small-caliber airway tube can be inserted into the mouth to breathe well. One other measure is strong cooperation with anesthesiologist. As a result of the measures taken, neither airway obstruction nor respiratory difficulty developed in our patients. The secondary deformities of BCLN are frequently compounded by the presence of maxillary retrusion and related lower lip protrusion.8,22 The orthognathic surgery and orthodontic treatment are the best options before the soft tissue reconstruction to correct the dentoskeletal discrepancies.6,8,11 The proponents of this approach advocate that the final decision regarding the need for additional soft tissue to the upper lip can only be made after all other contours are made as near-normal as possible. Cutting and Warren successfully treated secondary correction of the bilateral cleft lip deformities by using three-stage procedure.8 Initially, they performed LeFort I osteotomy with or without distraction osteogenesis to correct the anatomic position of the midface.
M. Eski et al. Before the Abbe flap, the rhinoplasty had been performed as a secondary procedure. However, we used a one-stage operation involving the simultaneous placement of an Abbe flap and rhinoplasty. This procedure also improved the facial profile of our patients. However, if needed or the patient desired the orthognathic surgery, it should be performed in these cases. There are no standardized measures for assessing the aesthetic or functional outcomes following rhinoplasty.29 Several authors have described outcome measures to assess the patient satisfaction and have reported significant improvement in the quality of life for patients following rhinoplasty regardless of whether the indication was cosmetic or posttraumatic.29 For assessing the outcome from patients’ perspective, only one question was asked: whether the surgery improved their facial appearance or not and whether they are satisfied by the results or not? However, in order to qualify the improvement of the basic anatomic units that were intended to correct, we utilized objective methods that were based on measurements of pixel units. In terms of columellar length and upper lip projection, the amount of improvement was not evaluated objectively in previous studies.22,24,26 Subjective methods were used for evaluation of the results that were obtained by the different reconstructive tools for correction of related deformities of the secondary bilateral cleft lip patient. In this study, the evaluation of the columellar length and the subnasale and columella (sn-c) distance were selected for measurement following the Mulliken’s method.3,30,31 Unlike his method, the upper lip improvement was evaluated by measurement of the most anterior point of the upper lip (Ul0 , labiale superius) to the vertical plane tangent to the most anterior point of the lower lip (Ll0 ) in our study.3,21 However, because the Abbe flap is elevated from lower lip, alteration of the lower lip projection is possible during postoperative period. This situation implies a need for more stable reference point to obtain more accurate results. In addition, it should be noted that these patients had procumbent lower lip that needed to be corrected. After harvesting the Abbe flap from the lower lip, the protrusion of the lower lip was also corrected. The lower lip was located in the relatively natural position following flap elevation. The insertion of the Abbe flap to the released upper lip advanced the upper lip anteriorly. The end result of this surgery is the relative changes between the upper lip and the lower lip. For this reason, our results showed the relative changes to each other of the upper and the lower lip. Because of the compatibility, the lateral aspects were selected for measurement of these parameters. This measurement enabled us to assess the outcome objectively following this simultaneous surgery. This was the strength of the present study. However, the number of patients and duration of postoperative follow-up may have been the weakness of our study. Although 6 months is an adequate duration of postoperative follow-up, 4e18 months were used in previous studies for the assessment of postoperative results.32,33 It is reported that 6 months is required for the second stage of operation following the Abbe flap, and in this period, scars become inconspicuous.22 Further studies are needed to investigate the longterm results over 2 years.
Evaluation of the results of simultaneous open rhinoplasty and Abbe flap
Conclusion Based on our measurement method, postoperative changes of two important anatomical units have been determined successfully. These findings represent evidence in support of the success of the simultaneous rhinoplasty and Abbe flap for the reconstruction of the secondary BCLN deformity.
Ethical approval Not required.
Funding None.
Conflict of interest None declared.
Acknowledgment We thank Anil Aykan Barnbrook, Ph.D.c, Mimar Sinan Fine Arts University, Social Science Institute, Department of Graphic Design, for helping in the evaluation of the images.
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12. Millard DR. Composite lip flaps and grafts in secondary cleft deformities. Br J Plast Surg 1964;17:22e9. 13. Serafin D, Georgiade NG. Secondary reconstructive procedures for patients with clefts. In: Pediatric plastic surgery, Princeton; 1984. p. 352e78. 14. Brown JB, McDowell F. Secondary repair of cleft lips and their nasal deformities. Ann Surg 1941;114:101. 15. Millard DR. Columellar lengthening by a forked flap. Plast Recontr Surg 1958;22:454. 16. Cronin TD. Lengthening columella by use of skin from the nasal floor and alae. Plast Reconstr Surg 1958;21:417. 17. Cronin TD, Upton J. Lengthening of the short columella associated with bilateral cleft lip. Ann Plast Surg 1978;1:75. 18. Brauer RO, Foerster DW. Another method to lengthen the columella in the bilateral cleft lip. Plast Reconstr Surg 1966; 38:27. 19. Edgerton MT, Carson MD, McKnelly LD. Lengthening of the short columella by skin flaps from the nasal tip and dorsum. Plast Reconstr Surg 1967;40:343. 20. Straith CL, Straith RE, Laeson JM. Reconstruction of the harelip nose. Plast Reconstr Surg 1957;20:455. 21. Shetye PR, Caterson EJ, Grayson BH, McCarthy JG. Soft-tissue profile changes following early Le Fort III distraction in growing children with syndromic craniosynostosis. Plast Reconstr Surg 2013;132(4):945e54. 22. Lo LJ, Kane AA, Chen YR. Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbe ´ flap revisited. Plast Reconstr Surg 2003;112(5):1219e27. 23. Daniel Rollin K. Nasal base. In: Daniel Rollin K, editor. Rhinoplasty, an atlas of surgical techniques. 1st ed. New York: Springer; 1999. p. 139e62. 24. Yoshimura Y, Nakajima T, Nakanishi Y, et al. Secondary correction of bilateral cleft lip deformity with simultaneous Abbe flap and nasal repair. J Cranio Maxillofac Surg 1998; 26(1):17e21. 25. Cho BC, Choi KY, Lee JH, et al. The correction of a secondary bilateral cleft lip nasal deformity using refined open rhinoplasty with reverse-U incision, VeY plasty, and selective combination with composite grafting: long-term results. Arch Plast Surg 2012;39(3):190e7. 26. Yonehara Y, Mori Y, Chikazu D, et al. Secondary correction of bilateral cleft lip and nasal deformity by simultaneous placement of an Abbe flap, septal cartilage graft, and cantilevered iliac bone graft. J Oral Maxillofac Surg 2008;66:581e8. 27. Millard DR, McLaughlin CA. Abbe ´ flap on mucosal pedicle. Ann Plast Surg 1979;3:544. 28. Holmstrom H. The Abbe ´ flap converted to an island flap. Scand J Plast Reconstr Surg 1986;20:51. 29. Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg 2011; 128(2):49e73. 30. Mulliken JB. Bilateral complete cleft lip and nasal deformity: an anthropometric analysis of staged to synchronous repair. Plast Reconstr Surg 1995;96:9e23. 31. Kohout MP, Aljaro LM, Farkas LG, et al. Photogrammetric comparison of two methods for synchronous repair of bilateral cleft lip and nasal deformity. Plast Reconstr Surg 1998;102(5): 1339e49. 32. Bonne OB, Wexler MR, De-Nour AK. Rhinoplasty patients’ critical self-evaluations of their noses. Plast Reconstr Surg 1996; 98(3):436e9. 33. Meningaud JP, Lantieri L, Bertrand JC. Rhinoplasty: an outcome research. Plast Reconstr Surg 2008;121(1):251e7.