- Email: [email protected]
Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction
YIJOM-4359; No of Pages 6
Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx https://doi.org/10.1016/j.ijom.2020.01.015, available online at https://www.sciencedirect.com
Clinical Paper Cleft Lip and Palate
Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction F. C. -S. Chang, C. G. Wallace, Y. -C. Hsiao, J. -J. Huang, C. S. -W. Liu, Z. -C. Chen, P. K. -T. Chen, J. -P. Chen, Y. -R. Chen: Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction. Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx. ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Cleft lip and/or cleft palate are the most common congenital craniofacial anomalies. Philtral ridge morphology is an important aesthetic component of unilateral cleft lip (UCL) repair. To this end, we have developed two techniques of philtral ridge reconstruction: (1) asymmetric mattress muscle sutures, and (2) overlapping mattress muscle sutures. The objective of this retrospective cohort study was to compare their outcomes in UCL repairs. Group I patients (n = 30) underwent UCL repair before August 2003, including philtral ridge reconstruction by asymmetric mattress muscle sutures. Group II patients (n = 30) underwent UCL repair after August 2003, including philtral ridge reconstruction by overlapping mattress muscle sutures. Philtral morphology was evaluated by ultrasonographic and three-dimensional photographic measurements, examining cleft side philtral projection and philtral ridge symmetry. These demonstrated that group II patients had better philtral column symmetry and projection on the cleft side when compared to group I. Overlapping mattress muscle sutures produced better philtral morphology in UCL repairs than asymmetric mattress muscle sutures.
The philtral dimple corresponds to the median decussation of the orbicularis oris muscle in the midline, with contributions from the nasalis and levator labii superioris muscles1. It is challenging to create aesthetically harmonious lateral philtral ridges with a central philtral dimple during unilateral complete cleft lip repair (CLR). 0901-5027/000001+06
Upper lip thickness at the philtral ridge (about 11 mm) and in the philtral dimple (about 7 mm) differ by approximately 4 mm 2. This should be considered during philtral reconstruction to achieve a more natural appearance following CLR. We previously reported the ‘asymmetric mattress muscle sutures’ technique, which
F.C.-S. Chang1,2,3, C. G. Wallace2,4, Y.-C. Hsiao2, J.-J. Huang2, C.S.-W. Liu5, Z.-C. Chen2, P.K.-T. Chen2,6, J.-P. Chen1, Y.-R. Chen2 1
Department of Chemical and Materials Engineering, College of Engineering, Chang Gung University, Taoyuan, Taiwan; 2 Craniofacial Research Centre, Department of Medical Research, Department of Plastic and Reconstructive Surgery and Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 3 Department of Plastic Surgery, Xiamen Chang Gung Hospital, Xiamen, China; 4 Department of Plastic Surgery, Royal Devon and Exeter Hospital, Exeter, UK; 5Department of Surgery, United Christian Hospital, Kwun Tong, Hong Kong; 6Department of Plastic and Reconstructive Surgery, Taipei Medical University Hospital, Taipei, Taiwan
Key words: cleft lip and palate; philtral ridge; orbicularis oris muscle; cheiloplasty; lip reconstruction. Accepted for publication
involves suturing the lateral orbicularis peripheralis into an over-riding insertion compared to the medial muscle, in order to cause an elevation on the cleft side philtral ridge (Fig. 1)3; however, long-term follow-up revealed progressive philtral ridge flattening on the cleft side. This prompted us to modify the technique in August 2003 so that the
ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015
YIJOM-4359; No of Pages 6
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Chang et al. Primary cheiloplasty
Fig. 1. Asymmetrical edge-to-edge suturing of the orbicularis oris muscle: the lateral orbicularis oris muscle is sutured to over-ride the medial muscle. (c; cm; op.). c: Columella; cm: C-Flap Mucosa; op: Orbicularis Peripheralis Muscle.
lateral orbicularis was sutured further medially to overlap the medial orbicularis oris muscle. We termed this the ‘overlapping mattress muscle sutures’ technique (Fig. 2)4,5. The objective of this study was to compare the long-term outcomes of these two different methods of philtral ridge reconstruction through objective assessments of the cleft side philtral projection and philtral ridge symmetry.
Patients and methods
This was a retrospective cohort clinical trial designed to compare the long-term outcomes of two different methods of orbicularis oris muscle reconstruction. The study received ethical approval from the Institutional Review Board of Chang Gung Memorial Hospital (IRB No. 1045673B). All patients provided IRB-ap-
proved fully informed written consent for inclusion. Sixty patients who had undergone primary complete unilateral CLR at the Craniofacial Centre of Chang Gung Memorial Hospital from January 2000 to December 2006, performed by a single surgeon (PKTC), were enrolled from the outpatient clinic. Of these, 30 consecutive patients had undergone the ‘asymmetric mattress muscle sutures’ technique (group I; Fig. 1). The other 30 consecutive patients had undergone the ‘overlapping mattress muscle sutures’ technique (group II; Fig. 2). Inclusion criteria were (1) complete unilateral CLR, (2) no other craniofacial malformations or systemic disease, (3) primary CLR performed by one surgeon, and (4) no secondary lip revision surgery performed prior to ultrasonographic or three-dimensional (3D) photographic measurements.
Fig. 2. Overlapping vertical mattress suture of the orbicularis oris muscle: the lateral orbicularis oris muscle is sutured to overlap the medial orbicularis oris muscle. (c; cm; op.). c: Columella; cm: C-Flap Mucosa; op: Orbicularis Peripheralis Muscle.
Points were inked on the Cupid’s bow and a Mohler rotation–advancement cheiloplasty was designed. The rotation flap was created with a curved incision extending from the columella base across the free border of the lip at a right angle to the lip axis. An oblique incision across the columella base was created and this incision could be extended but was not allowed to cross the non-cleft side philtral column. A columella flap (C-flap) was fashioned and the mucosa of the C-flap defined. The advancement flap incision was made to pass along the cleft margin and an L-flap was developed. The incision was continued along the piriform aperture to the base of the inferior turbinate. An inferior turbinate flap was designed. The flaps were positioned and the orbicularis muscle repair was performed. For group I, the lateral orbicularis oris muscle was sutured to over-ride the medial orbicularis oris muscle (Fig. 1). For group II, the lateral orbicularis oris muscle was sutured to overlap the medial orbicularis oris muscle (Fig. 2)3.
Ultrasonographic measurements
All ultrasonographic measurements of the thickness of the philtral ridge and philtral dimpling were performed on the cleft and non-cleft sides by a single sonographer using the same machine (Terason t3000, 12-MHz transducer; Teratech Corporation, Burlington, MA, USA), on transverse images obtained at the patients’ last clinical follow-up appointments. During each examination, the probe was placed perpendicular to the lip with its inferior border aligned to the Cupid’s bow, with plenty of conductive jelly to avoid lip compression. The following parameters were measured (Fig. 3): (1) cleft side philtral column: the distance between the skin surface at the highest philtral projection and the inner mucosa of the upper lip on the cleft side; (2) non-cleft side philtral column: the distance between the skin surface at the highest philtral projection and the inner mucosa of the upper lip on the non-cleft side; and (3) philtral dimpling: the distance between the skin surface of the most depressed indentation between the philtral ridges and the inner mucosa of the upper lip on the midline. The following were then calculated: (a) philtral column symmetry: non-cleft side philtral column minus cleft side philtral column, and (b) cleft side philtral column projection: cleft side philtral column minus philtral dimpling.
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015
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Philtral ridge morphology after reconstruction
Fig. 3. Ultrasound of the upper lip: D—D non-cleft side philtral column; +—+ philtral dimpling; x— x cleft side philtral column.
3D photographic measurements
3D photographic measurements were conducted using the 3dMDhead system (3dMD, Atlanta, GA, USA). Facial images were captured at the last clinic visit with each patient sitting upright and equidistant between the cameras. Data were analysed using the 3dMDpatient software platform (3dMD, Atlanta, GA, USA). The following steps were critical to the photographic philtral measurements. First, the face was oriented to the intercanthal line in both coronal and axial views. The A plane was cut 1 mm superior to the cleft side white skin roll. All of the image inferior to this plane and posterior to the auricle was discarded. The face was then up-rotated 90 degrees with the upper lip placed cephalically (Fig. 4). Second, a line defining the upper lip baseline reference was placed, lying parallel to the intercanthal line and connecting the alar bases. A geometric lattice with 1 cm spaces was then placed on the image, which was then saved and transferred to Photoshop (CS5 extended version 12.0; Adobe Systems Inc., San Jose, CA, USA) (Fig. 5). The following measurements were taken: (1) cleft side philtral column: the distance between the skin of the highest philtral projection and the baseline of the upper lip on the cleft side; (2) non-cleft side philtral column: the distance between the skin of the highest philtral projection and the baseline of upper lip on the noncleft side; and (3) philtral dimpling: the distance between the skin surface of the most depressed indentation between the philtral ridges and the baseline of upper lip on the midline. The following were then calculated: (a) philtral column symmetry: non-cleft side philtral column minus cleft side philtral column, and (b) cleft side philtral column
projection: cleft side philtral column minus philtral dimpling. Statistical analysis
The x2 test was used to compare demographic data between the two groups (sex and cleft side). The independent t-test was used to compare age at operation and age at the time of the study (age when the 3D photograph and ultrasound measurements were performed). Statistical significance was defined as a P-value of less than 0.05. The data are presented as the mean standard deviation unless otherwise stated. Results
Thirty patients in group I and 30 patients in group II completed the study. Their demographic data are shown in Table 1. Ultrasonographic and 3D photographic measurements
According to both the ultrasound scan and 3D photographic measurements, group II philtral columns were significantly more symmetric than those in group I (ultrasound: 0.06 0.75 mm vs 0.62 1.09 mm, P = 0.024; 3D photographs: 0.18 0.68 mm vs 0.87 1.05 mm, P = 0.004). Group II philtral ridges were more projected than those in group I (ultrasound: 1.36 0.89 vs 0.50 0.84 mm, P < 0.001; 3D photographs: 1.22 0.74 vs 0.43 0.65 mm, P < 0.001). Discussion
In 1958, Millard emphasized the importance of achieving natural looking results with his proposed rotation–advancement CLR. Amongst other features, a natural looking result requires a Cupid’s bow with
3
symmetrical alae, a philtral dimple, a matching philtrum column, and a camouflaged scar6. The restoration or repair of the orbicularis oris muscle constitutes a key surgical step that has been modified in several different ways7. Millard used interrupted sutures to repair the orbicularis oris muscle8. Randall et al. proposed that the medial muscle flap should overlap the lateral muscle flap9. Mulliken and Martı´nezPe´rez dissected the orbicularis oris muscle from the skin and mucosa before repair, opposing the deep orbicularis oris muscle (pars marginalis) first and placing vertical mattress sutures from inferiorly to the superior border10. Cutting and Dayan emphasized that the muscle should be repaired in a ‘praying hands’ fashion with a buried horizontal mattress suture11. Salyer et al. emphasized a key muscle suture to position the alar base, then interrupted repair of the muscle12. Lim et al. used the palmaris longus tendon to reconstruct the philtral column in a secondary setting13. At the Chang Gung Craniofacial Centre, one of our modifications of the rotation– advancement technique was to suture the orbicularis oris muscle of the lateral advancement flap over-riding the orbicularis oris muscle of the medial rotation flap (Fig. 1) to create a philtral column on the cleft side3. This showed good initial outcomes, but longer term follow-up revealed a gradual loss of philtral column projection on the cleft side (Fig. 6). We therefore further modified the technique in August 2003 by suturing the orbicularis oris muscle of the lateral advancement flap over the orbicularis oris muscle of the medial rotation flap, creating a stronger philtral column on the cleft side. Based on our clinical observations, this modified method has shown improved outcomes on the cleft side and has become our established method of philtral column reconstruction (Fig. 7). However, the longterm outcomes have never been assessed formally until now. Rogers et al. performed a comprehensive review of the normal and cleft orbicularis oris muscle, as well as various techniques of philtral ridge reconstruction, and mentioned that there are no objective, long-term data comparing these techniques14. A recent publication by Naidoo and Bu¨tow reports the use of two inverted horizontal mattress sutures to repair the orbicularis oris muscle, with a take-down suture to create central dimpling. They presented convincing 1-week and 6-month postoperative pictures, but neither subjective nor objective measurements were performed15. Several studies have used a
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015
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Fig. 4. (A) An axial plane cut was sited 1 mm superior to the cleft side white roll. (B) All of the image below this axial plane was deleted. (C) The head posterior to the auricle was deleted. (D) The head was up-rotated 90 degrees, placing the upper lip into the cephalic position. The lip contour is highlighted with the red–white dotted line. A square lattice (10 mm 10 mm) was then overlaid (for interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.).
visual analogue scale (VAS) to evaluate philtral column results in patients with secondary cleft lip repairs16–18; however, this is subjective by nature. We have previously used a caliper to measure the lip height, lip width, philtrum width, philtrum length, and vermillion thickness during general anaesthesia before starting surgery19; however it is difficult to accurately measure the philtral column projection and philtral dimpling with a caliper. In the current study, ultrasound and 3D digital photogrammetric images were used as cost-effective and non-invasive tools to evaluate the surgical outcomes. Ultrasound has been used previously for the clinical evaluation of muscle changes, such as volumetric evaluation of the masseter muscle following botulinum toxin A injection20,21. One can accurately delineate the philtral column and lip mucosa and hence measure philtral projection and dimpling of the upper lip with ultrasound, as long as plenty of ultrasound gel is
Fig. 5. The philtral column ridges and philtral dimpling were measured from the base line, which connects the inner canthi. Blue line: non-cleft side philtral column; green line: philtral dimpling; black line: cleft side philtral column (for interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.).
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015
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Table 1. Patient demographic data.a Number of patients Age at operation, months Age at the time of the study, years Sex Male Female Cleft side Left Right
Group I
Group II
30 4.44 2.74 16.62 0.94
30 3.60 1.33 13.41 0.87
15 15
16 14
22 8
19 11
P-value 0.139 <0.001 0.796 0.405
Data presented as the number of patients, or mean standard deviation value. a Group I patients: UCL repair including philtral ridge reconstruction by asymmetric mattress muscle sutures. Group II patients: UCL repair including philtral ridge reconstruction by overlapping mattress muscle sutures.
Fig. 6. Typical presentation of a group I patient. In these four patients (panels A, B, C, and D represent four different patients), the cleft side philtral column had similar projection to the non-cleft side philtral column. The central dimple was more accentuated.
Fig. 7. Typical presentation of a group II patient. In these four patients (panels A, B, C, and D represent four different patients), the cleft side philtral column showed less projection compared to the non-cleft side philtral column. The central dimple was less accentuated.
applied to avoid compression of the upper lip with the probe. A potential confounding issue with ultrasound scanning is operator dependence. However, in expert hands, ultrasound measurements offer levels of accuracy that even allow calibration22. High resolution magnetic resonance imaging or computed tomography (CT) scans are alternatives, but are expensive and time-consuming, and CT provides poor soft tissue views and inflicts ionizing radiation. The 3D digital photogrammetric images (3dMDhead system; 3dMD, Atlanta, GA, USA) used in this study capture the entire face at its highest resolution within 1.5 milliseconds, offering a geometric accuracy of less than 0.2 mm. Such rapid image capture is particularly suitable for evaluating young children non-invasively,
without ionizing radiation (unlike 3D CT) and has been shown to be valid and reliable in the craniofacial setting23,24. The thickness of the upper lip cannot be measured directly through the 3dMDpatient or 3dMDvultus systems because the baseline for measurements is under the skin surface. To circumnavigate this problem, we converted 3D into 2D images and overlaid a 10-mm lattice, allowing linear measurements to be performed with the imaging software. This study has some limitations. There was a statistically significant difference in age at the time of the study between group I and group II patients, which arose due to the consecutive inclusion of patients. It could be assumed that group I, being older, might have thicker upper lips, but philtral column symmetry (non-cleft side
philtral column minus cleft side philtral column) and cleft side philtral column projection (cleft side philtral column minus philtral dimpling) were used to minimize the effect of upper lip thickness. In conclusion, this study demonstrated that the overlapping mattress suture technique for orbicularis oris muscle reconstruction offers sustained philtral column height with better symmetry than the asymmetrical mattress suture technique.
Funding
We are grateful for the support of this project by a research grant of Ministry of Science and Technology, Republic of China (105-2314-b-182a-080-).
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015
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Chang et al.
Competing interests
There are no competing interests to declare. Ethical approval
The study received ethical approval from the Institutional Review Board of Chang Gung Memorial Hospital (IRB No. 1045673B). Patient consent
All patients signed the IRB-approved informed consent. References 1. Latham RA, Deaton TG. The structural basis of the philtrum and the contour of the vermilion border: a study of the musculature of the upper lip. J Anat 1976;121:151–60. 2. Ivy RH. The philtrum of the upper lip. Plast Reconstr Surg 1967;40:94–5. 3. Noordhoff MS, Chen Y, Chen K, Hong KF, Lo LJ. The surgical technique for the complete unilateral cleft lip–nasal deformity. Operative Techniques in Plast Reconstr Surg 1995;2:167–74. 4. Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PKT. Botulinum toxin to improve results in cleft lip repair. Plast Reconstr Surg 2014;134:511–6. 5. Chang CS, Por YC, Liou EJ, Chang CJ, Chen PK, Noordhoff MS. Long-term comparison of four techniques for obtaining nasal symmetry in unilateral complete cleft lip patients: a single surgeon’s experience. Plast Reconstr Surg 2010;126:1276–84. http://dx. doi.org/10.1097/PRS.0b013e3181ec21e4. 6. Millard DR. Complete unilateral clefts of the lip. Plast Reconstr Surg 1960;25:595–605. 7. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research.The Report of an American Academy of Sleep Medicine Task Force Sleep 1999;22:667–89.
8. Stal S, Brown RH, Higuera S, Hollier LHJ, Byrd HS, Cutting CB, Mulliken JB. Fifty years of the Millard rotation–advancement: looking back and moving forward. Plast Reconstr Surg 2009;123:1364–77. 9. Randall P, Whitaker LA, LaRossa D. The importance of muscle reconstruction in primary and secondary cleft lip repair. Plast Reconstr Surg 1974;54:316–23. 10. 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;104:1247–60. 11. Cutting CB, Dayan JH. Lip height and lip width after extended Mohler unilateral cleft lip repair. Plast Reconstr Surg 2003;111:17– 23. 12. Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip–nose repair: a 33-year experience. J Craniofac Surg 2003;14:549–58. 13. Lim AA, Allam KA, Taneja R, Kawamoto HK. Construction of the philtral column using palmaris longus tendon. Plast Reconstr Surg 2012;129:374e–5e. 14. Rogers CR, Meara JG, Mulliken JB. The philtrum in cleft lip: review of anatomy and techniques for construction. J Craniofac Surg 2014;25:9–13. 15. Naidoo S, Bu¨tow KW. Philtrum reconstruction in unilateral cleft lip repair. Int J Oral Maxillofac Surg 2019;48:716–9. http://dx. doi.org/10.1016/j.ijom.2018.11.003. 16. Cho BC, Baik BS. Formation of philtral column using vertical interdigitation of orbicularis oris muscle flaps in secondary cleft lip. Plast Reconstr Surg 2000;106:980–6. 17. Kim SW, Oh M, Park JL, Oh AK, Park CG. Functional reconstruction of the philtral ridge and dimple in the repaired cleft lip. J Craniofac Surg 2007;18:1343–8. http://dx. doi.org/10.1097/scs.0b013e31814e07de. 18. Li L, Xie F, Ma T, Zhang Z. Reconstruction of philtrum using partial splitting and folding of orbicularis oris muscle in secondary unilateral cleft lip. Plast Reconstr Surg 2015;136:1274–8. http://dx.doi.org/ 10.1097/prs.0000000000001795. 19. Chou PY, Luo CC, Chen PKT, Chen YR, Samuel Noordhoff M, Lo LJ. Preoperative
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lip measurement in patients with complete unilateral cleft lip/palate and its comparison with norms. J Plast Reconstr Aesthet Surg 2013;66:513–7. http://dx.doi.org/10.1016/j. bjps.2012.12.002. To EW, Ahuja AT, Ho WS, King WW, Wong WK, Pang PC, Hui AC. A prospective study of the effect of botulinum toxin A on masseteric muscle hypertrophy with ultrasonographic and electromyographic measurement. Br J Plast Surg 2001;54:197–200. http://dx.doi. org/10.1054/bjps.2000.3526. Choe SW, Cho WI, Lee CK, Seo SJ. Effects of botulinum toxin type A on contouring of the lower face. Dermatol Surg 2005;31:502– 7. discussion 507–508. Goldberg BB, Pollack HM, Capitanio MA, Kirkpatrick JA. Ultrasonography: an aid in the diagnosis of masses in pediatric patients. Pediatrics 1975;56:421–8. Schimmel M, Christou P, Houstis O, Herrmann FR, Kiliaridis S, Muller F. Distances between facial landmarks can be measured accurately with a new digital 3-dimensional video system. Am J Orthod Dentofacial Orthop 2010;137:580.e1–e. http://dx.doi. org/10.1016/j.ajodo.2009.03.039. discussion 580–581. Wong JY, Oh AK, Ohta E, Hunt AT, Rogers GF, Mulliken JB, Deutsch CK. Validity and reliability of craniofacial anthropometric measurement of 3D digital photogrammetric images. Cleft Palate Craniofac J 2008;45:232–9. http:// dx.doi.org/10.1597/06-175.
Address: Philip Kuo-Ting Chen Craniofacial Research Centre Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital at Linkou 5 Fu-Hsin St. Guei-Shan 333 Taoyuan Taiwan Tel.: +886-3-3281200 ext. 2430. Fax: +886-3-3271029 E-mail: [email protected]
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015
Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx https://doi.org/10.1016/j.ijom.2020.01.015, available online at https://www.sciencedirect.com
Clinical Paper Cleft Lip and Palate
Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction F. C. -S. Chang, C. G. Wallace, Y. -C. Hsiao, J. -J. Huang, C. S. -W. Liu, Z. -C. Chen, P. K. -T. Chen, J. -P. Chen, Y. -R. Chen: Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction. Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx. ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Cleft lip and/or cleft palate are the most common congenital craniofacial anomalies. Philtral ridge morphology is an important aesthetic component of unilateral cleft lip (UCL) repair. To this end, we have developed two techniques of philtral ridge reconstruction: (1) asymmetric mattress muscle sutures, and (2) overlapping mattress muscle sutures. The objective of this retrospective cohort study was to compare their outcomes in UCL repairs. Group I patients (n = 30) underwent UCL repair before August 2003, including philtral ridge reconstruction by asymmetric mattress muscle sutures. Group II patients (n = 30) underwent UCL repair after August 2003, including philtral ridge reconstruction by overlapping mattress muscle sutures. Philtral morphology was evaluated by ultrasonographic and three-dimensional photographic measurements, examining cleft side philtral projection and philtral ridge symmetry. These demonstrated that group II patients had better philtral column symmetry and projection on the cleft side when compared to group I. Overlapping mattress muscle sutures produced better philtral morphology in UCL repairs than asymmetric mattress muscle sutures.
The philtral dimple corresponds to the median decussation of the orbicularis oris muscle in the midline, with contributions from the nasalis and levator labii superioris muscles1. It is challenging to create aesthetically harmonious lateral philtral ridges with a central philtral dimple during unilateral complete cleft lip repair (CLR). 0901-5027/000001+06
Upper lip thickness at the philtral ridge (about 11 mm) and in the philtral dimple (about 7 mm) differ by approximately 4 mm 2. This should be considered during philtral reconstruction to achieve a more natural appearance following CLR. We previously reported the ‘asymmetric mattress muscle sutures’ technique, which
F.C.-S. Chang1,2,3, C. G. Wallace2,4, Y.-C. Hsiao2, J.-J. Huang2, C.S.-W. Liu5, Z.-C. Chen2, P.K.-T. Chen2,6, J.-P. Chen1, Y.-R. Chen2 1
Department of Chemical and Materials Engineering, College of Engineering, Chang Gung University, Taoyuan, Taiwan; 2 Craniofacial Research Centre, Department of Medical Research, Department of Plastic and Reconstructive Surgery and Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 3 Department of Plastic Surgery, Xiamen Chang Gung Hospital, Xiamen, China; 4 Department of Plastic Surgery, Royal Devon and Exeter Hospital, Exeter, UK; 5Department of Surgery, United Christian Hospital, Kwun Tong, Hong Kong; 6Department of Plastic and Reconstructive Surgery, Taipei Medical University Hospital, Taipei, Taiwan
Key words: cleft lip and palate; philtral ridge; orbicularis oris muscle; cheiloplasty; lip reconstruction. Accepted for publication
involves suturing the lateral orbicularis peripheralis into an over-riding insertion compared to the medial muscle, in order to cause an elevation on the cleft side philtral ridge (Fig. 1)3; however, long-term follow-up revealed progressive philtral ridge flattening on the cleft side. This prompted us to modify the technique in August 2003 so that the
ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015
YIJOM-4359; No of Pages 6
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Chang et al. Primary cheiloplasty
Fig. 1. Asymmetrical edge-to-edge suturing of the orbicularis oris muscle: the lateral orbicularis oris muscle is sutured to over-ride the medial muscle. (c; cm; op.). c: Columella; cm: C-Flap Mucosa; op: Orbicularis Peripheralis Muscle.
lateral orbicularis was sutured further medially to overlap the medial orbicularis oris muscle. We termed this the ‘overlapping mattress muscle sutures’ technique (Fig. 2)4,5. The objective of this study was to compare the long-term outcomes of these two different methods of philtral ridge reconstruction through objective assessments of the cleft side philtral projection and philtral ridge symmetry.
Patients and methods
This was a retrospective cohort clinical trial designed to compare the long-term outcomes of two different methods of orbicularis oris muscle reconstruction. The study received ethical approval from the Institutional Review Board of Chang Gung Memorial Hospital (IRB No. 1045673B). All patients provided IRB-ap-
proved fully informed written consent for inclusion. Sixty patients who had undergone primary complete unilateral CLR at the Craniofacial Centre of Chang Gung Memorial Hospital from January 2000 to December 2006, performed by a single surgeon (PKTC), were enrolled from the outpatient clinic. Of these, 30 consecutive patients had undergone the ‘asymmetric mattress muscle sutures’ technique (group I; Fig. 1). The other 30 consecutive patients had undergone the ‘overlapping mattress muscle sutures’ technique (group II; Fig. 2). Inclusion criteria were (1) complete unilateral CLR, (2) no other craniofacial malformations or systemic disease, (3) primary CLR performed by one surgeon, and (4) no secondary lip revision surgery performed prior to ultrasonographic or three-dimensional (3D) photographic measurements.
Fig. 2. Overlapping vertical mattress suture of the orbicularis oris muscle: the lateral orbicularis oris muscle is sutured to overlap the medial orbicularis oris muscle. (c; cm; op.). c: Columella; cm: C-Flap Mucosa; op: Orbicularis Peripheralis Muscle.
Points were inked on the Cupid’s bow and a Mohler rotation–advancement cheiloplasty was designed. The rotation flap was created with a curved incision extending from the columella base across the free border of the lip at a right angle to the lip axis. An oblique incision across the columella base was created and this incision could be extended but was not allowed to cross the non-cleft side philtral column. A columella flap (C-flap) was fashioned and the mucosa of the C-flap defined. The advancement flap incision was made to pass along the cleft margin and an L-flap was developed. The incision was continued along the piriform aperture to the base of the inferior turbinate. An inferior turbinate flap was designed. The flaps were positioned and the orbicularis muscle repair was performed. For group I, the lateral orbicularis oris muscle was sutured to over-ride the medial orbicularis oris muscle (Fig. 1). For group II, the lateral orbicularis oris muscle was sutured to overlap the medial orbicularis oris muscle (Fig. 2)3.
Ultrasonographic measurements
All ultrasonographic measurements of the thickness of the philtral ridge and philtral dimpling were performed on the cleft and non-cleft sides by a single sonographer using the same machine (Terason t3000, 12-MHz transducer; Teratech Corporation, Burlington, MA, USA), on transverse images obtained at the patients’ last clinical follow-up appointments. During each examination, the probe was placed perpendicular to the lip with its inferior border aligned to the Cupid’s bow, with plenty of conductive jelly to avoid lip compression. The following parameters were measured (Fig. 3): (1) cleft side philtral column: the distance between the skin surface at the highest philtral projection and the inner mucosa of the upper lip on the cleft side; (2) non-cleft side philtral column: the distance between the skin surface at the highest philtral projection and the inner mucosa of the upper lip on the non-cleft side; and (3) philtral dimpling: the distance between the skin surface of the most depressed indentation between the philtral ridges and the inner mucosa of the upper lip on the midline. The following were then calculated: (a) philtral column symmetry: non-cleft side philtral column minus cleft side philtral column, and (b) cleft side philtral column projection: cleft side philtral column minus philtral dimpling.
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015
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Philtral ridge morphology after reconstruction
Fig. 3. Ultrasound of the upper lip: D—D non-cleft side philtral column; +—+ philtral dimpling; x— x cleft side philtral column.
3D photographic measurements
3D photographic measurements were conducted using the 3dMDhead system (3dMD, Atlanta, GA, USA). Facial images were captured at the last clinic visit with each patient sitting upright and equidistant between the cameras. Data were analysed using the 3dMDpatient software platform (3dMD, Atlanta, GA, USA). The following steps were critical to the photographic philtral measurements. First, the face was oriented to the intercanthal line in both coronal and axial views. The A plane was cut 1 mm superior to the cleft side white skin roll. All of the image inferior to this plane and posterior to the auricle was discarded. The face was then up-rotated 90 degrees with the upper lip placed cephalically (Fig. 4). Second, a line defining the upper lip baseline reference was placed, lying parallel to the intercanthal line and connecting the alar bases. A geometric lattice with 1 cm spaces was then placed on the image, which was then saved and transferred to Photoshop (CS5 extended version 12.0; Adobe Systems Inc., San Jose, CA, USA) (Fig. 5). The following measurements were taken: (1) cleft side philtral column: the distance between the skin of the highest philtral projection and the baseline of the upper lip on the cleft side; (2) non-cleft side philtral column: the distance between the skin of the highest philtral projection and the baseline of upper lip on the noncleft side; and (3) philtral dimpling: the distance between the skin surface of the most depressed indentation between the philtral ridges and the baseline of upper lip on the midline. The following were then calculated: (a) philtral column symmetry: non-cleft side philtral column minus cleft side philtral column, and (b) cleft side philtral column
projection: cleft side philtral column minus philtral dimpling. Statistical analysis
The x2 test was used to compare demographic data between the two groups (sex and cleft side). The independent t-test was used to compare age at operation and age at the time of the study (age when the 3D photograph and ultrasound measurements were performed). Statistical significance was defined as a P-value of less than 0.05. The data are presented as the mean standard deviation unless otherwise stated. Results
Thirty patients in group I and 30 patients in group II completed the study. Their demographic data are shown in Table 1. Ultrasonographic and 3D photographic measurements
According to both the ultrasound scan and 3D photographic measurements, group II philtral columns were significantly more symmetric than those in group I (ultrasound: 0.06 0.75 mm vs 0.62 1.09 mm, P = 0.024; 3D photographs: 0.18 0.68 mm vs 0.87 1.05 mm, P = 0.004). Group II philtral ridges were more projected than those in group I (ultrasound: 1.36 0.89 vs 0.50 0.84 mm, P < 0.001; 3D photographs: 1.22 0.74 vs 0.43 0.65 mm, P < 0.001). Discussion
In 1958, Millard emphasized the importance of achieving natural looking results with his proposed rotation–advancement CLR. Amongst other features, a natural looking result requires a Cupid’s bow with
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symmetrical alae, a philtral dimple, a matching philtrum column, and a camouflaged scar6. The restoration or repair of the orbicularis oris muscle constitutes a key surgical step that has been modified in several different ways7. Millard used interrupted sutures to repair the orbicularis oris muscle8. Randall et al. proposed that the medial muscle flap should overlap the lateral muscle flap9. Mulliken and Martı´nezPe´rez dissected the orbicularis oris muscle from the skin and mucosa before repair, opposing the deep orbicularis oris muscle (pars marginalis) first and placing vertical mattress sutures from inferiorly to the superior border10. Cutting and Dayan emphasized that the muscle should be repaired in a ‘praying hands’ fashion with a buried horizontal mattress suture11. Salyer et al. emphasized a key muscle suture to position the alar base, then interrupted repair of the muscle12. Lim et al. used the palmaris longus tendon to reconstruct the philtral column in a secondary setting13. At the Chang Gung Craniofacial Centre, one of our modifications of the rotation– advancement technique was to suture the orbicularis oris muscle of the lateral advancement flap over-riding the orbicularis oris muscle of the medial rotation flap (Fig. 1) to create a philtral column on the cleft side3. This showed good initial outcomes, but longer term follow-up revealed a gradual loss of philtral column projection on the cleft side (Fig. 6). We therefore further modified the technique in August 2003 by suturing the orbicularis oris muscle of the lateral advancement flap over the orbicularis oris muscle of the medial rotation flap, creating a stronger philtral column on the cleft side. Based on our clinical observations, this modified method has shown improved outcomes on the cleft side and has become our established method of philtral column reconstruction (Fig. 7). However, the longterm outcomes have never been assessed formally until now. Rogers et al. performed a comprehensive review of the normal and cleft orbicularis oris muscle, as well as various techniques of philtral ridge reconstruction, and mentioned that there are no objective, long-term data comparing these techniques14. A recent publication by Naidoo and Bu¨tow reports the use of two inverted horizontal mattress sutures to repair the orbicularis oris muscle, with a take-down suture to create central dimpling. They presented convincing 1-week and 6-month postoperative pictures, but neither subjective nor objective measurements were performed15. Several studies have used a
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015
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Fig. 4. (A) An axial plane cut was sited 1 mm superior to the cleft side white roll. (B) All of the image below this axial plane was deleted. (C) The head posterior to the auricle was deleted. (D) The head was up-rotated 90 degrees, placing the upper lip into the cephalic position. The lip contour is highlighted with the red–white dotted line. A square lattice (10 mm 10 mm) was then overlaid (for interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.).
visual analogue scale (VAS) to evaluate philtral column results in patients with secondary cleft lip repairs16–18; however, this is subjective by nature. We have previously used a caliper to measure the lip height, lip width, philtrum width, philtrum length, and vermillion thickness during general anaesthesia before starting surgery19; however it is difficult to accurately measure the philtral column projection and philtral dimpling with a caliper. In the current study, ultrasound and 3D digital photogrammetric images were used as cost-effective and non-invasive tools to evaluate the surgical outcomes. Ultrasound has been used previously for the clinical evaluation of muscle changes, such as volumetric evaluation of the masseter muscle following botulinum toxin A injection20,21. One can accurately delineate the philtral column and lip mucosa and hence measure philtral projection and dimpling of the upper lip with ultrasound, as long as plenty of ultrasound gel is
Fig. 5. The philtral column ridges and philtral dimpling were measured from the base line, which connects the inner canthi. Blue line: non-cleft side philtral column; green line: philtral dimpling; black line: cleft side philtral column (for interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.).
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Table 1. Patient demographic data.a Number of patients Age at operation, months Age at the time of the study, years Sex Male Female Cleft side Left Right
Group I
Group II
30 4.44 2.74 16.62 0.94
30 3.60 1.33 13.41 0.87
15 15
16 14
22 8
19 11
P-value 0.139 <0.001 0.796 0.405
Data presented as the number of patients, or mean standard deviation value. a Group I patients: UCL repair including philtral ridge reconstruction by asymmetric mattress muscle sutures. Group II patients: UCL repair including philtral ridge reconstruction by overlapping mattress muscle sutures.
Fig. 6. Typical presentation of a group I patient. In these four patients (panels A, B, C, and D represent four different patients), the cleft side philtral column had similar projection to the non-cleft side philtral column. The central dimple was more accentuated.
Fig. 7. Typical presentation of a group II patient. In these four patients (panels A, B, C, and D represent four different patients), the cleft side philtral column showed less projection compared to the non-cleft side philtral column. The central dimple was less accentuated.
applied to avoid compression of the upper lip with the probe. A potential confounding issue with ultrasound scanning is operator dependence. However, in expert hands, ultrasound measurements offer levels of accuracy that even allow calibration22. High resolution magnetic resonance imaging or computed tomography (CT) scans are alternatives, but are expensive and time-consuming, and CT provides poor soft tissue views and inflicts ionizing radiation. The 3D digital photogrammetric images (3dMDhead system; 3dMD, Atlanta, GA, USA) used in this study capture the entire face at its highest resolution within 1.5 milliseconds, offering a geometric accuracy of less than 0.2 mm. Such rapid image capture is particularly suitable for evaluating young children non-invasively,
without ionizing radiation (unlike 3D CT) and has been shown to be valid and reliable in the craniofacial setting23,24. The thickness of the upper lip cannot be measured directly through the 3dMDpatient or 3dMDvultus systems because the baseline for measurements is under the skin surface. To circumnavigate this problem, we converted 3D into 2D images and overlaid a 10-mm lattice, allowing linear measurements to be performed with the imaging software. This study has some limitations. There was a statistically significant difference in age at the time of the study between group I and group II patients, which arose due to the consecutive inclusion of patients. It could be assumed that group I, being older, might have thicker upper lips, but philtral column symmetry (non-cleft side
philtral column minus cleft side philtral column) and cleft side philtral column projection (cleft side philtral column minus philtral dimpling) were used to minimize the effect of upper lip thickness. In conclusion, this study demonstrated that the overlapping mattress suture technique for orbicularis oris muscle reconstruction offers sustained philtral column height with better symmetry than the asymmetrical mattress suture technique.
Funding
We are grateful for the support of this project by a research grant of Ministry of Science and Technology, Republic of China (105-2314-b-182a-080-).
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Chang et al.
Competing interests
There are no competing interests to declare. Ethical approval
The study received ethical approval from the Institutional Review Board of Chang Gung Memorial Hospital (IRB No. 1045673B). Patient consent
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Address: Philip Kuo-Ting Chen Craniofacial Research Centre Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital at Linkou 5 Fu-Hsin St. Guei-Shan 333 Taoyuan Taiwan Tel.: +886-3-3281200 ext. 2430. Fax: +886-3-3271029 E-mail: [email protected]
Please cite this article in press as: Chang FCS, et al. Long-term comparison study of philtral ridge morphology with two different techniques of philtral reconstruction, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.015