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Simultaneous Correction of Scars and Tissue Deficiency With Composite Grafts in Secondary Cleft Lip Deformity
J Oral Maxillofac Surg 70:e419-e427, 2012
Simultaneous Correction of Scars and Tissue Deficiency With Composite Grafts in Secondary Cleft Lip Deformity Dong Won Lee, MD,* Young Seok Kim, MD,† and Be-young Yun Park, MD, PhD‡ Purpose: In secondary cleft lip deformities, repetitive surgeries lead to increased tension and defor-
mities in the upper lip, ultimately resulting in new deformities such as wide scars and a tight lip. The simultaneous correction of a wide scar and tissue deficiency in the upper lip is paradoxical unless sufficient tissue is supplied to the scant upper lip. The authors describe a method to transfer composite tissue for the improvement of secondary cleft lip deformities and present an analysis of the outcomes. Materials and Methods: Ninety-one patients with secondary cleft lip, a wide scar, and tight lip were enrolled. After complete excision of the scar, the defect was covered with a composite graft that included skin and subcutaneous fat. The results were rated by 2 investigators blinded to the image of the scar and the morphology of the upper lip. The skin color of the 25 grafts was analyzed using a narrowband spectrophotometer using the Commission International d’Eclairage L*a*b* color coordinates. Results: All grafts survived without sequelae. The scores of the scar images and general morphology were 8.3/10 and 8.2/10, respectively. Spectrophotometric analysis displayed no differences between the composite tissues and normal upper lip skin in each color coordinate, indicating that the composite tissue had a good color match with a normal upper lip. Conclusions: The use of a composite graft on the upper lip can be a reliable option to correct a wide hypertrophic scar and tight lip simultaneously, resulting in a satisfactory scar image and an improvement of upper lip morphology. © 2012 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 70:e419-e427, 2012 For decades, surgeons have striven to provide a complete primary operation for patients with cleft lip, resulting in the development of many operative techniques. Nonetheless, secondary cleft lip deformities and scars on the upper lip are considered unavoidable. To correct these secondary cleft lip deformities,
many operative techniques have been attempted, but few methods have been capable of producing satisfactory outcomes.1-3 In general, patients with cleft lip cannot be treated with only a single operation, and repetitive surgeries lead to deformities in the skin and increased tension on the upper lip, ultimately resulting in hypertrophic scars, wide scars, tight lip, short lip, and loss of a philtral ridge. Therefore, after primary surgery of the cleft lip, the underlying problem of a tissue deficit must be addressed. From this point of view, the dermofat graft,4 Abbé flap,5 and the composite graft are important methods because these use tissue from distant areas and supply sufficient tissue to the scant upper lip. The use of composite grafts has several advantages, such as obtaining a desired shape and contour without producing a large defect at the donor site; however, the viability of the graft decreases with increasing size. Although composite grafts for lengthening the short columella in patients with cleft lip are
Received from Institute of Human Tissue Restoration, Department of Plastic Reconstructive Surgery, Yonsei University Health System, Severance Hospital, Seoul, Korea. *Clinical Assistant Professor. †Assistant Professor. ‡Professor. Address correspondence and reprint requests to Dr Park: Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, 250 Seongsan-ro, Seodaemungu, Seoul 120-752, Korea; e-mail: [email protected] © 2012 Published by Elsevier Inc on behalf of the American Association of
Oral and Maxillofacial Surgeons 0278-2391/12/7007-0$36.00/0 doi:10.1016/j.joms.2012.02.026
e419
e420 widely used,6,7 there have been few reports concerning the use of composite grafts for the treatment of upper lip scars. The rate of survival of a composite graft on a secondary cleft lip deformity is low regardless of size, because the recipient tissues have multiple scars owing to multiple consecutive surgeries. However, the successful transfer of composite tissue can lead to the correction of unwanted scars and secondary deformities of the upper lip that result from unfavorable tension. Therefore, the authors introduced a method to successfully transfer composite tissues to secondary cleft lip deformities and analyzed the results based on an independent rating system and skin color analysis by spectrophotometry.
Materials and Methods Of patients with secondary cleft lip who underwent surgery from March 2003 through May 2010, patients with hypertrophic scars, wide scars on the upper lip, tight lip, short lip, and hairless scars in male patients were considered eligible for the treatment. Of 91 patients who were under indication, 57 patients were male and 34 patients were female. The age at the operation ranged from 5 to 57 years (mean, 21.6 yrs). The institutional review board reviewed and approved the design of this study. SURGICAL TECHNIQUE
The surgical technique began with an injection of a local anesthetic with epinephrine to the scar, but the donor site was prepared with a local anesthetic without epinephrine. This procedure was followed by excision of the primary operative scar on the upper lip as widely as possible in a rectangular pattern; then, abnormal tension of surrounding tissues was released. If the orbicularis oris muscle was found to be out of position, rearrangement of the muscle was performed. The size of the required tissue was measured accurately, and composite tissues of skin and subcutaneous fat were obtained from the preauricular area, suprabrow area, chin, or scalp. The donor site was decided according to skin color, existence of hair, and the patient’s preference. Subcutaneous fat tissue with sufficient thickness to contain hair follicles was included in the composite tissue. The composite tissue was carefully transferred onto the upper lip. The grafted tissue was repaired with continuous nylon sutures, and a mild compressive dressing was applied to prevent hematoma beneath the composite tissue. Other surgical methods, such as nasal tip rhinoplasty and vermilion plasty, could also be performed on a case-by-case basis.
COMPOSITE GRAFTS IN SECONDARY CLEFT LIP ASSESSMENT BY SCORING SYSTEM
The level of overall outcomes for these procedures was assessed in the outpatient clinic using a visual analog scale (range, 0 to 10).8 Two blinded investigators provided visual analog scale scores for 2 aspects. First, the image of the scars was evaluated, with 0 points given when the investigator believed that a patient’s scar on the upper lip was caused by a cleft lip surgery and 10 points when the investigator did not believe the scar was caused by the surgery. A second evaluation was the general morphology of the upper lip, with 0 points given when the investigator noted no change after surgery and 10 points for a satisfactory upper lip with much improvement and no deformity. Each patient’s score was the mean value of the 2 investigators’ scores. SKIN COLOR ANALYSIS
Skin color was gauged in 25 patients using a portable spectrophotometer (CM-700d, Konica Minolta Sensing Inc, Osaka, Japan) and an analysis program (CM-SA, Konica Minolta Sensing Inc).9 This hand-held spectrophotometer was operator-independent and used a measuring area that was 3 mm in diameter. Because the spectrophotometer and the analysis program were linked, the Commission International d’Eclairage L*a*b* color coordinates could be shown at the same time as the measurement. L* indicates lightness and a* and b* are the chromaticity coordinates. The coordinates a* and b* indicate color directions: positive a* is the red direction, negative a* is the green direction, positive b* is the yellow direction, and negative b* is the blue direction. The authors measured the skin color of 6 body parts: the grafted composite tissue, the normal upper lip, the forehead, the cheek, the chin, and the anterior aspect of the forearm. The authors checked the scores 3 times for each part and calculated the mean value of the 3 measurements. All color measurements were performed by the same clinician. Analysis was performed using SPSS 13.0 (SPSS, Inc, Chicago, IL). Analysis of variance was performed to determine the differences between the grafted composite tissue and the other 5 body parts according to each color coordinate. Furthermore, a post hoc test was performed for multiple comparisons to examine differences between any 2 parts. An adjusted level of P ⬍ .05 was considered statistically significant. In addition, to investigate the optimal donor site with a good color match with the upper lip, the differences in color between the upper lip and the other sites were calculated. Differences were obtained from the standard equation ([⌬L*]2 ⫹ [⌬a*]2 ⫹ [⌬b*]2)½, where ⌬L*, ⌬a*, and ⌬b* represent the differences in the respective measured L*a*b* val-
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FIGURE 1. Serial features of a composite graft on postoperative A, day 1, B, day 3, C, day 5, D, day 7, and E, year 1. On postoperative day 1, the composite graft appeared light pink, but the graft turned bluish owing to blood congestion until postoperative day 3. Then, the color gradually became pinkish. In general, congestion did not subside until postoperative day 3. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
ues.10 All results were presented as mean ⫾ standard deviation.
Results Ninety-one patients underwent surgery, including 9 cases of double composite grafts, resulting in the use of 99 composite grafts. The composite grafts had a mean width of 6.6 ⫾ 2.7 mm (range, 3 to 12 mm) and a mean length of 13.7 ⫾ 6.7 mm (range, 4 to 35 mm). Regarding the donor of the composite graft, 30 grafts were transferred from the preauricular area, 34 grafts from the suprabrow area, 7 grafts from the chin, and 28 grafts from the postauricular scalp. Hair-bearing chin and scalp tissues were used as the donor sites of composite tissue for male patients with hairless scars on the upper lip.
Immediately after the operation, most composite grafts showed a pale color, and on postoperative day 1, the color of the composite tissue changed to light pink. It turned bluish owing to blood congestion until postoperative day 3 and then gradually became pinkish (Fig 1). An area that maintains congestion would undergo de-epithelialization and then undergo partial necrosis. Five grafts resulted in partial-thickness loss of the composite graft postoperatively, and the other grafts showed good results without any complications. In the cases of partial-thickness loss of the composite graft, the defects healed spontaneously without sequelae after trimming the necrotic tissues. There were no complications related to the donor site in any cases, and the scars were inconspicuous.
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COMPOSITE GRAFTS IN SECONDARY CLEFT LIP
FIGURE 2. Visual analog scale for the evaluation of postoperative results of composite grafts shows scores for top, the image of the postoperative scar and bottom, the general morphology of the upper lip. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
ASSESSMENT BY SCORING SYSTEM
addition, b* of the composite tissue differed from the forehead and chin. However, there were no obvious differences between the composite tissue and the normal upper lip in all aspects of L*, a*, and b*, suggesting that the composite tissue had a good color match with the normal upper lip. In terms of the differences in the color of the upper lip, the difference values were 3.8 ⫾ 2.4 in the grafted composite tissue, 5.1 ⫾ 2.1 in the forehead, 6.8 ⫾ 2.3 in the cheek, 5.5 ⫾ 2.8 in the chin, and 8.7 ⫾ 3.4 in the forearm (Table 1). The difference between the normal upper lip and the composite graft was minimal, followed by the forehead. These results indicate that among the listed donor sites, the suprabrow area, which is included in the forehead esthetic unit, could be considered the optimal donor site. The final results are presented in Figures 3-5.
The overall outcomes using visual analog scale scores were assessed in 91 patients with secondary cleft lip, and the follow-up period ranged from 12 to 51 months (mean, 30.7 mo). The mean score for the image of the postoperative scar was 8.3 ⫾ 1.7, and the mean score of the general morphology of the upper lip was 8.2 ⫾ 1.5 (Fig 2). The results were evaluated as satisfactory overall for the 2 aspects. SKIN COLOR ANALYSIS
Twenty-five grafts underwent skin color analysis by spectrophotometry after a mean follow-up period of 24 months. Seven grafts were from the preauricular area, 11 grafts were from the suprabrow area, 1 graft was from the chin, and 6 grafts were from the postauricular scalp. The mean values of L*, a*, and b* of the grafted composite tissue, normal upper lip, forehead, cheek, chin, and forearm are listed in Table 1. For L*, the composite tissue was significantly different from the cheek, chin, and forearm, and for a*, it differed from the forehead, cheek, and forearm. In
Discussion Treatment of secondary cleft lip varies by the degree and location of the deformity. In general, for the
Table 1. RESULTS OF SPECTROPHOTOMETRIC ANALYSIS
Grafted composite tissue Upper lip Forehead Cheek Chin Forearm (anterior aspect)
L*
P
a*
P
b*
P
56.0 ⫾ 3.7 57.5 ⫾ 3.4 58.1 ⫾ 2.3 61.2 ⫾ 3.2 59.6 ⫾ 3.6 61.3 ⫾ 3.2
.570 .266 ⬍.001* .015* ⬍.001*
13.2 ⫾ 2.8 11.9 ⫾ 1.8 11.2 ⫾ 1.9 10.4 ⫾ 1.9 12.1 ⫾ 2.4 7.9 ⫾ 2.0
.295 .049* .003* .479 ⬍.001*
16.3 ⫾ 2.4 17.1 ⫾ 2.2 19.1 ⫾ 2.0 17.8 ⫾ 1.9 18.5 ⫾ 1.8 18.2 ⫾ 2.5
.727 .003* .217 .024* .070
Color Difference From Upper Lip† 3.8 ⫾ 2.4 5.1 ⫾ 2.1 6.8 ⫾ 2.3 5.5 ⫾ 2.8 8.7 ⫾ 3.4
Note: Data are presented as mean ⫾ standard deviation. *Statistical significance compared with composite graft (P ⬍ .05). †Color difference from the upper lip was calculated from the standard equation ([⌬L*]2 ⫹ [⌬a*]2 ⫹ [⌬b*]2)½. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
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FIGURE 3. A 28-year-old man with a bilateral complete cleft lip underwent lip repair at 4 months of age. A, B, Preoperative views. The patient had an asymmetric scar and a short lip. C, D, Postoperative views 2 years after receipt of a hair-bearing composite graft from the chin. The process of graft acceptance is shown E, immediately after scar excision, F, immediately after surgery, G, 1 day postoperatively, and H, 3 days postoperatively. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
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COMPOSITE GRAFTS IN SECONDARY CLEFT LIP
FIGURE 4. A male pediatric patient underwent lip repair of a right complete cleft lip at 3 months of age. A, B, Preoperatively, the patient had a short lip and a hypertrophic scar on his upper lip. He underwent a secondary surgery with a preauricular composite graft at 8 years of age. C, D, Appearance at 6-year postoperative follow-up. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
correction of scars on the upper lip, a straight-line excision can be considered,11,12 and for correction of the vermillion deformity, Z-plasty and V-Y advancement are recommended.1,12 In addition, for correction of a mild short lip, Z-plasty of the upper lip is preferred.2 However, these methods are not indicated for severe deformities and possibly may worsen the outcome by causing increased tension owing to tissue loss. For the treatment of severe forms of tight lip, many surgeons have suggested the Abbé flap as the treatment of choice.1,2 To restore a deformed cupid bow owing to severe scarring, the senior author suggests a cicatricial rectangular flap from the upper vermilion to the nostril base that contains the previ-
ous scar.13 The distal part of the flap is the nostril base and covers the cupid bow by flap transposition. In this method, however, tension around the superior half of the upper lip, which is caused by tissue deficiency and the postoperative scar, is an inevitable result. To overcome this issue, the authors considered the application of a composite graft to the defect in the upper lip resulting from complete excision of the scar. The use of a composite graft with cartilage was introduced by Schimid14 to reconstruct the philtrum of a bilateral cleft lip, although this technique is not generally used. Release of tension by the transfer of composite tissue may be the preferred choice to stop
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FIGURE 5. A male patient received lip repair of the left complete cleft lip at 3 months of age. A, B, Preoperative views show a hypertrophic and hairless scar on the upper lip. When he was 19 years old, he received a secondary surgery with a hair-bearing composite graft from the postauricular scalp. C, D, Appearance at 3.5-year postoperative follow-up. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
the vicious cycle of secondary cleft lip. Composite grafts on the upper lip have several advantages over other methods. First, deficit tissue can be replaced by tissues from other regions. The Abbé flap functions similarly to composite grafts but results in scars on the lower lip and has adverse effects on the function of the orbicularis oris muscle.15 Composite grafts do not impose defects on the donor site, and there is no morphological deformity after harvesting. In the selection of a donor site, an invisible donor scar, the color match to the upper lip, and the possibility of primary closure should be considered; the preauric-
ular area, suprabrow area, chin, and scalp are thought to be the recommended donor sites. Second, rearrangement of the orbicularis oris muscle can be performed simultaneously. Although discontinuity of the orbicularis oris muscle is definitively corrected during primary lip repair, a relapse commonly occurs. Therefore, an assessment of muscular continuity in patients with secondary cleft lip should not be overlooked.16 Through excision of the previous lip scar, the orbicularis oris muscle can be dissected from adjacent tissues and rearranged before composite grafting. After rearrange-
e426 ment of the muscle, the shape of the defect in the upper lip is usually altered. Third, the composite graft is involved in the formation of the philtrum. Indeed, the most important step in the formation of the philtrum is the reconstruction of muscular interdigitation and the release of tension.17-19 Using a composite graft, the release of tension can be achieved and may result in a natural appearance of the philtrum. Fourth, hair-bearing composite grafts in male patients can hide scars on the upper lip. In cases of prominent hairless scars on the upper lip, hair-bearing composite grafts can effectively cover the defect, producing a camouflaged effect to the postoperative scar. The Abbé flap and temporal island flap can also be used to transfer hair-bearing tissues.20 Alternatively, hair micrografts may be considered for hiding the scars.21 The authors were able to achieve satisfactory results in 34 cases using hair-bearing composite grafts from the chin and scalp. Skin color can be measured objectively by numerical figures using many types of colorimeters.22 The Commission International d’Eclairage L*a*b* color coordinates were introduced in this study to compare colors. This L*a*b* color space has been suggested to provide uniform color differences with visual differences and is commonly used worldwide.10,23 The composite graft showed no significant difference in each value of L*a*b* compared with the normal upper lip, but other sites showed significant differences in at least 2 values of L*a*b*. Moreover, the difference value in color between the upper lip and the composite graft was minimal. Except for the composite graft, the forehead color was most similar to the upper lip followed by the chin, cheek, and forearm. When tissues from these sites were transferred to the upper lip in the form of a composite graft, the color appeared closer to that of the upper lip. The authors hypothesize that the composite tissues not only keep the characteristics of the donor site but also are influenced by the recipient site. The vascular supply of the grafted composite tissue is supplied by the margin of the recipient site, and the survival of the tissue decreases with increasing size. Most patients with secondary cleft lip deformity undergo corrective surgery several times, so that scar tissues remain around the margins of the recipient site even after full excision of the cutaneous scar tissue. A composite graft in a patient with secondary cleft lip is like a graft within scar tissue, and thus the survival rate of the composite graft inherently decreases, although the tissue is very small. To increase the survival of the composite graft, the following precautions should be taken during surgery: the composite tissue should be handled gently using an atraumatic technique during harvesting and grafting; meticulous hemostasis should be performed to prevent hemato-
COMPOSITE GRAFTS IN SECONDARY CLEFT LIP
mas beneath the composite tissue; scar tissues should be excised as completely as possible; and vasoconstrictors such as epinephrine should not be used during the surgery. Furthermore, the width of the composite tissue should not exceed 7 to 8 mm to ensure survival of the composite graft. The authors described a composite grafting technique and analyzed the results to show the superiority of this technique but did not present control groups for comparison. Thus, the limitation of this study is that it is not a controlled study but an observational study with analysis. In conclusion, using composite grafts on the upper lips of patients with secondary cleft lip can resolve the fundamental problems of deficient tissues. This is a reliable option to correct a wide hypertrophic scar and tight lip simultaneously, resulting in a satisfactory scar image and improvement of upper lip morphology over a relatively longterm follow-up. Acknowledgments The authors are grateful to Dong-Su Jang (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his help with the figures.
References 1. Byrd HS, El-Musa KA, Yazdani A: Definitive repair of the unilateral cleft lip nasal deformity. Plast Reconstr Surg 120:1348, 2007 2. Stal S, Hollier L: Correction of secondary cleft lip deformities. Plast Reconstr Surg 109:1672, 2002 3. Delaire J: Theoretical principles and technique of functional closure of the lip and nasal aperture. J Maxillofac Surg 6:109, 1978 4. Patel IA, Hall PN: Free dermis-fat graft to correct the whistle deformity in patients with cleft lip. Br J Plast Surg 57:160, 2004 5. Holmström H: The Abbe island flap for the correction of whistle deformity. Br J Plast Surg 40:176, 1987 6. Cho BC, Park JW, Baik BS: Correction of severe secondary cleft lip nasal deformity using a composite graft: Current approach and review. Ann Plast Surg 48:131, 2002 7. Cheon YW, Park BY: Long-term evaluation of elongating columella using conchal composite graft in bilateral secondary cleft lip and nose deformity. Plast Reconstr Surg 126:543, 2010 8. Takemura Y, Liu J, Atsumi R, et al: Development of a questionnaire to evaluate patient satisfaction with medical encounters. Tohoku J Exp Med 210:373, 2006 9. Yun IS, Lee WJ, Rah DK, et al: Skin color analysis using a spectrophotometer in Asians. Skin Res Technol 16:311, 2010 10. Van der Horst CM, Koster PH, de Borgie CA, et al: Effect of the timing of treatment of port-wine stains with the flash-lamppumped pulsed-dye laser. N Engl J Med 338:1028, 1998 11. Sadove AM, Eppley BL: Correction of secondary cleft lip and nasal deformities. Clin Plast Surg 20:793, 1993 12. Farmand M: Secondary lip correction in unilateral clefts. Facial Plast Surg 18:187, 2002 13. Park BY, Roh TS: Rectangular flap for horizontal upper vermilion tightness in secondary cleft lip deformity. Plast Reconstr Surg 104:1976, 1999 14. Schimid E: Transactions of the Third International Congress of Plastic Surgery. Amsterdam, Excerpta Medica Foundation, 1964, p 306 15. Smith JW: The anatomical and physiologic acclimatization of tissue transplanted by the lip switch technique. Plast Reconstr Surg 26:40, 1960
LEE, KIM, AND PARK 16. Climo MS: Diastasis of the orbicularis oris muscle in repaired unilateral clefts of the lip. Cleft Palate J 6:316, 1969 17. Randall P, Whitaker LA, LaRossa D: The importance of muscle reconstruction in primary and secondary cleft lip repair. Plast Reconstr Surg 54:316, 1974 18. Briedis J, Jackson IT: The anatomy of the philtrum: Observations made on dissections in the normal lip. Br J Plast Surg 34:128, 1981 19. Kim SW, Jeong YW, Cheon JE, et al: Orbicularis oris muscle defects in philtral deformities in the repaired cleft lip. J Korean Soc Plast Reconstr Surg 37:427, 2010
e427 20. Millard DR Jr: Cleft Craft: The Evolution of Its Surgery. Vol 2, Bilateral and Rare Deformities. Boston, MA, Little Brown, 1977, pp 439, 454, 464 21. Kiliç A, Emsen IM, Ozdengil E, et al: Lip scars camouflaged using microhair transplantation on male patients. Plast Reconstr Surg 106:1340, 2000 22. Masuda Y, Yamashita T, Hirao T, et al: An innovative method to measure skin pigmentation. Skin Res Technol 15:224, 2009 23. Rah DK, Kim SC, Lee KH, et al: Objective evaluation of treatment effects on port-wine stains using L*a*b* color coordinates. Plast Reconstr Surg 108:842, 2001
Simultaneous Correction of Scars and Tissue Deficiency With Composite Grafts in Secondary Cleft Lip Deformity Dong Won Lee, MD,* Young Seok Kim, MD,† and Be-young Yun Park, MD, PhD‡ Purpose: In secondary cleft lip deformities, repetitive surgeries lead to increased tension and defor-
mities in the upper lip, ultimately resulting in new deformities such as wide scars and a tight lip. The simultaneous correction of a wide scar and tissue deficiency in the upper lip is paradoxical unless sufficient tissue is supplied to the scant upper lip. The authors describe a method to transfer composite tissue for the improvement of secondary cleft lip deformities and present an analysis of the outcomes. Materials and Methods: Ninety-one patients with secondary cleft lip, a wide scar, and tight lip were enrolled. After complete excision of the scar, the defect was covered with a composite graft that included skin and subcutaneous fat. The results were rated by 2 investigators blinded to the image of the scar and the morphology of the upper lip. The skin color of the 25 grafts was analyzed using a narrowband spectrophotometer using the Commission International d’Eclairage L*a*b* color coordinates. Results: All grafts survived without sequelae. The scores of the scar images and general morphology were 8.3/10 and 8.2/10, respectively. Spectrophotometric analysis displayed no differences between the composite tissues and normal upper lip skin in each color coordinate, indicating that the composite tissue had a good color match with a normal upper lip. Conclusions: The use of a composite graft on the upper lip can be a reliable option to correct a wide hypertrophic scar and tight lip simultaneously, resulting in a satisfactory scar image and an improvement of upper lip morphology. © 2012 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 70:e419-e427, 2012 For decades, surgeons have striven to provide a complete primary operation for patients with cleft lip, resulting in the development of many operative techniques. Nonetheless, secondary cleft lip deformities and scars on the upper lip are considered unavoidable. To correct these secondary cleft lip deformities,
many operative techniques have been attempted, but few methods have been capable of producing satisfactory outcomes.1-3 In general, patients with cleft lip cannot be treated with only a single operation, and repetitive surgeries lead to deformities in the skin and increased tension on the upper lip, ultimately resulting in hypertrophic scars, wide scars, tight lip, short lip, and loss of a philtral ridge. Therefore, after primary surgery of the cleft lip, the underlying problem of a tissue deficit must be addressed. From this point of view, the dermofat graft,4 Abbé flap,5 and the composite graft are important methods because these use tissue from distant areas and supply sufficient tissue to the scant upper lip. The use of composite grafts has several advantages, such as obtaining a desired shape and contour without producing a large defect at the donor site; however, the viability of the graft decreases with increasing size. Although composite grafts for lengthening the short columella in patients with cleft lip are
Received from Institute of Human Tissue Restoration, Department of Plastic Reconstructive Surgery, Yonsei University Health System, Severance Hospital, Seoul, Korea. *Clinical Assistant Professor. †Assistant Professor. ‡Professor. Address correspondence and reprint requests to Dr Park: Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, 250 Seongsan-ro, Seodaemungu, Seoul 120-752, Korea; e-mail: [email protected] © 2012 Published by Elsevier Inc on behalf of the American Association of
Oral and Maxillofacial Surgeons 0278-2391/12/7007-0$36.00/0 doi:10.1016/j.joms.2012.02.026
e419
e420 widely used,6,7 there have been few reports concerning the use of composite grafts for the treatment of upper lip scars. The rate of survival of a composite graft on a secondary cleft lip deformity is low regardless of size, because the recipient tissues have multiple scars owing to multiple consecutive surgeries. However, the successful transfer of composite tissue can lead to the correction of unwanted scars and secondary deformities of the upper lip that result from unfavorable tension. Therefore, the authors introduced a method to successfully transfer composite tissues to secondary cleft lip deformities and analyzed the results based on an independent rating system and skin color analysis by spectrophotometry.
Materials and Methods Of patients with secondary cleft lip who underwent surgery from March 2003 through May 2010, patients with hypertrophic scars, wide scars on the upper lip, tight lip, short lip, and hairless scars in male patients were considered eligible for the treatment. Of 91 patients who were under indication, 57 patients were male and 34 patients were female. The age at the operation ranged from 5 to 57 years (mean, 21.6 yrs). The institutional review board reviewed and approved the design of this study. SURGICAL TECHNIQUE
The surgical technique began with an injection of a local anesthetic with epinephrine to the scar, but the donor site was prepared with a local anesthetic without epinephrine. This procedure was followed by excision of the primary operative scar on the upper lip as widely as possible in a rectangular pattern; then, abnormal tension of surrounding tissues was released. If the orbicularis oris muscle was found to be out of position, rearrangement of the muscle was performed. The size of the required tissue was measured accurately, and composite tissues of skin and subcutaneous fat were obtained from the preauricular area, suprabrow area, chin, or scalp. The donor site was decided according to skin color, existence of hair, and the patient’s preference. Subcutaneous fat tissue with sufficient thickness to contain hair follicles was included in the composite tissue. The composite tissue was carefully transferred onto the upper lip. The grafted tissue was repaired with continuous nylon sutures, and a mild compressive dressing was applied to prevent hematoma beneath the composite tissue. Other surgical methods, such as nasal tip rhinoplasty and vermilion plasty, could also be performed on a case-by-case basis.
COMPOSITE GRAFTS IN SECONDARY CLEFT LIP ASSESSMENT BY SCORING SYSTEM
The level of overall outcomes for these procedures was assessed in the outpatient clinic using a visual analog scale (range, 0 to 10).8 Two blinded investigators provided visual analog scale scores for 2 aspects. First, the image of the scars was evaluated, with 0 points given when the investigator believed that a patient’s scar on the upper lip was caused by a cleft lip surgery and 10 points when the investigator did not believe the scar was caused by the surgery. A second evaluation was the general morphology of the upper lip, with 0 points given when the investigator noted no change after surgery and 10 points for a satisfactory upper lip with much improvement and no deformity. Each patient’s score was the mean value of the 2 investigators’ scores. SKIN COLOR ANALYSIS
Skin color was gauged in 25 patients using a portable spectrophotometer (CM-700d, Konica Minolta Sensing Inc, Osaka, Japan) and an analysis program (CM-SA, Konica Minolta Sensing Inc).9 This hand-held spectrophotometer was operator-independent and used a measuring area that was 3 mm in diameter. Because the spectrophotometer and the analysis program were linked, the Commission International d’Eclairage L*a*b* color coordinates could be shown at the same time as the measurement. L* indicates lightness and a* and b* are the chromaticity coordinates. The coordinates a* and b* indicate color directions: positive a* is the red direction, negative a* is the green direction, positive b* is the yellow direction, and negative b* is the blue direction. The authors measured the skin color of 6 body parts: the grafted composite tissue, the normal upper lip, the forehead, the cheek, the chin, and the anterior aspect of the forearm. The authors checked the scores 3 times for each part and calculated the mean value of the 3 measurements. All color measurements were performed by the same clinician. Analysis was performed using SPSS 13.0 (SPSS, Inc, Chicago, IL). Analysis of variance was performed to determine the differences between the grafted composite tissue and the other 5 body parts according to each color coordinate. Furthermore, a post hoc test was performed for multiple comparisons to examine differences between any 2 parts. An adjusted level of P ⬍ .05 was considered statistically significant. In addition, to investigate the optimal donor site with a good color match with the upper lip, the differences in color between the upper lip and the other sites were calculated. Differences were obtained from the standard equation ([⌬L*]2 ⫹ [⌬a*]2 ⫹ [⌬b*]2)½, where ⌬L*, ⌬a*, and ⌬b* represent the differences in the respective measured L*a*b* val-
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FIGURE 1. Serial features of a composite graft on postoperative A, day 1, B, day 3, C, day 5, D, day 7, and E, year 1. On postoperative day 1, the composite graft appeared light pink, but the graft turned bluish owing to blood congestion until postoperative day 3. Then, the color gradually became pinkish. In general, congestion did not subside until postoperative day 3. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
ues.10 All results were presented as mean ⫾ standard deviation.
Results Ninety-one patients underwent surgery, including 9 cases of double composite grafts, resulting in the use of 99 composite grafts. The composite grafts had a mean width of 6.6 ⫾ 2.7 mm (range, 3 to 12 mm) and a mean length of 13.7 ⫾ 6.7 mm (range, 4 to 35 mm). Regarding the donor of the composite graft, 30 grafts were transferred from the preauricular area, 34 grafts from the suprabrow area, 7 grafts from the chin, and 28 grafts from the postauricular scalp. Hair-bearing chin and scalp tissues were used as the donor sites of composite tissue for male patients with hairless scars on the upper lip.
Immediately after the operation, most composite grafts showed a pale color, and on postoperative day 1, the color of the composite tissue changed to light pink. It turned bluish owing to blood congestion until postoperative day 3 and then gradually became pinkish (Fig 1). An area that maintains congestion would undergo de-epithelialization and then undergo partial necrosis. Five grafts resulted in partial-thickness loss of the composite graft postoperatively, and the other grafts showed good results without any complications. In the cases of partial-thickness loss of the composite graft, the defects healed spontaneously without sequelae after trimming the necrotic tissues. There were no complications related to the donor site in any cases, and the scars were inconspicuous.
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FIGURE 2. Visual analog scale for the evaluation of postoperative results of composite grafts shows scores for top, the image of the postoperative scar and bottom, the general morphology of the upper lip. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
ASSESSMENT BY SCORING SYSTEM
addition, b* of the composite tissue differed from the forehead and chin. However, there were no obvious differences between the composite tissue and the normal upper lip in all aspects of L*, a*, and b*, suggesting that the composite tissue had a good color match with the normal upper lip. In terms of the differences in the color of the upper lip, the difference values were 3.8 ⫾ 2.4 in the grafted composite tissue, 5.1 ⫾ 2.1 in the forehead, 6.8 ⫾ 2.3 in the cheek, 5.5 ⫾ 2.8 in the chin, and 8.7 ⫾ 3.4 in the forearm (Table 1). The difference between the normal upper lip and the composite graft was minimal, followed by the forehead. These results indicate that among the listed donor sites, the suprabrow area, which is included in the forehead esthetic unit, could be considered the optimal donor site. The final results are presented in Figures 3-5.
The overall outcomes using visual analog scale scores were assessed in 91 patients with secondary cleft lip, and the follow-up period ranged from 12 to 51 months (mean, 30.7 mo). The mean score for the image of the postoperative scar was 8.3 ⫾ 1.7, and the mean score of the general morphology of the upper lip was 8.2 ⫾ 1.5 (Fig 2). The results were evaluated as satisfactory overall for the 2 aspects. SKIN COLOR ANALYSIS
Twenty-five grafts underwent skin color analysis by spectrophotometry after a mean follow-up period of 24 months. Seven grafts were from the preauricular area, 11 grafts were from the suprabrow area, 1 graft was from the chin, and 6 grafts were from the postauricular scalp. The mean values of L*, a*, and b* of the grafted composite tissue, normal upper lip, forehead, cheek, chin, and forearm are listed in Table 1. For L*, the composite tissue was significantly different from the cheek, chin, and forearm, and for a*, it differed from the forehead, cheek, and forearm. In
Discussion Treatment of secondary cleft lip varies by the degree and location of the deformity. In general, for the
Table 1. RESULTS OF SPECTROPHOTOMETRIC ANALYSIS
Grafted composite tissue Upper lip Forehead Cheek Chin Forearm (anterior aspect)
L*
P
a*
P
b*
P
56.0 ⫾ 3.7 57.5 ⫾ 3.4 58.1 ⫾ 2.3 61.2 ⫾ 3.2 59.6 ⫾ 3.6 61.3 ⫾ 3.2
.570 .266 ⬍.001* .015* ⬍.001*
13.2 ⫾ 2.8 11.9 ⫾ 1.8 11.2 ⫾ 1.9 10.4 ⫾ 1.9 12.1 ⫾ 2.4 7.9 ⫾ 2.0
.295 .049* .003* .479 ⬍.001*
16.3 ⫾ 2.4 17.1 ⫾ 2.2 19.1 ⫾ 2.0 17.8 ⫾ 1.9 18.5 ⫾ 1.8 18.2 ⫾ 2.5
.727 .003* .217 .024* .070
Color Difference From Upper Lip† 3.8 ⫾ 2.4 5.1 ⫾ 2.1 6.8 ⫾ 2.3 5.5 ⫾ 2.8 8.7 ⫾ 3.4
Note: Data are presented as mean ⫾ standard deviation. *Statistical significance compared with composite graft (P ⬍ .05). †Color difference from the upper lip was calculated from the standard equation ([⌬L*]2 ⫹ [⌬a*]2 ⫹ [⌬b*]2)½. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
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FIGURE 3. A 28-year-old man with a bilateral complete cleft lip underwent lip repair at 4 months of age. A, B, Preoperative views. The patient had an asymmetric scar and a short lip. C, D, Postoperative views 2 years after receipt of a hair-bearing composite graft from the chin. The process of graft acceptance is shown E, immediately after scar excision, F, immediately after surgery, G, 1 day postoperatively, and H, 3 days postoperatively. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
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FIGURE 4. A male pediatric patient underwent lip repair of a right complete cleft lip at 3 months of age. A, B, Preoperatively, the patient had a short lip and a hypertrophic scar on his upper lip. He underwent a secondary surgery with a preauricular composite graft at 8 years of age. C, D, Appearance at 6-year postoperative follow-up. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
correction of scars on the upper lip, a straight-line excision can be considered,11,12 and for correction of the vermillion deformity, Z-plasty and V-Y advancement are recommended.1,12 In addition, for correction of a mild short lip, Z-plasty of the upper lip is preferred.2 However, these methods are not indicated for severe deformities and possibly may worsen the outcome by causing increased tension owing to tissue loss. For the treatment of severe forms of tight lip, many surgeons have suggested the Abbé flap as the treatment of choice.1,2 To restore a deformed cupid bow owing to severe scarring, the senior author suggests a cicatricial rectangular flap from the upper vermilion to the nostril base that contains the previ-
ous scar.13 The distal part of the flap is the nostril base and covers the cupid bow by flap transposition. In this method, however, tension around the superior half of the upper lip, which is caused by tissue deficiency and the postoperative scar, is an inevitable result. To overcome this issue, the authors considered the application of a composite graft to the defect in the upper lip resulting from complete excision of the scar. The use of a composite graft with cartilage was introduced by Schimid14 to reconstruct the philtrum of a bilateral cleft lip, although this technique is not generally used. Release of tension by the transfer of composite tissue may be the preferred choice to stop
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FIGURE 5. A male patient received lip repair of the left complete cleft lip at 3 months of age. A, B, Preoperative views show a hypertrophic and hairless scar on the upper lip. When he was 19 years old, he received a secondary surgery with a hair-bearing composite graft from the postauricular scalp. C, D, Appearance at 3.5-year postoperative follow-up. Lee, Kim, and Park. Composite Grafts in Secondary Cleft Lip. J Oral Maxillofac Surg 2012.
the vicious cycle of secondary cleft lip. Composite grafts on the upper lip have several advantages over other methods. First, deficit tissue can be replaced by tissues from other regions. The Abbé flap functions similarly to composite grafts but results in scars on the lower lip and has adverse effects on the function of the orbicularis oris muscle.15 Composite grafts do not impose defects on the donor site, and there is no morphological deformity after harvesting. In the selection of a donor site, an invisible donor scar, the color match to the upper lip, and the possibility of primary closure should be considered; the preauric-
ular area, suprabrow area, chin, and scalp are thought to be the recommended donor sites. Second, rearrangement of the orbicularis oris muscle can be performed simultaneously. Although discontinuity of the orbicularis oris muscle is definitively corrected during primary lip repair, a relapse commonly occurs. Therefore, an assessment of muscular continuity in patients with secondary cleft lip should not be overlooked.16 Through excision of the previous lip scar, the orbicularis oris muscle can be dissected from adjacent tissues and rearranged before composite grafting. After rearrange-
e426 ment of the muscle, the shape of the defect in the upper lip is usually altered. Third, the composite graft is involved in the formation of the philtrum. Indeed, the most important step in the formation of the philtrum is the reconstruction of muscular interdigitation and the release of tension.17-19 Using a composite graft, the release of tension can be achieved and may result in a natural appearance of the philtrum. Fourth, hair-bearing composite grafts in male patients can hide scars on the upper lip. In cases of prominent hairless scars on the upper lip, hair-bearing composite grafts can effectively cover the defect, producing a camouflaged effect to the postoperative scar. The Abbé flap and temporal island flap can also be used to transfer hair-bearing tissues.20 Alternatively, hair micrografts may be considered for hiding the scars.21 The authors were able to achieve satisfactory results in 34 cases using hair-bearing composite grafts from the chin and scalp. Skin color can be measured objectively by numerical figures using many types of colorimeters.22 The Commission International d’Eclairage L*a*b* color coordinates were introduced in this study to compare colors. This L*a*b* color space has been suggested to provide uniform color differences with visual differences and is commonly used worldwide.10,23 The composite graft showed no significant difference in each value of L*a*b* compared with the normal upper lip, but other sites showed significant differences in at least 2 values of L*a*b*. Moreover, the difference value in color between the upper lip and the composite graft was minimal. Except for the composite graft, the forehead color was most similar to the upper lip followed by the chin, cheek, and forearm. When tissues from these sites were transferred to the upper lip in the form of a composite graft, the color appeared closer to that of the upper lip. The authors hypothesize that the composite tissues not only keep the characteristics of the donor site but also are influenced by the recipient site. The vascular supply of the grafted composite tissue is supplied by the margin of the recipient site, and the survival of the tissue decreases with increasing size. Most patients with secondary cleft lip deformity undergo corrective surgery several times, so that scar tissues remain around the margins of the recipient site even after full excision of the cutaneous scar tissue. A composite graft in a patient with secondary cleft lip is like a graft within scar tissue, and thus the survival rate of the composite graft inherently decreases, although the tissue is very small. To increase the survival of the composite graft, the following precautions should be taken during surgery: the composite tissue should be handled gently using an atraumatic technique during harvesting and grafting; meticulous hemostasis should be performed to prevent hemato-
COMPOSITE GRAFTS IN SECONDARY CLEFT LIP
mas beneath the composite tissue; scar tissues should be excised as completely as possible; and vasoconstrictors such as epinephrine should not be used during the surgery. Furthermore, the width of the composite tissue should not exceed 7 to 8 mm to ensure survival of the composite graft. The authors described a composite grafting technique and analyzed the results to show the superiority of this technique but did not present control groups for comparison. Thus, the limitation of this study is that it is not a controlled study but an observational study with analysis. In conclusion, using composite grafts on the upper lips of patients with secondary cleft lip can resolve the fundamental problems of deficient tissues. This is a reliable option to correct a wide hypertrophic scar and tight lip simultaneously, resulting in a satisfactory scar image and improvement of upper lip morphology over a relatively longterm follow-up. Acknowledgments The authors are grateful to Dong-Su Jang (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his help with the figures.
References 1. Byrd HS, El-Musa KA, Yazdani A: Definitive repair of the unilateral cleft lip nasal deformity. Plast Reconstr Surg 120:1348, 2007 2. Stal S, Hollier L: Correction of secondary cleft lip deformities. Plast Reconstr Surg 109:1672, 2002 3. Delaire J: Theoretical principles and technique of functional closure of the lip and nasal aperture. J Maxillofac Surg 6:109, 1978 4. Patel IA, Hall PN: Free dermis-fat graft to correct the whistle deformity in patients with cleft lip. Br J Plast Surg 57:160, 2004 5. Holmström H: The Abbe island flap for the correction of whistle deformity. Br J Plast Surg 40:176, 1987 6. Cho BC, Park JW, Baik BS: Correction of severe secondary cleft lip nasal deformity using a composite graft: Current approach and review. Ann Plast Surg 48:131, 2002 7. Cheon YW, Park BY: Long-term evaluation of elongating columella using conchal composite graft in bilateral secondary cleft lip and nose deformity. Plast Reconstr Surg 126:543, 2010 8. Takemura Y, Liu J, Atsumi R, et al: Development of a questionnaire to evaluate patient satisfaction with medical encounters. Tohoku J Exp Med 210:373, 2006 9. Yun IS, Lee WJ, Rah DK, et al: Skin color analysis using a spectrophotometer in Asians. Skin Res Technol 16:311, 2010 10. Van der Horst CM, Koster PH, de Borgie CA, et al: Effect of the timing of treatment of port-wine stains with the flash-lamppumped pulsed-dye laser. N Engl J Med 338:1028, 1998 11. Sadove AM, Eppley BL: Correction of secondary cleft lip and nasal deformities. Clin Plast Surg 20:793, 1993 12. Farmand M: Secondary lip correction in unilateral clefts. Facial Plast Surg 18:187, 2002 13. Park BY, Roh TS: Rectangular flap for horizontal upper vermilion tightness in secondary cleft lip deformity. Plast Reconstr Surg 104:1976, 1999 14. Schimid E: Transactions of the Third International Congress of Plastic Surgery. Amsterdam, Excerpta Medica Foundation, 1964, p 306 15. Smith JW: The anatomical and physiologic acclimatization of tissue transplanted by the lip switch technique. Plast Reconstr Surg 26:40, 1960
LEE, KIM, AND PARK 16. Climo MS: Diastasis of the orbicularis oris muscle in repaired unilateral clefts of the lip. Cleft Palate J 6:316, 1969 17. Randall P, Whitaker LA, LaRossa D: The importance of muscle reconstruction in primary and secondary cleft lip repair. Plast Reconstr Surg 54:316, 1974 18. Briedis J, Jackson IT: The anatomy of the philtrum: Observations made on dissections in the normal lip. Br J Plast Surg 34:128, 1981 19. Kim SW, Jeong YW, Cheon JE, et al: Orbicularis oris muscle defects in philtral deformities in the repaired cleft lip. J Korean Soc Plast Reconstr Surg 37:427, 2010
e427 20. Millard DR Jr: Cleft Craft: The Evolution of Its Surgery. Vol 2, Bilateral and Rare Deformities. Boston, MA, Little Brown, 1977, pp 439, 454, 464 21. Kiliç A, Emsen IM, Ozdengil E, et al: Lip scars camouflaged using microhair transplantation on male patients. Plast Reconstr Surg 106:1340, 2000 22. Masuda Y, Yamashita T, Hirao T, et al: An innovative method to measure skin pigmentation. Skin Res Technol 15:224, 2009 23. Rah DK, Kim SC, Lee KH, et al: Objective evaluation of treatment effects on port-wine stains using L*a*b* color coordinates. Plast Reconstr Surg 108:842, 2001