The management of secondary cleft lip deformities

The Management of Secondary Cleft Lip Deformities KERWIN M . MARCKS, M .D ., ALLAN E . TREVASKIS, M .D ., * MEREDITH J . PAYNE, M .D . AND JOHN E . Kicos, M .D ., Allentown, Pennsylvania

order to appreciate the full value of methods employed in dealing with the management of secondary cleft lip deformities, we would like to present a series of cases to illustrate what we mean when we stress the fact that "prevention" of these types of deformities is of paramount importance .

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the same principles and again preserving the full prolabium and skin-vermilion ridge which will add considerable length to the horizontal diameter of the lip and prevent a tight lip which is often a distinct characteristic in other methods of repair . We are gathering more and more evidence by clinical research that the

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Fr( i . Case e . Photograph showing mucous membrane and muscle defect with . ; massive scar deformity at distal end of prolabium . Repair accomplished by muscle adjustment and mucous membrane advancement . Skin-vermilion ridge of prolabiunr maintained . FIG. 2 . Case r . Photograph showing completed lip . Note the good condition of the prolabium and why the prolabium should be maintained in the lip at the initial procedure and in all subsequent procedures . The first group as presented consists of a prolabium should be part of the lip, and should series of cases with unilateral lip deformities, not be distorted or sacrificed at the initial both complete and incomplete, which were bilateral lip repair . This is very well illusrepaired by the method we adopted with trated in an old bilateral cleft lip (Case I, modifications in 1951 . As one will observe, we Figs . I and 2) in which the prolabimn had been are attempting to approach construction of as maintained initially and secondary repair was normal a lip as possible, utilizing the full value simplified . We have also established evidence of the Cupid's bow and skin-vermilion ridge . that skeletal muscle does exist in the prolabium The second group shows the progress made and that there is a growth of hair evident in in repair of bilateral lip deformities, utilizing later life, Because of the importance of this "Present address : St . Louis, Missouri . American Journal of Surgery, Volume g5, June, rps8 932



Secondary Cleft Lip Deformities

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FIG . 3 . Case u . Photograph showing labial sulcus adhesions which are frequently encountered . The more severe types do interfere at times with the insertion of orthodontic appliances or replacements and should be repaired . FIG . 4 . Case ii . Photograph showing the method employed to correct this defect . The gingival margin is left to granulate . Skin grafts are an unnecessary evil in this location . FIG . s . Case m . Shows a mild unilateral lip deformity with short medial and lateral elements but Cupid's bow intact . Fie . 6 . Case u[ . Shows a repaired lip utilizing a Z-plasty procedure which not only changes the scar line but lengthens both elements .

method in the prevention of secondary cleft lip deformities, we shall elaborate a great deal more in a separate publication . Suffice it to say that we are well pleased with our results to date and we firmly believe this contribution will be a great factor in an attempt to reach a satisfactory solution to this problem . Either way, we must adopt an attitude of

"better attention" to what nature has provided . As soon as we realize this and adhere to the principles of plastic surgery, there will be less scarring and less necessity for performing secondary procedures . True, there will always be some minor adjustments that must be attended to at a later date but nothing coinpared to what will be presented later . Let us 933

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Case tv . Shows a slightly more severe deformity which adapts itself very satisfactorily to this Z-plasty procedure . FIG . 7 .

Case iv . Shows the completed lip . Note the alignment of the skinvermilion ridge, the fullness of the lip and an excellent tooth replacement . FIG . 8 .

Case v . This case is presented to particularly demonstrate the frequent drooping of the tip of the nose on the affected side. It also demonstrates the malalignment of the skin-vermilion portion of lip . Fic . to . Case v . Shows the correction of the nasal tip deformity and formation of a Cupid's how . We do not use this latter procedure too frequently since it does sacrifice the ridge . FIG . 9 .

do justice to ourselves and use all our efforts from the very beginning .

we have contributed something to the complete rehabilitation of this type of patient . The actual treatment of these types of patients depends on the problems that exist . We should like to present the following classification : Mild Deformities . This type usually involves just the skin or mucous membrane and can be corrected by simple adjustment in the skin-vermilion ridge section, or floor of the nostril . Mucous membrane redundancy is

TREATMENT

There have been many methods of repair described in the literature . Most are valuable in that they provide a definite foundation for the development and planning of a technic to be used . We are indeed grateful for this help . If we can add just a little bit more to what has already been done, we can truthfully say that 9 34

Secondary Cleft Lip Deformities

Case vi . Note the marked scar deformity existing in proIabium with distortion of skin-vermilion ridge . The occlusion has been satisfactorily restored prior to surgery. The lip appeared to have sufficient tissue present so that we believed an Abbe flap was not indicated . FIG . I I .

FIG . 12 .

Case vi . Shows profile of the patient before operation .

Case vi . Shows the completed lip repaired by formation of flaps and transpositioning beneath the good portion of the prolabium . Initially the lip was too short in its vertical dimension . FIG . 13.

FIG . 14 .

Case vi . Shows profile of patient after operation.

placed in this category . This is very evident when the patient smiles . A V-Y advancement or a Z-plasty in the horizontal plane is usually sufficient to correct it . Labial sulcus adhesions are frequently encountered . Utilizing mucous membrane coverage for the lip and permitting the gingiva to granulate is our answer to the problem . We have no cases on record in which a skin graft in the labial sulcus was necessary in order to increase the depth of the sulcus . Closure of a small labial fistula can also be included in this group . This can usually be corrected by rebuilding the floor of the nostril anteriorly and advancing the mucous mem-

brane over the repaired defect or by inverting a mucous membrane flap, leaving the base to granulate or provide covering by mucous membrane advancement . (Case v, Figs . 3 and 4.) Moderately Severe Deformities . These can he classified according to the degree of severity . Case iii (Figs . i and 6) is an example of the milder variety whereas Case iv (Figs . 7 and 8) is a more severe deformity . The principle in the treatment is the same but the extent of surgery necessary to produce the same effect is more extensive . Usually this type requires complete reopening of the lip and floor of the nostril . Repair is 935

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Case vii . Demonstrates the more severe type of lip deformity where extra tissue is necessary . Note the massive scar deformity in the prolabial region together with the flat lip . FIG . 15 .

FIG . 16.

Case vii . Shows the insertion of the Abbe flap .

Case vu . Demonstrates the full lip with the scar lines simulating the philtral ridges . FIG . 17.

FIG . I8. Case vu . Shows the profile after operation . Note the full pouting upper lip .

accomplished by full advancement of both lip elements to produce as much pouting as possible . Readjustment of the afar base and floor of nostril and Z-plasty to lengthen the medial element, lateral element or both, is performed . With the lip wide open, this is an opportune moment to repair such labial and anterior palatal defects that might exist . Usually there is sufficient nasal mucoperiosteum present to provide lining for the nostril . Since covering is extremely scarce in this

region, the raw surface may be left to granulate or a mucous membrane horizontal flap from the upper lip can be transferred over the defect to provide covering . The initial incision for reopening of the lip always incorporates the scar tissue present on the skin surface of the lip, but we never excise scar incorporated in the mucous membrane of the lip until the final stage of repair . The mucous membrane is frequently deficient and the interdigitation of even scar flaps will help 936

Secondary Cleft Lip Deformities a great deal . If sufficient, the scar tissue can always be excised at this time . Frequently there are "touch-up" procedures necessary following the repair for moderately severe deformities . These may incorporate nasal tip repair as well as further skin-vermilion adjustment . One of these methods is illustrated in Case v . (Figs . 9 and Io .) Nasal tip repair is so involved that it must be discussed in a separate presentation . Severe Deformities . In this category we place the cases in which marked deformity persists and in which readjustment of material still available will be required (evident in Case vi, Figs . I1, 12, 13 and 14), or when extra tissue will be required in order to produce the desired result, either in the form of a fullthickness graft or an Abbe flap . As a rule, we never insert an Abbe flap as an initial procedure . We usually reopen the lip, make all corrections necessary to the underlying structures as described under "Moderately Severe Deformities," repair the lip and wait until all reaction has subsided before insertion of the tissue . This localizes the surface area exposed at the time of the insertion and minimizes the possibility of hemorrhage at some other part of the lip which might interfere with the morbidity of the procedure . We believe that the environment ought to be perfect before insertion of adjacent tissue . The lip elements can be adjusted in proportion at the time of insertion . No V-section of the lower lip should be performed for redundancy until it has definitely been verified that it is not required in the upper lip . This type of flap is well illustrated in Case vii, Figures 15, 16, 17 and 18 .

lip deformity as a prevention for secondary lip deformities . We have presented some procedures that we use in the treatment of lip deformities . Some are original but the most have been contributed, in part at least, by many pioneers in this field . We are indebted to many previous publications . Repair, especially in the unilateral deformity, has incorporated the principles of Z-plasty almost entirely . The angle is variable but the principle is the same . Coordination between the various services (dental, speech and psychology) has been stressed since it appears to be one of the most important entities in the final rehabilitation of the patient . Acknowledgment : We again wish to acknowledge the help given us by our associates at the Allentown Hospital Cleft Palate Clinic, by Dr . Herbert K . Cooper and his associates at the Lancaster Cleft Palate Clinic and by Dr . Robert H . Ivy, Chief of Cleft Palate Section, Pennsylvania Department of Health . REFERENCES

and BRowN, J . B . A plea for better average harelip repairs . Dallas M. J ., 17 : 4-9,

I . BLAIR, V . P . 1931 . 2 . BLAIR, V . P .

3. 4.

5. 6.

and LETTERMAN, G . The role of the switched lower lip flap in upper lip restorations . Plait. of Reconstruct . Surg ., 5 : 1-26, I95o . BROWN, J . B . and MACDOWELL, F . Plastic Surgery of the Nose . St. Louis, t951 . C. V . Mosby Co. BROWN, J . B . and MAcDOWELL, F . Secondary repair of cleft lips and their nasal deformities . Ann . Surg., 114 : for-117, 1941 . CANNON, B . The split vermilion bordered lip flap . Surg ., Gy n ec . er Obst ., 73 : 95-9Z 1941CANNON, B . The use of vermilion bordered flaps in surgery about the mouth, Surg ., (y-nee, er Obsr .,

74 :458-462, [942 . 7 . DAVIS, J . S . and KITLOWSKI, E . A .

REHABILITATION

The final result will not depend on the surgery itself. We are deeply indebted to the various dental services, speech pathologists and psychologists in the complete rehabilitation of the patient . Surgery is frequently delayed until dental care has been instituted or replacements inserted . Close coordination between these services will determine the efficiency required in the over-all care of this type of patient .

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The theory and practical use of Z-incision for the relief of scar coutractures . Ann . Sure ., tug : toot-1015 . 1939 . GiLLIES, S. H . and KILNER, T . P . Hare-lip : operations for correction of secondary deformities .

Lancet, 2 : 1369, 1932 . 9 . MARCKS, K . M ., TREVASKIs, A. F . and D .AC.OSTA, A . Further observations in cleft lip repair . Plast . er Reconstruct . Surg ., u : 392 -402 . 1953to- MAm :KS, K . M ., TREVASKLS, A . E ., Tuem<, M . and PAYNE, M . J . Transactions of International

Congress of Plastic Surgery. Stockholm, Sweden, 1955 . II . SMITH, F . Planning the reconstruction . Surgery, 15 : 1 - 15, 1944T2- TRUSLER, H. M . and GLANZ, S . Secondary repair

SUMMARY

of unilateral cleft lip deformity : square flap technique. Plait . er Reconstruct . Surg ., 1o : 83-91 .

We have stressed the importance of care and tenderness in the initial repair of a cleft

1952 .

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