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nose repair: Bardach's technique
UNILATERAL CLEFT LIP/NOSE REPAIR: BARDACH'S TECHNIQUE JANUSZBARDACH, MD
Construction of the nasal floor is of great importance in unilateral cleft lip/nose repair. In my technique, this construction is achieved by creating mucoperiosteal and mucoperiochondrial flaps on the lateral nasal wall and on the nasal septum, which are then sutured together in two layers. By extending the closure anteriorly, the nasolabial fistula is also closed at the time of primary cleft lip repair. Construction of the nasal floor can be successfully achieved in narrow and medium-sized unilateral clefts. In wide clefts, where two-layer closure may be more difficult to achieve, one-layer closure may suffice. Copyright 9 1995 by W.B. Saunders Company KEY WORDS: Bardach's technique, cleft/lip nose, nasal floor construction
The technique for primary repair of unilateral cleft lip and nose described in this report evolved from the concepts and principles initiated by Tennison 1 and was further developed by Marcks et al, 2 Hagerty, 3 and Randall. 4 My modifications 5"6 of the technique include correction of the nasal deformity at the time of primary lip repair by constructing the floor of the nose; positioning the base of the ala so that it is symmetric with the opposite side; straightening the columella; and closure of the nasolabial fistula. Special attention is paid to constructing a deep sulcus and to properly aligning the vermilion. I do not make any incisions in the sulcus or undermine the soft tissue from the face of the maxilla. My clinical and experimental experiences have shown that incisions in the sulcus and undermining the soft tissue may be detrimental to facial growth because of extensive scarring on the anterior surface of the maxilla. Incisions in the sulcus destroy the fibrous band between the alveolar ridge at the cleft margin and the lip segment on the cleft side. In my opinion, it is necessary to preserve the fibrous band, because it helps pull the lesser maxillary segment into proper alignment. In this report, I would like to focus on construction of the floor of the nose and closure of oronasal fistulas, surgical aspects of cleft lip repair that are not always clearly presented.
PRINCIPLES OF PRIMARY CLEFT LIP/NOSE REPAIR The basic principle behind primary lip repair is to rearrange both lip segments to create symmetry in the vertical dimension on both sides. The lip height must be precisely measured to design the size and position of the triangular flap on the lesser lip segment that will be inFrom the University of Iowa, iowa City, IA. Address reprint requests to Janusz Bardach, MD, Professor Emeritus of Plastic Surgery, The University of Iowa, Iowa City, IA 52242. Copyright 9 1995 by W.B. Saunders Company 1071-0949/95/0203-000755.00/0
serted into a triangular gap created on the larger lip segment. The incision that follows the design of the triangular flap allows for appropriate lengthening of the tissue on both lip segments to achieve symmetry of both sides, as well as a symmetric Cupid's bow. Reconstruction of the vermilion may require additional maneuvering because its thickness may differ in both lip segments. Special attention is paid to constructing a deep normal sulcus and to rearranging the orbicularis oris muscle from an oblique to a horizontal position. I consider correction of the nasal deformity an integral part of primary cleft lip repair. Construction of the nasal floor in two layers is achieved by suturing mucoperiosteal and mucoperichondrial flaps from the lateral nasal wall and nasal septum. By extending the closure anteriorly, the nasolabial fistula is also closed; although in very wide clefts, this may be difficult to achieve. Closure of the nasolabial fistula may remain complete or the fistula may reopen as a result of maxillary expansion during orthodontic treatment. I do not attempt to reshape or realign the lower lateral cartilage in this operation. However, I do place the base of the ala into a symmetrical position with the opposite side and thereby improve the shape of the nostril. Taking precise measurements to design the incision lines decreases the margin of error and allows for approximation of the lip segments in a proper anatomical alignment. I would like to stress that, without making incisions in the sulcus or undermining the soft tissue, lip repair can be achieved with minimal tension, even in cases of wide clefts. Most secondary deformities following lip repair using the triangular flap technique consist of an asymmetric vermilion or a notch in the vermilion. Both secondary deformities require correction.
ESSENTIAL STEPS IN CLEFT LIP/NOSE REPAIR The surgeon begins the operation by precisely measuring the height of the lip from the tips of the Cupid's b o w to the base of the columella. Both measurements are taken
Operative Techniques in Plastic and Reconstructive Surgery, Vol 2, No 3 (August), 1995: pp 187-192
187
Fig 1. Unilateral cleft lip, alveolus, and palate. Design of Incisions Inside the nasal cavity and on the lip segments for application of the triangular flap technique. (Reproduced from: Salyer K and Bardach J. Atlas of Craniofaclal and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
Fig 2. Incision along the lower edge of the nasal septum continued Into the lip. Note the upper flap Inside the nasal cavity is mucoperiosteal and mucoperichondrlal flap. The lower flap extends from the nasal septum onto the alveolar ridge of the larger maxillary segment. It is a mucoperlosteal and mucosal flap. Note the gap opened for insertion of the triangular flap, which is created on the lesser lip segment. (Reproduced from: Salyer K and Bardach J. Atlas of Craniofacial and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
Fig 3. Two mucoperiosteal flaps are raised on the lateral nasal wall: one is turned upward, and the other is turned downward. Note seperatlon of the vermilion and triangular flap created on the lesser lip segment that will be inserted into the gap on the larger segment. (Reproduced from: Salyer K and Bardach J. Atlas of Craniofacial and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
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JANUSZ BARDACH
Flg 4. Separatlon of the muscles of the orblculsrls orls muscle on both sides of the cleft to rearrange them Into the horlzontal allgnment. All flaps In the nasal cavlty and on the llp are prepared for suturing. (Reproduced from: Salyer K and Bardach J. Atlas of Cranlofaclal and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
Fig 5. Closure of the nasal floor In one and two layers. The most posterior portion of the nasal floor Is usually a one-layer closure. In the anterlor portion, a two-layer closure can be accompllshed except In very wide clefts. (Reproduced from: Salyer K and Bardach J. Atlas of Cranlofaclal and Cleft Surgery. Raven Press, 1996. Copyrlght Raven Press).
Fig 6. Creation of the sulcus and closure of the mucosa and muscle layers. (Reproduced from: Salyer K and Bardach J. Atlas of Cranlofaclal and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
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Figs 7 and 8. Final closure of the skln, muscle, and vermlllon. (Reproduced from: Salyer K and Bardach J. Atlas of Cranlofaclal and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
from the larger lip segment. The difference between the measurements determines the length of the sides of the triangular flap to be designed on the lesser portion of the lip as well as the length of the incision, which will create the gap in the larger lip segment in which the triangular flap will be inserted. An incision is carried on the nasal septum 1 to 2 mm
above the lower edge of the septum (Fig 1). It is carried forward on the vermilion cutaneous border of the lip. With a number 11 blade, the incision is carried through the skin, muscle, and mucosa. The mucoperichondrial flap on the nasal septum is raised using a Freer knife. At the base of the columella, the orbicularis oris muscle is released from its attachment. The mucoperiosteal flap is
Fig 9. (A) Severe unilateral cleft lip, alveolus, and palate. Note severe nasal deformity. (B) One year after primary cleft lip/nose repair was performed using the triangular flap technique and correction of the nasal deformity described in the paper. (C) The same patient 6 years later. The lip required no further correction. A slight nasal asymmetry will require correction at a later age.
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JANUSZ BARDACH
Fig 10. (A) Unilateral cleft lip, alveolus, and palate and severe nasal deformity. (B) Following lip repair using triangular flap technique and correction of the nasal deformity. (C) The same patient 4 years later.
raised and turned downward, with the epithelium facing the sulcus. In this way, the flaps are raised inside the nasal cavity as well as on the larger lip segments. "Attention is then turned to the lateral maxillary and lip segment (Fig 2). The incision starts inside the oral cavity below the lower turbinate, in the groove between the lateral nasal wall and the palatal plate. Then the incision is carried forward along the vermilion cutaneous border, separating part of the vermilion and creating a triangular flap in the lower portion of the lip segment. With these CLEFT LIP/NOSE REPAIR: BARDACH'S TECHNIQUE
incisions completed, the mucoperiosteal flaps inside the nasal cavity are undermined. The base of the ala is mobilized, and the attachment of the orbicularis oris muscle is released. The fibrous band that extends from the alveolar ridge to the lesser lip segment is preserved. Following these preparations, closure begins as deep as is technically possible inside the nasal cavity (Fig 3). The mucoperiosteal flap from the lateral wall is sutured to the mucoperiosteal flap from the vomer and alveolar ridge. This layer not only constitutes the lower layer of
191
the reconstructed nasal floor b u t also closes the nasolabiaI fistula in its anterior portion. The second layer is closed by suturing the mucoperichondrial flap from the s e p t u m with the mucoperiosteal flap from the lateral nasal wall. By reconstructing the nasal floor in two layers, the alar base is approximated medially into a symmetric position. This type of reconstruction of the nasal floor is also helpful in bringing the maxillary segments into proper alignment. It also improves the position of the columella by pulling its base into the midline. After reconstructing the floor of the nose, closure of the lip starts with closure of its mucosal layer in the sulcus (Figs 4 a n d 5). It is important that the triangular flap created in the skin a n d muscle will also include the mucosa, facilitating the s y m m e t r y of the reconstructed lip (Fig 6). It is essential to create a symmetrical Cupid's bow a n d symmetrical vermilion. I use vertical mattress sutures on skin a n d muscles to avoid leaving chromic sutures in the muscles. After complete closure of the
192
skin, reconstruction of the vermilion m a y require some adjustments on both sides w h e n the w i d t h and thickness vary (Figs 7 a n d 8). This can be solved by transposing triangular flaps from the thicker side to the thinner so that t h e y are equal (Figs 9 a n d 10).
REFERENCES 1.
2. 3. 4. 5. 6.
Tennison CW: The repair of unilateral cleft lip by the stencil method. Plast Reconstr Surg 9:115, 1952 Marcks KM, Trevaskis AE, DaCosta A: Further observations in cleft lip repair. Plast Reconstr Surg 12:392, 1953 Hagerty RF: Unilateral cleft lip repair. Surg Gynecol Obstet 106:119, 1958 Randall P: A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast Reconstr Surg 23:331, 1959 Bardach J: Rozszczepy Wargi Gornej i Podniebienia. Warszawa, Panstwowy Zaklad Wydawnictw Lekarskich, 1967 Bardach J, Salyer K: SurgicalTechniques in Cleft Lip and Palate (ed 2). St Louis, MO, Mosby-Yearbook, 1991
JANUSZ BARDACH
Construction of the nasal floor is of great importance in unilateral cleft lip/nose repair. In my technique, this construction is achieved by creating mucoperiosteal and mucoperiochondrial flaps on the lateral nasal wall and on the nasal septum, which are then sutured together in two layers. By extending the closure anteriorly, the nasolabial fistula is also closed at the time of primary cleft lip repair. Construction of the nasal floor can be successfully achieved in narrow and medium-sized unilateral clefts. In wide clefts, where two-layer closure may be more difficult to achieve, one-layer closure may suffice. Copyright 9 1995 by W.B. Saunders Company KEY WORDS: Bardach's technique, cleft/lip nose, nasal floor construction
The technique for primary repair of unilateral cleft lip and nose described in this report evolved from the concepts and principles initiated by Tennison 1 and was further developed by Marcks et al, 2 Hagerty, 3 and Randall. 4 My modifications 5"6 of the technique include correction of the nasal deformity at the time of primary lip repair by constructing the floor of the nose; positioning the base of the ala so that it is symmetric with the opposite side; straightening the columella; and closure of the nasolabial fistula. Special attention is paid to constructing a deep sulcus and to properly aligning the vermilion. I do not make any incisions in the sulcus or undermine the soft tissue from the face of the maxilla. My clinical and experimental experiences have shown that incisions in the sulcus and undermining the soft tissue may be detrimental to facial growth because of extensive scarring on the anterior surface of the maxilla. Incisions in the sulcus destroy the fibrous band between the alveolar ridge at the cleft margin and the lip segment on the cleft side. In my opinion, it is necessary to preserve the fibrous band, because it helps pull the lesser maxillary segment into proper alignment. In this report, I would like to focus on construction of the floor of the nose and closure of oronasal fistulas, surgical aspects of cleft lip repair that are not always clearly presented.
PRINCIPLES OF PRIMARY CLEFT LIP/NOSE REPAIR The basic principle behind primary lip repair is to rearrange both lip segments to create symmetry in the vertical dimension on both sides. The lip height must be precisely measured to design the size and position of the triangular flap on the lesser lip segment that will be inFrom the University of Iowa, iowa City, IA. Address reprint requests to Janusz Bardach, MD, Professor Emeritus of Plastic Surgery, The University of Iowa, Iowa City, IA 52242. Copyright 9 1995 by W.B. Saunders Company 1071-0949/95/0203-000755.00/0
serted into a triangular gap created on the larger lip segment. The incision that follows the design of the triangular flap allows for appropriate lengthening of the tissue on both lip segments to achieve symmetry of both sides, as well as a symmetric Cupid's bow. Reconstruction of the vermilion may require additional maneuvering because its thickness may differ in both lip segments. Special attention is paid to constructing a deep normal sulcus and to rearranging the orbicularis oris muscle from an oblique to a horizontal position. I consider correction of the nasal deformity an integral part of primary cleft lip repair. Construction of the nasal floor in two layers is achieved by suturing mucoperiosteal and mucoperichondrial flaps from the lateral nasal wall and nasal septum. By extending the closure anteriorly, the nasolabial fistula is also closed; although in very wide clefts, this may be difficult to achieve. Closure of the nasolabial fistula may remain complete or the fistula may reopen as a result of maxillary expansion during orthodontic treatment. I do not attempt to reshape or realign the lower lateral cartilage in this operation. However, I do place the base of the ala into a symmetrical position with the opposite side and thereby improve the shape of the nostril. Taking precise measurements to design the incision lines decreases the margin of error and allows for approximation of the lip segments in a proper anatomical alignment. I would like to stress that, without making incisions in the sulcus or undermining the soft tissue, lip repair can be achieved with minimal tension, even in cases of wide clefts. Most secondary deformities following lip repair using the triangular flap technique consist of an asymmetric vermilion or a notch in the vermilion. Both secondary deformities require correction.
ESSENTIAL STEPS IN CLEFT LIP/NOSE REPAIR The surgeon begins the operation by precisely measuring the height of the lip from the tips of the Cupid's b o w to the base of the columella. Both measurements are taken
Operative Techniques in Plastic and Reconstructive Surgery, Vol 2, No 3 (August), 1995: pp 187-192
187
Fig 1. Unilateral cleft lip, alveolus, and palate. Design of Incisions Inside the nasal cavity and on the lip segments for application of the triangular flap technique. (Reproduced from: Salyer K and Bardach J. Atlas of Craniofaclal and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
Fig 2. Incision along the lower edge of the nasal septum continued Into the lip. Note the upper flap Inside the nasal cavity is mucoperiosteal and mucoperichondrlal flap. The lower flap extends from the nasal septum onto the alveolar ridge of the larger maxillary segment. It is a mucoperlosteal and mucosal flap. Note the gap opened for insertion of the triangular flap, which is created on the lesser lip segment. (Reproduced from: Salyer K and Bardach J. Atlas of Craniofacial and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
Fig 3. Two mucoperiosteal flaps are raised on the lateral nasal wall: one is turned upward, and the other is turned downward. Note seperatlon of the vermilion and triangular flap created on the lesser lip segment that will be inserted into the gap on the larger segment. (Reproduced from: Salyer K and Bardach J. Atlas of Craniofacial and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
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JANUSZ BARDACH
Flg 4. Separatlon of the muscles of the orblculsrls orls muscle on both sides of the cleft to rearrange them Into the horlzontal allgnment. All flaps In the nasal cavlty and on the llp are prepared for suturing. (Reproduced from: Salyer K and Bardach J. Atlas of Cranlofaclal and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
Fig 5. Closure of the nasal floor In one and two layers. The most posterior portion of the nasal floor Is usually a one-layer closure. In the anterlor portion, a two-layer closure can be accompllshed except In very wide clefts. (Reproduced from: Salyer K and Bardach J. Atlas of Cranlofaclal and Cleft Surgery. Raven Press, 1996. Copyrlght Raven Press).
Fig 6. Creation of the sulcus and closure of the mucosa and muscle layers. (Reproduced from: Salyer K and Bardach J. Atlas of Cranlofaclal and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
CLEFT LIP/NOSE REPAIR: BARDACH'S TECHNIQUE
189
Figs 7 and 8. Final closure of the skln, muscle, and vermlllon. (Reproduced from: Salyer K and Bardach J. Atlas of Cranlofaclal and Cleft Surgery. Raven Press, 1996. Copyright Raven Press).
from the larger lip segment. The difference between the measurements determines the length of the sides of the triangular flap to be designed on the lesser portion of the lip as well as the length of the incision, which will create the gap in the larger lip segment in which the triangular flap will be inserted. An incision is carried on the nasal septum 1 to 2 mm
above the lower edge of the septum (Fig 1). It is carried forward on the vermilion cutaneous border of the lip. With a number 11 blade, the incision is carried through the skin, muscle, and mucosa. The mucoperichondrial flap on the nasal septum is raised using a Freer knife. At the base of the columella, the orbicularis oris muscle is released from its attachment. The mucoperiosteal flap is
Fig 9. (A) Severe unilateral cleft lip, alveolus, and palate. Note severe nasal deformity. (B) One year after primary cleft lip/nose repair was performed using the triangular flap technique and correction of the nasal deformity described in the paper. (C) The same patient 6 years later. The lip required no further correction. A slight nasal asymmetry will require correction at a later age.
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JANUSZ BARDACH
Fig 10. (A) Unilateral cleft lip, alveolus, and palate and severe nasal deformity. (B) Following lip repair using triangular flap technique and correction of the nasal deformity. (C) The same patient 4 years later.
raised and turned downward, with the epithelium facing the sulcus. In this way, the flaps are raised inside the nasal cavity as well as on the larger lip segments. "Attention is then turned to the lateral maxillary and lip segment (Fig 2). The incision starts inside the oral cavity below the lower turbinate, in the groove between the lateral nasal wall and the palatal plate. Then the incision is carried forward along the vermilion cutaneous border, separating part of the vermilion and creating a triangular flap in the lower portion of the lip segment. With these CLEFT LIP/NOSE REPAIR: BARDACH'S TECHNIQUE
incisions completed, the mucoperiosteal flaps inside the nasal cavity are undermined. The base of the ala is mobilized, and the attachment of the orbicularis oris muscle is released. The fibrous band that extends from the alveolar ridge to the lesser lip segment is preserved. Following these preparations, closure begins as deep as is technically possible inside the nasal cavity (Fig 3). The mucoperiosteal flap from the lateral wall is sutured to the mucoperiosteal flap from the vomer and alveolar ridge. This layer not only constitutes the lower layer of
191
the reconstructed nasal floor b u t also closes the nasolabiaI fistula in its anterior portion. The second layer is closed by suturing the mucoperichondrial flap from the s e p t u m with the mucoperiosteal flap from the lateral nasal wall. By reconstructing the nasal floor in two layers, the alar base is approximated medially into a symmetric position. This type of reconstruction of the nasal floor is also helpful in bringing the maxillary segments into proper alignment. It also improves the position of the columella by pulling its base into the midline. After reconstructing the floor of the nose, closure of the lip starts with closure of its mucosal layer in the sulcus (Figs 4 a n d 5). It is important that the triangular flap created in the skin a n d muscle will also include the mucosa, facilitating the s y m m e t r y of the reconstructed lip (Fig 6). It is essential to create a symmetrical Cupid's bow a n d symmetrical vermilion. I use vertical mattress sutures on skin a n d muscles to avoid leaving chromic sutures in the muscles. After complete closure of the
192
skin, reconstruction of the vermilion m a y require some adjustments on both sides w h e n the w i d t h and thickness vary (Figs 7 a n d 8). This can be solved by transposing triangular flaps from the thicker side to the thinner so that t h e y are equal (Figs 9 a n d 10).
REFERENCES 1.
2. 3. 4. 5. 6.
Tennison CW: The repair of unilateral cleft lip by the stencil method. Plast Reconstr Surg 9:115, 1952 Marcks KM, Trevaskis AE, DaCosta A: Further observations in cleft lip repair. Plast Reconstr Surg 12:392, 1953 Hagerty RF: Unilateral cleft lip repair. Surg Gynecol Obstet 106:119, 1958 Randall P: A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast Reconstr Surg 23:331, 1959 Bardach J: Rozszczepy Wargi Gornej i Podniebienia. Warszawa, Panstwowy Zaklad Wydawnictw Lekarskich, 1967 Bardach J, Salyer K: SurgicalTechniques in Cleft Lip and Palate (ed 2). St Louis, MO, Mosby-Yearbook, 1991
JANUSZ BARDACH