Use of the Abbé flap in revision of the bilateral cleft lip-nose deformity

Use of the Abbk flap in revision of the bilateral cleft lip-nose deformity Michael LOUISIANA

C. Kinnebrew, STATE

D.D.S., M.D.,*

UNIVERSITY

MEDICAL

New Orleans, La.

CENTER

SCHOOL

OF DENTISTRY

Use of the versatile Abbe flap for lip-nose revision of a representative adult with bilateral cleft lip and palate is reported. The deformity is discussed, and the surgical plans are developed and executed. Presented is a technique for reliably securing the lateral orbicularis oris muscle components to the philtrum. which ensures viability of the transposed flap and provides functional continuity across the midline while accentuating the philtral dimple

I

t has been stated variously that “the bilateral cleft never looks good” in the final analysis. This, unfortunately, is often true. Contributing to this specter are both relative and absolute tissue deficiencies within the nasomaxillary complex. These deficits have their genesis in utero, where the affected embryologic processes that were to become nose, lip, philtrum, or premaxilla, for example, either fail to develop by focal agenesis or fail to fuse with their partners.’ In the latter case the involved region then grows discordantly without the reciprocal trophic stimulus and regulation of anatomically and functionally related facial parts. An example is the protruding premaxilla of a bilateral complete cleft that may be reasonably related to the cranium above but extremely anteropositioned relative to the lagging lateral facial segments,2.3 as if the innate facial growth had been expressed as anterior projection of the premaxilla, septum, and vomer, while overlooking the disjoined lateral maxillofacial components. Reciprocally, the prolabium is often quite small, rendered so through failure of functional and anatomic continuity with and subsequent trophic induction from the lateral lip segments. Some surgeons commit the patient to repair in early infancy in an attempt to correct these abnormal relationships and institute concordant development. The price the patient often pays is tissue growth restriction and collapse engendered by scar formation in the surgical beds, superimposed upon the primary facial tissue deficiencies.

*Associate Surgery.

Professor,

Department

of Oral

and

Maxillofacial

In the bilateral complete cleft, the problems of inadequate tissue mass become manifest. These problems and their initial manipulation in the primary repair often dictate the requirements of secondary revision. For example, the prolabium may be a mere nubbin of tissue, part of which should have contributed to the development of both columella and philtrum. Such reparative designs as the LeMesurier-Hagedorn technique consign the prolabium to the columellar base and rely upon advancement of the lateral lip segments beneath it to complete the Cupid’s bow and tubercle.4 By comparison, the Millard repair shares the prolabium between the columella and nostril sill and the philtrum. Tissue salvaged from the prolabium is “banked” in the nostril sill for later release of a tethered nasal tip.5 Still other approaches, such as the later Veau designs, place the prolabium centrally in the lip, with straight-line closures then achieved between the “philtrum” and lateral lip segments6, ’ Acceptable results may be seen with any of these approaches, granted the necessity for revisions such as lengthening of the columella and nasal tip by, for example, forked flaps from the philtrum, V-Y advancement, or transplantation of composite grafts from the auricle.s-” Similarly, acceptable standards may have to include a longer lip, as in the LeMesurier repair, or a short, retracted philtrum, as in the Veau straight-line closure.‘z However, the extreme case will see the need for further addition of tissue to the lip, which replaces the existing philtrum and releases the columella superiorly while bringing suture lines into natural skin folds and restoring labial form. In this regard the Abbe flap from the lower lip has no peer.13

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Fig. 1. Frontal (A) andlateral (B) projectionsof a 34-year-oldmanwith secondarydysmorphiaof bilateral cleft lip and palate. At conversationaldistancethe nasaltip is depressed, the philtrum continuouswith the columellarbase,and the tubercle notchedand retracted.

The Abbe flap has long enjoyed wide application in secondary cleft lip and nose reconstruction.1c19 It not only represents the most readily harvested tissue mass that can reliably satisfy all of the basic demands placed upon it, but it provides added benefits as well. Not uncommonly the patient with a cleft exhibits a lower lip that is ptotic and anteriorly placed relative to the upper lip. All too often this represents a retruded maxilla, which must be corrected by advancement surgery as a first stage. An equally ,operative consideration, however, lies within the discrepancy of a tightly scarred upper lip relative to a hypotonic, flaccid lower lip. This situation may also have contribution from adaptations of the craniofacial musculature to chronic mouth breathing (as may be seen in cleft patients with and without pharyngeal flaps). 20.21In the latter case the interlabial relationship may be greatly improved by the transfer of tissue from inferior to superior. Skin, mucosa, and potentially dynamic muscle are transferred, the philtral dimple and column are restored, the mucocutaneous ridge is completed, a tubercle is fabricated, and equal bulk and tension between the lips are obtained. Further, simultaneous nasal tip release is achieved as the midline soft tissues are displaced superiorly and the flap is introduced.

The apparent panacea of the Abbe flap to bilateral cleft revision is not without problems. To ensure viability of the transferred segment, a supporting pedicle from the inferior labial vasculature must be maintained during revascularization of the host bed. With the lips held together by the pedicle, the airway may be compromised. Pediatric airways placed to either side of the vascular bridge may prevent this problem. Close postoperative observation must control the apprehensive patient, who may actually tear his flap down. As sufficient revascularization is obtained from the host bed, a releasing procedure divides and insets the bridge back into the lower lip while achieving the desired upper lip contours, which is a demanding tissue manipulation. At the time of release, a revision of the lower midline scar also is desirable. Later refinement of the vermilion border of the upper lip must also be performed to achieve tubercle definition. The technique for harvesting a lower lip flap is standard, but the design must be varied according to the existing configuration of the upper lip to be revised, which invariably is unique. The revisional design of the bilateral cleft lip-nose deformity and a technique for secondary reconstruction are illustrated in the following case report.

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2. Clinical appearance (A) and scaledtabulation(B) of the lip-nosedeformity.

Fig.

CASE

PRESENTATION

A 34-year-oldman wasreferred by his prosthodontist. An existingoverdenturewasto be replacedto maintainthe occlusion,although evaluationwassoughtregardingrevision of residual bilateral cleft lip-nose deformity (Fig. 1). The patient had undergoneinitial treatmentat 3 months of age for completebilateral cleft lip and palate by an apparentstraight-linecheiloplastyfacilitated by a premaxillary retropositionalosteotomy.The latter procedurealso ablatedthe alveolar clefts and oral-nasalcommunications anteriorly. When the patient was9 monthsof age, a Van Langenbeckrepair of the palate was performed,and he underwent lip and noserevisionsin the teen-ageyears. Orthodontic treatment had been partially successfulin correcting the dentalarch discrepancy,while maxillomandibular balancehad been aided by a downward growth pattern of the mandible as opposedto the usual more horizontal mandibulardevelopment.Speechtherapy alone had achievedexcellent results;no residuaof cleft palate speechwasapparent. Examination revealedthe stigmataof a bilateral cleft, which wastabulated for the labionasalregion as follows (Fig. 2): I. The nasaltip wasdepressed and deviatedto the right with inferior rotation of the alar cartilages and retraction of the columella.

3. The reconstructive surgical scheme. Internal nasalrim incisions(broken line) combinedwith a midline columellarincisionprovidedaccessfor repositioningof the alar cartilages.The existingphiltral tissuesweretranslated superiorly and laterally to lengthen the columella and create the nostril sill. The lateral lip segmentswere to advancemedially, rotating inferiorly to lengthenthe midportionsof the lip. The incisionaloutline of the Abbe flap is shownas somewhatshorter than actual dimension.The arteriovenousbundleis depictedwithin the pedicle. Fig.

2. The left alar basewas lateralized and depressed, accentuatedby lateralization of the left nasolabial fold. 3. The philtrum waspallid, hairless,and short. 4. No mucocutaneous ridge (white roll) wasapparentin the philtrum, the Cupid’sbow was narrow, and the philtral ridgesdivergedsuperiorly. 5. Obvious vermilion notching was present, with no apparenttubercle (the “whistle-tip” deformity). 6. Bulging of the orbicularis musclecomponentson pursedlip posturing,alongwith the superiorlydivergent philtral ridges,signifiedmidlinemuscularunion in the vermilion areaonly, with noattachmentsto the anterior nasalspineor septum. The labial architecture, on composite,gave the impression of an upper lip that wassuperiorly retracted at the midline and laterally divergent at the nasolabialjunction. The lower lip wasnotably ptotic. Left-sidednasalairway obstruction was also present, although this offered no

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Fig. 5. Securingthe muscularcomponentsfunctionally acrossthe mid-line. At discretelevels,heavy polyglycolic acid sutures transfix muscle and fascia of one lateral segment,passthrough the coronal plane of the flap, and similarly transfix the oppositemuscularsegmentbefore retracing the path through the midline flap to be tied on the originating side. Superiorly, the nasalismuscleand obliquefibersof the orbicularisare securedto the anterior nasalspineand septum.

Fig. 4. Diagrammatic representationof procedurejust prior to incision of Abbe flap. At this point the alar cartilageshave been anchoredto the strut and to each other, and the forked flapshavebeentrimmed andsutured laterally to the alar busesto create the nostril sills.Medial advancementof the lateral segmentshas.eradicated the midlineretraction, indicating the correct dimensions of the Abbe flap. Orbicularis musclecomponentsare schematized.

contribution to velopharyngealcompetencyas determined by cul-de-sactesting.22The obstructionwasattributed to a bony spur from the maxillary crest. A dentoskeletal open-bite was present anteriorly. This was in company clinically with mild midfacial hypoplasia, although a concordant maxillomandibularrelationshipwas approximated.This wasreadily amenableto prostheticrehabilitation, accordingto the patient’sdesires. The reconstructive scheme is seen in Fig. 3. At surgery, an oral-endotrachealtube wassecuredby a wire bridle to the lower teeth to maintainits properdepth while allowingpassivehorizontal movementof the tube without distorting the lips. The left-sided nasal obstruction was approachedinitially. The maxillary crest wasfound to be hypertrophied and deviated into the left nasal passage. This wasreduced,then freed for midlinerepositioningby a horizontal osteotomyat the base.A septal cartilaginous strut washarvestedfor lifting the nasaltip, and the septum wasvertically scored.The strut wasintroducedthrough a

vertical incision in the columella,which, combinedwith internal nasalrim incisions,alsoallowedaccessfor dissection andadvancementof the alar cartilages.The mobilized alar cartilagesweresecuredto eachother and to the strut graft with heavy nonresorbablesuture. The tissuetransfer that allowedelevationof the tip was obtainedby shifting the existing philtral tissuesuperiorly in the form of trailing forked flaps.Theseweremarkedand incisedthrough and through asa preliminary step.At the columellar base area, the residual of these flaps was trimmed and diverted laterally to join the alar basesand complete the nostril sills. At this point a reasonable lengtheningof the columella had been obtained, and a gentle lateral flare had been imparted to the columellar base.A triangular excision taken intranasally from the baseof the left ala allowedmedialrotation to correct its lateralized position. The lateral lip segmentswere then advancedand tacked at the point of convergenceof the nostril sills, philtral ridges, and columellar bases.An increasein the length of the midportionof the lip resulted, and the final philtral length and width becamereadily apparent(Fig. 4). A brief discussionof the philtral outline and its mated lateral lip segmentsis appropriateat this point. One must note the changein lip length when the midline superior retraction is releasedand the lateral lip segmentsare realigned;that measurement is transferredto the lower lip as the Abbe flap is outlined. This will provide not only grosslymatchingsegmentlengthsbut will alsoensuresuch fine pointsas alignmentof the mucocutaneous ridgesand cupid’s-bowpeaksin the final result. In marking, it must be borne in mind that the normal philtrum is not in the

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Fig. 7. Two weekspostoperativelythe releasingincisions are markedand incisedto sharevermilion bulk optimally for marginaleversion.

6. Layered closureof the nasaland labial wounds completed.Shortenedportex tubesand quarter-inch antibiotic gauzeprovidenasalairwaysand augmentparaseptal splints.A pediatric airway is placedin the labial fissure oppositethe pedicle. Fig.

shapeof an abrupt triangle; it is more of a gradually diverginganglewhich takesorigin from the columella(the philtral column), includesa prominentdimple(the mentolabial fold in the Abbe flap), and endsin the cupid’s-bow peaks.Further, the effectsof contracture in the maturing scarbedsmustbe duly consideredin designingthe repair, for example,the prominenttendencyfor three-dimensional contracture along linear suture lines, which must be counteractedby eversionof the matchedepithelial edges. Pointsof anatomicdemarcationwithin the lip, suchasthe white roll, vermilion border, and wet line, should be overbulkedand overeverted.The useof biconcavematching surfacesand the introduction of white-roll offset flaps will facilitate ridgeformation in the fully maturedscarnot only by simplebulk increasebut alsoby the Z-plasty effect that disorients and lessensthe contracture otherwise expectedalong a linear scar. The Abbe flap wasmeasuredand outlinedslightly offset from the mid-line for easeof transfer and incised. The position of the inferior labial artery was noted on the transectedmargin,and the pedicle-sidearterial pulsations

werepalpatedto avoid injury to the vascularbundleasthe through-and-throughincisionapproachedit superiorly. It is not sufficient merely to inset the Abbe flap and proceedwith closure.The lateral musclebundlesmust be separatedinto componentsfor example,the nasalismuscle, obliqueorbicularisfibersand horizontal orbicularisfibers) and mustbe securedto the nasalseptumand their fellows acrossthe midline, respectively.23,24 Firm, interdependent anchorageis necessary not only asa foundationfor normal lip architectureand function but alsoto precludewidening of the philtrum and of the scars from unantagonized lateral muscle pull. However, where the musclesare directly opposedthrough the midportion (the Abbe flap), lossof the philtral dimple and ridgesmay occur, resulting in a tight, flattenedlip. As an alternative, weusea seriesof two to three sutures,which passthrough the inner and outer fascial layers with the lateral muscle fibers, and transfix the coronalplaneof the flap’smuscularlayer (Fig. 5). The net result is accentuationof the philtral dimple, functional continuity of the muscleat discretelevels,and forced eversionof the skin and mucosaledges.Further, vascular compromiseof the flap is avoided, as might otherwisebe expectedby deepsuturesthat tend to strangulate the tissuesthey circumscribe. As the foregoing stepswere executed, layered closure wascompletedwith simplechromicgut suturessubcutaneously andin the oral mucosaand fine cuticular suturesfor skin. The suturing proceededjudiciously near the pedicle margins,often with simpleepithelialclosurein this area to maintain deep vascularity. Concluding the procedure, internal nasalsplinting wasobtained,consistingof heavy siliconerubberparaseptalsheetssecuredtransseptallywith mattress sutures;then portex tubes were trimmed and placed in each nasalpassage.This was augmentedwith quarter-inchantibiotic-impregnatedgauzepacking.As the patient emergedfrom the genera1anesthesia,extubation wasperformed,and a pediatric oropharyngealairway was placedto augmentthe nasalairways (Fig. 6). On the fifth postoperativeday the sutureswereremoved,

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Fig. 8. (A) The lip after 6 months’maturation of the surgicalwounds.(B) Scallopingvermilion excisions markedto sculpt the tubercle; the excisionplanespurposelyconvergefrom the marginsto the depth of the wound.(C) Simplesuturingwithout underminingensuresinversionof the suturelines,leavingthe tubercle in gentle prominence.

along with the nasal tubes and gauze packing. The paraseptalsplintswere removedat 2 weeks,whenthe lips weredivided in the outpatient clinic with the patient under intravenoussedationand local anesthesia. The releasingincisionswerecarefully markedto provide sufficient bulk at all margins for adequate vermilion eversion (Fig. 7). Here, as in similar cases,a formal revisionof the lower lip scarwasperformed,which firmly secured the orbicularis muscle bundles, provided a Zplasty at the mucocutaneousridge, and evertedthe mucosal margins.The upper lip was openedand undermined bilaterally in the vermilion area, and the lateral muscles again were functionally securedby meansof transfixing suturesthrough the intervening central massprior to final closure. Routine wound care followed; the cuticular sutureswere removedat 5 days. Six monthspostoperativelythe patient underwent vermilion adjustment. This was designedto remove bulk optimally and impart subtle contour to the tubercle and lateral vermilion border. For this revision, intravenous sedationand regionalblock anesthesiawereused.Infiltration of the surgicalsite,althoughdesirableasa hemostatic agent,wasavoidedsincehydraulic distortion locally would hinder symmetrical reduction. The excisionswere performedin a scallopingpattern behindand on either sideof

the tubercle. As is done for reduction cheiloplasty, the incisionswere begunat the periphery and beveledtoward the central depth to form a wedge-shaped defect. Simple surface closure then followed without undermining to invert the scallopedsurfaces.It is helpful here to perform the excisionon onesideinitially and then tack it temporarily closedwhile the oppositesideis symmetricallyreduced (Fig. 8). The patient reportedparesthesiain the philtrum at 6 monthsand full return of sensationat approximately 1 year. Photographstaken 14monthspostoperativelyare shown in Figs. 9 and 10. DISCUSSION

The case reported here represents one in a series of five Abbe flaps performed over a period of 18 months. Thorough tabulation of the deformity in every case has served to underscore the unique qualities of each and has allowed a customized treatment scheme for each. Highly acceptable results have been obtained with the Abbe flap, as evidenced by our own series and those cases treated elsewhere either with or without this versatile procedure. This transfer of supple new bulk from the lower lip to the

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9. Postoperativeappearanceat 14 months. On frontal view (A), the alar basesare seento be symmetric,and the hair-bearing,similarly textured philtrum is well-balancedto the lateral lip segments, with tubercledefinition. On lateral view (B), the lip-columellaangleis gently notched,and upperand lower lips are proportioned,although sometip depressionremains. Fig.

10. Closeview of the lip illustrates nicely defined philtral dimple,equallengthsof the lip segments, mucocutaneousridge continuity, and well-definedtubercle. Fig.

scarred central portion of the upper lip not only restores normal labial contours but also liberates the central tissues of the lip for reconstruction of the external nose. The lower lip suffers negligibly from having donated a part of itself; its frequent preoperative ptotic posture is actually improved. The fine

midline scar at the donar site is hardly noticeable. At worst, the sometimes horrible disfigurement of cleft lip and palate is transformed into a merely traumatized or “busted” lip and, at best, the result is a finely balanced upper and lower lip that escape all but the closest scrutiny. Further refinement in the use of the Abbe flap will likely be forthcoming in one-stage transfer by microsurgery. The need will still exist, however, for calm observation and periodic revision up to the end point, since it is clearly less difficult to remove tissue than to add it. Whatever the advancement in its applications, the Abbe flap will remain ideal in reconstruction of the tissue-deficient upper lip. SUMMARY

Use of the Abbe flap is reported in secondary reconstruction of the lip and nose of a representative adult with bilateral cleft lip and palate. The approach to comprehensive management of this deformity is detailed, including the presurgical assessment, the individualized surgical plan, and the specifics of the surgical technique. Further, a variation is suggested for functional anchorage of the

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lateral lip segmentsacross the transferred flap, which maintainsthe philtral dimple and accentuates the philtral ridges while ensuring vascularity, survival, of the flap. The author gratefully

acknowledges

the contribution

and of

Drs. Israel Finger and David Dominguezin the prosthodontic rehabilitation of this patient and thanks Dr. David Hudson

for his participation

in the surgical

manage-

ment. REFERENCES 1. Noordhoff, M. S., and Cheng, W.: Median Facial Dysgenesis in Cleft Lip and Palate, Ann. Plast. Surg. 8: 83, 1982. 2. King, B. F., III, Workman, C. H., III, and Latham, R. A.: An Anatomical Study of the Columella and the Protruding Premaxilla in a Bilateral Cleft Lip and Palate Infant, Cleft Palate J. 16: 223, 1979. 3. Latham, R. A.: Development and Structure of the Premaxillary Deformity in Bilateral Cleft Lip and Palate, Br. J. Plasl.. Surg. 26: 1, 1973. 4. LeMesurier, A. B.: Hare Lips and Their Treatment, Baltimore, 1962, Willihms & Wilkins. 5. Millard, D. R., Jr.: Complete Bilateral Cleft Lip, Primary Lip and Nose Correction. In Transactions of the Fifth International Congress of Plastic and Reconstructive Surgery, Melbourne, 197 I, Butterworth’s, pp. 185-I 92. 6. Veau, V.: Operative Treatment of Complete Double Harelip, Am. J. Surg. 76: 143, 1922. I. Millard, D. R., Jr: Cleft Graft, the Evolution of Its Surgery, Bilateral and Rare Deformities, Boston, 1977, Little, Brown & Ccnpany. 8. Eskeland, G., Borchgrevink, H., and Abyholm, F. E.: Columella Lengthening In Bilateral Cleft Lip Patients, Experience With the Forked Flap Procedure, Stand. J. Plast. Reconstr. Surg. 13: 429, 1979. 9. Cronin, T. D., and Upton, J.: Lengthening of the Short Columella Associated with Bilateral Cleft Lip, Ann. Plast. Surg. 1: 75, 1978. IO. Brauer, R. O., and Forester, D. W.: Another Method to Lengthen the Columella in the Double Cleft Patient, Plast. Reconst. Surg. 38: 27, 1966. II. Meade, R. J.: Composite Ear Grafts for Reconstruction of the Columella, Plast. Reconstr. Surg. 23: 134, 1959.

I 2. Adams, W. M., and Adams, L. H.: Misuse of the Prolabium in the Repair ofBilateralCleftLip.Plast.Reconstr. Surg.12: 225, 1953. 13. Abbe, R.: A New Plastic Operation for the Relief of Deformity Due to Double Harelip, Med. Rec. 53~447, 1898. 14. Kazanjian, V. H.: Estlander-Abbe Operation in Treating Secondary Harelip Deformities and Defects of the Upper Lip Resulting From Cancer, Plast. Reconstr. Surg. 2: 307, 1947. 15. Blair, V. P., and Letterman, G. S.: The Role of Switched Lower Lip Flap in Upper Lip Reconstruction, Plast. Reconstr. Sura. 5: 1. 1950. 16. Thompson, N., and Pollard, A. C.: Motor Function in Abbe Flaps, Br. J. Plast. Surg. 14: 66, 1961. 17. McGregor, I. A.: The Abbe Flap-Its use in Single and Double Cleft Lips, Br. J. Plast. Surg. 16: 46, 1963. 18. Millard, D. R.: Composite Lip Flaps and Grafts in Secondary Cleft Deformities, Br. J. Plast. Surg. 17: 22, 1964. 19. Jackson, I. T., and Soutar, D. S.: The Sandwich Abbe Flap in Secondary Cleft Lip Deformity, Plast. Reconstr. Surg. 66: 38, 1980. 20. Miller, A. J., and Vargervik, K.: Neuromuscular Adaptation in Experimentally Induced Oral Respiration in the Rhesus Monkey (Macaca mulatta), Arch. Oral Biol. 25: 579, 1980. 21. Potter, J.: The Nasal Tip in Bilateral and Unilateral Harelip, Ann. Plast. Surg. 6: 86, 1981. 22. Bzoch. K. R. (editor): Communicative Disorders Related to Cleft Lip and‘palate; ed. 2, Boston, 1979. Little, Brown & Company. 23. Delaire, J.: The Potential Role of Facial Muscles in Monitoring Maxillary Growth and Morphogenesis. In Carlson, Davis S. and McNamara, James A. (editors): Muscle Adaptation in the Craniofacial Region, Monograph 8, Craniofacial Growth Series, Ann Arbor, 1978, Center for Human Growth and Development, The University of Michigan, pp. 157-I 80. 24. Schendel, S. A., and Delaire, J.: Functional Musculoskeletal Correction of Secondary Unilateral Cleft Lip Deformities: Combined Lip-Nose Correction and Le Fort I Osteotomy, J. Maxillofac. Surg. 9: 108, 1981. Reprint

requests

to:

Dr. Michael C. Kinnebrew Department of Oral and Maxillofacial Surgery LSU Medical Center School of Dentistry 1100 Florida Ave. New Orleans, La. 70119