Deepithelialized Oral Vestibular Flap (Boot Flap) for Treatment of Free Border Deformities after Unilateral Cleft Lip Surgery

Abstract

Sir:FigureDeficiency of the free border of the lip is seen among the secondary deformities of cleft lip surgery. To correct the deficiency, we designed a new method: the deepithelialized oral vestibular flap (boot flap). This simple method can repair mild tissue deficiency of the free border. The flap was designed on the oral vestibule along the primary suture line (Fig. 1, left). Generally, the flap was on the cleft side; however, it can be on the contralateral side.Fig. 1: Case 1. (Above, left) A 21-year-old woman with tissue deficiency on the free border of the upper lip. (Below, left) Marking for the boot flap. (Above, right) The flap is raised. (Below, right) Immediate postoperative view.The surface mucosa can be easily deepithelialized before flap elevation. The volume of the flap was 10 to 20 percent larger than required because mild atrophy of the flap occurred in one case postoperatively. The flap is elevated over the orbicularis oris muscle layer, so it contains subcutaneous tissue (Fig. 1, above, right). However, a small part of the orbicularis oris muscle can be contained. A submucosal pocket was dissected over the muscle through the primary suture line. The boot flap was inserted into the pocket. The flap was fixed with 5-0 polydioxanone absorbable sutures. The mucosal deficiency was corrected by advancing the flap made by the previous incision along the buccal sulcus (Fig. 1, below, right). Finally all incisions were closed with 6-0 nylon and absorbable sutures. A boot flap was used from July of 2005 to August of 2010 to correct deficiencies of the free border of the lip in 20 patients with unilateral cleft lip. All patients were operated on under general anesthesia. Of the 20 patients, nine were male patients and 11 were female patients, aged 9 to 21 years. Eighteen patients could be followed postoperatively for 12 to 80 months (average, 24.5 months). Mild atrophy of the flap was noted in one patient. In the other 17 patients, good results were obtained. A little swelling caused by overcorrection was noted for a few months. After that, good contours were seen. Softness of the flap continued postoperatively, with no firmness. There were no complications. A 21-year-old woman had a right vermilion border deformity. She had had a primary repair for right incomplete cleft lip. She came to our department complaining of sagittal deficiency of the free border of the lip (Fig. 2, above). A boot flap was used. The postoperative clinical course was uneventful. Follow-up at 2 years 8 months showed a good soft lip, with maintenance of flap volume (Fig. 2, below).Fig. 2: Case 1. (Above) Sagittal deficiency of the free border of the lip. (Below) Two-year postoperative results.Deepithelialized mucosal-submucosal turnover flaps1 or mucosal transposition flaps2 have been used to correct “whistling lip” deformity. These flaps resemble each other. They are formed inside the vermilion-mucosal junction where new incisional scars are added. Our method does not cause an additional incisional scar. The blood supply of the flap may be a concern because the flap is turned over. However, many reports of composite grafts (e.g., temporoparietal fascial graft,3 temporalis fascia graft,4 and free dermis-fat graft5) show good results. Therefore, the blood supply of the boot flap need not be a concern, but too much tension should be avoided when fixing the boot flap. Yuki Otsuki, M.D. Koichi Ueda, M.D., Ph.D. Kazuhiro Otani, M.D., Ph.D. Akira Yamada, M.D., Ph.D. Jun Akamatsu, M.D., Ph.D. Osaka Medical College, Takatsuki, Japan, Chikarori Hospital, Kochi, Japan DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received. PATIENT CONSENT The patient provided written consent for the use of her images.