Repair of Transverse Facial Cleft in Hemifacial Microsomia: Long-Term Anthropometric Evaluation of Commissural Symmetry

Abstract

Cleft of the oral commissure is an uncommon malformation that results from incomplete mesenchymal merging of the mandibular and maxillary prominences of the first pharyngeal arch. Many operative techniques have been proposed to repair this cutaneous and muscular defect. Most authors recommend cutaneous closure by Z-plasty or W-plasty, but these geometric techniques cause additional cutaneous scarring; furthermore, the risk of commissural migration after repair of a transverse facial cleft is poorly documented. Anthropometry was used to evaluate the operative outcome in 13 patients with hemifacial microsomia who underwent repair of a transverse facial cleft by the senior author between 1980 and 2001. The procedure included (1) apposition of the orbicularis oris muscle; (2) linear cutaneous closure; and (3) construction of the commissure using an inferiorly based, rectangular vermilion-mucosal flap. The average age at repair was 11 months, and the mean follow-up was 10.3 years. Comparing the cleft and noncleft sides, the position of the commissure was within 1 mm in all patients, whereas the melolabial fold was asymmetric in six patients. The average length of the scar was 17 mm, and the scar extended lateral to the melolabial fold in all but one patient. No patients were found to have had lateral commissural migration. The authors conclude that Z-plasty or W-plasty is unnecessary in repair of a transverse facial cleft. Closure of the orbicularis oris muscular ring is the critical step in the procedure to provide oral continence and a counterforce to the contraction of the cutaneous scar. There is no lateral creep of the commissure or hypertrophic scarring after straight-line cutaneous closure.