Cleft Lip Revision Research Articles

The Fisher Subunit Anatomical Approach for Cleft Lip Revisions

Abstract Many techniques exist to reapproximate a cleft lip but can leave unsatisfactory results with nonanatomic scars and a short upper lip, creating a need for revision. Many revisions focus on adjacent tissue transfers and realignment of landmarks, but in the senior authors' experience, recreating the defect and utilizing the Fisher repair for revision have led to aesthetically pleasing results and less noticeable scars. A database was collected that included all cleft lip revisions performed at a large, comprehensive children's hospital from October 2018 to July 2021. Inclusion criteria included any cleft patient with a cleft lip revision performed by two craniofacial surgeons. Data collected included sex, characteristics of the cleft lip, age at initial and index repair, type of initial repair, previous revisions, type of revision with any additional tissue rearrangement, and any nose repair. Sixty-five patients were included in the study for analysis. The type of initial repair was known in sixty-four cases (98%), and fifty-four were Millard repairs (83%). Twenty-two patients (33%) had a previous revision prior to their index revision. Sixty patients (92%) underwent the Fisher repair technique for their index revision and forty-six patients (70%) underwent nasal revision. In follow-up, all patients demonstrated an improvement in lip aesthetics. This study demonstrates a large subset of patients that have undergone cleft lip revision using the Fisher technique. In the senior surgeons' experience, the Fisher repair technique in the setting of cleft lip revision is an ideal way to address the shortcomings of historical repair techniques.

Costochondral Graft Rejection or Foreign Body Reaction 55 Years After Cleft Lip Revision: Case Report and Review of Literature

Costochondral Graft Rejection or Foreign Body Reaction 55 Years After Cleft Lip Revision: Case Report and Review of Literature

Aesthetic evaluation of nasolabial reconstruction using abbe flap in bilateral cleft lip patients with secondary deformities

The Abbe flap is a common technique frequently utilized in secondary surgery for bilateral cleft lip deformities, but objective indications for the Abbe flap remain unclear, and postoperative aesthetic evaluations are limited. The study group consisted of 92 bilateral cleft lip patients with secondary deformities aged 7-39 years, and the control group consisted of 33 people aged 19-35 years. Thirteen objective nasolabial aesthetic parameters were selected to evaluate patients' nasolabial aesthetics. Minor secondary deformities were characterized by a smaller lip height index than severe deformities, as well as a smaller columellar angle compared with moderate and severe deformities (P<0.05). For all patients, significant differences were found between preoperative and postoperative values of intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, lip vermilion height index, lip protrusion angle, columellar-labial angle, and nasal tip angle (P<0.05). For patients with minor deformity, intercanthal distance/philtrum width ratio and intercanthal distance/medial cutaneous upper lip height ratio showed no significant change postoperatively (P>0.05), and labial protrusion angle was smaller than the control group (P<0.05). Patients undergoing secondary surgery using an Abbe flap achieved good nasolabial aesthetics. Intercanthal distance/medial upper vermilion height ratio, intercanthal distance/medial upper lip height ratio, lip height index, columellar-labial angle, nasolabial angle, nasal tip angle, and columellar angle are the objective aesthetic indicators for Abbe flap selection. Intercanthal distance/philtrum width ratio, intercanthal distance/medial cutaneous upper lip height ratio, and labial protrusion angle are reference parameters for choosing an Abbe flap for secondary bilateral cleft lip revision.

The Fisher Subunit Anatomical Approach for Cleft Lip Revisions

Introduction: Many techniques exist to reapproximate a cleft lip but can leave unsatisfactory results with non-anatomic scars and a short upper lip. Because of this, the need for cleft lip revision often arises years after the initial repair. Many revisions focus on adjacent tissue transfers and realignment of landmarks, but in the senior authors’ experience, entirely re-creating the defect and utilizing the Fisher repair for revision has led to aesthetically pleasing results and less noticeable scars. Materials and Methods: A database was collected that included all cleft lip revisions performed at a large, comprehensive children’s hospital from October 2018 to July 2021. Inclusion criteria included any cleft patient with a cleft lip revision performed by two craniofacial surgeons regardless of previous repair history. Data collected included sex, characteristics of the cleft lip (laterality and complete or incomplete defect), age at initial repair, type of initial repair, any previous revisions, age at index revision, type of revision with any additional tissue rearrangement, and any nose repair. Results: Sixty-five patients were included in the study for analysis. The type of initial repair was known in sixty-four cases (98%), and fifty-four were Millard repairs (83%). Twenty-two patients (33%) had a previous revision prior to their index revision. The average revision age was 9.6 years. Sixty patients (92%) underwent the Fisher repair technique for their index revision and forty-six patients (70%) underwent some form of nasal revision. In follow-up, all patients demonstrated an improvement in lip aesthetics. Conclusion: The necessity for cleft lip revision derives from suboptimal results of initial treatment. Here we have demonstrated a large subset of patients that have undergone cleft lip revision using the Fisher technique. In the senior surgeons’ experience, the Fisher repair technique in the setting of cleft lip revision is an ideal way to address the shortcomings of historical repair techniques.

Commentary on: Botulinum Toxin to Improve Lower Blepharoplasty Scar: A Double-Blinded, Randomized, Vehicle-Controlled Clinical Trial.

It is rare and refreshing to see a prospective double-blind, placebo-controlled study in aesthetic surgery. To some extent this is due to the nature of our field and the practical and ethical constraints that prevent randomizing or blinding treatments in cosmetic surgical patients. However, the authors of “Botulinum Toxin to Improve Lower Blepharoplasty Scar: A Double-Blinded, Randomized, Vehicle-Controlled Clinical Trial” 1 have accomplished this task quite cleverly. As the authors have pointed out, the benefit of botulinum toxin A (BoNT-A) injection in scar healing for keloid scar revision has been shown in previous studies,2 and in their own prior study on cleft lip revision scars.3 One difference between these prior studies and the current one is that the earlier studies address scars in locations that have already been shown to be hypertrophied at least in part because of muscle action tending to pull perpendicular to the scar or...

Correction of Post-Cleft Lip Nostril Floor Stenosis: Para-Alar Flap Combined With Lip Revision.

Post-cheiloplasty nostril floor stenosis is a scarcely reported secondary deformity. The aim of the current study was to assess the outcome of para-alar flap for management of nostril floor stenosis post-unilateral cleft lip repair. This is a retrospective case series study reviewing consecutive patients presenting with nostril floor stenosis following repair of unilateral cleft lip who were managed by the inferiorly based para-alar flap and lip revision. Differential nostril width was measured preoperative, immediate, and late postoperative. We reported 8 patients (3 boys and 5 girls) with an average age of 9.8 years (range: 4.5-19). Satisfactory results with good nostril symmetry measures were achieved, and no restenosis has been observed during the follow-up periods. The donor site scars were negligible. There was no reported partial or total flap loss. Para-alar flap was found to be an effective reconstructive option for patients with nostril floor stenosis post-unilateral cleft lip repair and can be combined safely with cleft lip revision.

The Operation Rainbow Canada Technique for Unilateral Cleft Lip Revision.

Purpose of this article is to demonstrate the "Operation Rainbow Canada" cleft lip revision technique. This is a surgical technique used by Operation Rainbow Canada on volunteer surgical missions in developing nations. We show how to convert previous Millard or straight line cleft lip repairs to a Fisher anatomic subunit repair, placing a favourable scar along the philtrum. We show a case series of results and explain how this technique gives satisfying aesthetic results for patients seeking unilateral cleft lip revision. This technique combines the principles of the anatomic subunit repair for primary cleft lip repair as described by Fisher and the correction of the cleft nose deformity as described by McComb. We apply these 2 techniques to unilateral cleft lip revision at the same operation. Patients for revision unilateral lip and nose deformities were treated with this technique over the course of several international surgical missions. There were over 90 cases of revisions performed by our group on previous repaired cleft lips. These procedures were done in India, China, and Cambodia. Previously repaired cleft lips can be improved by our revision procedure. We show how incorporating 2 triangular flaps to lengthen the cleft side of the repaired lip can be done in a revision setting. During lip revision, McCombs sutures can be placed to improve the aesthetic of the nose and correct the nasal alar dome.

Perth scoring system for assessment of the cleft lip

Background: Currently, there is no standardised assessment tool to assess facial aesthetics in cleft lip and palate surgery. Inter-centre comparison is hampered by the use of different aesthetic indices with low intra- and inter-rater reliability.&#x0D; Aim: The Perth scoring system is a new assessment tool for unilateral cleft lip which scores four key components of the cleft lip/nose repair: lip length, white roll, alar insertion point and vermillion. The aim of this study was to validate the Perth scoring system as a reliable and useful new assessment tool and to demonstrate the use of the scoring system to measure improvements after cleft lip revision.&#x0D; Method: Nineteen patients who underwent cleft lip revision by the senior author were selected. Pre- and postoperative photos were presented to a panel of raters to score. Scores were analysed to determine the intra-and inter-rater reliability and to compare outcomes.&#x0D; Results: Almost all patients (15/16) had improvement in scores (range 1.09–5.59) after cleft lip revision. Intra raters’ agreement scores from lowest to highest were: lip length (0.65), white roll (0.7), alar insertion point (0.78) and vermillion (0.78). The total intra-class correlation coefficient was 0.96 (0.94–0.98, 95% CI, P&lt;0.000).&#x0D; Conclusion: This new scoring system is a valid and useful tool for assessment of the unilateral cleft lip. The high rate of intra- and inter-rater reliability allow it to serve as a useful tool to compare surgical outcomes both within and between centres. Further field testing with a larger cohort of patients is required.

Autologous Fat Transplantation to Improve Lip Contour in Secondary Cleft Lip Deformity.

The insufficient volume of lip is one of the pathological problems of cleft lip, despite that the cleft lip the muscles and skin are repositioned. Autologous fat is an ideal material for soft tissue repair, including correction of contour deformity, restoration of volume insufficient, and even improvement of tissue characteristics. In this study, the authors evaluated the result of fat grafting in improvement of lip contour in secondary cleft lip deformity. The authors performed a retrospective analysis of their series of patients who underwent lip fat grafting. A total of 65 subjects with lip fat grafting for cleft lip revision were recruited for the study. The photographs documented the original malformation and the posttreatment photographs. The authors recruited female and male raters, who were experts in the field or lay persons to form a panel of 12 raters altogether. Symmetry and aesthetics were improved after fat grafting based on vermillion border (P = 0.02), symmetry of lip (P = 0.007), and nasal profile including upper lip (P = 0.04) using a 1- to 5-point scale. After treatment, both sides of the lip are more symmetrical, the thickness of the filling part is significantly increased, the filling area is soft, the appearance is satisfied. Fat grafting is an efficient secondary procedure to improve lip contour after cleft lip repairs.

Influence of different techniques of secondary cleft lip revision surgery on upper lip projection

Patient dissatisfaction with labial appearance in the adult cleft lip is frequently linked to poor upper lip projection. Other areas of concern include asymmetry and impaired upper lip height. Different surgical techniques are available to address volumetric deficiencies, according to extent and localization. However, data comparing outcomes in these different areas are limited. The main aim of this study was to assess the relative gains in upper lip projection. An evaluation of upper vermilion height and symmetry was also performed. Thirty-seven consecutive patients treated by a single surgeon had their pre- and postoperative results measured using standardized photographs; these were analysed using subjective and objective outcome measures. Seven examiners evaluated anonymized pre- and postoperative side and front views for subjective evaluation. The objective analysis was performed using Adobe Photoshop. Fifteen lip revisions, four Abbe flaps, 12 dermal grafts, and six PermaLip implants were performed. In bilateral cleft lip and palate patients, Abbe flaps showed the most significant improvement in labial projection, followed by PermaLip implants and dermal grafts. In unilateral cleft lip and palate patients, PermaLip implants best addressed impaired lip projection, followed by dermal grafts. Overall, functional lip revisions showed excellent outcomes for upper lip symmetry; however, only minor changes in labial projection were found.

Secondary Cleft Rhinoplasty in 1720 Patients: Are National Practices Consistent With Guidelines?

To assess the timing, type, and associated adjunct procedures for secondary cleft rhinoplasty nationally. Data were extracted from a national database of all secondary cleft rhinoplasty procedures (Current Procedural Terminology [CPT] codes 30460 and 30462). Frequency statistics were utilized to analyze demographics, comorbidities, surgical procedures, and timing. Chi-squared analysis and Fisher exact test were used for analysis. National Surgical Quality Improvement Program-Pediatric Database. A total of 1720 patients met inclusion criteria for secondary cleft rhinoplasty repair. No relevant intervention. Age, demographics, comorbidities, and associated procedures. Over 5 consecutive years, 1720 patients underwent secondary cleft lip rhinoplasty nationally. Mean patient age was 9.3 ± 5.3 years. Unilateral cleft rhinoplasty patients were older (9.0 years) than bilateral patients (7.8 years; P = .001). Rib grafting was performed in 6.3% of patients at a mean age of 10.6 years with a higher proportion of Asian and female patients. Auricular grafts were more commonly performed by otolaryngology than plastic surgery. The most common adjunct procedures included secondary cleft lip revision (33.1%) and tympanostomy tube placement (10.2%). When subdividing by type of cleft rhinoplasty, tip rhinoplasty was performed at a mean age of 7.3 years compared to rhinoplasty with osteotomies and a major septal component at 12.1 years (P < .001). This study reveals that a large proportion of cleft rhinoplasties are performed in skeletally immature patients. Although patients undergoing rib grafting, nasal osteotomies, and a major septal component were older, these procedures are still performed in a large proportion of patients who are younger than expected.

Current approaches to cleft lip revision

Cleft lip repair requires multidisciplinary follow-up throughout a child's life and often requires lip revision surgery in adolescence to restore function and symmetry of the lip. There is significant variability in the approaches taken for lip repair and therefore a review of current techniques and subsequent guidance to secondary cleft lip repair is warranted. New methods of secondary reconstruction can be divided into superficial or muscle related. Recent suggestions for superficial reconstruction include botulinum toxin injection, silicone gel sheeting, local flap reconstruction, fat grafting, and CO2 laser ablation. Suggestions for muscular reconstruction include pedicled prolabial flaps, modified Abbe flap, and orbicularis oris eversion. Secondary cleft lip deformities can be classified as superficial or muscle related. Superficial problems require relatively minor treatments such as laser, local scar revisions, small local flaps, mucosal excision, or fat grafting. Muscle deformities generally require total lip revision and rerepair as a first step to achieving longstanding improvements in lip esthetics and function. Cleft lip revision should only be considered in concert with the patient, be based on the patient's concerns and desires, and offered at the appropriate timeline to improve social integration and/or psychosocial wellbeing.

Philtrum reconstruction in unilateral cleft lip repair

The philtrum is an important aesthetic structure in the midface. A number of philtrum reconstruction techniques have been advocated for secondary cleft lip revision procedures. Conventional surgical management involves end-to-end orbicularis oris muscle approximation during primary cleft lip repair, often resulting in a flat lip appearance that requires secondary revision surgery at a later stage. A novel modification of the approximation of the orbicularis oris muscle is described that may be implemented with any cleft lip technique in order to create an accentuated philtrum column for a natural looking philtrum. The muscle roll technique results in eversion of the orbicularis oris muscle, successfully recapturing the philtrum column topography. This is achieved by utilizing two inverted horizontal sutures, with an additional philtrum takedown suture placed in the region of the dimple to accentuate the philtrum anatomy and three-dimensional profile. This novel technique in unilateral cleft lip repair addresses philtrum architecture during primary surgery, which may reduce the requirement for secondary surgical intervention. Its application may be particularly suitable in outreach programmes where postoperative follow-up may be compromised.

Secondary Cleft Nasolabial Deformities

Secondary or residual cleft lip and nasal deformities following primary unilateral or bilateral cleft lip repair are common. Many classification systems have been proposed to describe congenital cleft lip and palate deformities before repair. This article proposes a one-of-a-kind classification system for residual cleft deformities and describes its application to 136 cleft lip revision cases from cleft outreach missions worldwide. Patients' demographics and deformities were classified preoperatively, and a database of the classification was created. Postoperatively, the type of surgery performed was added to the database and comparison was done using an independent t test. Kappa coefficient was 0.92 and showed excellent agreement between the type assigned preoperatively to the patient and the type of procedure done. This system proves to provide good descriptions of the deformities, is user friendly, facilitates the planning of the corrective surgical procedure, and enhances the communicative lingo between surgeons and members of cleft multidisciplinary care teams. It is broadly applicable in outreach missions with limited resources and cleft referral centers with considerable load.

Bilateral cleft lip revision: techniques and results

Bilateral cleft lip deformities can be difficult to correct and it is universally agreed that a large number of cases will require further revisions after the primary repair. The need for secondary repair and the type of secondary deformities is determined by the following:1.Type and severity of the initial cleft.2.The principles applied in the primary repair of these deformities. This presentation will look at the effect of different principles applied during the primary repair and how to manage the secondary deformities resulting from use of different principles of repair. The principles of repair will be considered under the following heads:1.Presurgical orthopaedics2.Lip adhesion procedures3.Staging of bilateral lip repair4.The utilisation of the prolabial tissues5.Muscle approximation6.Reconstruction of the central vermilion7.Sulcal release incision8.Management of the nasal deformities.

Structural Fat Grafting to Improve Reconstructive Outcomes in Secondary Cleft Lip Deformity.

To describe the technique and results of structural fat grafting in cleft lip revision, including patient satisfaction and aesthetic outcome. Retrospective case series. Multidisciplinary cleft care center. All patients who underwent structural fat grafting between June 2006 and September 2012 for cleft lip revision, with appropriate photographic follow-up included. Twenty-two cases were reviewed; 18 had sufficient data to be included. Patients underwent structural fat grafting for cleft lip revision, most commonly injecting fat under deficient philtral columns, the nostril base, and upper lip. Blinded observers rated outcomes using the Asher-McDade nasolabial appearance rating scale. Patients completed questionnaires assessing their satisfaction. A paired Student's t-test was used to test outcomes for significance (alpha = 0.05). Patients were an average of 16 years old (range: 6-43); average length of follow up was 11.7 months. Overall symmetry and aesthetics were improved based on the nasal form (P = 0.006) and vermillion border (P = 0.04) when rated using the Asher-McDade scale. No complications were recorded. Patients were significantly happier with their appearance after fat grafting (P < 0.001) and were uniformly positive when questioned about the ease of the surgery and rate of recovery. Structural fat grafting is a safe and effective way to improve symmetry and enhance facial proportions in patients with cleft lip. Given the high degree of patient satisfaction, few complications, and durable results, fat grafting offers many advantages in cleft lip revision.

National Estimates of and Risk Factors for Inpatient Revision Surgeries for Orofacial Clefts.

To provide national estimates of the number and cost of primary and revision cleft lip and palate surgeries in the U.S. and to determine patient and hospital characteristics associated with disproportionate use of revision surgery. Retrospective cross-sectional study using data obtained from the 2003, 2006, and 2009 Kids' Inpatient Database. Inpatient. Children with CL, CP, or CLP undergoing inpatient cleft lip and/or palate surgery. Inpatient cleft lip and/or palate surgery. Orofacial cleft surgery estimates, estimates of primary versus revision surgeries, and estimated inflation-adjusted hospitalization costs. In 2009, there were a total of 2824 and 5431 hospitalizations for cleft lip and palate surgeries, respectively. Revision surgery accounted for 24.2% of cleft lip surgeries and 36.8% of cleft palate surgeries. Children with CLP (OR 1.87, 95% CI: 1.48-2.38), a syndromic diagnosis (OR 1.47, 95% CI: 1.16-1.87), or private insurance (OR 1.71, 95% CI: 1.41-2.09) were more likely to undergo cleft lip revision surgery. Similar risk factors were found for children undergoing cleft palate revision. Mean cost per hospitalization ranged from $7564 to $8393 in 2009, depending on surgery type, and did not change significantly (in 2009 U.S. $) between 2003 and 2009. Interventions to reduce revision surgery by improving results of primary surgery should be targeted in the population of identified high-risk (e.g., syndromic) patients. In addition, the association of health insurance status with revision surgery highlights the need to understand and address the impact of economic disparities on cleft care delivery.

The Burden of Care for Children With Unilateral Cleft Lip: A Systematic Review of Revision Surgery.

To identify the average rate of revision surgery following cleft lip repair. PubMed, CINAHL, and SCOPUS were searched from database inception through March 2013 using the search terms cleft lip and surgery. Two investigators independently screened all abstracts and determined eligibility from review of full manuscripts using prespecified inclusion and exclusion criteria. Strengths and limitation of the studies were assessed, followed by qualitative synthesis. The I(2) test of homogeneity was performed to determine if meta-analysis was appropriate. The search identified 3034 articles. Of those, 45 met the inclusion criteria. Studies were primarily case series and retrospective cohort studies, with only one randomized controlled trial. One-third of studies (n = 15) did not describe how the study sample was selected. Follow-up duration was not reported in one-fourth of studies (n = 11). Nasolabial aesthetics were reported in 44% of studies (n = 20). The incidence of revision surgery ranged from 0% to 100%. Meta-analysis was precluded because of study heterogeneity (I(2) = 97%). The average incidence of cleft lip revision surgery cannot be estimated from the published literature, due to significant heterogeneity among existing reports and limited study quality. To provide valid information about the burden of care for unilateral cleft lip, a population-based or multicenter longitudinal cohort study is necessary; this study should measure the number of surgical procedures and the patient's aesthetic outcomes.

Cleft Rhinoplasty- Columellar lengthening prolabial reconstruction with Abbe flap.

Introduction:A single center's experience of correction of cleft lip/palate associated rhinoplasty using Abbe flap is relatively rare in literature. The outcome and perception of the Abbe flap for cleft rhinoplasty at patient, surgeons, and patient's caregiver level have not been found in literature. This manuscript aims to address this lacuna through the use of rhinoplasty outcomes evaluation questionnaire (ROEQ).Materials and Methods:A retrospective analysis of preoperative satisfaction and prospective analysis of postoperative satisfaction of patients who underwent cleft rhinoplasty were carried out using ROEQ. This was used twice measuring the pre- and post-operative periods.Results:Twenty-one cases of bilateral cleft lip and palate who had earlier undergone (0.5–3 years back) cleft rhinoplasty and lip revision with Abbe's flap formed the study group. The mean age of the 21 subjects was 22.87 ± 4.23 years. There were 13 males and 8 females forming the study group. The mean presurgical ROEQ score was 19.8 ± 11.2, while the postsurgical score was 78.5 ± 21.2. This difference was statistically significant (P = 0.001). The difference in score between the time period was 58.7%.Discussion:From the ROEQ and other qualitative parameters, it is possible to demonstrate the impact of Abbe flap for cleft rhinoplasty and its impact on the quality of life of patients. Most of the patients and caregivers believed that this approach achieved a good or excellent postoperative result. The biological and operators factors behind such a success are discussed in light of previously published literature.

The effects of lip revision surgery on nasolabial esthetics in patients with cleft lip

1) To determine the concordance among surgeons on subjective assessments of nasolabial esthetics in children with repaired cleft lip; and 2) to evaluate longitudinal changes in nasolabial esthetics in relation to cleft lip revision surgery. School of Dentistry at University of North Carolina, Chapel Hill. Children with repaired unilateral cleft lip: 32 had lip revision surgery and 27 did not have surgery. Retrospective observational study from a non-randomized clinical trial. Ratings of nasolabial esthetics performed by six surgeons using the Asher-McDade scale at baseline and 12-month follow-up. Concordance among surgeons ranged from poor to acceptable. Nasolabial ratings at follow-up were better in the Revision group than in the Non-Revision group, although differences were small. The most prevalent change in the Revision Group was improvement in one or more units on the scale, while 'no change' was most prevalent in the Non-Revision group. Participants in the Revision group were more likely to receive a 'no' in relation to the need for lip or nose revision at the follow-up visit. There were mild esthetic improvements observed in relation to lip revision surgery, which should be interpreted with caution given the subjectivity of the rating method used.