Cleft Lip Revision Research Articles

Construction of the Philtral Column Using Palmaris Longus Tendon

Sir:FigureThe philtrum and the Cupid bow are the most prominent features of the upper lip and are crucial for normal appearance. Unfortunately, projection of the philtral ridge is a common deficiency of repaired cleft lips. Many methods for constructing the philtral dimple and column have been described, most commonly involving the manipulation of orbicularis oris muscle or using various autologous grafts to augment the philtral column.1–3 Despite these developments, no single procedure has achieved complete satisfactory results. The palmaris longus tendon, present in 75 to 95 percent of the population, is well established as a graft because of its ease of harvest, minimal donor-site morbidity, and long-term viability. Recently, the palmaris longus tendon graft has been used as a cosmetic and reconstructive option for upper lip augmentation and also has been reported as a philtral graft in cleft lip repair.4,5 Since December of 1998, the senior author (H.H.K.) has used the palmaris longus graft to correct the depression of the philtral scar following cleft lip repair. After harvesting the palmaris longus, creation of the recipient site begins with a 5-mm incision made in the nasal floor remote from the philtrum. Sharp dissection with iris scissors creates a subcutaneous tunnel underneath the philtral scar that extends caudally 1 to 2 mm into the vermilion. The tendon is folded onto itself and secured with 5-0 chromic suture to create a graft that is at least four layers thick. Guide sutures of 4-0 Vicryl are placed through both ends of the graft. A groove director is directed down the subcutaneous philtral tunnel with its end positioned under the lip vermilion. A large Keith needle with the attached 4-0 Vicryl suture is passed down the groove director and brought out through the lip vermilion. On removal of the groove director, the multilayered tendon graft is manipulated down the tunnel using the Vicryl guide sutures. The graft is secured at each end with one or two percutaneous 5-0 plain catgut sutures. The incision is closed with 5-0 chromic suture. In 1997, Youn and colleagues reported the use of palmaris longus tendon to construct the philtral column in the secondary cleft lip deformity.5 Our experience similarly finds the palmaris longus tendon to be an ideal graft. However, there are significant differences between our experience and previously published reports. Although Youn and colleagues used grafting of the tendon in conjunction with open cleft lip revision, we found the transfer of the palmaris longus graft alone to be adequate in the majority of cases. We also describe a closed technique using one small incision in the nasal sill that offers significant advantages over previously reported methods. Long-term follow-up of up to 10 years proves that a significant portion of this volume persists. This results in the effacement of the depressed philtral scar in all patients, which contributes significantly to a good cosmetic outcome (Fig. 1). In our experience, all patients were satisfied with the improvement in lip appearance and no patient required another operation.Fig. 1: (Above) Preoperative appearance. (Below) Postoperative appearance 29 months after a palmaris graft to the left philtrum.Capt. Alan A. Lim, M.D., M.C., U.S.N. Department of Plastic and Reconstruction Surgery, Naval Medical Center Portsmouth, Portsmouth, Va. Karam A. Allam, M.D. Department of Plastic Surgery, Sohag University, Sohag, Egypt Rashimi Taneja, M.D. Fortis Fit. Lt. Rajan Dhali Hospital, Sector B, Pocket 1, Aruna Asaf Ali Marg, Vasant Kunj, New Delhi, India Henry K. Kawamoto, M.D., D.D.S. Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, Santa Monica, Calif. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. DISCLAIMER The views in this article are those of the authors and do not necessarily reflect the official policy or position of the U.S. Department of the Navy, U.S. Department of Defense, or U.S. government.

Bilateral Cleft Lip Revisions: The Abbe Flap

Secondary deformities of the bilateral cleft lip are unfortunately very common, and severe cases can involve scar contracture, vermilion deficiency, and a tight upper lip. In these cases, reconstruction often requires replacement of the central philtral unit with full-thickness tissue, including vermilion, orbicularis oris, and skin. The Abbe flap offers full-thickness reconstruction of the central aesthetic unit of the upper lip by replacing the deficient and scarred tissue and restoring functional competence to the oral sphincter. A review was performed of the authors' operating room video files to evaluate their technique for performing secondary bilateral cleft lip revision using the Abbe flap. The Abbe flap has been used successfully for secondary revisions of the bilateral cleft lip at the Texas Children's Hospital. A technique video was made using video clips from two secondary bilateral cleft lip revisions. Results of bilateral cleft lip repair are often poor because of inappropriate use of the hypoplastic prolabial tissue, failure to anatomically reunite the orbicularis muscle, and scarring. The Abbe flap is an effective tool for reconstruction of the philtral landmarks, reconstitution of oral competence of the orbicularis, and recreation of Cupid's bow and the central pout. Although this procedure is relatively straightforward, special attention to designing the new philtrum, marking intact landmarks, and careful dissection of the labial artery are required for successful reconstruction.

The Use of Dermal Fat Grafts for the Correction of Secondary Cleft Lip Deformities

Sir: Surgeons who treat patients with cleft lip deformities face a wide array of challenges, both in the initial repair of the distorted anatomy and in the frequent “touch-up” procedures to improve secondary deformities. Common local techniques include V-Y vermilion advancement, Z-plasties, elliptical excision, Abbé flaps, and Kapetansky flaps.1,2 When local tissues are inadequate for volumetric correction, a wide range of grafting material is frequently used with variable results.3,4 Eight patients underwent cleft lip revision performed by a single surgeon using our dermal fat grafting technique at our facility between 1997 and 2001. The defect was outlined with a surgical marker, and the vertical incision placed on the posterior (oral) aspect of the marking. A subcutaneous pocket was dissected while staying within the markings of the defect, and the dermal graft was harvested. The size and shape of the graft were slightly larger than those of the outlined lip defect, to allow for trimming and slight overcorrection of the defect, since 10 to 15 percent resorption is expected (Fig. 1). The skin to be used was de-epithelialized in situ and excised full thickness with a thin layer of fat on the undersurface of the dermis. The graft was placed on the lip externally and trimmed to fit the defect optimally (Fig. 2). The graft was then drawn inside the pocket using two U stitches of 5-0 chromic gut suture, with the dermis side inward and the mucosal incision closed.Fig. 1.: Defect outlined on lip.Fig. 2.: Dermal fat graft overlying defect, trimmed to fit defect optimally with slight overcorrection.The charts were reviewed along with the standardized preoperative and postoperative photographs. Of the eight patients who underwent cleft lip revision, five had unilateral cleft deformities and three had bilateral deformities. All but one of the patients had a concomitant cleft palate. The average follow-up was 22 months. The average age at the time of operation was 12 years. Two of the patients, both with unilateral deformities, were noted to have a “slight excess fullness” on the grafted side but did not require a repeated operation. The initial patient in the series developed a palpable nodule of fat necrosis that required removal in addition to excision of excess vermilion. No other patients required repeated procedures for their cleft lip deformities (Table 1).Table 1: Patient DataThe method we have described has yielded consistent and durable results. The technical aspect of harvesting and placing the graft is straightforward and has a shallow learning curve. Our method differs from that reported in another recently published article5 and features a precisely dissected pocket to define the deficit to be augmented. We prefer to place our grafts with the dermis side down, believing the outwardly placed fat has a softer feel and graft take is better with the dermis adjacent to the labial muscle layer. Grafting can be combined with other procedures, such as V-Y advancement. In addition, the majority of these patients do not require the creation of any other scars, due to the harvest of tissue in the iliac region from bone-graft-harvest donor sites. In the event of incomplete correction, the procedure can be easily repeated for further focused augmentation. Craig Staebel, M.D. Charles N. Verheyden, M.D., Ph.D. Department of Surgery Division of Plastic Surgery Scott & White Memorial Hospital and Clinic The Scott, Sherwood, and Brindley Foundation The Texas A & M Health Science Center College of Medicine Temple, Texas DISCLOSURES There were no sources of funding supporting the work, and there is no financial interest to declare on behalf of either author.

Use of Tragus Cartilage for Grafting

Sir: We read Singh and Bartlett’s article in Plastic and Reconstructive Surgery1 with great interest and think it is very remarkable to remember, as the authors did, all the applications of ear cartilage for facial reconstruction. We would like to add a small contribution describing a possible source of cartilage that is not normally considered. Removal of tragus cartilage does not have any functional or aesthetic effects; the cartilage itself can be easily used for composite or simple cartilage grafting. We have used it many times both for columella reconstruction (as a composite graft) and in secondary cleft lip operations (as a simple graft) to rebuild the Cupid’s bow. Careful examination of tragus cartilage and comparison with the Cupid’s bow reveals how similar they are in size and shape (Fig. 1). We normally draw the tragal cartilage passing through a retrotragal incision to avoid scarring and remove the cartilage only. The perichondrium is left intact to preserve the consistency of the tragus. The excised cartilage is then positioned at the Cupid’s bow level after a suitable subcutaneous space is prepared by means of a small incision in the lip mucosa (Fig. 2). The aesthetic effect is truly remarkable. The only possible problem is a difference in cartilage consistency. However, if the cartilage is inserted sufficiently deeply in the lip, only a slight thickening will be felt on palpation. This does not alter in any way the sensitivity or natural effect of the result obtained.Fig. 1: . Cleft lip revision in a 36-year-old woman. Marking denotes the tragus of the cartilage that will be placed on the lip.Fig. 2: . Intraoperative view of the graft ready to be inserted at the level of the Cupid’s bow.Fabio M. Abenavoli, M.D. Andrea Servili, M.D. Roberto Corelli, M.D. Chirurgia Plastica ed Estetica San Pietro Hospital, Fatebenefratelli Rome, Italy

The Anatomy of Cupidʼs Bow in Normal and Cleft Lip

This is a gross and microscopic examination of the cutaneous-vermilion-mucosal region (Cupid's bow) in infants with normal lip as compared to cleft lip. Morphologic observations of lips in situ were made with magnification. Specimens for histology were from the normal upper lip of infants (n = 3) and adults (n = 4), and from redundant tissue made available during primary repair of cleft lip (n = 13) and cleft lip revision (n = 4). Tissues were analyzed with hematoxylin and eosin, Gomori trichrome, and Fontana-Masson stains. Immunoperoxidase stains were used to emphasize vascular endothelium and epithelial cytokeratins. Our observations support the hypothesis that the anterior projection of the pars marginalis of the musculus orbicularis oris gives rise to the normal cutaneous-vermilion junction ("white skin roll" of Gillies-Millard). The band of vellus hairs, found atop the vermilion-cutaneous junction, also highlights the rim of Cupid's bow. There was no abrupt alteration in vasculature, melanin, or cytokeratin content in the white roll. Proceeding caudally, the vermilion-mucosal region was characterized by progressively increasing epidermal thickness and size of rete ridges, decreasing melanin, more superficial capillaries, and an abrupt transition from keratinized to nonkeratinized squamous epithelium ("red line" of Noordhoff). In the cleft lip specimens, where white roll was absent, there was hypoplasia and disorientation of the underlying pars marginalis component of m. orbicularis oris. Vellus hair follicles were seen in the zone of presumptive white roll in clefts, just as in normal lip. Frequently, these pilar units contained disproportionately large sebaceous glands. In some cleft lip specimens, ectopic sebaceous glands were noted in the oral mucosa. We also observed a deficiency of vermilion width on the medial side of unilateral cleft lip, whereas the width of the vermilion at the crest of the bow was normal or slightly increased in the lateral cleft segment. A narrow vermilion band and exposed hypoplastic mucosa were characteristic of the prolabium in the bilateral complete cleft deformity. The findings of this study are pertinent to technical details for construction of the Cupid's bow and vermilion in unilateral and bilateral cleft lip.

Experience with the Functional Cleft Lip Repair

The first 12 functional cleft lip repairs performed on unselected consecutive patients immediately following the completion of training by the author are presented. Previous reports on this cleft lip repair have shown excellent results but have always been based on patients operated on by the originator of the procedure. This report gives credence to the ease with which a cleft lip repair that gives reproducible good results can be taught and learned even by plastic surgeons with limited experience. It reviews the technical steps of the procedure, which emphasizes wide undermining and release of the orbicularis oris muscle on the lateral side of the cleft to allow redraping and lengthening of the lip skin, step-by-step layered closure of the mucosa, muscle, and skin, and further vertical lengthening of the lip with a Z-plasty skin closure. Three elements that are difficult to achieve or restore with cleft lip revision are evaluated: (1) achievement of a good skin scar, (2) maintenance of the alar-facial groove, and (3) achievement of adequate lip height without sacrificing horizontal lip length. Ten of the 12 patients had a satisfactory scar, 9 patients had a good alar-facial groove, and all patients had a normal-appearing horizontal lip length. Nine patients required secondary surgery; however, in six patients, this included correction of the nasal deformity that was not corrected at the time of cleft lip repair.

The “Alar Shift” revisited

Summary The alar shift operation of Gillies and Kilner has fallen into disrepute. One reason may have been that it was incorrectly presented. The procedure gives excellent results in the correction of secondary cleft lip nasal deformities and can be combined with the Millard type of secondary cleft lip revision, because it is based on the same fundamental plastic surgical principle, enunciated by Gillies, First replace anatomical structures in their normal positions.