Lip Deformity Research Articles

Triangular flap technique for unilateral cleft lip deformity

The triangular flap lip repair is one of the two main techniques used for the correction of a cleft lip deformity worldwide. Many surgeons in Indian subcontinent and Europe use the triangle flap technique as their first choice. This CME article describes the details of the triangular flap technique as modified by Dr. C P Sawhney. The rationale of the technique, lip markings, planning of incisions, and the detailed operative steps are described. The merits and demerits of this versatile technique are also discussed.

Millard's rotation advancement technique for unilateral cleft lip repair

The unilateral cleft lip deformity includes defects of the lip and also the associated deformities in the nose. The Millard's rotation advancement technique is a versatile one for the repair of these deformities. The principle of the technique is that the raised Cupid's bow point medial to the cleft is brought down level with its noncleft side counterpart by a rotation incision, which extends to the base of the columella and ends with a back cut. The resulting defect beneath the base of the columella is filled with an advancement flap from the cleft side. The advantages of the techniques are many. The most significant one is that it adheres to the basic principles of esthetic surgery, with the main scars being along the relaxed skin tension lines. It is a versatile technique producing optimal results in all types in unilateral cleft lip patients ranging from the microform to the widest of complete clefts. The incision in this technique is so placed that there is easy access to address the associated defects of the nose. Technical refinements have been added to the classical description of the procedure to address the deficiencies in the repair. We describe important refinements introduced at our center by Dr. H. S. Adenwalla. Universally, this technique is still the most popular.

Correction of lip and nasal deformities in bilateral cleft operated with Le Mesurier procedure

IntroductionBilateral cleft lip surgery recently evolved with the generalization of cheilorhinoplasty replacing cheiloplasty alone. The aim of this study was to analyze lip and nasal deformities of bilateral cleft lip operated on with the Le Mesurier procedure, and then to evaluate possible secondary surgical solutions used in our Cleft Center. Patients and methodsWe retrospectively reviewed a total of 39 patients born between 1991 and 2009 with a bilateral cleft all type included (isolated lip, lip and alveolar, associated or not with a cleft palate), all treated at the Caen University Hospital with a Le Mesurier procedure for the primary cleft lip closure. We studied population characteristics, the number of secondary surgical procedures for lip and nasal deformities. We analysed therapeutic approaches of the different secondary surgical procedures used and their morphological results. Results85% of patients needed at least one secondary surgical procedure, 28% two procedures, 15% three procedures and 8% four or more procedures. Median age at secondary surgery was 6,8. 79% had a “scar repositioning”, 33% managed the vermilion, 18% a restoration of the volume of the lip, 12% a philtral tissue sacrifice, 9% a procedure on Cupid's bow, 24% a surgery for nasal tip projection, 45% a columella lengthening and 58% a reposition of the alar base. DiscussionLe Mesurier procedure for bilateral clefts leads to deformities that require secondary surgical procedures. We propose an algorithm to manage loop scar in this procedure.

Primary Repair of Bilateral Cleft Lip Deformity and Absent Prolabium With a Full-Thickness Skin Graft.

Bilateral cleft lip deformities makeup 10% of orofacial clefts and are uncommon when compared to unilateral cleft lip.1,2 These cleft deformities have significant physical and long-term psychosocial effects on not only the patient but their family. With bilateral cleft lip deformity, the cutaneous approximation of the lateral lip segments are dependent on a sufficient prolabium to reconstruct the philtrum.3,4 Deficient skin equates to tight midline closure and subsequent unsightly scarringIn the subclinical phenotype of bilateral cleft lip and palate, where the patient has an absent or deficient prolabium, achieving tension free closure in the primary surgical setting is a reconstructive dilemma.5 This clinical report describes the use of a full-thickness skin graft to reconstruct the philtrum in a 12-month-old boy with bilateral cleft lip deformity, absent prolabium, absent columella and absent nasal septum to provide an aesthetic subunit repair.

Primary Nasal Correction in Unilateral Cleft Lip: An Ongoing Journey.

A cleft lip deformity, whether unilateral or bilateral, is usually associated with a deformity of the nose. In present day cleft surgery, it is routine to perform a varying extent of correction of the nasal deformity. There is often relapse and ongoing deformity which warrant further nasal surgery. The authors describe their method of nasal correction which includes using a hypodermic needle to help achieve repositioning and suspension of the nasal cartilages. The authors reviewed 100 consecutive cases of unilateral cleft lip who had nasal correction since June 2018. There were 59 males and 41 females with a mean age of 5.5 months. There were 72 complete and 28 incomplete cleft lips. The steps in nasal correction include septal repositioning, sutures to approximate the ala domes, and upper medial crura, suspension of the lower lateral cartilage to the upper lateral cartilage and sutures to approximate the skin, lower lateral cartilage, and mucosa in a sandwich fashion. The patients were followed up for a range of 9 to 21 months with a mean of 18 months. The correction immediately postop and at 2 weeks follow up was good. However, at 1 year follow up there was some evidence of relapse. The correction achieved was, however, superior to that achieved before this method. None of the relapses were deemed severe enough to warrant further surgery at this stage. This method of nasal correction is recommended to achieve superior outcomes in the surgical treatment of unilateral cleft lips.

The Genetic Aspect of Non-Syndromic Cleft Lip and Palate towards Candidate Genes in the Etiology : A literature Review

Cleft lip and cleft palate (CL/P) is a cleft lip deformity indicated by an opening or an uncommon cleft in the lip or roof of the mouth (palate). The differences in ethnicity, gender, and the correlation with genetic factors influence the prevalence of Non-syndromic CL/P. This study was conducted through a literature review on genes that were allegedly associated with Non-syndromic CL/P. Genetics play a role, to a greater or lesser extent, in all diseases. Besides, palatogenesis involves many diverse genes in a complex process. In this case, oral cleft phenotypes develop when this process is disrupted in some manner because of gene dysfunction. Various genetic approaches, including genome-wide and candidate gene association studies as well as linkage analysis, have been undertaken to identify etiologic factors, but results have often been inconclusive or contradictory. Therefore, it concludes that the genetic basis of CL/P is still controversial because of the genetic complexity of clefting.

Revisional Techniques for Secondary Cleft Lip Deformities.

Secondary deformities of repaired cleft lips are an unfortunate complication despite the meticulous approach of modern primary procedures. Most of these surgeries take place in the patient's early life and must be strategically planned to provide optimal cosmesis with minimal interventions. Depending on the level of severity, treatment of the secondary deformities ranges from noninvasive or minimally invasive techniques to complete revision cheiloplasty. Many novel topical, injectable, and laser therapies have allotted physicians more technical flexibility in treating superficial distortions. Nonetheless, surgical techniques such as diamond excision and adjacent tissue transfer remain popular and useful reconstructive modalities. Deformities involving the orbicularis oris must be completely taken down to allow full access to the muscle. Complete revision cheiloplasty requires recreation of the cleft defect and reconstruction similar to the primary repair. Due to the myriad of presentations of these secondary deformities, familiarity with the various treatments available is imperative for any cleft surgeon.

Change in nostril ratio after cleft rhinoplasty: correction of nostril stenosis with full-thickness skin graft.

BackgroundPatients with secondary deformities associated with unilateral cleft lip and nose might also suffer from nostril stenosis due to a lack of tissue volume in the nostril on the cleft side. Here, we used full-thickness skin grafts (FTSGs) to reduce nostril stenosis and various methods for skin volume augmentation. We compared the changes in the symmetry of both nostrils before and after surgery.MethodsFrom February 2016 to January 2020, 34 patients underwent secondary cheiloplasty and open rhinoplasty for secondary deformities of the unilateral cleft lip and nose with nostril stenosis. FTSG was used on the nostril floor, nasal columella, and alar inner lining. The measured nasal profile included the nostril surface, nostril circumference, width of the nostril floor, and distance from the alar-facial groove to the nasal tip. The “overlap area,” which was defined as the largest overlapping area when the image of the cleft nostril was flipped to the left and right and overlaid on the image of the normal side nostril, was also calculated. The degree of symmetry was evaluated by dividing the value of the cleft side by that of the normal side of each measured profile and expressed as “ratios.”ResultsThe results of all profile ratios, except for the nostril floor width, became significantly close to 1, which represents full symmetry. The overlap area ratio improved from 62.7% to 77.3%, meaning that the length and width of the nostril as well as the overall shape became similar (p<0.05).ConclusionWhen performing cleft rhinoplasty with nostril stenosis, FTSG is useful to achieve symmetry in the nostril size and shape. Skin grafting is simpler to perform than the other types of local flap, and the results are generally satisfactory.

Intraoral Digital Impression for Speech Aid/Obturator in Children: Report of 2 Cases

Cleft patients may develop an abnormal opening (fistula) between the oral and the nasal cavities. Surgical repair minimizes the adverse effect on speech and feeding. However, an obturator prosthesis is a nonsurgical approach to help close the communication. The purpose of the case report presented is to show the clinical use of an intraoral digital impression in the fabrication of obturator/speech aid appliances in children with cleft lip and palate deformity. Minimal adjustments were needed, and patients and caregivers responded positively. Prostheses demonstrated good stability and retention at delivery. The use of digital technology seems to have several benefits as an alternative method for capturing impressions, especially in young children with cleft lip and palate deformity.

Aesthetic Enhancement of the Vermilion Using Dermofat Graft in Patients With Cleft Lip Deformity.

There is an increasing patient expectation for better esthetics, manifesting through anatomical harmony, projection, and volume of the upper lip relative to the lower lip, in patients with cleft deformity. The aim of this study is to investigate the outcome of vermilion augmentation using autologous dermofat graft (DFG) to enhance the lip using both quantitative and qualitative assessment. Patients with secondary cleft lip deformity who received the surgical treatment in our institution from 2015 to 2018 were recruited. Panel assessment was performed on standardized preoperative and postoperative digital photographs. A patient questionnaire was used for the reported outcome. Image processing and analyses were applied to measure the lip change. Statistical analyses were performed. A total of 91 patients were included. The mean age at operation was 22.7 years, and postoperative follow-up was 3.6 years. There were no complications in the study group. The panel assessment showed significant improvement (P < .00001) on upper lip vermilion in both frontal and lateral profile views. Ninety-five percent of patients reported improvement of the upper lip projection and volume. Quantitative image analysis showed an increase in the upper lip vermilion ratio in 97% of the cases in frontal views and improvement of the vermilion projection in 87% of the cases in the superimposed lateral views. The use of DFG is an effective and reproducible method for vermilion augmentation and aesthetic enhancement in patients presenting with upper lip insufficiency relative to the lower lip.

The Genetic Aspect of Non-Syndromic Cleft Lip and Palate towards Candidate Genes in the Etiology : A literature Review

Cleft lip and cleft palate (CL/P) is a cleft lip deformity indicated by an opening or an uncommon cleft inthe lip or roof of the mouth (palate). The differences in ethnicity, gender, and the correlation with geneticfactors influence the prevalence of Non-syndromic CL/P. This study was conducted through a literaturereview on genes that were allegedly associated with Non-syndromic CL/P. Genetics play a role, to a greateror lesser extent, in all diseases. Besides, palatogenesis involves many diverse genes in a complex process.In this case, oral cleft phenotypes develop when this process is disrupted in some manner because of genedysfunction. Various genetic approaches, including genome-wide and candidate gene association studiesas well as linkage analysis, have been undertaken to identify etiologic factors, but results have often beeninconclusive or contradictory. Therefore, it concludes that the genetic basis of CL/P is still controversialbecause of the genetic complexity of clefting

Buccal Mucosa Graft Harvest in Children and Young Adults: Case Series and Harvest Technique.

Buccal mucosa is a great choice for urethroplasty for urethral stricture repair because of ease of harvesting, pliability of the graft, and minimal donor site morbidity. These procedures are performed at our institution as a combined case with Pediatric Otolaryngology and Urology. Harvesting buccal mucosal grafts in younger patients is more technically challenging due to limited oral cavity access and smaller area available for tissue harvest, but is able to be performed safely and with limited morbidity with the addition of parotid duct cannulation and use of retraction sutures to the graft harvest technique. This retrospective case series reports harvest technique, outcomes, and complications of children and young adult males undergoing buccal or lower lip mucosal graft harvesting to repair congenital urethral strictures. Outcome measures were perioperative bleeding, trismus, pain, numbness, parotid duct injury and lip deformity. Six patients underwent nine harvest procedures. Technique modifications included application of anterior graft margin stay sutures to help stabilize the graft mucosa and cannulation of the parotid duct with lacrimal probes to avoid duct injury and to maximize graft size. Overall, buccal mucosal graft harvesting is a well-tolerated procedure with minimal complications using proper harvest technique.

Three-Dimensional Computed Tomography Scan Analysis of Secondary Labial Deformities in Patients With Unilateral Cleft Lip/Cleft Palate After Revisional Surgery.

Surgical reconstruction of secondary labial deformities associated with isolated unilateral cleft lip (UCL) and/or UCL and palate (UCLP) is challenging. There have been few studies in the literature looking at labial soft tissues quantitatively to assess surgical results. To apply a novel computer-aided, 3-dimensional reconstruction technique based on CT scan images to conduct quantitative preoperative and postoperative assessments in patients with UCL/UCLP undergoing surgical revision of secondary labial deformities. Preoperative and postoperative spiral computed tomographic (CT) scans of the face were performed in 21 randomly selected UCL or UCLP patients, who underwent secondary lip revision surgery. The data was then imported to the SimPlant 11.04 software system. Fixed point-to-point, linear distance, and angles were measured, statistically analyzed and used to assess the effect of the surgery. Preoperative measurements showed that the thickness of the upper vermilion at the apex of the Cupid's bow on the affected side was greater than that on the unaffected side. The distance from the apex of the Cupid's bow to the ipsilateral subnasal point of the affected side was smaller than that of the unaffected side (P < 0.05). After surgery, the subjects were rescanned at an average of 9 months, and the curative effects were evaluated. The statistically significant preoperative differences between the affected and unaffected sides were not found postoperatively indicating surgical success. This study demonstrates the utility of a novel method to measure and assess results in the surgical revision of UCL/UCLP patients with secondary lip deformities. This knowledge can aid the surgeon in selection of treatment techniques.

Modified Stair-Step Flap With Turnover Flap for Drooling Correction After Lower Lip Composite Defect Reconstruction.

Oral commissure and buccal complex defects are commonly seen after cancer ablation. Free flap reconstruction can offer adequate soft tissue volume and outer skin lining. However, oral incompetence often occurs when an oral commissure has defects, particularly when the patient receives postoperative radiotherapy. The purpose of this article was to describe our method of the modified stair-step technique and improve the oral competence. This study involves 22 patients who had partial lower lip and/or upper lip defects and underwent flap reconstruction and/or postoperative radiotherapy resulting in oral incontinence. Fourteen patients had been treated with an anterolateral thigh flap, 7 patients had been treated with a radial forearm flap, and 1 patient had been treated with a fibular osteocutaneous flap. Our modified stair-step commissuroplasty was done in all cases, and a debulking procedure was done in each second operation. Acceptable oral continence and contour were achieved in 19 patients. Some patients still had drooling after their second operation, but it was considerably less than before. This technique is an easy procedure for revision of lower lip deformities after oral commissure reconstruction.

Variational Characteristics of Nasolabial Appearance and Its Influencing Factors for the Unilateral Cleft Lip Repair With Modified Huaxi Technique.

After many years in clinical practice, the authors found that the long-term aesthetics of the upper lip and nose following repair of a unilateral cleft lip deformity using the Huaxi method remained unsatisfactory. The immediate postoperative effect was often good, while the long-term postoperative effect was poor. Therefore, this study aimed to evaluate the characteristics and influencing factors of a modified Huaxi method for repairing unilateral cleft lip over time, and to explore the relationship between immediate and long-term outcomes after cleft lip surgery. Patients with unilateral cleft lip who visited the Department of Maxillofacial Surgery of the Stomatological Hospital of Zunyi Medical University from June 2014 to March 2016 were selected. The study group consisted of 51 consecutive patients (30 boys and 21 girls), aged between 3 months and 2 years. Of these, 24 presented with complete unilateral cleft lip (12 wore a nasoalveolar mold as required, 12 did not) and 27 with incomplete unilateral cleft lip (13 wore a nasoalveolar mold as required, 14 did not). Photographs were taken of 51 patients before surgery and immediately, 7 days, and 6 months postoperatively. Various indexes of nasolabial contour of each patient were measured using iWitness photogrammetry, and the slit width; lip height ratio, lip width ratio, nostril width ratio, and nostril height ratio of the healthy side; and degree of deviation of the nasal columella were calculated. Long-term symmetry of lip height and width remained stable postoperatively (P > 0.05), whereas nostril height symmetry was significantly reduced (P > 0.05). Nasal width symmetry and midpoint deviation of the nasal columella were stable in patients with nasoalveolar molding (P > 0.05), but significantly decreased in patients without nasoalveolar molding (P < 0.05). In patients with complete unilateral cleft lip, there was a significant correlation between fissure width and lip width symmetry 6 months postoperatively (r = 0.431, P < 0.05). The symmetry of the upper lip is satisfactory and stable following surgical repair with the modified Huaxi technique. However, undercorrection of nasal symmetry is commonplace. Fissure width and nasoalveolar molding may influence long-term aesthetics following unilateral cleft lip repair.

The unilateral cleft lip repair

ObjectiveTo determine if there is a benefit of 2-stage cleft lip repair in regard to improving facial symmetry and facilitating definitive lip, nose, and palate repair. Study designRetrospective chart review of patients born with complete, unilateral cleft lip deformity that underwent a two-stage repair described as a stage 1 straight line repair and a stage 2 modified Millard repair, for which a complete set of records, and peri-operative and post-operative photos were available. All cases were performed by a single surgeon. SettingTertiary care center craniofacial team. MethodsMeasurements were taken from intraoperative, perioperative, and postoperative images of patients before and after each stage. Ratios were then created comparing the affected size to the unaffected side, and these were averaged between observers. ResultsA 19% increase in the width of area of the presumptive C flap was obtained between the unrepaired and the post-stage I images. The nostril width of the cleft side was 1.2× the width of the unaffected side, demonstrating a 140% decrease in nostril width at the completion of stage II. The cleft side nostril width was maintained slightly larger than the noncleft side as desired. Symmetry of the upper lip length was achieved, as the length of the cleft side lateral lip after stage II was 92% of the unaffected side. ConclusionWe believe this study provides evidence for our observations that a two-stage repair can be performed with functionally and aesthetically pleasing outcomes as an alternative to presurgical nasoalveolar molding.

Discussion on Working in Peru: A 25-Year Experience With Voluntary Cleft Missions, and a Technique for the Primary Repair of the Unilateral Cleft Lip and Nasal Deformity.

Discussion on Working in Peru: A 25-Year Experience With Voluntary Cleft Missions, and a Technique for the Primary Repair of the Unilateral Cleft Lip and Nasal Deformity.

Comparative study between fisher anatomical subunit approximation technique and millard rotation- advancement technique in unilateral cleft lip repair

ABSTRACT Introduction: The ideal lip repair is characterized by; the symmetrical shape of nasolabial folds and both alae of the nose with a natural-looking philtrum and Cupid’s bow in both static and dynamic states, in addition to a hidden scar. Objective: to compare between Fisher anatomical subunit approximation technique and Millard rotational advancement technique in unilateral cleft lip repair. Methods: Prospective study for 40 patients presented to Alexandria Main University hospital with unilateral cleft lip deformity between March 2019 and October 2020. Twenty patients with unilateral cleft lip deformity were repaired by Fisher anatomical subunit approximation technique, while the other twenty were repaired by Millard rotational-advancement technique. The postoperative photographs of the patients were captured and processed in computer photogrammetry software through which anthropometric parameters including (lip height, lip width, vermilion height, and alar base width) were compared between the normal side and the repaired side. In this software, each anthropometric parameter length on the normal side is taken as a control with a fixed value of (1) then the same parameter on the repaired side was measured as a ratio of this value to avoid bias. Comparison between both groups for assessment of the quality of cleft lip repair was also done based on Steffensen grading criteria. Results: Comparison between both techniques in unilateral cleft lip repair showed that there was no significant difference between them in the anthropometric measurements. While the comparison between the two groups using Steffensen grading criteria showed that Fisher’s technique surpassed Millard’s technique. Conclusion: We recommend the use of the Fisher anatomical subunit approximation technique in unilateral cleft lip repair for its superior results over the Millard rotational advancement technique.

The correlation between the severity of anterior crossbite and skeletal deformities in post-surgery cleft lip and palate among children

Introduction: Cleft lip and palate is the most common craniofacial malformations, which is a congenital deformity of lip and palate or both. Anterior crossbite is occlusal characteristics that are often found in patients with cleft lip and palate who had surgery, caused by dentoalveolar or skeletal abnormalities, can be distinguished based on the cephalometric analysis. This research was aimed to analyse the correlation between the severity of anterior crossbite and skeletal deformities in post-surgery cleft lip and palate among children. Methods: The research design was an analytic correlation with the sample selection based on purposive sampling. The research was conducted from 14 cleft lip and palate patients in the primary dentition (aged 4-6 years old) who had surgery (for 2-3 years) using analysis of study models and cephalometric digital. Statistical analysis was conducted by Spearman Rank Correlation Coefficient test to analyse the relationship between the severity of anterior crossbite with skeletal deformities. Results: Statistic test showed that 42.86% of the anterior crossbite in the cleft lip and palate post-surgery in primary dentition had a very high level of severity, thus leading to very poor occlusion. As many as 21.43% had a high level of severity, which leads to poor occlusion, and 35.71% had a moderate level of severity, which leads to fair occlusion. The Spearman Coefficient of Rank Correlation test results showed a weak correlation between the severity of anterior crossbite with skeletal deformities with coefficient relation of 0.13 and p-value of 0.48 (p&lt;0.05). Conclusion: There is a weak correlation between the severity of anterior crossbite with skeletal deformities in post-surgery cleft lip and palate among children.

A custom-made conformer wrapped in lower oral mucosa for the correction of severely contracted socket.

To investigate the clinical effects of a custom-made conformer wrapped in lower oral mucosa for the correction of severely contracted socket. Clinical data and photographs of 32 patients with severely contracted socket were retrospectively analyzed. Among the 32 cases, 21 were males and 11 were females. Their ages ranged from 20 to 71 years (mean, 45 years). Each patient underwent conjunctival sac plasty using a custom-made conformer wrapped by oral mucosa, then compression bandage for 1 month. All patients received tarsorrhaphy 6 months postoperatively, and an artificial eye was worn 1 week later. All the grafts were fully vascularized. The conjunctival sacs had enough space to fit the desirable artificial eyes, and adequate aesthetic outcomes were reached postoperatively. The mean depth of the upper fornix was 4.28 ± 0.66 mm preoperatively and 18.84 ± 0.65 mm postoperatively (p < 0.01), and lower fornix depth was 2.69 ± 0.42 and 8.78 ± 0.82 mm, respectively (p < 0.01). Lower lip deformity occurred in one case. A custom-made conformer wrapped in lower oral mucosa was a safe and effective grafting material. The grafts can be effectively used in the reconstruction of severely contracted socket and lead to good cosmetic outcomes.