Secondary Cleft Lip Deformity Research Articles

Surgical Correction of Whistle Deformity Using Cross-Muscle Flap in Secondary Cleft Lip

BackgroundThe whistle deformity is one of the common sequelae of secondary cleft lip deformities. Santos reported using a crossed-denuded flap for primary cleft lip repair to prevent a vermilion notching. The authors modified this technique to correct the whistle deformity, calling their version the cross-muscle flap.MethodsFrom May 2005 to January 2011, 14 secondary unilateral cleft lip patients were treated. All suffered from a whistle deformity, which is characterized by the deficiency of the central tubercle, notching in the upper lip, and bulging on the lateral segment. The mean age of the patients was 13.8 years and the mean follow-up period was 21.8 weeks. After elevation from the lateral vermilion and medial tubercle, two muscle flaps were crossed and turned over. The authors measured the three vertical heights and compared the two height ratios before and after surgery for evaluation of the postoperative results.ResultsNone of the patients had any notable complications and the whistle deformity was corrected in all cases. The vertical height ratios at the midline on the upper lip and the affected Cupid's bow point were increased (P<0.05). The motion of the upper lip was acceptable.ConclusionsA cross muscle flap is simple and it leaves a minimal scar on the lip. We were able to reconstruct the whistle deformity in secondary unilateral cleft lip patients with a single state procedure using a cross-muscle flap.

The Application of Bilateral Lip Mucosa Flaps in Repairing Upper Vermilion Defects

The lip is a primary aesthetic feature of the human face. Repair of vermilion defects represents a unique challenge to the reconstructive surgeon. The methods of repair are various and have both advantages and disadvantages. Bilateral lip mucosa flaps were applied to the repair of upper vermilion defects, and the effects were observed and reported in this article. The bilateral lip mucosa flaps were designed. Two reverse triangular flaps were designed on both sides of the upper vermilion defect. These 2 flaps have the common pedicle in the vermilion depression site. Alternatively, a "λ" incision may be used in the wet vermilion. Then, the mucosa flaps were raised, and the dissection was performed between the orbicularis oris muscles and oral mucosa glands. Next, the bilateral mucosa flaps were rotated down 90° and inserted into the "λ" incision to increase the tissue volume of the middle upper lip and deepen the labiogingival sulcus. The common pedicle of the mucosa flaps was formed to the vermilion tubercle, and the incisions were sutured layer by layer. From 2005 to 2010, the bilateral mucosa flaps procedures were performed on 30 secondary cleft lip patients (bilateral, n=22; unilateral, n=8). Lateral projection measurements of the reconstructive vermilion tubercle showed a mean increase of 149%. Satisfactory results were obtained, both cosmetically and functionally, in all 30 patients. There were minimal perioperative complications. The postoperative scars are not remarkable at all. The technique is relatively simple. The bilateral lip mucosa flaps provided a versatile and reliable option for the correction of vermilion defects from secondary cleft lip deformities.

Simultaneous Correction of Scars and Tissue Deficiency With Composite Grafts in Secondary Cleft Lip Deformity

In secondary cleft lip deformities, repetitive surgeries lead to increased tension and deformities in the upper lip, ultimately resulting in new deformities such as wide scars and a tight lip. The simultaneous correction of a wide scar and tissue deficiency in the upper lip is paradoxical unless sufficient tissue is supplied to the scant upper lip. The authors describe a method to transfer composite tissue for the improvement of secondary cleft lip deformities and present an analysis of the outcomes. Ninety-one patients with secondary cleft lip, a wide scar, and tight lip were enrolled. After complete excision of the scar, the defect was covered with a composite graft that included skin and subcutaneous fat. The results were rated by 2 investigators blinded to the image of the scar and the morphology of the upper lip. The skin color of the 25 grafts was analyzed using a narrowband spectrophotometer using the Commission International d'Eclairage L*a*b* color coordinates. All grafts survived without sequelae. The scores of the scar images and general morphology were 8.3/10 and 8.2/10, respectively. Spectrophotometric analysis displayed no differences between the composite tissues and normal upper lip skin in each color coordinate, indicating that the composite tissue had a good color match with a normal upper lip. The use of a composite graft on the upper lip can be a reliable option to correct a wide hypertrophic scar and tight lip simultaneously, resulting in a satisfactory scar image and an improvement of upper lip morphology.

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.

Acellular human dermis, a good option for correcting the free border deficiency in secondary cleft lip deformity

Free border deficiency is often seen after repairing the primary cleft lip. Mild deficiency of this area can be corrected by rearranging available local tissue, but, in severe cases, the absolute shortage of tissue requires recruitment of other tissues for a satisfying result. Although many types of materials have been used, filling materials alone have not provided favourable results. We have therefore attempted to overcome these limitations by combining V-Y advancement of the labial mucosa, with providing additional tissue to the deficient area with acellular human dermis or temporoparietal fascia. From September 2001 to January 2009, a combination of acellular human dermis or temporoparietal fascia graft with mucosal V-Y advancement was performed on 20 patients with free border deficiency of secondary cleft lip. Ten patients received temporoparietal fascia graft, and the others received acellular human dermis grafts. Results were evaluated by the surgeon based on the aesthetic appearance and consistency of the free border of the upper lip. All 20 patients were satisfied with the results. There were no significant differences in absorption rate, texture and volume between the acellular human dermis and temporoparietal fascia group. There were no complications such as infection, graft exposure and epidermal cysts in both groups. The use of acellular human dermis is a simple and effective method for managing severe cases of free border deficiency. Combined with V-Y advancement of the labial mucosa, it is as effective as temporoparietal fascia, offering long-lasting results without major complications in managing this difficult problem.

Volume Enhancement of Upper Lip in Secondary Cleft Deformity Using Composite Mastoid Tissue

Secondary cleft lip deformity correction needs thorough assessment and planning to optimize treatment and achieve good results. Deficient volume of the upper lip, which is one of the most common secondary cleft lip deformities, has been addressed in many ways using tissues from local or distant areas. Consideration must be given to safety, easy availability of the tissues, minimum morbidity, and longevity of the results when selecting a procedure. This retrospective study included ten patients with a minimum follow-up of 1year. Composite mastoid fascia was harvested through a postauricular incision and used to augment deficient lip volume in secondary cleft lip deformities. Clinical assessment and measurement was performed by measuring the vertical height and projection of the deficient upper lip before and after surgery. At the end of 1year the average increase in the vertical height of the vermilion was 27.11% compared to the preoperative readings, with an average loss of 12.81% of increase at 1year. The lateral projection showed an increase of 23.88% compared to the reading taken before surgery, with a loss of 9.75% at the end of 1year. The donor site incision was concealed behind the ear and lip incisions were invisible in the long term. There were no major complications. This is a good way of augmenting the lip with due consideration given to longevity of the result and minimal morbidity. This method might also by used for permanent cosmetic lip enhancement for those with very thin lips.

Correction of Secondary Cleft Lip Deformity: The Whistle Flap Procedure

The Kapetansky flap was described to repair a whistle deformity or central vermilion defect following a primary bilateral cleft lip repair. The authors studied a modification of this technique, called the Whistle (wide-hinged island swing transposition labial enhancement) flap, to correct a wide array of secondary cleft lip deformities. Patients with secondary cleft lip deformity who underwent the Whistle flap correction were studied (n = 21). Vertical lip height, lateral lip projections, and three-dimensional volumetric measurements were recorded along with physician and parent-patient satisfaction surveys. From 1994 to 2006, 23 Whistle flap procedures were performed on 21 cleft lip patients (bilateral, n = 13; unilateral, n = 8). The average age at surgery was 15.4 years (range, 13 to 21 years). The average follow-up was 27.6 months. The vertical height of the cleft side Cupid's bow to vermilion bottom had a mean increase of 164 percent. Lateral projection of the upper lip showed a mean increase of 117 percent. Preoperatively, patients exhibited mean volumetric asymmetry of 29.4 percent, and this was reduced following treatment to approximately 3.1 percent. Physician satisfaction using a modified Whitaker classification (categories I through IV) demonstrated that 56 percent of patients were category I (no refinements necessary) and 44 percent were category II (minor revisions are advisable). Parent-patient satisfaction in the follow-up period was a mean of 3.5 as measured using a five-point scale ranging from 0 to 4. There were minimal perioperative complications. The Whistle flap procedure provided a versatile and reliable option for the correction of vermilion defects from secondary cleft lip deformities.

Correction of the Secondary Bilateral Cleft Lip Deformity Encountered in Guatemala

Correction of the Secondary Bilateral Cleft Lip Deformity Encountered in Guatemala

Correction of the Secondary Bilateral Cleft Lip Deformity Encountered in Guatemala

Correction of the Secondary Bilateral Cleft Lip Deformity Encountered in Guatemala

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: application of occult Abbé flap

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: application of occult Abbé flap

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.

O.077 Secondary cleft lip deformity correction by composite graft

O.077 Secondary cleft lip deformity correction by composite graft

The Abbé Island Flap for the Reconstruction of Severe Secondary Cleft Lip Deformities

Primary repair of the cleft lip is often associated with secondary deformities, which require revision and secondary reconstruction. Patients with one or all of the following, a tight lip restricting use of orthodontic appliances, absence of a Cupid's bow, or absence of vermilion tubercle, were treated with the Abbé island flap. A triangular muco-musculo-cutaneous island flap was designed in the central segment of the lower lip. A full-thickness incision of skin, muscle, and mucosa was made in the midline of the upper lip, dividing the lip into two segments, and the island Abbé flap was inserted. One week after surgery, the pedicle of the island flap was divided and the inset of the flap completed. Sixty patients with severe secondary cleft lip deformities (36 males and 24 females) were treated. Good aesthetic and functional results were achieved during 1 to 17 years of follow-up. Insertion of the Abbé flap resulted in release of the tight upper lip and a new, inconspicuous scar. Use of orthodontic appliances was facilitated, and tightness of the tissue, which restricted the expansion of the alveolar process, was eliminated. Adequate tissue was transferred to the upper lip, which improved the bulk of the lip and vermilion tubercle. The retrusion of the midface and the projection of the upper lip were also improved, and the upper and lower lips became better balanced. Donor site morbidities were insignificant. Use of the Abbé flap in selected patients resulted in successful reconstruction of secondary cleft lip deformities.

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited.

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.

Correction of secondary cleft lip deformities.

After studying this article, the practitioner should be able to (1) describe the common secondary deformities of the cleft lip, (2) determine the appropriate timing for surgical intervention to correct the deformities, and (3) determine the best method of addressing each of the individual secondary deformities of the cleft lip. Secondary deformities are common in children born with a cleft lip and palate. Patients with cleft lip deformity will undergo multiple surgical procedures early in life, so it is imperative to prioritize treatment of their secondary deformities and minimize the number of interventions needed. Of the many approaches used to correct these problems, surprisingly few work well consistently. As with all plastic surgery, the timing and procedure should be predicated on the severity of the deformity.

Taking charge and doing the right thing.

Leadership is a combination of strategy and character. If you must be without one, be without the strategy.—General H. Norman Schwarzkopf

Reconstruction of the superior labial sulcus in secondary bilateral cleft lip deformities: an inverted U-shaped flap.

A shallow buccal sulcus deformity following bilateral cleft lip repair is not rare. A variety of techniques are described for the secondary reconstruction of a deficient sulcus. Most of these are associated with a variable amount of contraction with subsequent obliteration of the sulcus. In this article, an inverted U-shaped flap is described for the secondary reconstruction of the deficient sublabial sulcus. In these patients, mobility of the upper lip was severely restricted, so orthodontic treatment was not possible. This technique was used in nine patients whose primary cleft lip repairs were performed in different institutions. The amount of re-adhesion or contraction was negligible, because a bare surface was not left behind and skin or mucosal grafts were not used. By advancing the lateral segments of the lip medially, projection of the upper lip was increased. The procedure resulted in adequate upper lip mobility for all patients, and sufficient sulcus was maintained during 1 to 6 years of follow-up. The patients experienced no difficulty with orthodontic appliances after this reconstruction.

The correction of secondary cleft lip deformities using dermofat grafts

The use of dermofat grafts in the correction of the secondary cleft lip deformity is described. Dermofat graft augmentation of the uper lip is a relatively well established technique in aesthetic surgery, however there have been no previous description of its application in cleft lip surgery. Eleven cases are presented in which dermofat grafts have been used to correct secondary cleft lip deformities. Alternative surgical techniques and the indications for dermofat grafting are discussed.

Augmentation of the Free Border of the Lip in Cleft Lip Patients Using Temporoparietal Fascia

Deficiency of the free border of the lip is frequently encountered in secondary cleft lip deformities. The free border of the lip consists of the orbicularis oris marginalis muscle and its overlying subcutaneous tissue, vermilion, and mucosa. The pathology may involve any or all of these components. When there is an absolute shortage of subcutaneous tissue or orbicularis oris marginalis muscle, extra tissue from another source must be used for augmentation. A temporoparietal fascial graft is a simple and reliable method to increase the fullness of the free border of the lip. The tissue is soft in consistency and displays minimal resorption. Most important, more complicated procedures such as an Abbé flap or tongue flap may be avoided. From July of 1988 until June of 1992, the temporoparictal fascial graft was used successfully to correct deficiencies of the free border of the lip in 20 patients with cleft lip deformities. There were two graft exposures that healed with conservative treatment. The procedure is a useful method of augmenting both lateral lip and central lip deficiencies in secondary and tertiary cleft lip deformities. (Plast. Reconstr. Surg. 95: 781, 1995.)

Augmentation of the Free Border of the Lip in Cleft Lip Patients Using Temporoparietal Fascia

Deficiency of the free border of the lip is frequently encountered in secondary cleft lip deformities. The free border of the lip consists of the orbicularis oris marginalis muscle and its overlying subcutaneous tissue, vermilion, and mucosa. The pathology may involve any or all of these components. When there is an absolute shortage of subcutaneous tissue or orbicularis oris marginalis muscle, extra tissue from another source must be used for augmentation. A temporoparietal fascial graft is a simple and reliable method to increase the fullness of the free border of the lip. The tissue is soft in consistency and displays minimal resorption. Most important, more complicated procedures such as an Abbé flap or tongue flap may be avoided. From July of 1988 until June of 1992, the temporoparietal fascial graft was used successfully to correct deficiencies of the free border of the lip in 20 patients with cleft lip deformities. There were two graft exposures that healed with conservative treatment. The procedure is a useful method of augmenting both lateral lip and central lip deficiencies in secondary and tertiary cleft lip deformities.