Vermilion Notching Research Articles

Utility of J-Shaped Scar Tissue-Based Flap for Secondary Bilateral Cleft Lip Repair: A One-Stage Procedure with Successful Outcomes on Correction of Vermilion Border, Volume Deficiency of Lip, and Muscular Function.

This study aimed to evaluate the utility of J: -shaped scar-tissue-based flap as a new technique in secondary bilateral cleft lip reconstruction in patients with challenging secondary deformities. A total of 52 patients, comprising 38 males and 14 females with a mean age of 21.0 years (range: 16-42 years), who underwent secondary bilateral cleft lip repair operation via the J: -shaped scar tissue flap technique in our clinic between 2014 and 2019 were included. Postoperatively, patients were followed up for an average of 2 years (range, 6 months to 5 years) to assess the outcomes regarding vermilion border, philtrum symmetry, function of the orbicularis muscle, and lip volumetric symmetry, based on the Global Aesthetic Improvement Scale (GAIS), patient-reported outcomes, and independent plastic surgeons' examinations. After an average follow-up of 2 years, outcomes regarding vermilion border, philtrum symmetry, function of the orbicularis muscle, and lip volumetric symmetry were successful, and none of the patients experienced new notch formation, muscular functional loss, lip volume loss, or asymmetry. Owing to good muscular function preventing the stretching, the postoperative scars become more acceptable to the patients. The technique has proven to be safe and successful through the GAIS objective assessment, as also confirmed by the examinations of the three independent surgeons, while the majority of patients reported an exceptional improvement in the appearance alongside a more than 95% satisfaction rate with the operation. In conclusion, our findings revealed successful functional and aesthetic outcome of using J: -shaped scar tissue flaps in secondary repair of cleft lips. The technique was associated not only with the correction of significant secondary deformities yielding an improved and symmetrical lip volume, correction of vermilion notch, and prevention of notch re-formation but also with the restoration of orbicularis oris muscle function and thus integrity of the lip with minimal scarring.

A CASE REPORT: UNILATERAL COMPLETE CLEFT LIP RECONSTRUCTION USING THE MODIFICATION MILLARD TECHNIQUE

Highlights: The modified Millard technique, including the Tennison triangular flap, is effective in preventing vermillion notching and reducing scar complications in cleft lip repairs. The technique addresses concerns related to compromised lip tissue and nostril deformities, leading to improved appearance and functionality. Scar thinning techniques and separate nasoraphy contribute to enhanced aesthetics and optimal healing in cleft lip repairs. Abstract: Introduction: With 1 in 700 live births worldwide, cleft lip with or without cleft palate is the most prevalent congenital craniomaxillofacial birth condition. More people have a unilateral cleft lip than a bilateral cleft lip. With the exception of vision, it can influence the morphology and nearly all facial functions. The purpose of this study is to give an overview and learn more about the management of lip repair using the modified Millard approach, which can prevent straight line closure and vermilion notching. Case Illustration: We present a case of a 4-month-old male who underwent a modified Millard procedure and had a unilateral full cleft lip. The findings revealed no vermillion notch, acceptable columellar and alar lengths, symmetrical Cupid's bow, lip height, lip width, and philtrum angle. Discussion: The modified Millard technique, including the Tennison triangular flap, improves the repair of cleft lips by preventing vermillion notching and reducing scar complications. It also addresses concerns related to lip tissue compromise and nostril deformities. Scar thinning techniques and separate nasoraphy contribute to enhanced aesthetics and optimal healing. These modifications aim to achieve improved appearance and functionality in cleft lip repairs. Conclusion: The modified Millard technique can be considered as a viable option for treating unilateral cleft lip due to its ability to create a balanced Cupid's bow, maintain appropriate lip height and width, and achieve satisfactory aesthetic results in the nasal area without vermillion notching.

Novel Passage of Dermis-Fat Graft for Augmentation of Vermilion Deficiency Following Cleft Lip Repair.

Despite timely repair of cleft lip, secondary deformities such as vermilion notching or "whistle deformity" often require further surgical treatment. The use of dermis-fat graft for soft tissue augmentation of the upper lip is an established technique. We propose an innovation on this technique, by which the dermis-fat graft can be placed reliably and with minimal dissection by use of a soft red rubber sheath to protect the Keith needle while delivering the graft through the submucosal pocket in the dry vermilion, thereby avoiding the needle inadvertently catching soft tissue inside the pocket. We recommend using an 8F red rubber catheter, cutting the catheter to be just shorter than a 2.5-inch Keith needle. This provides a sheath through which the Keith needle can be passed within the submucosal vermilion tunnel. We believe this to be much more reliable for vermilion augmentation than other techniques, including fat injection, and makes graft inset more predictable, faster, and simpler.

An assessment and comparison of nasolabial aesthetics in bilateral clefts using the anatomical subunit-based scale: a nasoalveolar moulding versus non-nasoalveolar moulding study

Nasoalveolar moulding is a presurgical orthopaedic technique used to improve the outcomes of bilateral clefts. However, the lack of a validated scale tailored to bilateral clefts makes it difficult to quantify the merits of nasoalveolar moulding and compare it to other techniques. In this study, a recently published anatomical subunit scale was used to evaluate and compare the early effects of nasoalveolar moulding. Two groups of similarly treated bilateral cleft patients were included: one in which patients underwent presurgical nasoalveolar moulding and one in which they did not. The nasolabial aesthetics were evaluated on two-dimensional photographs at 6 months post cheiloplasty. Cupid’s bow, vermilion symmetry, vermilion notching, premaxillary show at rest, scar aesthetics, columella height, columella height, and bialar width were all significantly better in the nasoalveolar moulding group. Using the new scale, it was found that nasolabial aesthetics at 6 months post cheiloplasty were significantly better in patients who had undergone nasoalveolar moulding in infancy.

White Roll Vermilion turn down flap in primary unilateral cleft lip repair: A novel approach.

Aim:Numerous modifications of Millard's technique of rotation – advancement repair have been described in literature. This article envisions a new modification in Millard's technique of primary unilateral chieloplasty.Material and Methods:Eliminating or reducing the secondary deformities in children with cleft lip has been a motivating factor for the continual refinement of cleft lip surgical techniques through the years. Vermilion notching, visibility of paramedian scars and scar contracture along the white roll are quite noticeable in close-up view even in good repairs. Any scar is less noticeable if it is in midline or along the lines of embryological closure. White Roll Vermilion turn down Flap (WRV Flap), a modification in the Millard's repair is an attempt to prevent these secondary deformities during the primary cleft lip sugery. This entails the use of white roll and the vermilion from the lateral lip segment for augmenting the medial lip vermilion with the final scar in midline at the vermilion.Result:With an experience of more than 100 cases of primary cleft lip repair with this technique, we have achieved a good symmetry and peaking of cupid's bow with no vermilion notching of the lips.Conclusion:WRV flap aims to high light the importance of achieving a near normal look of the cleft patient with the only drawback of associated learning curve with this technique.

An analysis of deformities in revision surgeries for secondary unilateral cleft lip.

To analyze the secondary cleft lip deformities and the possible causes in a cohort of cases. A case series. Services Institute of Medical Sciences and WAPDA Teaching Hospital Complex, Lahore, from September 2008 to March 2012. Consecutive cases of secondary unilateral cleft lip deformities were selected for the study. These cases were interviewed and deformities recorded. Pre and postoperative photographs were taken for comparison. Per operative photographs were taken, after marking of the incisions, to keep a record of the intervention needed to correct the deformities. These cases were then further analyzed to know the deformities and interventions needed for correction of these deformities. Study subjects comprised 114 males and 75 females. Secondary correction was the most common in second decade of life with 82 cases in this group. The most common deformity was unfavorable scar in 150 cases followed by notch at the vermilion border in 124 cases. Short lip was found in 119 cases. Complete revision of the repair was required in 158 cases and 25 cases required partial redo of the initial repair. In other 6 cases, only scar revision was carried out. Unfavorable scar followed by vermilion notch and short lip were the most common secondary cleft lip deformities. Better technique helps favorable scar. Vermilion notch and short lip can be overcome by switching from rotation advancement repair to the triangular flap repair of Noordhoff.

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.

Correction of secondary vermilion notching deformity in unilateral cleft lip patients: Complete revision of two errors

Background Vermilion notching deformity is one of the most common secondary deformities in unilateral cleft lip patients. Two errors during primary cheiloplasty seem to cause notching deformity. The first one is insufficiently lengthened oral lining of the medial lip compared to the cutaneous surface, and the other is medialized marking of the height of cupid’s bow on cleft side rather than marking it at the thickest portion of the vermilion. The authors were able to obtain satisfactory results after revising notching deformities by correcting these two errors. Methods A total of 104 patients (median age: 13) with secondary notching deformity underwent revision surgery from 1987 to 2009. After the new height of cupid’s bow on the cleft side was marked on the white roll with the greatest vermilion fullness, the notched vermilion including the cutaneous scar was elevated. For sufficient lengthening of the oral lining, the elevated tissue was interposed as an inferior pedicled flap into a relaxing incision of the central portion of the oral sulcus. Results The follow-up period ranged from 1 year to 12 years. The patients were satisfied with the aesthetic outcomes. Seven patients experienced lateral vermilion bulging which was easily corrected by an elliptical excision. Conclusion Complete revision by lengthening the oral lining of the central lip portion, and lateralizing the height of cupid’s bow of cleft side to the region where vermilion is thickest, is an effective method for correction of secondary notching deformity.

Free dermis—fat graft to correct the whistle deformity in patients with cleft lip

Vermilion notching or ‘whistle deformity’ is a common secondary deformity of the vermilion in patients with cleft lip. The free border of the lip is a composite structure consisting of the orbicularis oris and the overlying tissues, namely subcutaneous fat, vermilion and mucosa. A deficiency of all or one of these structures is responsible for the vermilion notch. An absolute shortage of the muscle or subcutaneous tissue necessitates the use of tissue from another source to correct the deformity. Dermis fat grafts have been used to augment the free border of the lip and correct this deformity. The technique is simple and reliable. The tissue is available in plenty, easy to harvest and could be repeated if necessary, i.e. in case of resorption. From June 1996 until January 2000 the technique was used in 10 patients. Of these 10, one was a bilateral cleft and nine were unilateral cleft lip deformities. A degree of graft resorption was seen in one patient, one had a partial graft loss due to ulceration and exposure. The first patient had a further augmentation.

Surgical creation of a Cupid's bow using W-plasty in patients after cleft lip surgery

The three-dimensional contour of the Cupid's bow is extremely important from a cosmetic standpoint, and many patients with bilateral or unilateral cleft lip require revision or reconstruction of the Cupid's bow. A number of surgical techniques have been reported for creating the Cupid's bow, among which the methods of Gillies and Onizuka are the most widely known. In the methods of Gillies and Onizuka, the dog-ear can result in excessive volume in the vermilion notch, raising the trough in the Cupid's bow and leading to regression during the post-surgical period. We have improved upon these techniques using the W-plasty and have obtained satisfactory results that preserve the white skin roll. In our method, the left and right prominence of the Cupid's bow is created through an incision of the white lip, while the central trough is created through a curvilinear incision of the vermilion mucosa. At the two sites of the white lip tissue and the curvilinear incision of the central vermilion tissue, the white skin roll is preserved as much as possible. In patients where the Gillies method had been used, the Cupid's bow tended to be flattened gradually after surgery. We report on the details of our method and the case reports using the technique.

Unilateral gate flap for reconstruction of the lower lip.

A unilateral gate-flap technique consisting of a nasolabial island flap is presented for the reconstruction of defects in the lower lip after excision of large, laterally located epidermoid tumors. The amount of healthy tissue resected is optimal. The reconstructed lower lip retains sensation and muscle function and is continent with a satisfying appearance. Temporary flap edema and a vermilion notch at the apex of the flap are both avoidable problems. This method may be used in selected patients with large advanced epidermoid cancers of the lower lip.

OUTCOME OF THE MILLARD ROTATION- ADVANCEMENT PROCEDURE FOR THE UNILATERAL CLEFT LIP IN TWO HOSPITALS OF BANNU

Objective: To evaluate the outcome of Millard's method in patients with unilateral cleft lip in two hospitalsof district Bannu.METHODS: This study was performed from Nov 2009 to Dec 2011 . Eighteen patients with Unilateralcleft lips were selected. The age range was 4-15 months. All patients underwent Millard procedure. Thesurgery was performed by different surgeons in the ENT and Pediatric Surgery department in Khalifa GulNawaz and DHQ Hospitals Bannu.Results: The total number of patients successfully operated in our study was 18 with 12 (66.6%) males and 6(33.3) females with a ratio of 2: 1. Patients with complete cleft lip were 15(62.5%) while three (12.5%) werefound with incomplete cleft lip. Wound infection was observed in 2 (11.1%) patients inspite of antibioticcover. Three (16.6%) patients had post-operative vermilion notch. Postoperative follow-up of 6 monthsrevealed the good results with an acceptable scar, good preservation of philtrum dimple and column, fullvermilion and lengthened columella and good alar cartilage reposition.Conclusions:Millard's technique is useful for repairing unilateral cleft lip in rebuilding nasal floor, theCupid' bow and in correction of the columella deviation, except for a relatively insufficient lip height andcolumella length at the operated side. Therefore it is concluded that the Millard method is an ideal procedurefor unilateral cleft lip repair.Key words: Unilateral cleft lip, Millard's procedure, vermilion notch