Reconstruction of cupid's bow: a quadrilateral flap technique

The cupid's bow is an important feature of the normal upper lip, and every effort should be made to reconstruct it during initial cleft lip surgery or trauma repair. However, a secondary surgical procedure is often necessary to improve the appearance and symmetry in the cupid's bow area. For this purpose, the authors present a quadrilateral type of interposition flap that can be used in both unilateral and bilateral cupid's bow reconstruction. This procedure is applicable only when adequate vermilion is available.     

Long-term outcome of simultaneous repair of bilateral cleft lip and nose (a 15 year experience).

We have performed primary repair of bilateral cleft lip and nose on 169 patients in the past 15 years. During the first eight years, we used a small triangular flap skin design for the lip and for the nose correction, we used a corrective nasal cartilage lifting suture through rim incisions in order to bring the nasal dome cartilage toward the center and create the columella. The small triangular flap at the columella base was rotated 90 degrees posteriorly to emphasize the contour of the nasolabial angle. In the subsequent 7-year period, the lip design was changed to the straight line method, and an inverted trapezoid suture was placed between the alar and nasal dorsum at four points. By this procedure displaced cartilages are moved into correct position and the alar groove became more distinct.Long-term observations showed a favorable configuration of the nose, and eliminated the bilateral cleft nose stigma with only minimum degree of growth disturbance. The remaining problem is the somewhat superior faced nasal tip. To leave the bilateral cleft lip nasal deformity uncorrected for a long period places great psychosocial burden on the patient and the family. We believe that it is desirable to conduct early lip and nose repair synchronously in a minimally invasive manner, as a collaborative effort between plastic surgeons with specialized training in cleft lip repair and an interdisciplinary team.     

Ambulatory cleft lip surgery: A value analysis

BACKGROUND:

Socialized health systems face fiscal constraints due to a limited supply of resources and few reliable ways to control patient demand. Some form of prioritization must occur as to what services to offer and which programs to fund. A data-driven approach to decision making that incorporates outcomes, including safety and quality, in the setting of fiscal prudence is required. A value model championed by Michael Porter encompasses these parameters, in which value is defined as outcomes divided by cost.

OBJECTIVES:

To assess ambulatory cleft lip surgery from a quality and safety perspective, and to assess the costs associated with ambulatory cleft lip surgery in North America. Conclusions will be drawn as to how the overall value of cleft lip surgery may be enhanced.

METHODS:

A value analysis of published articles related to ambulatory cleft lip repair over the past 30 years was performed to determine what percentage of patients would be candidates for ambulatory cleft lip repair from a quality and safety perspective. An economic model was constructed based on costs associated with the inpatient stay related to cleft lip repair.

RESULTS:

On analysis of the published reports in the literature, a minority (28%) of patients are currently discharged in an ambulatory fashion following cleft lip repair. Further analysis suggests that 88.9% of patients would be safe candidates for same-day discharge. From an economic perspective, the mean cost per patient for the overnight admission component of ambulatory cleft surgery to the health care system in the United States was USD$2,390 and $1,800 in Canada.

CONCLUSIONS:

The present analysis reviewed germane publications over a 30-year period, ultimately suggesting that ambulatory cleft lip surgery results in preservation of quality and safety metrics for most patients. The financial model illustrates a potential cost saving through the adoption of such a practice change. For appropriately selected patients, ambulatory cleft surgery enhances overall health care value.     

A preliminary observation on interdomal suture through bilateral reverse-J incisions to repair cleft lip nose deformity in the setting of traveling charity programs

Background

Nasal appearance is one of the most important factors in determining the success of a cleft repair. This preliminary study aimed to evaluate a simple variant of primary nose repair technique to achieve an optimal nasal esthetic outcome along with the lip repair in the setting of traveling charity programs, where time is an obvious limitation.

Methods

A cross-sectional study on the outcome of nose repair was conducted within the setting of traveling cleft charity programs. Nasal repair was done during primary cleft lip repair by bilateral reverse-J incisions inside the nostril followed by an interdomal suture, without postoperative nasal retainer. Pre- and postoperative photographs were evaluated based on two variables: (1) alar facial symmetry ratio and (2) columellar angle. The significance of improvements was assessed using Wilcoxon or paired samples t test. Postoperative esthetic outcome was also evaluated based on the Fujimoto–Imai method.

Results

From January 2007 to February 2012, there were 68 unilateral and 19 bilateral cleft cases, among which 44 unilateral and 3 bilateral cleft cases were eligible. The bilateral group was discarded from this study for being too small. In the unilateral group, the improvement in both variables was significant (p value?<?0.05). Esthetic outcome was found to be excellent in 21 unilateral cleft patients and good in 23.

Conclusions

This preliminary study showed that interdomal suture via bilateral reverse-J incisions is a potentially effective method to repair unilateral cleft lip nose deformity in the setting of traveling charity programs. Level of evidence: Level IV, therapeutic study.     

Renaissance of the Franz König bilateral lip repair procedure - clinical experiences with an one hundred year old technique

Surgical correction of bilateral cleft lips is known to have a lot of problems. The surgical principles of treatment of bilateral cleft lips are similar to those of unilateral clefts but differ in the area of the prolabium due to specific anatomical disorders of the orbicularis oris muscle. The postoperative results of simultaneous bilateral cleft lip repair according to K?nig were analysed retrospectively in 15 young children (6.1 +/- 1.1 years) paying special emphasis to the aesthetic and functional postoperative outcome of the upper lip and nose. The mean values were compared with measurements from normal infants at ages 8.3 +/- 1.8 years. Lip height and lip length were in 87 % similar to those of the age-matched normal group. Only two cleft patients showed a slightly shorter lip. Distortions of the lip function were not obvious. Our data show that K?nig's surgical procedure of bilateral cleft lip closure meets the requirements of modern surgical concepts of cleft lip repair and should belong to the armamentarium of modern face surgery.     

原长法联合前唇唇红"M"瓣整复双侧唇裂畸形

目的：探讨整复双侧唇裂畸形的技巧和美学问题。方法;对本组24例双侧唇裂畸形患者采用原长法,前唇唇红利用“M”瓣整复,并对其设计特点,前唇“M”瓣的应用等问题进行探讨。结果：除1例因感染唇红部裂开外,其余整复效果较为满意,唇红正中部组织较丰满,唇珠外形恢复良好。结论：参照自然唇的特点,审美水平,灵活的设计及手术技巧是整复双侧唇裂畸形的关键。     

双侧唇裂与鼻畸形同期整复的初步探讨

目的探讨双侧唇裂与鼻畸形同期整复的方法和美容效果。方法2003年3月～2004年12月，收治先天性唇裂患儿26例，男14例，女12例。年龄10个月～11岁。其中双侧完全性唇裂13例，均伴双侧完全性腭裂；双侧不完全性唇裂9例，均无腭裂；混合性唇裂4例，均伴单侧完全性腭裂。应用原长法的原则进行唇裂整复，术中解剖口轮匝肌，复位后进行框式缝合；唇珠的形态由侧唇红唇肌肉瓣完成；红唇缘原有自然形态完整保存；同期初步矫正鼻畸形。结果术后患儿创而均Ⅰ期愈合。鼻底宽度及丰满度均较满意，唇弓形态好，无口哨畸形。上唇静态及动态时外形均较好。26例均获随访10d～3个月，双侧不完全性唇裂患儿有较好的鼻尖及鼻孔形态，均不需进行二期手术；双侧完全性唇裂患儿有一定的鼻尖及鼻孔形态，仅遗留鼻小柱过短；混合性唇裂患儿两侧鼻翼基脚稍不对称。结论双侧唇裂与鼻畸形同期整复时，对传统的整复方法进行优化组合，取长补短，并进行适当完善和修改，另加一定的缝合技巧，可在术后近期静态与动态均达到较满意的效果。     

Abbe’s瓣修复双侧唇裂术后继发畸形患者围手术期护理

目的:探讨Abbe’s瓣修复双侧唇裂术后继发畸形患者的围手术期观察与护理措施及效果。方法:回顾性分析2008年7月～2012年6月我科收治15例选用Abbe’s瓣修复双侧唇裂术后继发畸形患者的临床资料。结果:15例患者未出现术后并发症,唇交叉瓣成活,伤口愈合良好,鼻唇畸形得到矫正,功能外形大为改观,患者心理状态获得促进和最大程度的康复。结论:安全、有效的围手术期观察与护理是Abbe’s瓣修复双侧唇裂术后继发畸形手术成功与否的重要保证。     

Secondary bilateral cleft lip-nose deformity correction by rhinoplasty with simultaneous Abbe flap

Aim:

The purpose of this article is to review modification and outcome of secondary rhinoplasty along with Abbé flap for correction of secondary bilateral cleft lip deformity.

Materials and Methods:

A total of thirteen patients of secondary bilateral cleft lip-nose deformity having tight upper lip, lack of acceptable philtral column, Cupid''s bow definition, irregular lip scars, and associated nasal deformity were selected. All the patients received Abbé flap and simultaneous nasal correction. All cases were treated during a period of three years. Mean patient age at the time of the operation was 21 years, and ranged from 16 to 27 years. The average follow-up period was three years.

Results:

Assessment of results was based on comparing preoperative and postoperative clinical photographs done by surgeon and patient relatives and patient satisfaction questionnaires. The columellar lengthening and upper lip vermillion correction achieved was satisfactory. There were no perioperative complications such as airway obstruction, bleeding, infection, wound disruption, or flap necrosis.KEY WORDS: Abbe flap, bilateral cleft lip, rhinoplasty     

Bilateral cleft lip

The surgeon's objectives are normal nasolabial appearance and normal speech. The principles for synchronous repair of bilateral cleft lip have been established, and the techniques continue to evolve. Primary repair impairs maxillary growth, but little can be done at this time except to practice gentle craftsmanship and to minimize tension on the lower labial closure. The cutaneous lip should never be reopened for revision, and the number of secondary procedures involving the nasal cartilages should be kept to a minimum. Many adolescents with repaired bilateral cleft lip need maxillary advancement to improve projection of the nasal tip, to protrude the upper lip, and to attain normal sagittal skeletal harmony. With expected improvements in the technology of distraction osteogenesis, maxillary advancement may someday become as acceptable as orthodontic treatment.     

Comprehensive treatment of bilateral cleft lip by multidisciplinary team approach

Repair of bilateral cleft lip presents numerous problems, and in our opinion, it is better to begin treatment at the earliest age possible. At Fujita Health University Hospital, we utilise a multidisciplinary team approach to cleft lip. Nonsurgical correction of the nasal deformity using a nose retainer and preoperative orthodontics using a Kuwahara-modified Hotz's palatal plate begins soon after birth. Surgical repair of the lip is done within the first 2 months of life, by the time the nose, alveolus and projecting prolabium are adequately reformed. A one-stage surgical procedure, including restoration of muscle union, labial sulcus construction and nasal correction is performed. After lip repair, lip and tongue pressure are well balanced by the plate, and a good alignment of the alveolus can be achieved. A total of 27 cases of bilateral cleft lip were treated from August 1986 to October 1990. In all cases, the postoperative course was uneventful, and no complications due to early surgery were encountered.     

Unfavourable results in the repair of the cleft lip

Introduction:

Unfavorable results in unilateral and bilateral cleft lip repair are often easy to spot but not always easy to prevent as to treat. We have tried to deal with the more common problems and explain possible causes and the best possible management options from our experience.

Unilateral cleft lip repair:

Unfavorable results immediately after repair involve Dehiscence and Scaring. Delayed blemishes include vermillion notching, a short lip, deficiency in the height of the lateral vermillion on the cleft side, white roll malalignment, oro-vestibular fistula, the cleft lip nose deformity, a narrow nostril and a “high-riding” nostril. We analyze the causes of these blemishes and outline our views regarding the treatment of these.

Bilateral cleft lip:

Immediate problems again include dehiscence as also loss of prolabium or premaxilla. Delayed unfavorable results are central vermillion deficiency, a lip that is too tight, bilateral cleft lip nose deformity, problems with the premaxilla and maxillary growth disturbances. Here again we discuss the causation of these problems and our preferred methods of treatment.

Conclusion:

We have detailed the significant unfavorable results after unilateral and bilateral cleft lip surgery. The methods of treatment advocated have been layer from our own experience.KEY WORDS: Cleft lip nose, contractures, high riding nostrils, scarring, unfavourable results, vermillion deficiency     

Repair of unilateral cleft lip: the rotation-advancement operation

The most obvious deformity in a unilateral cleft of the lip is asymmetry of the lip and nose. Operation must repair the cleft, lengthen the lip, restore muscle continuity, and create an adequate labial sulcus. Simultaneous correction of the nasal deformity should be carried out to the greatest extent possible at the same time. The rotation-advancement repair has advantages over other repairs in scar placement, correction of the nasal deformity, and conservation of lip and nose tissue. If revision of the lip or nose is required, it can be accomplished more easily following the rotation-advancement repair than other techniques.     

Repair of the unilateral cleft lip/nose deformity

Successful surgical repair of the unilateral cleft lip and nose deformity, defined as normal orbicularis oris function and near-perfect symmetry of the repaired lip and nose, demands that the surgeon possess complete understanding of the embryology and anatomy of the midfacial defects. The surgical approach to repair of the unilateral cleft lip/nose should place great emphasis on achieving symmetry, not only with the lip segments but also perhaps even more importantly with the nasal tip. The reconstruction should recreate an intact fully functional orbicularis oris muscle across the cleft and camouflage the scar optimally. We have found that modification of the Millard rotation-advancement flap technique, with particular attention to the primary nasal repair, provides the best outcomes. In patients who have undergone primary repair of the lip and/or nose deformity, secondary rhinoplasty is generally required, regardless of the technique used at the primary repair. The degree of nasal deformity, however, is less severe following primary repair of the asymmetric nasal tip. We have found that the sliding flap cheliorhinoplasty, Wang's modification of the Vissarionov technique, provides excellent results for most secondary cleft rhinoplasties.     

Management of the cleft lip deformity

A congenital cleft lip is a deformity that has significant physical and psychologic impact. Many surgical repairs have been proposed for reconstruction of unilateral cleft lip deformities, including straight-line repairs and various forms of geometric flap repair. This article classifies cleft deformities and describes the history and specific techniques of unilateral cleft lip repair. Understanding and application of these techniques can aid the cleft surgeon in maximizing function and appearance of a child born with a cleft lip deformity.     

Critical choices in cleft surgery: 18-year single-surgeon retrospective review of 900 cases

Background

Multidisciplinary management of orofacial clefts may lead to a successful treatment outcome. However, it is quite usual that lack of long-term treatment planning and collaboration among various specialists and lack of standardized surgical protocols result in poor esthetic and functional treatment outcomes. This article aims to hypothesize some critical determinants of outcome in cleft surgery.

Methods

Throughout a period of 18 years, 900 patients with different clinical types of congenital cleft anomaly were subject to primary repair of cleft lip, nose, and palate by single surgeon using various procedures, including preoperative nasoalveolar molding, two-stage and one-stage repair of complete cleft lip and palate, two-flap and one-flap palatoplasty, open tip rhinoplasty, and postoperative nasal molding.

Results

Clinical results of preoperative nasoalveolar molding and surgical repair of lip, nose, and palate were satisfactory for most patients, parents, and surgeon panel.

Conclusions

Treatment based on the individual patient’s facial assets and deficits must be the controlling factor in designing therapy. The essential key to successful management of clefts is to figure out the three-dimensional dynamics that govern the deformity and to recognize a fourth dimension for time along these dynamics in order to envision how a small difference in the position of a single suture during the first surgery can bring about a giant deformity upon completion of facial growth, hence the crucial role of the first surgery and its related concepts, techniques, and tactics in dictating the final outcome of the case.Level of Evidence: Level IV, therapeutic study.

     

THE EFFECT OF MUSCLE REPAIR ON POSTOPERATIVE FACIAL SKELETAL GROWTH IN CHILDREN WITH BILATERAL CLEFT LIP AND PALATE

The effect of orbicularis muscle repair on postoperative facial skeletal growth in bilateral cleft lip and palate patients was studied by analysis of cephalometric radiographs and dental casts. Sixty-two patients operated on between 1961-1989 were selected for the study. They were divided into three groups, group 1a (muscle repair; n = 12), group 1b (failed attempt at muscle repair; n = 5), and group 2 (no attempt at muscle repair; n = 45). Comparison of the morphological measurements among these three groups showed that there was a trend towards crossbite in the muscle repair group, but this difference was not significant. Mechanisms by which muscle repair might influence maxillofacial skeletal growth include the possibility that the area around the nasal septum might be the growth centre. The choice of operative technique in bilateral cleft lip and palate should be important.     

The cleft lateral lip element: do traditional markings result in secondary deformities?

In cleft surgery, two methods have traditionally been used to mark the height of cupid's bow on the lateral lip element. One technique measures the distance from the oral commissure to the height of cupid's bow on the noncleft side, and transposes this distance onto the cleft-side lateral lip element. The second technique marks the height of cupid's bow on the cleft-side lateral lip element where the white roll disappears. The authors believe these techniques may result in deformities of residual cleft tissue in the repair. Marking the height of cupid's bow on the cleft-side lateral lip element, just before the attenuation of lip fullness, can prevent this deformity. A retrospective study yielded a series of 17 patients with secondary deformities of residual cleft tissue in their repair. The method used to mark the lateral lip element was determined by chart review. Patients then underwent secondary surgery with excision of residual cleft tissue, and repair using the initial technique. A random group of primary cleft patients, repaired using the authors' technique for marking the lateral lip element, was likewise evaluated for the presence of residual cleft tissue in the repair. Of the 17 cases of secondary deformities, 14 were unilateral and 3 were bilateral. Among the unilateral cases, seven were repaired with a triangular flap and seven by rotation advancement. The bilateral cases were repaired using the modified Millard technique. The lateral lip element was marked using cessation of the white roll in 8 patients, and the commissure to the height the of cupid's bow in 2 patients, whereas in 7 patients the method was unreported. Using the authors' technique, both "controls" repaired primarily and cases repaired secondarily resulted in no redundant cleft tissue. Average follow-up was 11 months (range, 1-41 months). The authors think that traditional markings for establishing the height of cupid's bow on the cleft lateral lip element may result in residual cleft tissue in the repair. This deformity can be prevented by marking the height of cupid's bow on the cleft lateral lip element just before the attenuation of lip fullness.     

Repair of the bilateral cleft lip deformity

The bilateral cleft lip is a complex deformity involving discontinuity of the soft tissue layers of the lip and, frequently, the underlying bony structure. Satisfactory repair requires a thorough understanding of the anatomic deformity. The authors' philosophy and timing of the bilateral cleft lip repair are discussed. Details of the surgical technique are outlined.     

Congenital Bilateral Lower Lip Pits Associated with Fistulae of the Minor Salivary Glands: Case Report of the Principal Van Der Woude Syndrome’s Trait

Background

Van der Woude syndrome (VWS; OMIM 119300) is an autosomal dominant developmental malformation presenting with bilateral lower lip pits related to cleft lip, cleft palate, and other malformations in about half the patients. These congenital lip pits appear clinically as a defect in the vermilion border of the lip. They are commonly related to fistulae of minor salivary glands with or without excretion. Usually the cause of cosmetic defects, VWS is preferably treated through simple excision. This report aims to describe a case of VWS involving a patient who presented with isolated congenital bilateral lower lip pits related to fistulae of the minor salivary glands, which were treated successfully through simple excision.

Case Report

A 5-year-old girl with a diagnosis of congenital bilateral lip pits associated with fistulae of minor salivary glands was treated successfully through simple excision. The diagnosis was confirmed by clinical examination, sialography, and scintigraphy. A good aesthetic result was observed after 2 years of follow-up evaluation.

Conclusion

Physicians must be aware of VWS because, although underreported and frequently not diagnosed, it is the most common cleft syndrome.