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.     

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.     

A comparative study of maxillary growth following rotation-advancement and triangular flap unilateral cleft lip repairs: an experimental study in rabbits

The present study was designed to investigate 2 features of maxillary growth following Millard rotation-advancement and Tennison triangular flap cleft lip repairs in rabbits with surgically created defects simulating unilateral cleft lip and cleft alveolus. Sixty purebred New Zealand rabbits were used in this experiment. The animals were divided into 4 groups: 2 control groups (unoperated and unrepaired) and 2 experimental groups (lip repair with rotation-advancement and lip repair with triangular flap). Nineteen metric cranial variables were measured directly from the cleaned skulls. Direct cephalometric measurements were taken in the following dimensions: maxillary length, width and height, posterior facial width, and nasal deflection. Significant differences were noted between Millard rotation-advancement group and Tennison triangular flap group in 2 of 6 measurements of maxillary length. Analysis of variance revealed significantly statistical differences between Millard rotation-advancement group and Tennison triangular flap group in 3 of 6 measures of maxillary width. Analysis of variance revealed no significantly statistical differences between Millard rotation-advancement group and Tennison triangular flap group in maxillary height. Statistical differences were noted between Millard rotation-advancement group and Tennison triangular flap group in posterior facial width. There was no significantly statistical difference between Millard rotation-advancement group and Tennison triangular flap group for the nasal deflection measurements. The results of this study indicated that the features of maxillary growth were different between the 2 lip-repair techniques in rabbits with surgically created defects simulating unilateral cleft lip and alveolus.     

A comparative study of surgical results with rotation-advancement and triangular flap techniques in unilateral cleft lip

This paper presents a randomised comparative study of surgical results of unilateral cleft lip repair with 58 rotation-advancement and 50 triangular flap repairs, the two commonly used types of repair at present, carried out over a period of 6 years. The surgical results following both repairs were assessed on a scoring basis. No significant difference was found in overall postoperative appearance of lip and nose between the two types of repair. As a result, we recommend either technique for unilateral cleft of the lip.     

Unilateral complete cleft lip repair: orthotopic positioning of skin flaps.

The ideally repaired cleft lip should provide a symmetrical Cupid's bow, philtrum, and minimal scar. In the appearance of the upper lip, the philtrum plays a key role. The most popular method for unilateral cleft lip repair is the rotation-advancement technique introduced by Millard. This technique requires the rotation of the noncleft side flap in unilateral cleft lip. As the vertical discrepancy between the peaks of Cupid's bow is increased, the scarring becomes more evident. Also, where it crosses the philtral column in the oblique extension of the upper lip, it becomes apparent for the eye to notice. Thus, many surgeons have tried to modify this technique to improve the symmetry of the philtral columns. The philtral dimple is composed of centrally located thin dense subcutaneous tissue bordered by thick loose subcutaneous tissue producing the philtral columns laterally. The aim of this surgical modification is to form a more natural looking philtrum using its original anatomical structure. The tissue defect after rotation of the noncleft side flap is filled with the C flap, not the advancement skin flap from the cleft side. The C flap helps to form the upper philtral column into a more straight appearance. The skin flaps of the cleft side and noncleft side are placed either side of the philtral column, and the skin flap from the columella is not used for the repair of the philtrum. Twenty-five patients with unilateral complete cleft lip were repaired using this technique from 1996 to 1999. Adequate alignment of the Cupid's bow and symmetric philtral appearance were obtainable.     

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.     

Straight line repair of unilateral cleft lip: new operative method based on 25 years experience.

The resultant scar in the primary repair of unilateral cleft lip should ideally be straight and the mirror image of the philtrum on the non-cleft side. In 1993, we reported a new operative technique for unilateral cleft lip, in which we designed a straight line for the incision on the white lip. In order to produce the nostril floor, we used the white lip tissue in the area between the alar base and alveolus at the cleft side as a flap. We also used a small triangular flap above the white skin roll to prevent Cupid's peak from being drawn up. Unlike the rotation-advancement method, our technique does not leave a transverse scar at the alar base. Instead, it leaves a scar only along the line coincident with the natural philtral ridge. However, during observations of our patients, we noticed that the small triangular flap designed to be 1.5mm tended to become a conspicuous angular scar as the patients grew older. In addition, drooping of Cupid's peak on the cleft side was often observed with this small triangular flap. To make it less conspicuous, we made some modifications to the small flap above the white skin roll. With this new technique, we designed a semi-circular flap (1.5 x 3mm) above the white skin roll, instead of the small triangular flap. The suture line of our refined procedure draws a gentle curve, which looks almost straight because of skin elasticity. Moreover, the semi-circular flap causes less drooping of the upper lip than the triangular flap. We believe that revising the shape of the small flap on the white skin roll greatly improves patients' appearance. In this report, we present our refined techniques of primary repair of unilateral cleft lip.     

红唇粘膜瓣修复单侧唇裂术后继发红唇畸形

目的：探求一种新的矫正单侧唇裂术后继发畸形的手术方法。方法：应用红唇粘膜瓣技术矫正单侧唇裂术后继发畸形中的红唇畸形。结果：所有病例术后全部一期愈合,无粘膜瓣坏死,术后红唇形态满意。结论：红唇双叶瓣技术可以同时矫正口哨样畸形,加强唇珠形态,减薄裂隙外侧红唇粘膜厚度等多种红唇畸形,术后效果确切,值得推广。     

单侧唇裂修复同期鼻畸形矫正术

目的 探讨在修复伴有鼻畸形的先天性唇裂时,同期一次性矫正鼻部畸形,以最大程度地减少唇裂术后继发性鼻畸形发生的手术方法.方法 采用Millard术式或Millard术式＋三角瓣插入法,同时利用唇裂手术切口入路恢复大翼软骨、鼻肌及鼻小柱的正常解剖位置以矫正鼻畸形.结果 共修复单侧唇裂108例,术后随访1个月至3年,效果满意.结论 所有单侧唇裂均伴发鼻畸形,在唇裂修复同期进行鼻畸形的矫正,可获得即刻的手术效果和较为满意的远期疗效,并可能减少再次手术及手术难度.     

红唇双叶瓣修复单侧唇裂术后继发红唇畸形

目的:探索一种新的操作简单、实用性强的修复单侧唇裂术后继发红唇畸形的手术方法.方法:设计红唇双叶瓣矫正单侧唇裂术后红唇畸形.结果:所有病例术后切口均甲级愈合,旋转固定的唇粘膜瓣色泽红润血运良好,左右侧红唇组织厚度一致,口哨样畸形消失,唇珠明显.结论:应用红唇双叶瓣法可以同时矫正两侧红唇厚薄不均、口哨样畸形及唇珠不明显等多种唇裂术后继发红唇畸形,方法简洁,术后效果确切,是可行的且较理想的手术方法,值得推广.     

榫卯型口轮匝肌肌瓣修复单侧唇裂术后继发人中嵴畸形

目的探讨榫卯型口轮匝肌肌瓣修复单侧唇裂术后继发人中嵴畸形的疗效。方法 2009年1月-2011年8月,收治43例单侧唇裂修复术后继发人中嵴畸形患者。男23例,女20例;年龄18～31岁,平均23.6岁。左侧26例,右侧17例。唇裂采用MillardⅠ式修复15例,MillardⅡ式修复28例。唇裂修复术至此次手术时间为15～30年,平均21.7年。术中切取双侧口轮匝肌肌瓣,水平分成上、下两层;双侧下层肌瓣相互重叠缝合,上层肌瓣形成榫卯型结构,缝合于皮下。结果术后患者切口均Ⅰ期愈合。40例患者获随访,随访时间6～34个月,平均13.4个月。双侧人中嵴隆起、对称,人中凹形态接近正常,上唇动态效果满意。术后6个月38例明显改善,2例改善不明显。结论榫卯型口轮匝肌肌瓣手术操作简便,修复单侧唇裂术后继发人中嵴畸形能较好恢复解剖结构,术后获得良好上唇外形和功能。     

转移粘膜肌瓣加深前庭沟术式在单侧唇裂修复中的应用

目的:探讨一种转移健侧粘膜肌瓣加深前庭沟减少皮肤切口的术式在单侧唇裂修复中的临床效果。方法:利用裂隙健侧粘膜肌瓣加深前颌部前庭沟,达到延长健侧唇高恢复唇珠外形的目的,解剖复位口轮匝肌,矫正鼻唇畸形,减少皮肤切口及瘢痕。结果:采用该术式修复单侧唇裂44例,经1~2年随诊,患者唇部皮肤瘢痕不明显,唇弓唇珠外形满意,鼻小柱偏斜鼻翼外侧脚移位得到矫正,前颌部前庭沟深度增加。结论:该手术设计在单侧唇裂修复中值得推广。     

Anatomical study and improvement of rotation-advancement method in repair of cleft lip]

A new method of cleft lip repair, based on anatomical research of levator septi nasi and a peach-shaped musculocutaneous flap has been designed. The special features of this method are: 1. A small peach-shaped musculocutaneous flap is used as Millard's "c" flap, 2. all skin incisions are made on the edge of the cleft, 3. rotation-advancement repair is applied in the muscle layer. 32 patients have been followed for 6 years after the operation.     

应用双侧红唇瓣推进修复单侧唇裂术后继发红唇畸形

目的：探讨应用双侧红唇瓣推进修复单侧唇裂术后继发红唇畸形的临床效果。方法：切除红唇瘢痕畸形后,沿缺损两侧红白唇交界线切开并游离两侧正常红唇粘膜肌瓣,长度一般为1～2cm,向缺损区推进修复缺损。结果：术后患者唇弓形态完整良好,红唇丰满,手术瘢痕不明显。结论：在适应证选择适当的情况下,应用双侧红唇瓣推进修复单侧唇裂术后继发红唇畸形,方法简便,效果良好。     

A new technique for perioral muscle reconstruction and lip lengthening in complete unilateral cleft lip

BackgroundAdequate skin lengthening and symmetry may not be consistently obtained in unilateral cleft lip repair, especially in patients with complete cleft. The purpose of this study was to present the model of muscle dissection and approximation to facilitate lip lengthening and symmetry.MethodsThe design followed the rotation-advancement (RA) method without skin measurement. A curvilinear skin incision was made from subnasale to the Cupid's bow peak (CBP). Muscle dissection was continued to the contralateral nostril floor beneath the columellar base to facilitate downward rotation in the medial lip. Wide muscle dissection was performed in the lateral lip segment from the nasal mucosa passing the alar base. The lateral lip muscle was advanced and sutured to the medial lip muscle in a Z-plasty fashion. A small skin backcut was made above the CBP. Primary nasal correction was performed. A series of 138 patients with complete unilateral cleft lip and palate were included in this study. Standard photographs were collected for measurement in the nasolabial region.ResultsAdequate lengthening and symmetry of the lip was obtained. The ratio of vertical philtral height was 0.99±0.05 between the cleft and noncleft sides. The C flap was used for supplementary skin lengthening in 58% of cases. Postoperative lip retraction requiring massage occurred in 13%. Overall nasolabial appearance was satisfactory.ConclusionThe new technique of perioral muscle reconstruction facilitated to obtain lip lengthening and symmetry in the repair of complete unilateral cleft lip.     

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.     

单侧唇裂继发畸形整复术的术式改良

目的 探讨改良术式修复单侧唇裂术后继发唇、鼻畸形的效果.方法 手术切几线与口鼻轮廓线相一致,片使鼻翼外侧脚整体旋转复位,重建鼻槛及鼻底,通过鼻腔的V-Y黏软骨瓣使鼻翼软骨上推,矫正鼻畸形.结果 自2000年以来,应用此方法对69例单侧唇裂继发唇、鼻畸形患者进行了修复,均取得较满意的效果,术后瘢痕线不明显.结论 轮廓线切口以及鼻翼软骨上推复位的方法符合唇、鼻的解剖特征,是一种较好的手术方法.     

下鼻甲粘骨膜瓣在完全性唇裂鼻底修复中的应用体会

目的:探讨裂隙较宽的完全性唇裂整复术中鼻底修复的方法改进。方法:设计蒂在下的下鼻甲粘骨膜瓣,唇部切口按长庚法设计,制作下鼻甲粘骨膜瓣,患侧颊粘膜瓣及健侧唇"C"粘膜肌瓣共同修复完全裂开的鼻底。结果:127例完全性唇裂患者中,98例为单侧,29例为双侧,术后创口均甲级愈合,鼻底封闭良好,鼻外形矫正到位,左右基本对称。讨论:下鼻甲粘骨膜瓣制作简单,损伤小,能促使裂侧鼻翼外角自由内收,术后无异常并发症,是完全性唇裂鼻底良好修复的一种有效方法。     

鼻黏膜软骨瓣Z成形术修复单侧唇裂继发严重鼻畸形

目的 探讨一种单侧完全性唇裂继发严重鼻畸形的修复方法.方法 根据健侧鼻翼饱满度,于患侧鼻翼凹陷区做Z成形术设计,形成上下两鼻翼黏软骨瓣,通过交错换位,整体延长了短缩的患侧鼻翼软骨瓣的长度,再将重组的患侧鼻翼与健侧悬吊,恢复患侧鼻翼正常的解剖形态,以达到鼻畸形修复的目的.结果 12例单侧唇裂继发严重鼻畸形的患者术后两侧鼻翼饱满、对称,两侧鼻孔形态接近,外形满意.结论 患侧鼻翼黏膜软骨瓣Z成形术,对于修复严重的单侧完全性唇裂继发鼻畸形是一种良好的术式选择.     

A geometrically sound technique of vermilion repair in unilateral cleft lip.

In unilateral cleft lip, there is always a deficiency of vermilion on the medial side of the cleft, which can be augmented by techniques using excess vermilion from the lateral side of the cleft, like the use of a simple V-advancement flap. We developed a modification of Noordhoff's lateral vermilion flap that preserves the parallel relationship of the muco-vermilion line and the white roll but improves results in unilateral cleft lip patients. In a study of 30 patients undergoing surgical repair of complete unilateral cleft lip, we found that this method offers a superior alternative to the straight-line repair. This geometrically sound technique for vermilion reconstruction offers the cleft surgeon a simple and effective method for augmenting total lip height and creating a normal appearing Cupid's bow.