Upper Triangular Flap Method for Primary Repairs of Incomplete Unilateral Cleft Lip Patients. Minor to Two-Thirds Way Defects

Transcription

1 HEAD AND NECK SURGERY Upper Triangular Flap Method for Primary Repairs of Incomplete Unilateral Cleft Lip Patients Minor to Two-Thirds Way Defects Kyung S. Koh, MD, PhD,* Tae Suk Oh, MD,* and Jin Woo Song, MDÞ Abstract: Incomplete unilateral cleft lips show a wide range of deformities, ranging from microform to near-complete clefts. Because there are different amounts and qualities of tissue present on the cleft and nonycleft sides, surgical approaches should make distinctions based on the remnant tissue. A new procedure using an upper triangular flap that combines characteristics of both rotation advancement and straight line repair was applied and the surgical results were reviewed. Between June 2007 and April 2011, 28 patients with minor to two-thirds way unilateral cleft lips [minor (n = 12), one-third (n = 2), halfway (n = 11), and two-thirds way (n = 3)] were subjected to the upper triangular flap method. The patients ranged in age from 62 days to 6 years (mean, 9 months). The average follow-up period was 25 months (range, 12Y60 months). The repairs were successful in all 28 patients without complications. The scar was acceptable because it ran along the vertical philtral columns. During the follow-up period, long lip deformities and Cupid bow drooping were not observed in any of the patients. However, misalignment of the white skin roll was observed due to insufficient rotation at the cleft side in 1 patient. The repairs of minor to two-thirds way unilateral cleft lips using the upper triangular flap method allowed for a symmetric Cupid bow and philtrum. Moreover, this method allowed for satisfactory nostril sill reconstruction with acceptable scarring. The upper triangular flap method is recommended as an alternative to conventional methods for repair of minor to two-thirds way incomplete unilateral cleft lips. Key Words: incomplete cleft lip, upper triangular flap (Ann Plast Surg 2015;74: 318Y323) Surgical methods for repairing unilateral cleft lips have advanced continuously during the past few decades. 1Y5 Although many studies report the restoration of philtral structures when repairing unilateral cleft lips, 6,7 plastic surgeons still have difficulties when attempting to preserve the symmetric philtrum. Furthermore, most of these reports are about subjects with complete unilateral cleft lips; however, there are many patients with incomplete cleft lips that have some normal philtral structures. Therefore, different surgical methods must be applied depending on the degree of the cleft in the patient. Also, parents of patients with lesser degrees of cleft lip defects have higher expectations of surgical outcomes, so more discretion must be used when choosing the primary repair method, and more elaborate surgical skills may be required. Received December 25, 2012, and accepted for publication, after revision, April 5, From the *Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine; and Department of Plastic Surgery, Inje University, Seoul Paik Hospital, Seoul, Korea. Conflicts of interest and sources of funding: none declared. Reprints: Kyung S. Koh, MD, PhD, Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, poongnap 2-dong, Songpa-gu, Seoul , Korea. kskoh@amc.seoul.kr. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal s Web site ( Copyright * 2013 Wolters Kluwer Health, Inc. All rights reserved. ISSN: /15/ DOI: /SAP.0b013e318295dceb Various techniques have been used for incomplete unilateral cleft lip repairs. According to a survey by the American Cleft Palate- Craniofacial Association and the Canadian Society of Plastic Surgeons, 8 most surgeons (86%) prefer either the rotation-advancement method or a modified form of this method. The lower triangular flap method placed second with 6%, but this method destroys anatomical landmark tissues including Cupid bow. 9 Furthermore, although straight line repair is still used by some surgeons due to its simplicity and several aspects of its surgical legitimacy, only 2% of surgeons chose straight line repair as their preferred management tool for unilateral incomplete cleft lip. The rotation advancement technique results in distortion of the upper third of repaired lips, and the lower lip triangular flap method for medial lip lengthening disrupts normal anatomical landmark tissues, including Cupid bow, when repairing unilateral incomplete cleft lips. 9 In this study, a modified method for incomplete cleft lip repair is proposed that restores normal philtral structures and preserves lower lip anatomical landmarks. We term this the upper triangular flap method. This method was successfully used for patients with minor to two-thirds way incomplete unilateral cleft lips. PATIENTS AND METHODS Between June 2007 and April 2011, 28 patients with minor to two-thirds way unilateral cleft lips underwent repair using the upper triangular flap method. Yuzuriha and Mulliken 10 originally defined minor-form cleft as having a notched vermilion-cutaneous junction extending 3 mm or more above the normal Cupid bow peak. The patients ranged in age from 62 days to 6 years at the time of operation, with a mean age of 9 months. Except for 2 asymmetric bilateral cases, the clefts were on the right side in 6 cases and on the left side in 20 cases (Table 1). Eight patients had alveolar clefts in addition to cleft lips. The degrees of the clefts were as follows: minor (n = 12, 43%), one-third (n = 2, 7%), halfway (n = 11, 39%), and two-thirds way (n = 3, 11%). The senior author performed all of the operations. Three patients who were older than 1 year were subjected to operations. Operation Procedure The method involved first marking the superior peaks of Cupid bow on both the cleft and nonycleft sides. The vertical heights of the nonycleft side from the superior peaks of Cupid bow to the bases of the columella, and of the cleft side from the superior peaks of Cupid bow to the nostril sills were measured. The differences between the vertical heights of the cleft side and nonycleft sides were defined as the base lengths of the triangular flaps. Figure 1 illustrates and explains the details of operative markings. After adequate rotation of the medial segments, the triangular flaps were inserted into the gaps that were created near the bases of the columella. The muscles were released in a subdermal plane, and the detached muscles should be rotated down and then subsequently reoriented and repaired. Mucosal flaps were made from the mucosal sulci of the medial and lateral segments, and were repaired together without excess tissue. The triangular vermillion flaps were created on the lateral segments, Annals of Plastic Surgery & Volume 74, Number 3, March 2015

2 Annals of Plastic Surgery & Volume 74, Number 3, March 2015 Upper Triangular Flap Method TABLE 1. Characteristics of Patients Patients No. Age Follow-Up, mo Cleft Side Cleft Degree Alveolar Cleft Complications 1 87 d 60 Left Halfway Absent 2 76 d 45 Asymmetric bilateral (right: minimal) Halfway Absent 3 12 mo 35 Left Minor Absent 4 70 d 34 Right Halfway Present 5 68 d 32 Left Minor Present 6 4 mo 32 Left Minor Absent 7 8 mo 32 Right Minor Absent 8 6 y 32 Right Minor Absent 9 72 d 21 Left One-third Absent d 44 Left Halfway Absent d 30 Right Two-thirds Absent d 30 Right Minor Present 13 2 y 10 mo 25 Left Minor Present d 22 Left Halfway Absent 15 4 y 10 mo 20 Left Minor Absent 16 3 m 26 Left Minor Present 17 9 m 17 Left Minor Absent d 21 Asymmetric bilateral (right: microform) Two-thirds Absent d 18 Left Halfway Absent 20 4 mo 17 Left Halfway Absent d 15 Left Minor Absent d 12 Left Minor Absent d 13 Left Halfway Present d 12 Left Halfway Absent d 10 Left One-third Absent d 12 Left Two-thirds Present d 13 Right Halfway Absent d 12 Left Halfway Present White skin roll misalignment and were inset into the opening incisions along the red lines of the medial segments. Finally, the skin was repaired and a nasal retainer (Koken Co Ltd, Tokyo, Japan) was inserted into the nostrils (see supplemental digital content, video 1, RESULTS The upper triangular flap method was used to repair minor to two-thirds way incomplete unilateral cleft lips in 28 patients. The average follow-up time was 25 months, and ranged from 12 to 60 months. Satisfactory results were seen in all but 1 case, where white skin roll misalignment was observed. Postoperative complications, such as wound dehiscence and widened scarring, were not observed in any of the patients. Similarly, none of the patients developed long lip deformities during the follow-up period. The heights and shapes of the nostril sills were well maintained. Surgical results were not different between the older and younger groups. DISCUSSION Regarding selection of surgical procedures when treating patients with unilateral cleft lips, Thompson 11 wrote that all cleft lip surgeons have their favorite surgical technique for repairing the unilateral cleft lip. It is usually a hybrid of training, experience and imagination. However, all procedures should adhere to 1 dogmatic goal, which is the restoration of normal anatomical landmarks. This is the most important outcome of cleft lip repairs and is a requirement of all the different surgical procedures without exception. Incomplete unilateral cleft lips are characterized by distinctive anatomical conditions when compared with complete cleft lips. The entire thickness of the tissue always consists of the skin, subcutaneous, and muscular tissues on the cleft side, even if the elements are variable due to the degree of the cleft. 12 Currently, most surgeons use the rotation-advancement method to repair incomplete unilateral cleft lips. However, if the rotation-advancement method is applied to patients with minor to two-thirds way unilateral cleft lips, it can result in a distorted upper-third of the philtrum, because an abundance of tissue is present on the upper part of cleft side relative to the more severe forms of cleft. A survey examining long-term subjective and objective assessments of resultant scarring in patients who had undergone Millard repairs of their unilateral cleft lips without revisional surgeries showed that 50% were unhappy with the upper third, and 35% were unhappy with the lower-third of their scars. 13 Nakajima published a modified form of the straight line repair method, 14,15 but this technique is also unsuitable for incomplete cleft lips requiring large amount of rotation at the medial lip segments to achieve symmetric upper lips. 16 In addition, the straight line scar that runs from the sill to the lip sometimes seems to be a rhinorrhea that is running directly from the nose as it has a glistening whitish nature. Breaking the straight line with the addition of an upper triangular flap can solve this problem. Onizuka 17 performed unilateral cleft lip operations with the rotation-advancement method combined with a small triangular flap above the white skin roll to reduce the back-cut. However, if incomplete cleft lips were repaired based on the philtral length of the cleft sides, then lip drooping was observed. 18 * 2013 Wolters Kluwer Health, Inc. All rights reserved

3 Koh et al Annals of Plastic Surgery & Volume 74, Number 3, March 2015 FIGURE 1. Above, left, Intraoperative illustration (a, columellar base; b, nonycleft side white skin roll upper border; c, cleft side nostril sill; d, the lowest point of the upper triangular flap; e, cleft side white skin roll upper border; f, the corresponding point of the triangular apex on the nonycleft side; g, nonycleft side white skin roll lower border; h, cleft side white skin roll lower border). The difference between the lip heights of the cleft and nonycleft side corresponds to the base length of triangle. The distance between b and g matches with the distance between e and h, between a and b matches with between d and e, and the distance between f and a matches with that between c and d. The line af is similar to the usual rotation advancement incision for nonycleft side. On the line ce, the base of upper triangle flap cd is marked, the length of which equals to the difference between line ce and line ab. Above, right, Preoperative design of upper triangular flap. Below, left, Intraoperative photograph. Below, right, Immediate postoperative photograph. Triangular flaps and several variations have been used for years, and Mirault is usually considered to be an original advocate of the lateral triangular flap. However, he used triangular flaps from both the medial and the lateral side of the clefts with various designs. Marks and colleagues credit Tennison for presenting a different but practical approach with his triangular operation. Millard makes a point of bringing the normal Cupid bow into the proper position with an incision into the superior portion of the lip using an advancement flap from the lateral aspect. The results of this method are excellent for narrow clefts. Finally, Skoog uses a triangular flap in both the superior and inferior portions. 4 The lower triangular flap method has the advantage of tissue lengthening, but it also reported to have several disadvantages. First, the triangular flap could violate the potential vertical philtral columns and dimples. Second, nasal deformities cannot simultaneously be corrected, as a large amount of tissue is discarded to advance the alar base to the correct medial position. If the unilateral short vertical height of the columella is not corrected, then a nostril sill will not be created. Third, patients who undergo cleft repair with a triangular flap at the vermilion border may end up with an elongated white lip on the cleft because of postoperative growth of the triangular flap itself. 19 The upper triangular flap method applied here adapted contemporary trends for conserving tissue and preserving the symmetric philtrum (Fig. 2). It combined the advantages of the rotationadvancement method for the medial side and of straight line repair for the lateral side. Although lower triangular flaps are made in the lower part of the cleft where tissue is scarce, the upper triangular flap borrows tissue from the upper part of the cleft where sufficient tissue is present. In 3 infants with two-thirds way cleft lips, there was sufficient tissue to be used as a triangular flap on the upper lip, so the upper triangular flap method could be used (Fig. 3). Thus, upper triangular flap repairs are possible whenever there is sufficient upper lip tissue to use when forming the flap. In cases with insufficient muscle release or splitting of the medial segment during cleft repair, short lips or step deformities of * 2013 Wolters Kluwer Health, Inc. All rights reserved.

4 Annals of Plastic Surgery & Volume 74, Number 3, March 2015 Upper Triangular Flap Method FIGURE 2. Left, A preoperative photograph which shows the well-preserved philtral structures of the cleft side. Right, A photograph taken 12 months after the operation shows preservation of the philtral structures on the repaired side. FIGURE 3. The patient had a two-thirds way incomplete unilateral cleft on his left side. Left, A preoperative photograph. Right, A photograph taken 9 months after the operation shows the successful results. FIGURE 4. The patient underwent cleft lip repair using the upper triangular flap method. Left, A preoperative photograph shows the cleft. Right, A photograph taken 11 months after the operation shows a white skin roll misalignment due to insufficient rotation of nonycleft side. * 2013 Wolters Kluwer Health, Inc. All rights reserved

5 Koh et al Annals of Plastic Surgery & Volume 74, Number 3, March 2015 FIGURE 5. Above, left, A preoperative photograph. Above, right, A photograph taken 6 months after the operation. Below, A photograph taken 3 years after the operation. the white line can occur due to insufficient rotation (Fig. 4). These problems can later be corrected with small triangular flaps in the lower lips. Upper triangle flaps should not be inserted into the nostril sills, but rather into the rotation gaps beneath the bases of the columella. This allows for stabilization of the length of the medial side, and correct alar flaring. Discarding of excess tissue when excising the poor-quality cleft marginal tissue to achieve a balanced lip should be done with great care. This allows for approximation of the medial and lateral lip elements to be achieved without loss of landmarks. 20 Drawing triangular limbs with calipers makes it possible to get consistent and reliable immediate postoperative results. However, despite the upper position of the triangle flaps, long-term follow-ups are necessary to confirm whether the repaired lips grow beyond the normal length (Fig. 5). CONCLUSIONS Minor to two-thirds way unilateral cleft lips can be repaired with an upper triangular flap method. Our method results in the formation of a symmetric Cupid bow and avoids damaging the vertical philtral ridges and dimples. In addition, the resulting scar is relatively inconspicuous when compared to scars obtained with other methods, as it is the mirror image of the philtral ridge on the nonycleft side. Long-term results should be followed to check long lip deformities and Cupid bow drooping as the lips grow. The upper triangular flap method overcomes the flaws of other methods, and provides successful results when used to repair minor to two-thirds way unilateral cleft lips. REFERENCES 1. Mirault G. Deux lettres sur l operation du bec-de-lievre. J Chir (Paris). 1844;2: Thompson J-E. An artistic and mathematically accurate method of repairing the defect in cases of harelip. Surg Gynecol Obstet. 1912;14:147Y Tennison C-W. The repair of the unilateral cleft lip by the stencil method. Plast Reconstr Surg. 1952;9:115Y Randall P. A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast Reconstr Surg Transplant Bull. 1959;23:331Y Millard D-R. A radical rotation in single harelip. Am J Surg. 1958;95:318Y Salomonson J. Preserving aesthetic units in cleft lip repair. Scand J Plast Reconstr Surg Hand Surg. 1996;30:111Y Song R, Liu C, Zhao Y. A new principle for unilateral complete cleft lip repair, the lateral columellar flap method. Plast Reconstr Surg. 1998;102:1848Y1852; discussion 1853Y Sitzman T-J, Girotto J-A, Marcus J-R. Current surgical practices in cleft care: unilateral cleft lip repair. Plast Reconstr Surg 2008;121:261eY270e. 9. Millard D-R. Cleft Craft: The Evolution of Its Surgery. Vol. 1. Boston, Ma: Little, Brown; 1976: Yuzuriha S, Mulliken J-B. Minor-form, microform, and mini-microform cleft lip: anatomical features, operative techniques, and revisions. Plast Reconstr Surg. 2008;122:1485Y * 2013 Wolters Kluwer Health, Inc. All rights reserved.

6 Annals of Plastic Surgery & Volume 74, Number 3, March 2015 Upper Triangular Flap Method 11. Thompson H-G. Unilateral cleft lip repair. Oper Tech Plast Reconstr Surg. 1995;2:175Y Nishimura Y. The philtrum and unilateral cleft lip. Chir Plast. 1979;4:273Y Christofides E, Potgieter A, Chait L. A long term subjective and objective assessment of the scar in unilateral cleft lip repairs using the Millard technique without revisional surgery. J Plast Reconstr Aesthet Surg. 2006;59:380Y Nakajima T, Yoshimura Y. Early repair of unilateral cleft lip employing a small triangular flap method and primary nasal correction. Br J Plast Surg. 1993;46:616Y Nakajima T, Yoshimura Y, Yoneda K, et al. Primary repair of an incomplete unilateral cleft lip: avoiding an elongated lip and achieving a straight suture line. Br J Plast Surg. 1998;51:511Y Koh K-S, Choi J-W, Kim H. Minimal paring of skin flaps for primary repair of incomplete unilateral cleft lip. Plast Reconstr Surg. 2008;121: 1382Y Onizuka T. A new method for the primary repair of unilateral cleft lip. Ann Plast Surg. 1980;4:516Y Nakajima T, Tamada I, Miyamoto J, et al. Straight line repair of unilateral cleft lip: new operative method based on 25 years experience. J Plast Reconstr Aesthet Surg. 2008;61:870Y Saunders D-E, Malek A, Karandy E. Growth of the cleft lip following a triangular flap repair. Plast Reconstr Surg. 1986;77:227Y Fisher D-M, Sommerlad B-C. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg. 2011;128:342e. * 2013 Wolters Kluwer Health, Inc. All rights reserved