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British Journal of Oral and Maxillofacial Surgery 56 (2018) 621–625

Reconstruction of the oral commissure in patients with

unilateral transverse facial cleft
M. Tuersunjiang, X. Long, Y. Fu, J. Ke, H. He, J. Li ∗
Department of Oral and Maxillofacial Surgery, The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key
Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, #237 Luo Yu Road, Wuhan, Hubei, PR China

Accepted 29 June 2018

Available online 13 July 2018

Abstract

The normal commissure is not a simple joint of the upper and lower lip, but a triangular mucosal area. To reconstruct a symmetrical
oral commissure in patients with a unilateral transverse facial cleft, we designed composite vermilion flaps, including triangular flaps. We
retrospectively studied 17 patients with unilateral transverse facial clefts from 2013–2016. Three-dimensional images were obtained with a
3-dimensional photogrammetry system at the 1-year follow-up, and we used an anthropometric method to evaluate the postoperative symmetry
of the commissure. No obvious deformity was found during the follow-up examination, and comparison of the cleft and non-cleft sides by
the paired samples t test showed that in all cases both horizontally and vertically symmetrical commissures had been achieved.
© 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: unilateral transverse facial cleft; trigone of the commissure; Commissuroplasty; composite vermilion flaps

Introduction
A transverse facial cleft, also referred to as a Tessier 7 cleft, is
a relatively rare congenital malformation.1 It has a frequency
of 1:80 000 live births and is seen in every 100–300 facial
clefts.1,2 It results from the failure of mesodermal migration
or merging to obliterate the embryonic grooves between the
maxillary and mandibular prominences during the fourth and
fifth weeks of the embryonic phase of gestation.3 The extent
of the cleft is variable, and ranges from slight elongation
of the commissure to a stomal opening that approaches the
auditory canal, but from the side to the oral corner is more
common.4,5
∗ Corresponding author.
E-mail addresses: 2015283040089@whu.edu.cn (M. Tuersunjiang),
longxing@whu.edu.cn (X. Long), fuychuan@163.com
(Y. Fu), kejin@whu.edu.cn (J. Ke), 1403637559@qq.com (H. He),
lijian hubei@whu.edu.cn (J. Li).
Many people have had good results in repairing the trans-
verse facial cleft and gone on to study them in more detail.
Such papers have focused mainly on localising the new
commissure, and reconstructing the orbicular oris muscles.
However, papers about correction of the shape of the com-
missure are less common, because it is difficult to reconstruct
as a result of its unique and delicate anatomical structure.
We have noted that the normal commissure is not a simple
connection of the upper and lower lip, but a smooth triangu-
lar area that consists of segments in line. The patients who
we have operated on had the operation at about the age of
six months, and are followed up for a year. During the oper-
ation, we design composite vermilion flaps to construct an
oral commissure, reconstruct the muscle by overlapping and
joining it, and put in a skin suture with a small S-plasty along
the nasolabial fold. The anthropometric measurement of 3-
dimensional images was used to evaluate the symmetry of the
commissure after repair, and showed that we had obtained
anatomically reasonable results with this technique. Here we

https://doi.org/10.1016/j.bjoms.2018.06.020
0266-4356/© 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
622 M. Tuersunjiang et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 621–625
Fig. 1. Design of the new commissure and the composite vermilion flaps.
Fig. 2. Markings for repair of a unilateral transverse facial cleft.
describe the anatomy of the trigone of the commissure, and
its reconstruction.
Patients and methods
Between 2013 and 2016 we studied 17 patients with unilat-
eral transverse facial clefts, who had been operated on by
the corresponding author (JL). There were eight boys and
nine girls, mean (range) age 6 (4–12) months. Seven had a
cleft of the right lip and 10 of the left lip, and the extent of
the clefts varied from 5–20 mm long. No patient had a fam-
ily history of congenital facial deformities, or a history of
prenatal exposure to radiation or teratogenic drugs.
Surgical technique
The unilateral transverse facial cleft is repaired using com-
posite vermilion flaps to construct the commissure. Under
general anaesthesia, the points of the new commissure, C
and C’, are established by reference to the distance from the
commissure on the normal side to the midpoint of the Cupid’s
bow (Figs. 1 and 2). The reconstructed commissure is posi-
tioned 3–4 mm medially to provide balance for postoperative
retraction of the scar and the reconstructed position of the
commissure. The composite vermilion flaps, which involve
the triangular flaps, are designed to avoid a suture scar at the
point of the commissure. The horizontal incision lines along
the vermilion-cutaneous junction are drawn from the points
C and C’ to meet at points D and D’. The lines from D and
D’ are drawn to meet the base of the triangular flaps.
After injection of epinephrine-saline solution (1:200,000),
we make the horizontal and perpendicular incisions. They
allow the postoperative suture to be separated from the new
commissure, and contribute to closure of the skin without
tension. The vermilion flap is then dissected from the surface
of the orbicularis oris muscle, which is fully exposed and cut
off transversely at 4–5 mm. The zygomatic major and riso-
rius muscles, respectively, are separated and released. After
dissection, the muscle bundles are overlapped, with the supe-
rior muscle bundle placed over the inferior bundle, to restore
the ring structure of the orbicularis oris muscle and imitate
the normal modiolus of the oral commissure. In the area of
the commissure, the zygomatic major and risorius muscle are
sutured to the orbicularis oris muscle ring at a certain tension
to restore the normal attachment. The vermilion flap on the
upper lip is rotated to the lower lip, and then C and C’, D and
D’ are sutured to each other in the same layer to reconstruct
the trigone of the commissure. After the new commissure has
been sutured, a small S-plasty is made lateral to the nasolabial
fold to close the cutaneous sutures.
Anthropometry and statistical analysis
Three-dimensional images were taken by the 3dMD pho-
togrammetric system (3DMD LLC), and anthropometric
measurements made from the 3-dimensional images. The
line segment that connects the commissure and other facial
landmarks, the length of the commissure, and the corner of
the commissure, were measured on the 3dMD facial pho-
tographs (Fig. 3). The significance of differences between
the means was calculated using the paired samples t test with
the aid of IBM SPSS Statistics for Windows (version 21,
IBM Corp). Oral symmetry was assessed by comparing the
morphological data of the cleft side with that of the non-cleft
side.
Results
Seventeen patients with unilateral transverse facial clefts
were followed up for 1–3 years, after a symmetrical oral com-
missure had been reconstructed in all cases. There were no
contraction deformities or downward and lateral migration of
the commissure at rest (Figs. 4 and 5), and no limitation of
mouth opening during smiling or whistling. Anthropometric
data were measured one year postoperatively. Six measure-
ments were made to reflect the symmetry of the commissure
on the 3-dimensional image: labiale superius to the commis-
sure; the tip of the Cupid’s bow to the commissure; subalare
to the commissure; endocanthi to the commissure; length of
the commissure; and corner of the commissure. The results of
the t test showed that there were no significant differences in
 M. Tuersunjiang et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 621–625 623

Fig. 3. Anthropometric landmarks. Caption taken from the 3-dimensional

photogrammetry image. Ls = labiale superius; Cph = the tip of the Cupid’s
bow on the non-cleft side; Cph’ = the tip of the Cupid’s bow on the cleft
side; Sbal’ = subalare on the non-cleft side; Sbal = subalare on the cleft side;
E = endocanthi on the non-cleft side; E’ = endocanthi on the cleft side; C- Fig. 5. View three years postoperatively.
A = length of the commissure on the non-cleft side; C’-A’ = length of the
commissure on the cleft side; ∠ABC = corner of the commissure on the Table 1
non-cleft side; and ∠A’B’C’ = corner of the commissure on the cleft side. Anthropometric measurements in the commissure area (Data are given as
mean (SD) mm).
Measuring Cleft side Non-cleft side p value
points of the
new commissure
Labiale superius 20.33 (0.36) 20.02 (0.57) 0.06
Tip of Cupid’s bow 17.6 (1.44) 18.09 (0.94) 0.13
Subalare 22.52 (1.3) 22.44 (0.67) 0.08
Endocanthi 48.23 (1.06) 49.05 (1.78) 0.09
Length of commissure 2.68 (0.51) 2.46 (0.6) 0.25
Corner of commissure (◦ ) 38.2 (1.12) 37.64 (1.53) 0.16

The points of the new commissure, C and C’, were established by reference
to the distance from the commissure on the normal side to the midpoint of
the Cupid’s bow.

present in the vermilion do not exist in the commissure, and

Fig. 4. Preoperative view.
any of the measurements (Table 1), which means that there
was no obvious difference between the cleft and non-cleft
sides.
Discussion
The anatomical structure of the commissure is unique.
Anderson and Kurtay reported that a normal corner is not
a commissure, but a smooth and continuous segment of
vermilion.6 Onizuka described the outer edge of the ver-
milion of the upper and lower lips as two small triangles
that are not connected when the mouth is closed, and folded
inward at rest.7 Verheyden pointed out that wrinkles that are
the vermilion on the commissure is more like buccal mucosa.8
We looked carefully and found that the normal commis-
sure, which is formed by the convergence of the upper and
lower lip, is not just converging at a point, but forms a tri-
angular area of mucosa. The vermilion of the lower lip ends
in front of the commissure, but the mucosa still migrates to
the lateral 2–3 mm to form a smooth curve. The lines that
pass through the point that is the end of the vermilion of
the lower lip, and the commissure, intersect into a triangular
area and the angle ␣ is about 30–45◦ . The mucosa here will
be extended when the mouth opens and folded away when
it is closed. These special structures of the commissure not
only make the lip look symmetrical and harmonious but also
have an important role in oral functions, such as eating and
talking.
The shape and location of the commissure in patients
with unilateral transverse facial cleft change. The commis-
sure on the affected side cannot be closed at rest and is always
folded when smiling or whistling. It is shifted outwardly by
the traction of the dislocation of the zygomatic and risorius
624 M. Tuersunjiang et al. / British Journal of Oral and Maxillofacial Surgery 56 (2018) 621–625
muscles. The lower lip is pulled interiorly by the unstrained
depressors.9 The purpose of our operation is to reform this
triangular mucosal area by designing composite vermilion
flaps, reconstructing the orbicularis oris muscle, and making
a small S-plasty on the cheek. It is also to restore the natural
shape and colour of the commissure and correct its position.
Using the composite vermilion flaps is the most impor-
tant part of our procedure. Various flaps have been reported
to rotate into the commissure to build its shape. Fukuda
and Takeda described a method that used a square flap to
preserve the existing commissure, and so obtained a com-
missure without scars.10 However, this technique is limited
to patients with mild clefts. Kaplan reported an operative
technique that used a “v” flap with its base at the upper lip,9
which could avoid a suture line at the commissure, but it did
not include the vermilion of the lower lip and would generate
tension so that the scar became more pronounced over time.
Kajikawa et al recommended an oblique vermilion – mucosa
incision and suggested that the lines of the incision could be
extended to allow opening of the mouth, and the flap would
be folded inwards when the mouth closed.1 However, this
incision caused a straight suture at the commissure, so that it
changed into an acute angle rather than a smooth curve.
To reconstruct the natural commissure we designed the
opposing composite vermilion flap, including a triangular
flap. The flap on the upper lip rotated into the lower lip, and
the flaps were sutured to each other to form the triangular
area. In our series, the scar did not fall on the commissure,
so it could avoid the lateral migration caused by contractures
of the scar. The composite vermilion flaps could also avoid
the defect of the linear suture of the rectangular flap, so that
the scar was invisible postoperatively. The natural overlap-
ping of the upper and lower lip at the commissure to enable
the oral cavity to function was not affected. The results of
the analysis of the facial symmetry, done one year postoper-
atively, showed the long-term effect in that the normal shape
of the commissure was obtained by the use of the composite
vermilion flaps.
Reconstruction of the disrupted orbicularis oris muscle
affects the position and function of the commissure, as it
is located in the deep surface of the tissue of the labyrinth,
connecting the two sides of the modiolus. The contiguity
of the orbicularis oris muscle was impaired in patients with
a transverse facial cleft, as it is attached to the zygomatic
muscle and risorius muscles, which resulted in obvious dis-
location and dissection because of the fissure. The affected
commissure was therefore pulled both horizontally and ver-
tically, particularly when the infant was crying. The absence
of muscular backing between the skin and mucosal surface at
the new commissure gave an unattractive “goldfish” mouth
appearance.11 In our procedure, the zygomatic and risorius
muscles were released from the orbicularis oris and put in
the correct position, and then the muscle bundle of the upper
lip was overlaid and placed in front of that of the lower lip
to imitate the anatomical overlap. The normal attachment of
the zygomatic and risorius muscles at the commissure was
restored to achieve the natural oral commissure modiolus and
avoid “goldfish” mouth. In addition, repairing the orbicu-
laris oris muscle helps the location of the nasolabial fold so
that the relations between the commissure and the fold are
harmonious and natural.
Simple straight suturing, the earliest method used for cuta-
neous suture, crosses the nasolabial fold, so the scar is usually
obvious, and the commissure will migrate both downwards
and laterally because of the contraction of the scars. It is
therefore difficult to achieve a natural commissure by straight
suturing. Relative to the scar on the cheek that is closed in
a straight line, the edge of the Z-plasty is along the crease
of the nasolabial fold to avoid an obvious postoperative scar.
The Z-plasty has a role in the adjustment of the length of the
upper and lower margins of the wound or to remove a dog-
ear.1 A small Z-plasty designed at the commissure can also
prevent subsequent constriction, and the commissure will not
be pulled outwards. We changed the Z-plasty to an S-plasty
to repair the cutaneous defect, and found that a small, deli-
cate S-plasty can make the resulting scars look more natural
on the nasolabial fold. At the same time, it can repair excess
tissue to make the commissure look smooth.
Conclusion
We recommend the adoption of this surgical approach for
patients with unilateral transverse facial cleft. Certainly, the
design has some limitations. For example, the size of the
composite vermilion flap must be controlled, otherwise the
commissure will be folded, and because the composite ver-
milion flaps and small S-plasty are delicate, skilled surgical
technique is required. Our team will continue to follow-up
these patients to improve their surgical techniques.
Conflict of interest
We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission
This study was approved by the ethics review board of the
School and Hospital for Stomatology, Wuhan University, and
the parents provided informed consent.
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