Bilateral Cleft Lip Reconstruction M. Samuel Noordhoff, M.D., F.A.C.S. Taipan ‘Over pero of 8 years 140 itera ftps were operated cng» muscerepontionng bathe esp fesopny, Hoe use of Cree mal fap In imcerrtloginou inion sept to decree wearing Ind coatureby franpal earings epotonng ind wound ce without son Aad mo rok {he iano torbiate maken corte Sound clare ‘isle cay wahout tenon, Abel p otis tmoes Hap ah whiten a aed venience tmende fr reconarucon ofthe Cope Bow. Sale ont by Trecig he muscle none sheet a Seer Sioning infront ofthe premsila wah ereon Ofc ca clr poo osc pve the nee Ct rcemetng the hp ins socand procure The cre fpuon of the colombia done at Ito yes of age Oy ‘ancing mal flor iave onc the columella el fesuorilg the ay caragerseperty nid meta. (ihe nl sor uu wide eolumcia gt tnlog lode by the ue ofa composes ice et grate Reconstruction of the bilateral cleft lip de- formity poses many complex problems. Because ‘of variations in pathology, achieving a satisfac- tory result may be difficult. Development defi ciencies in the central median structures, as shown by Stark and Ehrmann,’ in a small prola- bium and premaxilla as well as deficient dorsal and lateral cartilages (Fig. 1, lei). These deficien- ies are essentially a median dysgenesis and can also be seen in the unilateral cleft lip.* In con- trast, the central structures may have a well- developed large prolabium and premaxilla (Fig. 2, above). Millard” has well outlined the derange- ments needing correction. ‘The surgeon needs to evaluate the extent of the derangement, the amount of tissue available for repair, and then choose a technique that will achieve a satisfactory reconstruction of the anatomic derangement without causing growth disturbances. PREOPERATIVE PREPARATION Preoperative orthopedics, although useful.’ are not used routinely because of poor patient cooperation, Preoperative gentle rubber band traction with Micropore tape helps to prevent severe protrusion of the premaxilla, Lip repair is done at the age of $ months. SURGICAL TECHNIQUE Prolabial Markings Protabial markings are described in Fig. 3. The width of the Cupid’s bow may be limited be of deficient protabium, as seen in the patient shown in Fig. I (left). The ideal width should be determined by racial characteristics. Usually, the distance from point 1 to 2 should be 3 to 4 mm, making a new Cupid’s bow 6 to 8 mm in width. ‘The lateral prolabial forked flap (PF in Fig. 3) will vary considerably in width depending on the size of the prolabium, Lateral Lip Markings ‘The lateral lip markings are made to corre- spond with those of the prolabium (Fig. 3). The “white line” identifies the cutaneovermilion j tion line or white skin roll. The “red line” iden- tifies the mucosal-vermilion junction line, w! parallels the white skin roll, converging and meeting at the free edge of the cleft. Starting from this point and moving laterally, point 2” is placed where the vermilion first becomes its wid- est. Usually the vermilion has its greatest width at a distance 3 to 4 mm laterally from the point at the cleft edge where the white skin roll and red line converge. The vermilion medial to point From the Deparment of Pati Surgery at Chang Gung Memorial Hospital. Received for publication Api 0, 1985; revised December 2 som Meeting the American Anociton of Pate Surgeons, in San Diego, California, April 28 0 May 1 1985, “46 -_ A PLASTIC AND RECONSTRUCTIVE SURGERY, July 1986 & Fic. 1. (Left) Preoperative view of a severe bilateral complete cet of the primary and secondary palate with deficiency of central structures bilateral celloptnty as described was done at 4 months (igh) Postoperative result at age 2 2" is used for reconstruction of the central pro- labial vermilion. Moving point 2’ medial will increase the horizontal width of the lip and leave less vermilion for reconstruction of the prolabial vermilion. Moving point 2’ laterally will decrease the horizontal width of the lip but leaves more vermilion and flap tissue for reconstruction of the central prolabial vermilion. The vertical limb for the philtral column, 2'~3’, is made the same length as the prolabial vertical limb, 2-3. Point 3" is arbitrarily placed near the ala, allowing the tissue medial to the line 2/-3' to be used as a lateral lip forked flap. This flap is not cut until the very last stage (see Fig. 10), since itis difficult to judge just where point 3” should be placed at this stage and whether skin closure can be accom- plished without tension if a lateral forked flap is. used. Release of Alar Cartilage ‘The buccal mucosal flap (L) is 0.5 to 0.75 cm in width and 1.5 to 2.0 cm in length (Fig. 4). After the flap is elevated, the alar cartilage is freed with a minimal amount of dissection by extending the incision from the piriform aper- ture upward between the upper and lower lateral alar cartilages to the dorsal cartilage. Dissection of Lateral Lip On the right side of Fig. 5, the orbicularis flap (OM) with attached 0.5 to 0.75 mm edge of skin (white skin roll) has been cut and turned down. ‘This will form a newly created Cupid's bow and tubercle. It is important to dissect the orbicularis peripheralis muscle (OP) in one sheet from the alar cartilage to the orbicularis marginalis flap (OM). The mucosa is left attached posteriorly. Prolabial Incisions In Fig. 5, the prolabial incisions have been made. It is important to incise the prolabial forked flap from point 2 (Fig. 3) along the skin edge posteriorly as far as possible to the junction line of mucosa and columella where it turns acutely upward in order to free the prolabium from the premaxilla. This results in a triangular defect behind the prolabial forked flap (PF), as seen on the right side of Fig. 5 and also seen in Fig. 8. The prolabial mucosa is thinned of sub- cutaneous tissue to cover approximately two- thirds of the premaxilla. It should not be brought all the way up to the nasal spine, allowing for adherence of the upper edge of the lip to theVol. 78, No. I / BILATERAL CLEFT LIP RECONSTRUCTION 47 xilla but still creating a buccal alveolar Repositioning of Alar Cartilages laced through the domes of the lower es allow them to be held symmet- rically while suturing them in their new position (Fig. 6). ‘The lower lateral cartilages are held by two types of sutures. One of these sutures (A) is between the dorsal and lower lateral cartilages and the others (B) are between the upper and ower lateral cartilages (Fig. 6, insert), Fic. 2. (Above) Bilateral complete cleft of primary and secondary palate. Bilateral Buccal Alveolar Mucosal Flap After repositioning the alar cartilages, the pre- viously elevated buccal alveolar mucosal flap (L in Fig. 4) is sutured into the lower half of the intercartilaginous incision, as seen on the left side of Fig. 6. Iti folded on itself to give more length for reconstruction of the nasal floor. Additional mucosa can be obtained from the inferior turbi- nate, as described in Fig. 7. This is preferred particularly in wide clefis, since the inferior tur- inate mucosa (A), when advanced to A’ (Fig. 7), allows a lower insertion of the mucosal flap (L) Ww inked forked fap cheiloplasty as described was done at 2 months of age. The columella was elongated atthe age of 94 years with nasal oor tissu. (Below, left and right) Postoperative result alver elongation of the columelia48 nilion junction it junction Tine. Poi The red line isthe mucom-vermilion is centrally placed on the prolabial Bare arbitrarily placed lly. Point 8 i placed just 1¢prolabial vertical limb with the base of ines, when incised, divide the prolabium ino 1p (P) attached to the columella ‘and two lateral prolabial forked F) ic. 4.8 buccal mucosal flap (L) based on alar vestibular skin is elevated from the lateral ip. The buccal alveolar incision line extends along the alveolus, turning inward at the piriform aperture and then upward between the upper land lower lateral cartilages the dorsal cartilage. PLASTIC AND RECONSTRUCTIVE SURGERY, July 1986 in the intercartilaginous incision. The mucosal flap (L) can completely close the imercartilagi nous incision down to the piriform aperture with adequate mucosa remaining for reconstruction of the nostril floor. The nostril floor is reconstructed by taking the edge of the folded back flap (Lin Fig. 6) and suturing it into the V-shaped notch behind the columella (Fig. 8). This results in an inner free edge of mucosa extending from the maxilla to premaxilla. This inner free edge of mucosa is eventually sutured to the free edge of the mucosa on the posterior aspect of the orbiculars flap (OP Fig. 5), thus effectively closing all previous incision lines without tension and leaving no open raw surface. He. 5. On the night side, the orbiculars Hap (UM) has been cut from the free edge ofthe cleft to include a 0.5 10 10.75 mm wide edge of skin (white skin rol). On the lft side the orbiculars peripherals muscle (OP) is dissected from the skin, alar base, and the lower edge of the aar eartlage. The ‘rolabial central skin fap (P) and prolabal forked ap (PA) Are elevated from the prolabium. The lateral incision of the prolabal forked Nap extends along the skin edge and turns Scutely up atthe junction ofthe calumellar skin and mucosa {to orm triangular notch as sen onthe right. The prolabial rmucoss (PM) is trimmed and sutured to the premaxilla (inser.Vol. 78, No. I / BILATERAL CLEFT LIP RECONSTRUCTION 49 Fic. 6, Traction sutures are placed in each alar dome to advance the alar cartilage superiorly. ‘The buccal micosal Map (L) is advanced into the midpoint of the intercartiagi- ‘nous incision with the mucosa Tolded back on itself vo give tore length. The insert shows the lower lateral cartilage ‘reporitoned and held with a suxpension suture (A) from the lower to the upper lateral cartilage and with intercartiagi- snows sutures (8). Reconstruction of Lip ‘The orbicularis peripheralis muscle (OP) with attached posterior mucosa is approximated with interrupted sutures (Fig. 9). The upper free edge ‘of mucosa is sutured to the free edge of the ‘mucosal flap (L) as it transverses from maxilla to premaxilla, where it is attached behind the col tumella (Fig. 8). It is important to attach the muscle to the nasal spine so that the lip does not drift inferiorly. Repositioning of Forked Flaps Up to this point, the lateral forked flap which was tentatively marked on the skin medial to the markings 3'-2' (Fig. 3) has not been cut because is difficult to determine how wide this flap hould be made. If there is enough skin to de- velop a lateral forked flap (Fig. 10), the forked Fic, 7. An alternative preferred method of releasing the alar cartilages to that described in Fig. 4 isto extend the incision From the piriform aperture down to inehide a lcm wide flap of mucosa from the inferior turbinate (A). This ‘mucosal flap is advanced into the intercatilaginous incision followed by the buccal mucosal Map (L), which folded on itself and sutured down to the piriform aperture, completely closing the intercartiliginous incision Fic. 8. "The folded back edge of the mucosa flap (1) is inerted into the triangular defect posterior tothe prolabial forked flap (PF) to reconstruct the posterior nosttl floor. ‘Additional sutures ure placed on the posterior free edge of the premaxillary macoss othe levelof the anterior prolabial ‘mucous (PI). ‘The mucosal Nap (L) now bridges the gap between maxilla and premaill.50 PLASTIC AND RECONSTRUCTIVE SURGERY, July 1986 Fic. 8. The prolabal skin Nap (P) and forked Naps (PF) are elevated. The orbicularis peripheralis muscle (OP) with attached posterior mucosa is sutured anterior tothe premax- ils and anchored to the nasal spine with one suture. An Adaltional retention suture from nasal spine to alat bate is ted if needed, Orbicularis marginale. Nape (OM) are ‘rimmed later to Bt under the prolabial skin Nap (P) flap is incised and the tip (A) is inserted at the apex of the posterior columella incision behind the prolabial forked flap (B) and in front of the previously inserted mucosal flap shown in Fig. 8. ‘The prolabial forked flap tip (B’) is inserted into the lateral incision line to point B. If the lateral skin is too tight to elevate a lateral forked flap, a horizontal incision is made and the tip of the prolabial forked flap (B’) inserted to point B (Fig. 11). followed by approxi- ‘mating points C to C’. The level of the horizontal incision allows the surgeon to balance lip length ‘when one side of the lip is vertically longer than the opposite side. Reconstruction of the Cupid's Bow ‘The orbicularis marginalis flaps (OM) were trimmed of excess tissue, as shown in Figs. 9, 10, and II, and are now sutured beneath the prola- bium with fine 7-0 sutures to reconstruct a new Cupid’s bow and tubercle. The paralleling white skin roll and red line are anatomically correct, showing the vermilion at its widest at the base of Fic. 10. The tip ofthe lateral forked flap (A) is inserted infront ofthe previously placed mucosal Nap (L), and behind the prolabal forked flap. The tip of the protabial forked flap Bis inserted into the lateral horizontal cut to point B Fg. 8) Fic. 11. When lateral skin tension is too tight to use a lateral forked flap, che prolabial forked flap tip is inserted in front of the mucosal fap into the lateral horizontal incision to point B. This allows closure of points ( 10 without tension,Vol. 78, No. I / BILATERAL CLEFT LIP RECONSTRUCTION 51 Fic. 12. ‘The completed procedure showing a. parallel white line (white skin roll) and red line with a balanced ‘ermilion width under the central prolabium. the philtral column with adequate vermilion width beneath the prolabium (Fig. 12). If point 2” (Fig. 3) is placed too far medial, i.c., too near the converging red line and white line at the cleft edge, the amount of vermilion medial to point 2’ will be inadequate for recon- struction of the central prolabial vermilion. This will result in a peaking effect, as seen in Fig. 13. This can be prevented in the initial planning by moving point 2’ laterally 1 or 2 mm (Fig. 3). Golumella. Lengthening ‘The columella is lengthened between 1 and 6 years of age by advancing tissue from the nasal floor as described by Cronin and Upton” and Millard.* The procedure usually requires a short- ening of the horizontal length of the lip. This is accomplished by removing a Burow’s triangle of skin from the nasolabial fold at the base of the ala. The alar bases and orbicularis are independ ently fixed by a suture to the nasal spine to prevent drifting. When inadequate tissue is avail- able for columella lengthening, a composite ear graft is used.” PosroperaTive CARE No extra oral devices such as Logan’s bow are used. After suture removal, the wound is sup- ported with Micropore tape. Gentle lip massage is started 3 to 4 weeks postoperatively. Discussion ‘The type of lip repair advocated is similar to that of Milard with certain points stresed and modified." A primary definitive lip repai important because reentering the lip surgically seems to produce prominent scars and a poor result. This requires muscle realignment in front of the premaxilla™"' and a good buccal alveolar sulcus.” When gentle retropositioning of the premaxilla by external elastic traction is done, less soft-tissue mobilization is required to achieve lip closure. This type of retropositioning of the premaxilla has not led to growth disturbances.* Unoperated clefts have good growth and arch relations. Itis therefore important that soft-tissue undermining from the maxilla be minimal and superficial to the periosteum. The least amount of undermining is done to achieve closure with- out excess tension. Mucosal Flap Millard inserted a Muir flap'* attached to the ‘maxilla into the intercartilaginous incision, allow- ing alar bases to move inward and upward. A ‘buccal mucosal flap which does not sacrifice ver- milion also accomplishes this. This flap is more versatile attached to the alar web, effecting a Fic, 13. An undesirable peaking effect of vermilion oc- ‘curs tthe center of the prolabium when point 2” (Fig 8) is placed too far medially.52 Fic, 14 (Above, lf) Preoperative bilateral complete cleft of the primary and secondary palate PLASTIC AND RECONSTRUCTIVE SURGERY, July 1986 he age of $ months when bilateral cheilopany as described was done. (Above, ng) Postoperative result at the age of 15 months showing a short Columella (Below eft and righ) An elongation ofthe columella was done atthe age of 8 years with a composite ear graft and 44 Z-plasty revision of the base 6 months liter. Postoperative rezult atthe age of 4 Years wound closure of the maxillary incision and as- sisting in nasal floor closure (Figs. 4 to 8). Bar- dach et al." noted growth disturbances in cleft rabbits with soft-tissue undermining. The mu- cosal flap provides complete wound closure with- ut tension, potentially decreasing the amount of scar tissue and contracture. It also permits movement of alar cartilages inward and upward both during primary cheiloplasty or, at a later stage, without necessitating mucosal incisions. Cupid's Bow and Vermilion ‘The Cupid’s bow may be reconstructed by leaving the prolabial vermilion attached to the protabium,'®"* or a new Cupid's bow may be reconstructed.” The vermilion may be left on the prolabium when there is a prominent white skin roll and when the prolabial vermilion is the same width as lateral lip vermilion. The latter seldom occurs, and usually a better result can be achieved by using orbicularis oris marginalis flaps (OM) from the cleft edge along with attached white skin roll, vermilion, and mucosa, as advo- cated by Millard® and Noordhoff” (Figs. 5 and 9 through 12). Interdigitation of lateral lip flaps does not satisfactorily create a paralleling white skin roll and red line and is anatomically incor- rect.Vol. 78, No, I / BILATERAL CLEFT LIP RECONSTRUCTION 58. Muscle The orbicularis oris peripheralis (OP) is dis sected in one continuous plane from the cartilaginous incision to the white ski freeing it from skin and alar base (Fig. 5). This allows the chaotically arranged orbicularis fibers, as described by Kernahan et al." to be freed and advanced with mucosa for lip closure (Fig. 5). Approximation of muscle and mucosa pro- ‘ceeds from lower lip, where there is less tension to prevent tearing of muscle fibers. The muscle isanchored to the nasal spine with the uppermost suture (Fig. 9) Lip Asymmetry Bilateral cleft lips that are complete on one side and incomplete on the other usually have excess tissue on the incomplete side. It is pre- ferred to do an adhesion cheiloplasty on the complete cleft side, which helps to balance the lip and stretch the tissue on the complete cleft side. A definitive cheiloplasty as described isdone about 6 months later. Elongation of Columelta Columella lengthening using banked nasal floor tissue® along with alar cartilage reposition- ing is done at 1 to 6 years of age. Cronin and Upton," in an excellent overview of columellar lengthening, recommend lengthening after the age of 2 or 3 years, with the average age of lengthening at 6 years. Nasal floor tissue can often be advanced in a subcutaneous plane onto the columella without making it into a bipedicle flap. The use of the L flap inserted behind the columella for nasal floor reconstruction (Figs. 6 and 8) provides additional tissue for elongation of the columella. The alar base and orbicularis muscle are sutured independently to the nasal spine to prevent the lip from pulling the colu- ella down (Fig. 9) ‘The alar cartilages are fixed to each other at the tip. In more severe deformities, further ele- vation superiorly and medially of the lower lat- eral upper crus is recommended by Broadbent and Woolf,” who feel that only an upper crus Tearrangement is necessary. It seems that both the upper and lower crus of the lower lateral cartilage are displaced and both need reposition- ing to achieve an acute columellar lip angle and tip projection, ‘The composite ear graft’ is utilized when there is deficient nasal floor tissue available for colu- mellar lengthening (Fig, 14). It is felt inadvisable to utilize forked flaps from a good-looking lip, since this usually produces unacceptable scars. In this series, 25 columellar lengthenings were done ‘on 140 bilateral cleft lip patients aged 1 to 7 years, and 5 were composite ear grafts. This ‘group of patients was seen over a period of 8 Years, with the longest follow-up of 8 years. ‘M, Samuel Noordhoff, M.D., F.A.CS Department of Plastic Surgery Chang Gung Memorial Hospital 199 Tun Hwa North Road Taipei, Taiwan 105 REFERENCES. 1. Sark, R. B.. and Ehrmann, N. A. The development ‘ofthe center of the face with particular reference 10 surgical correction of bilateral cleft lip. Plast. Re const. Surg. 21: 177, 1988. 2. Noordhoff, M. S., and Cheng, W. S. Median facial ‘dysgenesis in cleft lip and palate. Ann. Plast. Surg 8: 183, 1982. lard, D. R., Jr. Cleft Craft: The Bvolution of Is ‘Surgery, Vol. 2: The Bilateral and Rare Deformiies. Boston: Litle, Brown, 1977. P. 32. 1H, Effects of presurgical oral orthopedics on feral complete clefts of the lip and palate. Cleft Palate J. 19: 100, 1982. 5. Cronin, T-D.,and Upton,J. Lengthening of the short ‘columella associated with bilateral cleft ip. Ann. Plast Surg. 1:75, 1978, 6. Millard, D. R., Jr. Closure of bilateral cleft lip and ‘longation of columella by wo operations in infancy. Plast Reconstr. Surg. 47: 324, 1971 7. Meade, R. J. Composite ear grafts for reconstruction ‘of columella. Plat Reconstr. Surg. 23: 134, 1959. 8. Millard, DLR. Jr. Cleft Craft The Evolution of Is ‘Surgery, Vol. 2: The Bilateral and Rare Deformities. Boston: Little, Brown, 1977. P. 359. 9. Schultz, LW. Bilateral lft lips, Plast. Reconstr Surg 1: 388, 1946, 10. Duffy, M.M._ Restoration of orbicularis ovis muscle ‘continuity inthe repair of bilateral cleft lip. Br. J. Plast. Surg. 24: 48, 1971 11, Randall P, Whitaker, L.A. and LaRosa, D. The importance of muscle reconstruction in primary and secondary cleft ip repair. Plast. Reconstr. Surg. 54 316, 1974 12, Horton, C. E., Adamson, J. Es, Mdick, R. A., and “Taddeo, RJ. The upper lip sulcus in cleft lips. Plast Reconsir. Surg. 45:31, 1970. 13. Muir, LF-K- Repair ofthe cleft alveolus, Br. J. Past Surg 19:30, 1966, 14, Bardach,J. Mooney, Mand GiedrojeJuraha,Z. L.A ‘comparative study of facial growth following cleft ip repair with oF without softissue undermining: An ‘experimental study in rabbits, Plast. Reconatr. Surg. 60: 745, 1982. 15, Broadbent, T, R., and Woolf, RM. Bilateral Cleft Lip: One-Stage Primary Repair In N. G. Georgiade (EA), Symposium on Management of Cleft Lip and Palate 4. PeiAocated Deformitis. St. Lous: Mosby, 1974. P. 134 16. Black, P. W.,and Schefia, M. Bilateral clef lip repair: atting i all together.” Ann. Plast Surg. 12: 118, 198. 17. Noordhoff, M.S. Reconstruction of vermilion in uni- lateral and bilateral cleft lips. Plast Reconatr. Surg. 78:52, 1984, 18. Kernahan, D. A., Dado, D. V.,and Bauer, B.S. The AND RECONSTRUCTIVE SURGERY, July 1986 anatomy of the orbicularisoris muscle in unilateral lef ip based on a three dimensional histologic re- construction, Plast Reconstr Surg. 73: B75, 1984, 19, Broadbent, T. R., and Woolf, RM. Cleft lip nasal deformity. Ann. Plast. Surg. 12: 216, 1984. 20. Kapetansky, D. 1. Animation and cosmetic balance in Tepair of congenital bilateral cleft lip: A modified technique. Cleft Palate J. 11: 219, 1974.