Choice of incision for primary repair of unilateral complete cleft lip: a comparative study of outcomes in 796 patients

Updates in Cleft Care

Cleft lip and/or palate is a congenital malformation with a wide range of presentations, and its effective treatment necessitates sustained, comprehensive care across an affected child's life. Early diagnosis, ideally through prenatal imaging or immediately postbirth, is paramount. Access to longitudinal care and long-term follow-up with a multidisciplinary approach, led by the recommendations of the American Cleft Palate Association, is the best way to ensure optimal outcomes. Multiple specialties including plastic surgery, otolaryngology, speech therapy, orthodontists, psychologists, and audiologists all may be indicated in the care of the child. Primary repair of the lip, nose, and palate are generally conducted during infancy. Postoperative care demands meticulous oversight to detect potential complications. If necessary, revisional surgeries should be performed before the child begin primary school. As the child matures, secondary procedures like alveolar bone grafting and orthognathic surgery may be requisite. The landscape of cleft care has undergone significant transformation since early surgical correction, with treatment plans now tailored to the specific type and severity of the cleft. The purpose of this text is to outline the current standards of care in children born with cleft lip and/or palate and to highlight ongoing advancements in the field.

Closure of cleft lips with Pfeifer's wave line technique does not inhibit upper lip growth: A retrospective study

The aim of this study is to describe the growth of the upper lip after reconstruction with a Pfeifer wave-line incision in patients with unilateral and bilateral cleft lip and palate (CL/P) in the long term. This was a longitudinal, monocentric, retrospective study. Metric standardized lip length measurements were taken annually from the age of 6 months to the age of 16 years. Defined anatomical points were determined which describe the lip length from the nasal entrance to the highest point of the Cupid's bow. The lip length of the unaffected side in unilateral cleft patients was taken as control. A total of 234 patients with cleft lip with/without cleft palate (CL/P) were included in the study. At the time of the primary surgery, the medial sides in unilateral clefts were 2-4 mm and the lateral sides 1.5-2 mm shorter than the normal unaffected side (p≤0.001). Two main periods of growth, one during childhood (first to sixth years) and one during adolescence (12th-16th years) were seen. At the age of 16 years, the end of the observation period, the lip length in unilateral clefts resulted in a clinically not noticeable shortening of the cleft side (0.37±0.26 mm). There was no correlation between lip length development and primary cleft width at the time of primary cleft lip surgery at 6 months. The upper lip in patients with bilateral clefts developed symmetrically without any obvious asymmetry. Both sides showed a lip length difference of 0.1±0.05 mm at the age of 16 years (p=0.1). Compared to the upper lip length of the control group, bilateral clefts showed a slight tendency toward a longer upper lip (p=0.52). Within the limitations of the study it seems that when lip length development is a priority in cleft lip surgery, Pfeifer wave-line procedure is good option to achieve symmetric results in unilateral and bilateral cleft lip surgery and, therefore, is a relevant option among a variety of other techniques.

Modified Lip Revision Surgery for the Severe Whistle Lip Deformity in Bilateral Cleft Lip

PURPOSE

Whistle deformity is a sequela of primary surgical repair of the bilateral cleft lip that leads to a vertical tissue deficiency and a nonfunctional orbicularis oris muscle in the medial portion of the upper lip. This sequel is significantly limiting functionally and esthetically. We propose a complete labial revision with a secondary cheiloplasty of Mulliken and a submucosal inferiorly based flap in the central tubercle to increase the volume at this usually deficient area.

METHODS

We present our series of 9 patients with whistle deformity who underwent our modified technique. Width and length lip measurements were analyzed pre- and postoperatively.

RESULTS

There was a significant decrease in the width of the philtrum (mean 18.7% and 37% measured at the columella base and Cupid's apexes, respectively), an increase in the labial length (mean 11.2%), and improvement of the shape and volume of the vermilion in its middle third. All patients reported a very good to excellent improvement in the function and shape of their lips.

CONCLUSIONS

The addition to a complete revision cheiloplasty of our inferiorly based submucosal flap technique solved in a single operation the function of the orbicularis oris and the normal labial anatomy with good functional outcomes in all cases and improved esthetic results.

Evolving Trends in Unilateral Cleft Lip Repair Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery (ABPS) began collecting data from unilateral cleft lip (UCL) corrections in 2011 as a component of the continuous certification process. We evaluated these data to understand practice patterns in UCL repair, in the United States, and whether these practice patterns had changed over the past 9 years.

METHODS

Tracer data for UCL correction were reviewed from its inception in October 2011 through 2016 and compared to UCL cases between 2017 and March 2020. Trends in practice patterns were evaluated against literature reviews meant to coincide with the ABPS continuous certification data.

RESULTS

A total of 520 cases were included from October 2011 to March 2020. Median age of UCL repair was 4 months and 66% of patients were male. Fifty-one percent of cases presented with a complete cleft lip. There was a decrease in postoperative adverse events when data from 2011 to 2016 was compared to 2017 to 2019 (P = 0.020). Revisions were the most common postoperative adverse event (2%). There was a decrease in nasoalveolar molding from 25% to 12% (P < 0.001) and 56% of total cases underwent a concurrent primary cleft rhinoplasty. The rate of gingivoperiosteoplasty at the time of primary cleft lip repair also fell (9% versus 1%; P < 0.001).

CONCLUSIONS

This article reviews tracer data obtained by the ABPS for UCL repair. The American Board of Plastic Surgery tracer data provides a national, cleft lip-specific database with longer follow-up times than other large databases.

Strategic management of the minor-form and microform cleft lip: A long-term outcome assessment

OBJECTIVE

The treatment of the lesser form cleft lip deformity (i.e., minor-form, microform, and mini-microform) is challenging to achieve patient satisfaction. There are no studies investigating how treatment outcomes balance patients' expectations and satisfaction with surgical or non-surgical care relative to the initial nasolabial findings.

METHODS

Based on Mulliken's classification, consecutive records of patients with the lesser-form cleft lip from 1990 to 2015 were selected for analysis. Demographics, management, and revisions were reviewed. A panel analysis was performed based on the ratings from both professionals and non-professionals using patients' photographs. FACE-Q questionnaires were used to compare patient/parent-reported satisfaction to the normal controls.

RESULTS

A total of 135 patients were included. All of the minor-form (23/23), 89% (58/65) of the microform, and 62% (29/47) of the mini-microform patients underwent surgery. Fifty-two percent (15/29) of the mini-microform patients, who underwent surgery, showed no significant improvement. Post-operative upper lip scars and remaining nasal asymmetry were the most common concerns in the treatment group. However, the FACE-Q results showed that patients experienced a statistically significant improvement in their overall facial appearance and social function in their respective groups.

CONCLUSIONS

This study showed that differences exist in the perception of facial esthetics between the surgeon and the patient/parent. To achieve optimal individual treatment outcome and patient satisfaction, an awareness of the differences and treatment selection for patients are critical in surgical planning. This understanding and an open detailed discussion of overall long-term outcomes help in the management of patient expectations.

Tailored Microform Cleft Lip Repair: Personalizing Small Incisions, Orbicularis Reconstruction, and Rhinoplasty

BACKGROUND

In the last decade, many surgeons have reported their perspectives on microform cleft lip repair, including techniques for incision placement and size, philtral reconstruction, and nasal base reconstruction. This interest demonstrates continued controversy in the repair of microform cleft lip.

METHODS

This is a retrospective cohort of patients from 2010 to 2016. The authors included patients with microform cleft lip repaired by our described technique who had both preoperative photographs, as well as photographs taken at >1-year follow-up. Patient outcomes were assessed through anthropometric measurements and also subjectively by 3 senior residents of plastic surgery.

RESULTS

The inclusion criteria yielded 36 microform cleft lip patients. Most patients were satisfied with their results. Regarding subjective assessment, the scar appearance and symmetry was fairly good. Objective measurements indicated excellent symmetry, with the cleft side achieving 92.58% of the height and measurements of the non-cleft side.

CONCLUSIONS

Our method of combining labial muscle reconstruction through a personalized, small incision effectively corrects microform cleft lip deformity with minimal scar burden.

A 20-year experience in unilateral cleft lip repair: From Millard to the triple unilimb Z-plasty technique

Background:

This study describes a 20-year experience of treating patients with unilateral cleft lip. During this time, various techniques were used including Millard's technique and its modification and two types of geometrically designed procedures. The study objective was to compare surgical outcomes of different surgical techniques for unilateral cleft lip repair.

Materials and Methods:

This is a retrospective audit of outcomes after unilateral cleft lip repair performed by a single surgeon since 1995. Of the 827 patients who underwent surgery, 277 met the criterion of having anthropometric measurements performed ≥1 year postoperatively. The patients were stratified into three groups according to cleft severity: incomplete, complete with less deficiency (3–6 mm difference between cleft and non-cleft lip height) and complete with more deficiency (>6 mm difference between cleft and non-cleft lip height). Anthropometric measurements, scar assessment and complications were recorded.

Results:

There were no differences in outcomes between Millard and Reichert-Millard techniques for incomplete unilateral cleft lip. For complete unilateral cleft lip and less tissue deficiency, lip symmetry was better using upper rotation advancement plus double unilimb Z-plasty than the Reichert-Millard technique. For complete unilateral cleft lip and more tissue deficiency, lip symmetry was better after triple unilimb Z-plasty than after upper rotation advancement plus double unilimb Z-plasty.

Conclusions:

We presented a 20-year experience performing unilateral cleft lip repair. An individualised classification system with corresponding surgical techniques was successfully used during this period. The individualised surgical protocol used in this study allowed us to achieve improved surgical outcomes.

One-Stage versus Two-Stage Repair of Asymmetric Bilateral Cleft Lip: A 20-Year Retrospective Study of Clinical Outcome

BACKGROUND

Both one- and two-stage approaches have been widely used for patients with asymmetric bilateral cleft lip. There are insufficient long-term outcome data for comparison of these two methods. The purpose of this retrospective study was to compare the clinical outcome over the past 20 years.

METHODS

The senior author's (L.J.L.) database was searched for patients with asymmetric bilateral cleft lip from 1995 to 2015. Qualified patients were divided into two groups: one-stage and two-stage. The postoperative photographs of patients were evaluated subjectively by surgical professionals and laypersons. Ratios of the nasolabial region were calculated for objective analysis. Finally, the revision procedures in the nasolabial area were reviewed. Statistical analyses were performed.

RESULTS

A total of 95 consecutive patients were qualified for evaluation. Average follow-up was 13.1 years. A two-stage method was used in 35 percent of the patients, and a one-stage approach was used in 65 percent. All underwent primary nasal reconstruction. Among the satisfaction rating scores, the one-stage repair was rated significantly higher than two-stage reconstruction (p = 0.0001). Long-term outcomes of the two-stage patients and the unrepaired mini-microform deformities were unsatisfactory according to both professional and nonprofessional evaluators. The revision rate was higher in patients with a greater-side complete cleft lip and palate as compared with those without palatal involvement.

CONCLUSIONS

The results suggested that one-stage repair provided better results with regard to achieving a more symmetric and smooth lip and nose after primary reconstruction. The revision rate was slightly higher in the two-stage patient group.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The Skoog Lip Repair for Unilateral Cleft Lip Deformity: The Uppsala Experience

BACKGROUND

The Uppsala Craniofacial Center has been treating patients with unilateral cleft lip deformity using the lip repair technique described by Tord Skoog. The aim of this study was to determine complications after lip surgery and the incidence and indications for lip revisions in all patients born with unilateral cleft lip from 1960 to 2004.

METHODS

All patients who were born from 1960 to 2004 with unilateral cleft lip, cleft lip and alveolus, or cleft lip and palate and underwent lip repair were studied retrospectively. The timing, indication, complications of the primary procedure, and type of secondary surgery were recorded. Kruskal-Wallis and Fisher's exact tests were used, with Bonferroni correction.

RESULTS

The study included 443 patients. The total rate of early surgical complications was 6 percent (n = 26). Secondary surgery for short upper lip was performed in 3.8 percent (n = 17), 8.4 percent (n = 37) underwent reduction of excess vermillion, 8.6 percent (n = 38) underwent scar revision, 11 percent (n = 51) underwent revision for incongruent vermillion-cutaneous border, and 10 percent (n = 45) underwent revision for other indications. Altogether, 45 percent had no secondary revisions.

CONCLUSION

In conclusion, the Skoog lip repair is associated with a low total revision rate, and a short-lip deformity is rare.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A novel computer system for the evaluation of nasolabial morphology, symmetry and aesthetics after cleft lip and palate treatment. Part 1: General concept and validation

PURPOSE

The need for a widely accepted method suitable for a multicentre quantitative evaluation of facial aesthetics after surgical treatment of cleft lip and palate (CLP) has been emphasized for years. The aim of this study was to validate a novel computer system 'Analyse It Doc' (A.I.D.) as a tool for objective anthropometric analysis of the nasolabial region.

MATERIALS AND METHODS

An indirect anthropometric analysis of facial photographs was conducted with the A.I.D. system and Adobe Photoshop/ImageJ software. Intra-rater and inter-rater reliability and the time required for the analysis were estimated separately for each method and compared.

RESULTS

Analysis with A.I.D. system was nearly 10-fold faster than that with the reference evaluation method. The A.I.D. system provided strong inter-rater and intra-rater correlations for linear, angular and area measurements of the nasolabial region, as well as a significantly higher accuracy and reproducibility of angular measurements in submental view. No statistically significant inter-method differences were found for other measurements.

CONCLUSIONS

The hereby presented novel computer system is suitable for simple, time-efficient and reliable multicenter photogrammetric analyses of the nasolabial region in CLP patients and healthy subjects.

White Roll Vermilion turn down flap in primary unilateral cleft lip repair: A novel approach

Aim:

Numerous modifications of Millard's technique of rotation – advancement repair have been described in literature. This article envisions a new modification in Millard's technique of primary unilateral chieloplasty.

Material and Methods:

Eliminating or reducing the secondary deformities in children with cleft lip has been a motivating factor for the continual refinement of cleft lip surgical techniques through the years. Vermilion notching, visibility of paramedian scars and scar contracture along the white roll are quite noticeable in close-up view even in good repairs. Any scar is less noticeable if it is in midline or along the lines of embryological closure. White Roll Vermilion turn down Flap (WRV Flap), a modification in the Millard's repair is an attempt to prevent these secondary deformities during the primary cleft lip sugery. This entails the use of white roll and the vermilion from the lateral lip segment for augmenting the medial lip vermilion with the final scar in midline at the vermilion.

Result:

With an experience of more than 100 cases of primary cleft lip repair with this technique, we have achieved a good symmetry and peaking of cupid's bow with no vermilion notching of the lips.

Conclusion:

WRV flap aims to high light the importance of achieving a near normal look of the cleft patient with the only drawback of associated learning curve with this technique.

Evaluation of 5-year-old children with complete cleft lip and palate: Multicenter study. Part 1: Lip and nose aesthetic results

BACKGROUND AND PURPOSE

Cleft surgery is marked by all the controversies and the multiplication of protocols, as it has been shown by the Eurocleft study. The objective of this pilot study is to start a comparison and analyzing procedure between primary surgical protocols in French centers.

METHODS

Four French centers with different primary surgical protocols for cleft lip and palate repair, have accepted to be involved in this retrospective study. In each center, 20 consecutive patients with complete cleft lip and palate (10 UCLP and 10 BCLP per center), non syndromic, have been evaluated at a mean age of 5 [4,6]. In this first part, the aesthetic results of nose and lip repair were assessed based on the scale established by Mortier et al. (1997).

RESULTS

Considering nose outcome, primary cleft repair surgery including a nasal dissection gives a statistically significant benefit in terms of septum deviation. Considering lip result, muscular dehiscence rate is significantly higher in BCLP patients with a two-stage lip closure. The centers using Millard one-stage lip closure do not have uniform results. For UCLP patients, the quality of scar is not statistically different between Skoog and Millard techniques.

CONCLUSIONS

Primary results based on a simple, reproducible evaluation protocol. Extension to other centers required.

LEVEL OF EVIDENCE

Therapeutic study. Level III/retrospective multicenter comparative study.

Comparison of Outcome of Modified Millard's Incision and Delaire's Functional Method in Primary Repair of Unilateral Cleft Lip: A Prospective Study

BACKGROUND

Certain preoperative anatomical features may lead the surgeon to choose one particular incision pattern in preference to another. No one technique of cleft lip repair consistently produces ideal aesthetic and functional results.

OBJECTIVES

This study was conducted to compare the outcomes attained using two different designs of skin incision used for surgical correction of unilateral cleft lip.

MATERIALS AND METHODS

Modified Millard's incision and Delaire's functional method techniques were performed and evaluated on 18 patients who received primary unilateral cleft lip repair. Soft-tissue measurements of the lip and nose were recorded preoperatively. Analysis was based on postoperative assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, and nostril symmetry and appearance of the alar dome and base. Chi-square and Fisher exact test, Student t test (two tailed, independent) and Student t test (two tailed, dependent) were used for statistical analysis of study parameters at 5 % level of significance.

RESULTS

Preconceptions that one particular technique was better suited to certain preoperative cleft anatomical forms were not proven statistically. The outcome of our surgical methods was good and suggested quantitative changes with progressive diminution of asymmetry of the cleft and non cleft sides.

CONCLUSION

Lip length improvement was better in case of modified Millard's incision. The Delaire's functional method of cleft lip repair results in improved nasal symmetry due to correction of the abnormal insertions of the underlying musculature.

Dependence of columella development on the technique used for primary cleft lip closure

OBJECTIVE

Primary cleft lip closure can be achieved by use of different types of surgery. The procedures of Millard, Veau, and Delaire are among the techniques most frequently performed worldwide. The factors which affect development of the columella have not been studied, however.

SETTING

University Hospital of Leipzig, Germany, Department of Oral, Craniomaxillofacial and Facial Plastic Surgery.

PATIENTS, PARTICIPANTS

In a comparative, retrospective, non-randomised study, we obtained anthropometric details from photographs of 120 unilateral and bilateral cleft patients after cleft lip closure by use of the techniques of Millard or Veau (n = 60) and Delaire (n = 60). Length and shape of the columella was assessed twice-first at the age of 10 months and again at the age of 10 years. Anthropometric characteristics of columella morphology and development were compared between the two groups.

RESULTS

At the age of 10 months, the ratio of nasal height to width (interalar distance) was significantly different for unilateral and bilateral cases, and results were better for the Delaire groups (p = 0.001 unilateral and p > 0.001 bilateral). This effect was no longer apparent at 10-year follow up. Another index which tended to indicate better results in the Delaire groups was the nasal width index. In the summary of the anthropometric values investigated, however, differences between the Millard or Veau group and the Delaire group were marginal.

CONCLUSION

Cleft lip closure by the technique of Millard for unilateral cleft lips and of Veau for bilateral cases is neither better nor worse than Delaire cheiloplasty for unilateral and bilateral clefts.

The effects of lip revision surgery on nasolabial esthetics in patients with cleft lip

OBJECTIVES

1) To determine the concordance among surgeons on subjective assessments of nasolabial esthetics in children with repaired cleft lip; and 2) to evaluate longitudinal changes in nasolabial esthetics in relation to cleft lip revision surgery.

SETTING AND SAMPLE POPULATION

School of Dentistry at University of North Carolina, Chapel Hill. Children with repaired unilateral cleft lip: 32 had lip revision surgery and 27 did not have surgery.

MATERIALS AND METHODS

Retrospective observational study from a non-randomized clinical trial. Ratings of nasolabial esthetics performed by six surgeons using the Asher-McDade scale at baseline and 12-month follow-up.

RESULTS

Concordance among surgeons ranged from poor to acceptable. Nasolabial ratings at follow-up were better in the Revision group than in the Non-Revision group, although differences were small. The most prevalent change in the Revision Group was improvement in one or more units on the scale, while 'no change' was most prevalent in the Non-Revision group. Participants in the Revision group were more likely to receive a 'no' in relation to the need for lip or nose revision at the follow-up visit.

CONCLUSION

There were mild esthetic improvements observed in relation to lip revision surgery, which should be interpreted with caution given the subjectivity of the rating method used.

Unilateral cleft lip/nose repair using an equal bows /straight line advancement technique - A preliminary report and postoperative symmetry-based anthropometry

In the evolution of cleft lip repair there has been continuous attempt to minimize local trauma, improve lip and nasal appearance and, especially, prevent conspicuous scars. The surgical technique presented meets these criteria, resulting in an appropriate scar course in children with a specific philtral ridge shape. Postoperative digital anthropometry was performed in 18 patients who underwent unilateral cleft lip repair using the equal bows/straight line advancement technique and in matched healthy control individuals. Symmetry values were assessed for lip length, philtral ridge length, vermilion height, width of the alar base, nasocanthal length, circumference of the nostrils, nostril width and height in both cleft and control groups. Evaluation revealed no significant differences in the symmetry values between cleft patients and control group (lip length: p = 0.71, philtral ridge length: p = 0.52, vermilion height: p = 0.23, alar base width: p = 0.69, nasocanthal length: p = 0.25, nostril circumference: p = 0.17, nostril width: p = 0.34, nostril height: p = 0.33). Principles of cleft lip repair can be achieved using the described technique which provides adequate lip length and natural nasal appearance in patients with a parallel-shaped philtral ridge.

New Technique for Correction of the Microform Cleft Lip Using Trans/Intraoral Approach

The traditional method of treating microform cleft lip with nose deformity uses upper lip external incision, finally leading to a small scar on the upper lip. Hereafter, we present a new method for the correction of microform cleft lip using trans/intraoral approach. The new surgical technique is characterized as (1) using trans/intraoral approach and no incisions on the skin of the upper lip, (2) reconstruction of the "cross" muscular structure using the abnormal muscular insertions at the base of nasal columella and the nasal alar to restore nose deformity, and (3) repair of the lip deformity using two small Z-plasties to get the aesthetic and functional outcome. Thirty patients with microform cleft lip were repaired with our technique, and good functional and aesthetic results of repaired noses and upper lips were obtained in most cases.

Lip Height Improvement during the First Year of Unilateral Complete Cleft Lip Repair Using Cutting Extended Mohler Technique

Objective. To compare the cutaneous lip height at early and late postoperative periods and to objectively determine the average amount of lip height improvement during the first year of unilateral complete cleft lip repair using Cutting extended Mohler technique. Methods. In this prospective cohort study, 26 unilateral complete cleft patients and 50 noncleft subjects were included. Photographs were taken between 12 and 16 weeks (T1) and also taken between 12 and 13 months after surgery (T2). The cutaneous lip height distance (photogrammetric lip analysis) obtained in these two periods of time were measured and statistically analyzed. Results. The average lip heights were 24% ± 9% in T1 and 8% ± 6% in T2 (P < 0.01). The average lip height asymmetry in the noncleft individuals was 4.52% ± 1.89%. Conclusion. Since all principles to obtain a symmetrical Cupid's bow were performed, the postoperative pull-up of Cupid's bow is probably owed to the scar contracture, which improves by 2 times during the first year after surgery.

Primary septoplasty in the repair of unilateral complete cleft lip and palate

BACKGROUND

The purpose of this study was to assess and compare nasal symmetry in patients who underwent correction of a complete unilateral cleft lip using the Afroze incision without and with primary septoplasty using a standardized two-dimensional photographic analysis.

METHODS

A prospective cohort study of 190 consecutive patients with complete unilateral cleft lip and alveolus with cleft palate treated with or without septoplasty using the Afroze incision technique was conducted at a high-volume center. Eighty-two patients operated on without primary septoplasty and 76 patients operated on with primary septoplasty were evaluated. Nasal symmetry was compared between patients using two-dimensional photographic analysis. Ratios between the cleft side and the non–cleft side for five parameters were used to assess symmetry: alar base–to–interpupillary line distance, columella-to–Cupid's bow distance, nostril gap area, nostril width, and nostril height. The Mann-Whitney U test was used to calculate differences between the two groups.

RESULTS

Patients operated on with primary septoplasty showed more nasal symmetry compared with patients operated on without septoplasty. This difference was statistically significant for columella-to–Cupid's bow distance, nostril gap area, and nostril height (p = 0.008, p < 0.001, and p < 0.001, respectively) and for the distance between alar base and the alar base–to–interpupillary line distance (p = 0.145) the difference was present but not statistically significant. For nostril width, no difference was found (p = 0.850).

CONCLUSION

Patients treated with primary septoplasty showed better results in terms of nasal symmetry when analyzed using two-dimensional photographic analyses.

3D assessment of lip scarring and residual dysmorphology following surgical repair of cleft lip and palate: a preliminary study

OBJECTIVE

To evaluate lip scarring and the three-dimensional (3D) lip morphology following primary reconstruction in children with unilateral cleft lip and palate (UCLP) relative to contemporaneous noncleft data.

DESIGN

Retrospective, cross-sectional, controlled study.

SETTING

Glasgow Dental Hospital and School, University of Glasgow, U.K.

PATIENTS AND PARTICIPANTS

Three groups of 10-year-old children: 51 with UCLP, 43 UCL (unilateral cleft lip), and 68 controls.

METHODS

Three-dimensional images of the face were recorded using stereo cameras on a two-pod capture station, and 3D coordinates of anthropometric landmarks were extracted from the facial images. A novel method was applied to quantify residual scarring and the associated lip dysmorphologies. The relationships among outcome measures were investigated.

RESULTS

Residual lip dysmorphologies were more pronounced in UCLP cases. The width of the Cupid's bow was increased due to lateral displacement of the christa philteri left (cphL) in both UCL and UCLP patients. In the upper part of the lip, the nostril base was significantly wider in UCLP cases when compared with UCL cases and controls. Scar redness was more pronounced in UCL than in UCLP cases. No relationship could be identified between lip scarring and other measurements of lip dysmorphology.

CONCLUSIONS

Stereophotogrammetry, together with associated image analysis, allow early detection of residual dysmorphology following cleft repair.

Afroze incision for functional cheiloseptoplasty

Repair of unilateral cleft lip is a fascinating and challenging procedure. Although a great number of operations have been described for the unilateral cleft lip repair, none fulfill all the plastic surgical criteria, and in most cases, cleft lip repairs require secondary operations in an attempt to achieve described goals of primary cheiloplasty. The Afroze incision is a combination 2 incisions, that is, the Millard incision on the noncleft side and Pfeiffer incision on the cleft side. The flap design is the Millard flap on the noncleft side rotated downward, and the peak of the distal curve of the Pfeiffer flap is positioned in the triangular defect formed by the movement of the Millard flap. The proximal curve lengthens downward to receive the Millard's "C" flap. The advantage of this technique is that there is no tension on the postoperative scar because the incision is essentially horizontal in nature, and the contracture of the scar occurs horizontally rather than vertically. Primary septal repositioning is performed, which provides stability and exact positioning of the previously lifted alar crus of the cleft side and nasal tip, and the nose can grow in a balanced way with equal muscular force being exerted on both sides. This incision can be used in all types of complete unilateral cleft lip regardless of the width of the cleft, shortening the cleft lip segment.

Nasolabial esthetics in children with complete unilateral cleft lip and palate after 1- versus 3-stage treatment protocols

PURPOSE

Facial esthetics play an important role in social interactions. However, children with a repaired complete unilateral cleft lip and palate usually show some disfigurement of the nasolabial area. To date, few studies have assessed the nasolabial appearance after different treatment protocols. The aim of the present study was to compare the nasolabial esthetics after 1- and 3-stage treatment protocols.

MATERIALS AND METHODS

Four components of the nasolabial appearance (nasal form, nasal deviation, mucocutaneous junction, and profile view) were assessed by 4 raters in 108 consecutively treated children who had undergone either 1-stage closure (Warsaw group, 41 boys and 19 girls, mean age 10.8 years, SD 2.0) or 3-stage (Nijmegen group, 30 boys and 18 girls, mean age 8.9 years, SD 0.7). A 5-grade esthetic index of Asher-McDade was used, in which grade 1 indicates the most esthetic and grade 5 the least esthetic outcome.

RESULTS

The nasal form was judged the least esthetic in both groups and graded 3.1 (SD 1.1) and 3.2 (SD 1.1). The nasal deviation, mucocutaneous junction, and profile view were scored from 2.1 (SD 0.8) to 2.3 (SD 1.0) in both groups. The treatment outcome after the Warsaw and Nijmegen protocols was comparable. Neither overall nor any of the 4 components of the nasolabial appearance showed intercenter differences (P > .1).

CONCLUSIONS

The nasolabial appearance after the Warsaw (1-stage) and Nijmegen (3-stage) protocols was comparable. The technique of lip repair (triangular flap in Warsaw and Millard rotation advancement in Nijmegen) gave comparable results for the esthetics of the nasolabial area.