The lip is the primary aesthetic feature of the human body. In the secondary cleft lip deformity, mismatch of wet and dry vermilion and lip projection may be problematic. The whistling deformity was defined as insufficient tissue in the lower border of a repaired cleft lip, giving the appearance of whistling while in repose and worsening on activation. Many cleft lip patients require secondary reconstruction of the vermilion tubercle. Repair of vermilion deformity represents a unique challenge to the reconstructive surgeon.
The methods of reconstruction of the vermilion tubercle are various and have both advantages and disadvantages. For significant deformities, rotation advancement flap reoperation is often necessary. For lesser deformities, many options exist, including local flaps, Z-plasties, tongue grafts, and fillers (eg, hyaluronic acid, collagen, and fat grafts). The uses of local axial-based flaps have also been described. In addition, an Abbe flap may be used to recruit additional lip tissue and to correct the cleft lip deformity.1,2 Kapetansky3 described an axial-based double pendulum flap for correction of central lip deformities in bilateral cleft lip patients.
Our aim was to develop an effective method for correcting vermilion defects and to record our experience with this useful technique for providing cover for reconstruction of the vermilion tubercle. Each patient obtained a more natural contour of the vermilion tubercle and a more satisfactory proportion between the upper and lower lips. In the following, we introduce the design, technical details, and case experience of a new style of bilateral lip mucosa flaps (BLMF) for reconstruction of the vermilion tubercle in the secondary cleft lip deformity.
PATIENTS AND METHODS
A total of 34 patients were treated with BLMF for reconstruction of the vermilion tubercle during the past 8 years. Twenty-two patients were male and 12 were female. The oldest was 50 years old and the youngest was 7 years old. Twenty-five of the cases had bilateral secondary cleft lip, and 9 cases had unilateral secondary cleft lip. We retrospectively reviewed the pre-, intra-, and postoperative data of these 34 cases receiving BLMF.
Design, Excise, and Transfer of BLMF
The BLMFs were designed. For anesthesia, we injected 0.5% lidocaine containing 1:200,000 epinephrine. The size and shape of BLMF were designed according to the scope of the lesion and were marked with methylthioninium chloride or marking pen. Two reverse triangular flaps were designed on both sides of the upper vermilion defect. These 2 flaps have the common pedicle in the vermilion depression site. Alternatively, a “
” incision may be used in the wet vermilion. Then, the mucosa flaps were raised, and dissection was performed between the orbicularis oris muscles and oral mucosa glands (Fig. 1).
After adequate mobilization, the orbicularis oris muscle was then transposed from the area of lateral fullness into the central cleft deficiency toward the central tubercle. The orbicularis oris muscles could be closed centrally to overlap each other, increase the central lip volume, and reconstruct the continuity of the orbicularis (Fig. 2).
Next, the bilateral mucosa flaps were rotated down 90° and inserted into the
incision to increase the tissue volume of the middle upper lip and deepen the labiogingival sulcus (Fig. 3).
The common pedicle of the mucosa flaps was formed to the vermilion tubercle, and the incisions were sutured layer by layer (Fig. 4).
Three independent examiners (a plastic surgery resident, a pediatrician, and a craniofacial fellow) recorded upper lip measurements of images in the preoperative and follow-up periods. Measurements were used to calculate lip fullness. Lateral measurements of the upper lip were performed. For this lateral projection measurement, the right-angled distance from the N-P line (nasospinale to pogonion) to the anterior lip projection point was used. Augmentation percentage was documented using follow-up measurements compared with preoperative measurements.
An unpaired t test was used to determine significance between preoperative and follow-up measurements. Results between preoperative and follow-up lateral projection measurements are given as mean ± SD. A value of P < 0.05 was considered statistically significant.
Satisfactory results were obtained, both cosmetically and functionally, in all 34 patients. Each patient obtained a more natural contour of the vermilion tubercle. There were minimal perioperative complications. The postoperative scars are not remarkable at all. The color and texture matched well with the surrounding tissue. For the lateral projection of the upper lip, the right-angled distance from the N-P line (nasospinale to pogonion) to the anterior lip projection point showed a mean increase of 151% ± 42% after the operation (P< 0.05).
A 23-year-old male patient visited our clinic because of a central defect of vermilion tubercle, caused by secondary bilateral cleft lip deformity. He wanted to repair the deformed upper lip. The BLMFs were designed on his upper lip. There was little swelling in the flaps, but the whole flaps survived well. The shape and color was satisfactory at 7 days post operation. The patient can close his mouth completely, and no deformity has been left on his lip.
A 7-year-old boy with the vermilion tubercle defect on his upper lip, caused by bilateral secondary cleft lip, was presented. He wanted to recreate the vermilion tubercle. The BLMFs were designed on his upper lip. The flaps survived well at 7 days post operation. When the patient was followed up at 1 month post operation, he was very satisfied with the cosmetic effect.
A 20-year-old woman visited our clinic because of a central defect of upper vermilion, caused by secondary unilateral cleft lip deformity. She wanted to reconstruct the deformed upper lip. The result of the operation was satisfactory, from both the functional and the cosmetic standpoint. The patient can close her mouth completely, and no deformity has been left on her lip.
A large vermilion defect may require tissue transfer, such as tongue flaps, cross-lip vermilion flaps, palatal mucosal grafts, island flaps from the lower lip, palmaris longus grafts, temporoparietal fascial grafts, or an Abbe flap.4–6 A small vermilion deficiencies can be repaired with local rearrangement, such as Z-plasty, mucosal V-Y advancement, vermilion double V-Y advancement, mucosal transposition flaps, or Kapetansky flaps.7 However, they have disadvantages that make them undesirable. The tongue flap can result in color mismatch. Techniques using lower to upper transfer of tissue require 2 stages and lead to lower lip scarring. Fascial and dermis-fat grafts have their concomitant donor-site morbidity, and these methods cannot reconstruct lip beads.8
Kapetansky3 described a technique that involved superiorly based double-pendulum flaps that were transposed medially to reconstruct the defect. Kapetansky9 modified his own technique and added a back cut to increase vertical height, altered the amount of orbicularis taken in each portion of the flap, and decreased the depth of the mucosal incision.10 Juri et al11 modified the technique by increasing the amount of tissue taken laterally so that the flaps can be turned in medially in an effort to increase the thickness of the central zone. Matsuo et al12 used anteromedially based flaps that were then transposed in the mid-posterior prolabium to decrease lip tension, deepen the labiogingival sulcus, and recreate the tubercle; of course, this had the unfortunate drawback of disrupting the continuity of the orbicularis.
We consider our method to be useful because (1) the technique is simple and safe, (2) no or little healthy tissue is lost, (3) it can decrease lip tension, deepen the labiogingival sulcus, and recreate the tubercle, (4) the procedure reestablishes continuity of the orbicularis oris muscle and creates a more natural tubercle and central lip element, (5) this method has no conspicuous scars that remain in the upper lip, because all of the scars are hidden in the wet lip, and (6) the appearance of the repair is more natural and matches the normal lip well.
In conclusion, it is a technique in which the outlining of the incisions can vary according to different cases. We have developed an effective technique for repairing vermilion defect. The technique is relatively simple. The color and texture match well to the surrounding tissue of the BLMF, and the threat of scarring is eliminated because it is relatively hidden. In short, BLMFs are the ideal flaps for reconstruction of the vermilion tubercle.
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