Straight-line closure repair of unilateral cleft lips was first introduced in the 1840s,1,2 and since then, many different techniques have been attempted for cleft repair. The most significant of these is Millard’s “rotational advancement” technique devised in 1958. Millard3 published the operative method in 1976, and thereafter, this method became the fundamental technique used for unilateral cleft lip repair. Other investigators have improvised considerably on the original rotational advancement technique by adding variations such as vermilion flaps4 and triangular advancement flaps.5,6 Other adaptations of the rotational advancement technique are Mulliken’s7 modification and Fisher’s8 recently published anatomical subunit approximation technique.
These methods have several disadvantages and are difficult to adopt. For example, the rotational advancement technique and its modifications form an unnecessary scar below the nasal ala and columella. Further, Fisher’s technique involves some cumbersome steps and is difficult to apply to wide complete cleft lips not treated with presurgical nasoalveolar molding.
Therefore, we devised an intuitive and easily applicable technique that can be performed well by novice plastic surgeons. In this study, we describe our novel technique, known as Straight-Line Advanced Release Technique (StART), and its application in treating several cases of unilateral cleft lip. “Advanced release” indicates thorough muscle dissection to restore normal structure and create a balanced and natural muscle sling, whereas “straight line” stands for the straight-line skin closure to ensure minimal visibility and surgical design simplicity, whereby even novice plastic surgeons can adopt our technique.
PATIENTS AND METHODS
The present study was undertaken in accordance with the Declaration of Helsinki. Verbal and written informed consents were obtained from all of the participants. One hundred forty-five patients underwent unilateral cleft lip repair using StART. All of the surgeries were performed by the senior author from 1993 to 2012. Furthermore, all cases were first-time surgery on unilateral cleft lips for all patients, and cases of microform cleft lip were excluded (Table 1).
Straight-Line Advanced Release Technique
Figures 1 and 2 show the preoperative design of the surgical method. The peaks of the Cupid’s bow are marked at the vermilion-cutaneous junction at points 0 (the high-angled point of the noncleft side), 1 (the center of the Cupid’s bow), and 2 (the same distance from point 1 as like that from 0 to 1). A curved line is drawn from point 2 along the vermilion-cutaneous junction to point 4 (the membranous septal area). From point 2, a vertical straight line is drawn up to point 5 (the midpoint of the junction between the philtrum and columellar base), and the design of the slit incision is marked parallel to the direction from points 0 to 1. The incisional design for the downward releasing A flap and insertion of B flap into the upper philtral defect is drawn parallel to the noncleft side philtral ridge from point 5.
On the cleft side, point 3 is positioned on the vermilion-cutaneous junction, where the outline curvature of the red vermilion begins to inflect. A curved line is drawn from point 3 along the vermilion-cutaneous junction to point 6 (the internal valve area). A triangular flap design is added on the vermilion-cutaneous roll just above point 3. This triangular flap will meet with point 2 and merge into the small slit incision after dissection is completed. For marking the M (medial mucosal) flap, a straight line is drawn from point 2 on the red vermilion to point 7; it changes its course along the dry-wet vermilion junction and then continues to point 9. A straight line is drawn from point 3 on the red vermilion, which turns at point 8, and then continues along the dry-wet vermilion junction of the red vermilion to point 10. Thus, it forms the L (lateral mucosal) flap. From points 9 and 10, oral linings are marked through the gingivolabial sulcus, to points 11 and 12 (Figs. 1, 2).
Key landmarks are tattooed using gentian violet dye and a 26-gauge needle (Fig. 3). Next, 1% lidocaine with 1:200,000 epinephrine is infiltrated along the designed incision line. Incisions are made with number 15 blades; for incisions on the triangular flap, number 11 blades are used for greater precision. Dissection is performed to separate the orbicularis oris muscle from the abnormally inserted bony structure and the enveloped skin-mucosal flap. At this point, the extent of dissection is set as wide as possible. In the subcutaneous plane, the range of dissection was the philtral area on the noncleft side to the perialar area on the cleft side. The release and dissection below the orbicularis oris muscle ranges from the cleft margin to the anterior nasal spine and piriform aperture base on the noncleft side. On the cleft side, the release area of the abnormally inserted muscle covers the entire anterior maxillary plane. This maneuver is the most important step for deciding the entire lip contour line (Figs. 4–6).
After dissection on both sides of the cleft is completed, the orbicularis oris muscle is fully detached from the abnormal insertions. The freed orbicularis oris muscle is then reconstructed. In the present study, Ethibond 6-0 filament (Ethicon, Inc, United States) was used as the suture material. At this point, the orbicularis oris muscle should be repaired with full width, from the columellar base to the red vermilion (Figs. 7–9).
In manipulation of the oral linings, the operation method of incomplete cleft lips can be distinguished from that of complete cleft lips. In the case of incomplete cleft lips, a portion of the M flap is inserted into the oral side defect by releasing the buccogingival incision on the noncleft side. The L flap is adequately trimmed and sutured for closure of the remaining oral lining. Subsequently, the oral lining flap created by the buccogingival incision on the cleft side is sutured by proceeding medially from the lateral side.9
For the repair of complete cleft lips, only one mucosal flap is insufficient for covering the oronasal lining, and both medial and lateral mucosal flaps are required. The positions of the M and L flaps can be interchanged depending on the circumstances of the cleft defect (Fig. 10). After the tiny triangular flap is inserted into the slit incision in the white roll, the vermilion and skin closure continue toward the nasal base, making the bases of both nostrils symmetric. Further, after all planes of the lip wound are closed, a straight vertical skin suture line is achieved without any unnecessary transverse scar (Figs. 11, 12).
Unilateral cleft lip repair using StART was conducted in 145 patients between 1993 and 2012. The mean age at primary cheiloplasty was 3.3 months (range, 2.8–5.2 months). The longest follow-up period was 20 years. A total of 21 patients (14%) required a secondary operation on the lip after the first unilateral cheiloplasty. The main purposes of this revision cheiloplasty were peaking or notching correction (8 cases, 5%), correction of red vermillion bulging (7 cases, 5%), and correction of philtral vertical scars (6 cases, 4%) (Table 1). In all patients, satisfactory surgical outcomes were obtained with an indistinct straight-lined scar and a well-aligned lip contour (Fig. 13).
Mild alar buckling and a derotated nasal tip were the main causes of rhinoplasty as a planned surgery after the age of 5 years. In this group, the purpose of rhinoplasty was the correction of the nasal tip deformity and deviated septum. A wide or flared ala was not indicated as a complaint for secondary correction because the alar base widths in most cases were symmetric.
In the present study, we describe StART, a novel but easily applicable technique for the repair of unilateral cleft lips. Previously reported techniques are too cumbersome for young plastic surgeons to apply in the correction of various types of cleft lips. They require the measurement of many parameters, which may change because of stretching and release after dissection. Because the dissected muscle ends lengthen and move excessively during reconstruction of the perioral muscle sling, skin with certain preoperative numerical values is destined to be deformed passively during lip surgery. Therefore, rather than focusing on the skin, attention must be paid to the perioral muscle, which is the main framework in cleft lip repair. This is the principal concept underlying our technique and the rationale from which this technique was designed and developed.
The markings in StART are minimal, and positioned to meet the requirements for deciding on surgical incision and plain anatomical junction. With the use of essential landmarks, the second stage is set with the angle and ratio and not with numerical distances. In this design stage, the primary purpose is to maintain the natural shape of the Cupid’s bow. In Figure 1, angle a is designed to be the same as angle a′, and angle b is designed to be the same as angle b′. Thus, when both sides of the cleft meet, the most natural shape can be expected. In addition, to obtain natural continuity of the white roll and avoid an acute angulation in the reconstructed Cupid’s bow, a small slit incision line was marked in the triangular flap design from point 2 as angle c′, which is designed to be the same as angle c. As described above, we do not consider miscellaneous preoperative measurements important. Instead, we consider the proportion of normal anatomy of the lip as essential to obtain natural results. This is 1 aspect that distinguishes our method from other methods.8
We consider wide submuscular dissection over the abnormally inserted site as a significant procedure in cleft lip surgery. Because the core structure of the lip is the orbicularis oris muscle and the skin merely envelopes this muscle, we consider reconstitution of the complete muscle sling as more important rather than tailoring of the skin. Most patients with clefts show bilaterally contracted muscle, which develops because of the loss of the midline anchoring structure with breakdown of the muscle sling. To relocate the contracted muscle in the defective area, all muscle inserted into the neighboring structure around the cleft should be fully released without exception. It is known that the columellar base and the alar base on the cleft side are definitely affected by the pulling power of the abnormal muscle. Once the M and B flaps are elevated, the abnormal insertion of the orbicularis oris muscle around the anterior nasal spine is easily exposed. By gradually pulling and detaching the entire muscle bulk inferiorly, the extent of release of the abnormal orbicularis oris muscle can be adjusted. In the case of severe wide complete clefts, the dissection range can be extended to the piriform aperture base on the noncleft side. Reconstruction of the orbicularis oris muscle is then performed with full width and length, from the columellar base to the end of the red vermilion. The StART allows sufficient lip length and lowers skin tension, which prevents the scar from widening.10 On the cleft side as well, the abnormal insertion of the orbicularis oris muscle is detached and rotated to resemble normal anatomy.
After the abnormal muscle is released sufficiently, the skin-releasing incision at point 5 could be minimized, provided the relocated muscle does not create tension at the skin margin between points 2 and 5. However, skin tension must develop after muscle release in the case of highly contracted cleft lips. Then, a suitable vertical down-cut from point 5 enables relaxation of the tension and effective release of the A flap.11 The B flap is naturally inserted to cover the skin defect below the columellar base.
As mentioned above, the skin-releasing mechanism in StART involves a small triangular flap at the white roll and a downward back-cut incision at the upper philtrum. This triangular flap has a distinct difference from those in other methods, in that it is smaller.12 With only this tiny flap, we could achieve a natural white roll line with an inconspicuous postoperative scar (Fig. 14). Just below the columella, the B flap is flexibly used to fill the skin defect after downward shifting of the A flap and a straight-line suture. The role of the B flap differentiates StART from various other modifications of Millard’s original technique. Since the introduction of the rotational advancement technique, the C flap design under the columella has been used to lengthen the short side of the columella.13 In other modification, the lateral lip flap was advanced and wedged between the C flap and the rotated medial lip flap to achieve lengthening. However, this maneuver led to the formation of several unnecessary transverse scars around the philtral ridge. Later, Noordhoff, Onizuka, Mulliken, and Mohler arranged the C flap incision as far as the philtrum on the noncleft side,14 but their design also left surgical traces under the columella and alar base on the cleft side. In contrast, we designed the B flap from the peak of the Cupid’s bow (point 2) to the midpoint of the columellar base and created a small down-cut incision over but not involving the middle of the philtrum. Because the incision line dividing the A and B flaps is straight, a larger B flap compared with the C flap can be used. The B flap not only lengthens the columella but also fills the defect by releasing the A flap without the need for insertion of a lateral lip flap. Therefore, transpositioning the A flap with the B flap functions as a Z-plasty, and unnecessary transverse scars can be avoided.
Under the cleft-side alar rim, wide submuscular dissection over the anterior maxillary area helps repositioning of the alar rim without an additional incision along the alar base. After this maneuver, the alar base can be connected to the B flap with complete muscle repair under the nostril base, whereby alar flaring can be prevented without the “cinching technique.” In some modifications of Millard’s method, the cinching technique was performed simultaneously with cheiloplasty to prevent alar flaring and nostril base asymmetry.13 However, we believe that primary nasal tip plasty could hamper the growth potential of the nasal cartilage, especially in Asian children, who have a smaller nasal structure than children in the West. Therefore, we chose solid repair of the dissected orbicularis oris muscle beneath the alar base with repositioning the alar base to the normal position as the primary rhinoplasty to correct nasal deformity and recommend tip plasty and septoplasty several years later to obtain more promising results.
For repair of the oral lining, we used the rotation and advancement technique. By this technique, an adequate amount of mucosal tissue is obtained for an oral lining, notching deformities are rare, and central fullness is achieved. Finally, a 3-dimensional lip is obtained with a high possibility of having the natural tubercle shape.9 When there is inadequate eversion of the vermilion, as in the case of thin lips, individuals tend to appear aged and unattractive.15 To surgically correct this appearance, the tissue of the oral lining is stretched vertically to give the appearance of full lips.16,17 Various methods such as Z-plasty, transposition flaps to correct notching deformities, and the V-Y advancement technique for tubercle formation are used to obtain sufficient vertical tissue for the oral lining in a secondary cheiloplasty.18–20 The natural oral lining should be considered with high priority in lip surgery, especially for the primary repair of cleft lips, in which the skin and mucosa are insufficient.
After skin suture, a straight skin closure line can be obtained. The scar around the alar base has been a concern for most patients, and revision for this scarring has been very difficult.21 The absence of an incision around the alar base can be regarded as an important advantage of StART. Our procedure results in a similar straight-lined scar as those in Nakajima’s method22 and Fisher’s8 method. However, compared with these methods, ours yields a much higher and natural-appearing lip contour and the volume of the nostril base because of the B flap, and our preoperative design is concise and much easier to comprehend.
To acquire a natural and balanced shape in unilateral cleft lip repair, we recommend the novel StART. Most patients required only a single lip operation, and only few cases of postoperative peaking and notching deformities were encountered in the present study.
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