|Year : 2014 | Volume
| Issue : 1 | Page : 48-51
Reconstruction of the superior gingiva-labial sulcus in bilateral cleft lip palate patients: Our experience
Divya Narain Upadhyaya, Arun K Singh, Vijay Kumar, Brijesh Mishra, Veerendra Kumar
Department of Plastic Surgery, King George Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||5-Feb-2014|
Divya Narain Upadhyaya
B-2/128, Sector-F, Janakipuram, Lucknow - 226 021, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: In many bilateral cleft lip palate patients the prolabium often remains adherent to the premaxilla and the upper alveolar-labial sulcus is absent. Cleft surgeons have struggled with this problem for many decades and a number of procedures have been described in the literature to correct this deformity. Materials and Methods: A retrospective review of the records of all patients who underwent upper gingivobuccal sulcus reconstruction between August 2003 and December 2012 was carried out. Results: A total of 97 patients were underwent upper gingivolabial sulcus reconstruction with full thickness skin graft from August 2003 to December 2012, a period of 9 years and 5 months. Discussion: An adequate sublabial or gingivolabial sulcus is crucial to both the function as well as the esthetics of the upper lip. Paucity of tissues in bilateral cleft lip and palate patients during lip repair often leads to a 'tight' repair with little or no sulcus at all. The full thickness skin graft has many benefits. It can be harvested in greater quantities than the mucosal graft, takes well, is hairless and does not contract or harden to any significant degree. One significant disadvantage of the skin graft in the upper labial sulcus is its pigmentation that can continue to irk the patients even after several years and probably forever.
Keywords: Labial sulcus, reconstruction, skin graft
|How to cite this article:|
Upadhyaya DN, Singh AK, Kumar V, Mishra B, Kumar V. Reconstruction of the superior gingiva-labial sulcus in bilateral cleft lip palate patients: Our experience. J Cleft Lip Palate Craniofac Anomal 2014;1:48-51
|How to cite this URL:|
Upadhyaya DN, Singh AK, Kumar V, Mishra B, Kumar V. Reconstruction of the superior gingiva-labial sulcus in bilateral cleft lip palate patients: Our experience. J Cleft Lip Palate Craniofac Anomal [serial online] 2014 [cited 2019 May 26];1:48-51. Available from: http://www.jclpca.org/text.asp?2014/1/1/48/126564
| Introduction|| |
In many bilateral cleft lip palate patients the prolabium often remains adherent to the premaxilla and the upper alveolar-labial sulcus is absent. This peculiar deformity poses many problems for the patient as well as the treating physician [Figure 1]. The upper lip gives a tied down appearance and the patient has difficulty with many functions of the lip like speech or the blowing of certain musical instruments. The mobility of the upper lip is severely restricted and the lack of an upper labial sulcus poses a problem in orthodontic and prosthodontic treatment of the patient [Figure 2]. Cleft surgeons have struggled with this problem for many decades and a number of procedures have been described in the literature to correct this deformity. These range from the Orthodontic appliance technique of Falcone  to radical procedures such as partial ostectomy of the premaxilla and resurfacing with local mucosal flaps.  We describe our experience of reconstructing the superior gingivolabial sulcus by full thickness skin graft.
|Figure 1: Frontal and profi le pictures of an adult patient of bilateral cleft lip and palate. Note the lack of the upper gingivolabial sulcus and the adherent look of the upper lip|
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|Figure 2: An orthodontic appliance used to retract the protuberant premaxilla. Notice the importance of the sulcus in accommodating the anterior rim of the appliance|
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| Materials and Methods|| |
A retrospective review of the records of all patients who underwent upper gingivobuccal sulcus reconstruction between August 2003 and December 2012 was done. The demographic and photographic data was retrieved and analyzed. Follow-up photographs were compared with pre-operative photographs and the results tabulated.
The upper lip is everted with the help of 4/0 Silk sutures [Figure 3] and the incision is marked with Bonney's blue dye in the upper gingivolabial sulcus leaving a mucosal cuff of a few millimeters attached to the gingiva. The area is infiltrated with 1% Lignocaine with 1:200,000 adrenalines and is incised after optimum time has lapsed to allow for vasoconstriction. The dissection proceeds in a plane between the upper lip and the premaxilla taking care not to dissect too close to the premaxilla and to always leave the bone covered with sufficient tissue. The dissection proceeds right till the base of the columella. Once the right endpoint of dissection has been reached in the midline the sideways dissection is begun and proceeds to the point where the lateral elements meet the prolabial segment [Figure 4]. The resultant laxity of the upper lip can be appreciated on table when the lip does not look tethered anymore and the lateral elements do not feel 'tight'. A second team simultaneously harvests the full thickness skin graft from the hairless groin or the post-auricular area. The graft is defatted while the donor area is being closed. The defatting has to be meticulous to ensure good take of the graft. A perforation or two during defatting not only does not do any harm, but also enhances the skin graft take by allowing any sub-graft collection to drain spontaneously.
|Figure 3: The upper gingivolabial sulcus is exposed prior to marking and infiltration with adrenaline|
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|Figure 4: The defect created for the neo-sulcus. Note the cuff of gingiva at the upper alveolus that is spared to help suture the graft and the little tissue left over the premaxilla so as not to denude the bone|
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The graft is then inset into the new upper gingivolabial sulcus taking care to stich the graft into the recesses of the neo-sulcus properly. A few long ends of the sutures are left to help with the tie-over [Figure 5]. The graft is lined with tulle gras and packed with cotton wool soaked with betadine and wrung dry. The suture ends are then tied to each other to ensure compression of the graft and its adherence to the furthest crevices of the neo-sulcus [Figure 6].
|Figure 5: The graft has been sutured to the margins, quilted to the bed and suture ends left long to assist in the tie-over dressing. Note the few perforations in the graft for draining the sub-graft hematoma|
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Post-operatively the bolus dressing is removed on day 7 and the graft is inspected. Excess graft, if any, is trimmed at this time. The neo-sulcus is lavaged, moisturized and the patient sent for measurement for the orthodontic appliance, which he/she will have to wear.
| Results|| |
A total of 97 patients were underwent upper gingivolabial sulcus reconstruction with full thickness skin graft from August 2003 to December 2012, a period of 9 years and 5 months. Out of a total of 97 patients, 62 were males and 35 females. The age of these patients ranged from 2 years to 23 years with a mean of 4.5 years [Table 1]. The year-wise patient distribution and sex ratio were tabulated [Figure 7]. Seven patients out of 97 showed areas of partial graft loss (7.21%), rest all patients had complete graft take. The longest follow-up is now of 9½ year (range from 6 months to 9 years, 6 months; mean - 5.25 years) and the grafts have shown minimal or negligible contraction and the sulci continue to be good in depth and width [Figure 8].
|Figure 8: Long-term results of upper gingival sulcus creation using full thickness skin graft|
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| Discussion|| |
An adequate sublabial or gingivolabial sulcus is crucial to both the function as well as the esthetics of the upper lip. Paucity of tissues in bilateral cleft lip and palate patients during lip repair often leads to a 'tight' repair with little or no sulcus at all. Such patients have difficulty performing normal functions of the lip such as smiling, puckering, whistling, blowing etc. and also complain of the unsightly, tight and stretched appearance of the lip. From a physician's point of view an adequate upper labial sulcus is important for the application of orthodontic devices used for palatal expansion and premaxillary retrusion [Figure 9]. Another less looked-into aspect of a tight upper lip is a probable hindrance to maxillary growth due to circumferentially tight lip scar. An adequate gingival sulcus can therefore, have certain beneficial effects on the growth of the maxilla and may end up decreasing, probably, the rate of Le Fort I osteotomies. Another issue that needs documentation and which has been missed in our study is the quantification of sulcus depth by physical, serial measurements before surgery and subsequently at every follow-up.
|Figure 9: Different orthodontic appliances used to palatal expansion and premaxillary retrusion|
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The literature is littered with numerous techniques advanced by their advocates for the correction of this deformity, which attests to the difficulty of getting it right with any of them. More radical techniques of yore like premaxillary ostectomy are thankfully less heard of now.  Falcone has described a hinged flap of alveolar mucosa folded back upon itself and used to line the labial aspect of the created defect while the donor area on the premaxilla was left to heal on its own.  Horton et al.  in their study has described a V-Z advancement technique to prevent straight-line scar formation and covered the bare alveolus with a mucosal graft. Others have described numerous mucosal flaps for the same deformity such as the V-Y advancement flap, the Z-plasty flaps and the M-flap.  Most of these procedures are either too radical and leave the alveolar area denuded or fall short of creating a sufficiently deep sulcus. The mucosa of the upper lip is so short and scarred at the time of the secondary revision that if a deep sulcus is created it is impossible to resurface it with native mucosa and tissue must be imported from outside for the same. Use of lateral lip element flaps has its limitations in terms of the extent of advancement it can achieve and the deforming influence on the lateral elements. Mucosal grafts have been used with some success but the donor area is very limited and split skin graft often contract and g = harden over time. Wakami et al. have described a rectangular mucosal flap with artificial dermis for vermilion deformity of the upper lip, but it will not address the shallow sulcus.  The Abbe flap may solve many of these problems and provide and good sulcus and full upper lip, but it seems a bit of overkill for a deformity that can otherwise be managed easily.  The full thickness skin graft in contrast has many benefits. It can be harvested in greater quantities than the mucosal graft, takes well, is hairless and does not contract or harden to any significant degree. One significant disadvantage of the skin graft in the upper labial sulcus is its pigmentation that can continue to irk the patients even after several years and probably forever.
| References|| |
|1.||Falcone AE. Release of the adherent prolabium and deepening of the labial sulcus in the secondary repair of bilateral cleft lips. Plast Reconstr Surg 1966;38:42-4. |
|2.||Obwegeser H. Surgical preparation of the maxilla for prosthesis. J Oral Surg Anesth Hosp Dent Serv 1964;22:127-34. |
|3.||Horton CE, Adamson JE, Mladick RA, Taddeo RJ. The upper lip sulcus in cleft lips. Plast Reconstr Surg 1970;45:31-7. |
|4.||Hata Y, Ohmori S. A method of reconstruction of the sublabial sulcus and the vermilion tubercle in the secondary repair of the bilateral cleft lip deformity. Br J Plast Surg 1978;31:165-9. |
|5.||Wakami S, Harada T, Muraoka M, Ishii M. Rectangular mucosal flap with artificial dermis grafting for vermilion deformity in cleft lips. J Plast Reconstr Aesthet Surg 2010;63:22-7. |
|6.||Erol OO, Pence M, Agaoglu G. The Abbé island flap for the reconstruction of severe secondary cleft lip deformities. J Craniofac Surg 2007;18:766-72. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]