|IDEAS AND INNOVATIONS
|Year : 2014 | Volume
| Issue : 2 | Page : 104-108
Management of lateral lip element in rotation advancement technique for cleft lip repair: Tips and tricks
Gaurav S Deshpande1, Alex Campbell2
1 Department of Maxillofacial and Plastic Surgery, Operation Smile Guwahati Comprehensive Cleft Care Center, Guwahati, Assam, India
2 Operation Smile Inc., Norfolk, Virginia, USA
|Date of Web Publication||2-Aug-2014|
Dr. Gaurav S Deshpande
Operation Smile Guwahati Comprehensive Cleft Care Center, 2nd Floor, Mahendra Mohan Choudhary Hospital, Pan Bazaar, Guwahati - 781 001, Assam
Source of Support: None, Conflict of Interest: None
A new era in cleft lip repair began when Dr. Ralph D Millard introduced his technique of rotation and advancement. In 1987, Mohler described a variation of Millard's unilateral repair that included a columellar extension. In 2005, Fisher introduced the principle of anatomic subunit closure. These techniques can work very well across the spectrum of unilateral clefts of the lip, though challenges arise with wide clefts and those where there is a large discrepancy between the greater lip height and lesser lip height. In cases when the discrepancy is high, the surgeon often tries to gain the necessary lip height on the cleft side by shifting the Noordhoff's point more laterally, sacrificing excessive tissue. This often results in a lateral lip that is hypoplastic, giving an unnatural look to the repaired upper lip. Focus has traditionally been on getting the necessary lip height, sacrificing fullness of the lateral lip element. This paper describes several strategies to optimally manage the lateral lip element in rotation-advancement technique for unilateral cleft lip repair. The results with this technique are encouraging and can be utilized to offset the drawbacks of rotation-advancement technique in very wide and short cleft lips.
Keywords: Lateral lip element, Mohler′s repair, subunit repair principle, whistle deformity
|How to cite this article:|
Deshpande GS, Campbell A. Management of lateral lip element in rotation advancement technique for cleft lip repair: Tips and tricks. J Cleft Lip Palate Craniofac Anomal 2014;1:104-8
|How to cite this URL:|
Deshpande GS, Campbell A. Management of lateral lip element in rotation advancement technique for cleft lip repair: Tips and tricks. J Cleft Lip Palate Craniofac Anomal [serial online] 2014 [cited 2019 May 22];1:104-8. Available from: http://www.jclpca.org/text.asp?2014/1/2/104/137903
| Introduction|| |
Most reports of cleft lip repair in the literature have given more emphasis to the medial element of the cleft repair to gain necessary height for a symmetrical cupid's bow, and "adjusting" the lateral lip element to achieve this goal. Failure to adequately manage the lateral lip element can detract from overall results in a variety of ways. Common issues include a hypoplastic lateral lip element, unnatural peaking of cupid's bow, white roll mismatch, whistle deformity, and excess vermilion.
The keys to successful management of the lateral lip element are correct placement of the Noordhoff's point, adequate excision of cleft tissue, and appropriate design and placement of a triangle above the white roll.
| Materials and Methods|| |
This paper addresses the most commonly faced challenges in the management of the lateral lip element using Mohler's modification of the rotation-advancement technique. The author has applied the principles of Anatomic subunit repair in rotation-advancement technique when the discrepancy between the greater and the lesser lip height is more than 3 mm. If a discrepancy is <3 mm, the necessary height is gained by the rotation flap (generally no more than 2 mm can be gained) and Rose Thompson effect (accounts for 1 mm), which avoids the use of a cutaneous triangle above the white roll.
The common challenges that are faced and the strategies to overcome them are as follows:
The Noordhoff's point "dilemma"
Accurate placement of the Noordhoff's point is the key to getting a balanced lip. If this point is placed too medially, it may result in "whistle" deformity and if placed too laterally can compromise an already deficient lateral lip element. One approach is to measure the distance from the oral commissure to the height of cupid's bow on the noncleft side, and transposing this distance onto the cleft-side lateral lip element.  This technique is unreliable, and may often incorporate residual cleft tissue in the repair, creating a "whistle" deformity. Alternatively, as described by Noordhoff, it is best to use vermilion height to determine the point on the lateral lip that will form the base of the philtral column.  In this technique, the point is placed just as the white roll starts to fade into the cleft. This point also has to agree with the point near the nostril sill that will decide the height of the lip. If, in order to achieve the necessary height, the Noordhoff's point is placed too laterally, then the resulting lateral lip element may appear hypoplastic, giving an unnatural look to the repaired lip. As described by Fisher, there is a natural antero-superior convexity of the cutaneous roll that can be preserved by marking the Noordhoff's point in the appropriate location.  This gives a natural appearing lip as the author believes that the curvature of the lip should be incorporated from the lateral lip. When the curvature of the lip is incorporated using the medial lip, it may result in a very sharp cupid's bow, and the natural curvature may be lost.
Applying the principles of anatomic subunit repair for very short lips
The lateral lip element is commonly short in vertical height, especially in adults with untreated clefts. It has been pointed out that in order to gain the necessary height, it may be necessary to move the position of Noordhoff's point more laterally, and in doing so compromise lateral lip transverse length to achieve vertical height. Pool stated that vertical height of the lateral lip is difficult to obtain with the rotation-advancement repair only when the lateral lip is short in both its horizontal dimension and its vertical height.  It was concluded, that 63% patients had combined height and transverse length deficiencies of the lateral lip. For these patients with considerable deficiencies, an inferior triangle, needs to be incorporated for successful management of the lateral lip.  As described by Noordhoff, when the discrepancy of the lip height is large (>3 mm in our experience), a triangle needs to be incorporated above the white roll as it is not possible to achieve the necessary vertical height by only rotation flap.  This lower triangle also decreases the tendency for peaking of the lateral bow. Fisher has previously highlighted the key concept that design of the triangle should vary according to the length of the lateral lip element. Three situations can exist: Lateral lip is normal, long or short. [Figure 1] shows the design and placement of the triangle in different situations. If the lateral lip is normal, which means that adequate tissue is present in the lateral lip element, and the necessary lip height can be achieved without excessive lateral shift of the Noordhoff's point, then the triangle is incorporated in line with the future philtral column [Figure 1]a. This will avoid the use of superior tissue instead of lateral tissue, which is adequate in this situation. If the lateral lip is very long, meaning that excessive tissue is present on the lateral lip element, then the triangle is sloped down, so that it will also marginally negate the amount of gain from the Rose Thompson effect [Figure 1]b. Furthermore, a wedge of tissue may be excised at the superior margin as needed to match the necessary height. The most challenging, and most common, situation is when the lateral lip is very short. In this situation, the lateral lip is deficient and hypoplastic. In this case if the Noordhoff's point is moved too laterally to gain the necessary height, it will further compromise the already deficient lateral lip. Hence, in this situation, the design of the triangle is done to utilize the superior tissues rather than the lateral tissues to avoid hypoplastic lip [Figure 1]c. This helps to maintain Noordhoff's point medially, saving the precious lateral lip vermilion. Again, it has to be noted that the above mentioned three situations are only pertaining to the lateral lip and the discrepancy in lip height on the medial element in all the three situations is more than 3 mm. [Figure 2] shows the application of a lower triangle to the advancement flap. In this patient, the greater lip height is 10 mm and lesser lip height is 6 mm. The discrepancy is 4 mm, and the lateral lip element is also very short. With the rotation of the medial flap, 1.5 mm will be gained from the columellar extension and backcut, and 1 mm will be gained from the Rose Thompson effect. This necessitates incorporation of a triangle of 1.5 mm to gain the necessary length. In a very short lip such as this, the design and placement of a triangle above the white roll are the key to manage the lateral lip without sacrificing excess tissue. The triangle is placed as shown in [Figure 1]c, which utilizes the tissue superior to the white roll instead of the lateral lip element. This technique of placement of the triangle has resulted in saving 1.5 mm of lateral lip element (distance X in the [Figure 2], which will be equal to the base of the triangle), which otherwise would have been sacrificed to gain the necessary length. [Figure 3] shows the application of this principle and the final result with 1 year follow-up. Note the balance of the lip is maintained even in very short lateral lip element. A typical example of hypoplastic lateral lip is shown in [Figure 4]. In this case, the surgeon tried to gain the necessary length by compromising the lateral lip. A few results after utilizing this technique are shown in [Figure 5], [Figure 6] and [Figure 7].
|Figure 1: The design and placement of the triangle in different situations (a) ideal lip (when adequate tissue is present on the lateral lip) (b) long lip (when excessive tissue is present in the lateral lip) (c) short lip (when the lateral lip is deficient and hypoplastic)|
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|Figure 2: Actual measurements on a patient. Note the "X" is the amount of lateral lip tissue saved|
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|Figure 3: Markings, immediate postoperative result and long-term follow-up of the same patient. Note the balance of the lip achieved|
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|Figure 4: Immediate postoperative result showing excessive resection of the lateral lip in order to gain the necessary length. This type of deformity results in asymmetric lip which will not improve|
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|Figure 5: Pre- and post-operative appearance after utilizing the described technique|
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|Figure 6: Pre- and post-operative appearance after utilizing the described technique|
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|Figure 7: Pre- and post-operative appearance after utilizing the described technique|
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Avoiding whistle deformity
Vermillion notching is most often caused by inadequate excision of the cleft tissue and persistent tissue deficiency at the vermillion border. The best way of preventing this deformity is to mark Noordhoff's point to have adequate vermilion at the line of repair. Alignment and repair of the pars marginalis portion of the orbicularis muscle at the lip margin is essential in gaining adequate volume. Furthermore important are precise closure of the vermillion, while incorporating a lateral "v" flap, and accurate re-approximation of mucosa.
Managing excess vermilion
The problem of excess vermilion on the lateral lip element arises most often in incomplete clefts. This often results in a bulky lateral lip. In most instances, this problem is noted during the final stages of the repair, and there is evident mismatching of the vermilion. This problem can be solved by resecting a wedge of mucosa in the sulcus on the advancement flap and not near the junction of wet and dry vermillion, thus removing the excess. Care has to be taken that the mucosa and muscle have been adequately dissected. Furthermore, it is prudent not to inject excess local anesthetic solution into the lip tissues prior to surgery, causing increased tissue swelling and difficulty in assessing amount to be resected.
| Results|| |
The unilateral cleft lip repair and technical refinements have been incorporated in more than 500 patients by the primary author. The specific technique for saving tissue and volume of the lateral lip element in wide clefts has been practiced by the primary surgeon in 100 patients with discrepancy between the greater and the lesser lip of more than 3 mm. Although, measurements were not analyzed to note whether the difference after using this modification was statistically significant, the results with this technique were visually more pleasing. A more balanced lip is achieved, as proper design of the triangle saves precious tissue on the lateral lip element [Figure 5], [Figure 6] and [Figure 7].
| Discussion|| |
A new era began in the art of cleft surgery when Millard introduced his "rotation - advancement" technique at the First International Congress of Plastic Surgery in Stockholm in the year 1955. This technique has been modified countless times, but the principles of rotation and advancement have persevered as surgeons have sought to refine various elements in order to achieve an optimal repair. Historically most of the modifications have been focused on gaining the necessary length on the medial side. There is far less literature on the management of the lateral lip element, especially in situations where the discrepancy between lip height of the cleft side and noncleft side is high. It has been observed at our center, where we do not practice presurgical orthopedics, that rotation of the medial segment is often not enough to gain the necessary length. When a large discrepancy exists between the greater lip height and lesser lip height, a lateral triangle is inserted above the white roll to gain necessary length on the medial segment and prevent a short repair. This also produces a small amount of tension on the lip and accentuates the pout. Fisher has previously described various methods of incorporating this triangle in varying lengths of the lateral lip as part of his anatomic subunit repair.  This principle can be utilized in rotation-advancement technique as well when the discrepancy between the greater and lesser lip length is more than 3 mm. If the lateral lip is normal in length, then the triangle is incorporated along the future phitral column. If the lateral lip is very long, then the triangle is sloped downwards to negate the additional gain by Rose Thompson effect. In very short lips, the triangle is placed such that it utilizes the superior tissue rather than lateral tissue and prevents excessive resection of the valuable lateral lip element. The incisions can also be sloped more, almost 90° as they cross the white roll, which provides with an additional 1 mm length of the lateral lip element due to Rose Thompson effect.  Now the question is, why not follow anatomic subunit principle for all lips where the vertical and transverse discrepancy is more? In most cleft centers, especially in developing world, presurgical orthopedics is not practiced. Hence, very high discrepancy is observed between the greater lip length and the lesser lip length, sometimes more than 3 mm. In such situations, it may not be possible to gain the necessary length by using the principles of anatomic subunit closure alone. Combination of rotation-advancement and anatomic subunit principles can offer a better result than just one technique; this includes the preservation of the lateral lip. Alternatively, two triangular flaps can be inserted, one above the cutaneous roll, and the other below columella as described by Skoog. This technique gives a straight line closure and can avoid the drawbacks of rotation-advancement technique. Cutting and Dayan reported that although the lateral lip element is observed to be significantly short immediate postoperatively, this deficiency significantly improves in long-term follow-up.  The results were reported using black and white photographs. The use of photographs for reporting results has long been debated for accuracy as it is very challenging to get exact photographs, especially in children.  We also believe that this improvement will be marginal and all efforts have to be made to conserve the lateral lip element. This fact was also pointed by Farkas et al., who concluded in their anthropometric studies that the total growth remaining in the upper lip height as well as vermillion was very small after 1 year of age which explain that a cleft lip repair in early life may retain its quality fairly well throughout life.  But, the problem of adult untreated cleft lip repair is highly prevalent in the developing world. In such situations, all efforts need to be made to save all the tissue and simultaneously achieve a pleasing result.
| Conclusion|| |
The technique described to combine rotation-advancement technique and Fisher's anatomic subunit technique can offset the drawbacks of both the techniques when utilized alone. Although, a major drawback of this article is that no measurements were made to analyze the results, it has produced esthetically acceptable results. The next phase of this paper will be to record all the anthropometric measurements of the lip preoperatively and compare it in long-term follow-up to note the actual changes in the lip morphology.
| Acknowledgments|| |
This study was carried out at the Guwahati Comprehensive Cleft Care Center (Assam, India), located at the Mahendra Mohan Choudhury Hospital, Guwahati. The authors acknowledge the support of Government of Assam, the National Rural Health Mission, the Sir Dorabji Tata Trust and Allied Trusts, Operation Smile International, and Operation Smile India for providing infrastructure and funding to ensure that all patients at this center are treated free of costs with no commercial or financial gains to any member of the team. The authors would like to thank Dr. Lester Mohler MD and Dr. David Fisher MD for reviewing the manuscript and for their valuable comments.
| References|| |
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|4.||Pool R. The configurations of the unilateral cleft lip, with reference to the rotation advancement repair. Plast Reconstr Surg 1966;37: 558-65. |
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