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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 28-31

Z-Plasty technique using a large C-flap to maximize symmetry of Cupid´s bow and minimize scar in unilateral cleft lip repair


Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA

Date of Web Publication8-Feb-2018

Correspondence Address:
Dr. Lorelei Grunwaldt
Children's Hospital of Pittsburgh of UPMC, Children's Hospital Drive, 45th Street and Penn Avenue, Pittsburgh, Pennsylvania 15201
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_42_17

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  Abstract 


Purpose: Gaining symmetry of Cupid's bow can be challenging in cleft lip repair. We describe a technique that utilizes a modified rotation-advancement type repair to gain maximum length and to minimize scar. Methods: A retrospective chart review of unilateral cleft lip repairs performed by a single surgeon between 2010 and 2014, with at least 6 months of postoperative follow-up, Pre-, intra-, and post-operative photographs were reviewed. Patients included were those who had undergone unilateral cleft lip repair using a Z-plasty type rotation of the C-flap. Postoperative photographs were analyzed for overall symmetry of Cupid's bow and scar appearance using a 5-point visual analog scale (VAS) performed by five independent evaluators. Results: Twenty-three patients were analyzed. On VAS assessment by five independent observers, 22 out of 23 patients (96%) had good, very good, or excellent symmetry of Cupid's bow. All patients (100%) had good, very good, or excellent scar appearance. Twenty-two out of 23 patients (96%) had good, very good, or excellent overall appearance of the repaired lip. Conclusion: Z-Plasty with a very large C-flap as the method for the rotation flap in unilateral cleft lip repair is a useful technique for leveling Cupid's bow and for attaining scars that are nearly imperceptible. Further work will include longer-term follow-up, will look at the severity of the preoperative cleft, and will compare this to postoperative appearance of the lip (symmetry of Cupid's bow and scar).

Keywords: Cleft lip, Cupid's bow, Z-plasty


How to cite this article:
Naran S, Maricevich R, Grunwaldt L. Z-Plasty technique using a large C-flap to maximize symmetry of Cupid´s bow and minimize scar in unilateral cleft lip repair. J Cleft Lip Palate Craniofac Anomal 2018;5:28-31

How to cite this URL:
Naran S, Maricevich R, Grunwaldt L. Z-Plasty technique using a large C-flap to maximize symmetry of Cupid´s bow and minimize scar in unilateral cleft lip repair. J Cleft Lip Palate Craniofac Anomal [serial online] 2018 [cited 2018 Apr 22];5:28-31. Available from: http://www.jclpca.org/text.asp?2018/5/1/28/224903




  Introduction Top


Gaining symmetry of Cupid's bow can be challenging in cleft lip repair; this is especially true when the difference between the distance from the peak of Cupid's bow on the nonclefted side to the columellar-labial junction and the new peak of Cupid's bow on the clefted side to the columellar-labial junction is great. A common technique for unilateral cleft lip repair is the rotation-advancement technique, first described by D. Ralph Millard in 1955, whereby the medial part of the cleft simply had to be detached from its high attachments and rotated down to the proper position, and the lateral lip advanced into the gap created by the rotation.[1] A concern of many was the persistent shortness of the lip on the cleft side, which resulted in an unbalanced Cupid's bow. We offer an evolution of the C-flap using a Z-plasty technique and describe a modification of the rotation-advancement technique to gain maximum length and minimal scar.

Operative technique

Before cleft lip repair, patients were treated with either nasoalveolar molding or cleft lip adhesion to bring the cleft margins into close approximation and thereby optimize preoperative tissue positioning and reduce closure tension at the time of formal cleft lip repair. The nadir of Cupid's bow and the peak of Cupid's bow on the noncleft side are marked. This distance is measured and transposed over to find the new peak of Cupid's bow on the cleft side. The normal philtral column is marked. This distance is measured and used to design the rotation flap. The new philtrum is drawn from the peak of Cupid's bow on the cleft side to the top of the normal philtrum. The difference between the length of the unaffected philtrum and the new philtrum is drawn as a back cut down the normal column. The C-flap is drawn from a point inside the nostril floor [Figure 1] to the peak of Cupid's bow on the cleft side [Figure 2]. The C-flap is designed such that it is made up of all the excess skin between the rotation flap and the mucosal edge of the cleft; it is left very large intentionally to fill in the back cut from the rotation flap. It often looks too large, but it is never trimmed as it helps to have a large flap to lengthen the lip. Next, the advancement flap is drawn and it is made the same length as the unaffected philtral column. It is drawn from a point just below the alar base. The advancement flap is measured from superiorly to inferiorly staying out the nostril rather than starting the measurement where the white roll is normal as the latter may cause the flap to be drawn up into the nostril base distorting the nose. Once the markings are made, an ophthalmic blade is used to cut all of the flaps. The C-flap is elevated off the orbicularis muscle with a 15 C knife. The oral wet mucosal flaps are cut with the lateral lip flap having a small back cut to allow for further advancement. The dissection is taken superiorly to elevate the orbicularis off the premaxilla and to free up the tissues around the pyriform aperture. The rotation and advancement flaps are elevated off the orbicularis enough to allow approximation of the muscle but not obliterating the philtral dimple. Furthermore, the orbicular oris is taken down from its abnormal attachments to the nasal septum and the alar bases. The nasal tip dissection is performed to allow the lower lateral cartilage on the cleft side to elevate and is reapproximated with the normal unaffected ala; this is done by entering the space just below the C-flap and dissecting superiorly. Once all the flaps are cut and the dissection is complete, closure is begun.
Figure 1: Preoperative markings

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Figure 2: Intraoperative cuts

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First, the oral mucosa is advanced and closed with 4-0 chromic. Next, the orbicularis oris is closed with 3-0 poliglecaprone. Then, the C-flap is rotated into the back cut on the advancement flap, and it is fixated in place with a deep dermal polyglyconate suture. The peak of cupids bow on the cleft side is lined up such that the white rolls match each other and polyglyconate sutures are used to hold this landmark in place. The rest of the lip skin is closed with deep dermal interrupted sutures. The alar rim is opened on the cleft side and the skin of the nasal tip is freed from the lower lateral cartilages bilaterally. An interdomal stitch is placed using a 4-0 polydioxanone. The nasal rim is closed with 6-0 fast gut, and dermal glue is applied to the entire lip [Figure 3].
Figure 3: Postoperative closure

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  Methods Top


A retrospective chart review of all unilateral cleft lip repairs performed by a single surgeon between 2010 and 2014 was performed. Only patients with at least 6 months of postoperative follow-up were included in the study. Pre-, intra-, and post-operative photographs were reviewed. Patients included were those who had undergone unilateral cleft lip repair using a Z-plasty type rotation of the C-flap. Postoperative photographs were analyzed for symmetry of Cupid's bow, scar appearance, and overall appearance of the repaired lip using a 5-point visual analog scale (VAS) performed by five independent evaluators.


  Results Top


Thirty patients were evaluated (13 complete and 17 incomplete clefts); 18 male and 12 female. Eleven patients had right-sided clefts and 19 had left-sided clefts. All patients were repaired using the aforementioned technique. Seven patients were excluded because they did not have at least 6 months of postoperative follow-up. Twenty-three patients were analyzed. On VAS assessment by five independent observers, 22 out of 23 patients (96%) had good, very good, or excellent symmetry of Cupid's Bow. All patients (100%) had good, very good, or excellent scar appearance. Twenty-Two out of 23 patients (96%) had good, very good, or excellent overall appearance of the repaired lip [Figure 4].
Figure 4: Preoperative photographs on the left, and postoperative results on the right at 2.5 years for (a and b), 1.5 years for (c and d), and 5 years for (e and f)

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  Discussion Top


Upon its first introduction in 1955, the rotation-advancement technique overcame many of the disadvantages of earlier unilateral cleft lip repairs: it preserved Cupid's bow and the philtral dimple, improved nasal tip asymmetry, and camouflaged scars along the philtral columns and within the alar crease.[2] In his original description, there were three flaps; A was the medial rotation flap; B was the lateral advancement flap carrying the flared alar base, and C was the small triangular flap attached to the columella which was originally advanced across the nasal floor. A concern of many was the persistent shortness of the lip on the cleft side, which resulted in an unbalanced Cupid's bow; however, Millard felt that this was often secondary to inadequate rotation of the medial flap; this then led to the addition of back cut to enable greater downward rotation of the medial lip segment. The function of the C-flap has, therefore, evolved to fill the defect created by the back cut, and thus lengthen the columella.[2] Over the last half century, there have been several refinements of Millard's original technique, but the basic principles have remained the same.[3],[4],[5] Extended use of the C-flap was advocated by Mohler and later modified by Cutting.[6],[7] These methods offer additional means of achieving a balanced appearance of Cupid's bow. Despite this, gaining symmetry of Cupid's bow is still a challenge in unilateral cleft lip repair, especially given reluctance to place a scar across an anatomic landmark such as the philtral dimple and not within an esthetically camouflaged area such as the philtral column. The goal of cleft lip repair is philtral unit reconstruction and balancing of Cupid's bow. In addressing this challenge, scars must be made. The question is, what is worse… an unbalanced Cupid's bow, or a scar that crosses the philtral dimple? We find that placing an incision in the philtral dimple allows the surgeon an additional method with which to attain better symmetry of Cupid's bow and does not result in a conspicuous scar.

Our study is limited by a small sample size, and an inability to compare our results to those utilizing other techniques, as the senior surgeon (LJG) has exclusively utilized this technique since starting practice in 2010. Furthermore, we also appreciate that given the nature of cleft lip maturation; longer length of follow-up would be better. We do not advocate this method to be superior in balancing Cupid's bow to those described by Mohler, Cutting, or others. We concede our described technique places a transverse scar near the top of the philtrum, which may be more noticeable than scars placed utilizing other repair techniques. However, our aim was to objectively support our experience that these scars are not immediately noticeable and that the use of this technique provides additional length to better balance Cupid's bow. We offer this as an additional tool in the cleft surgeon's armamentarium. We present our experience with our modified technique and argue that the additional scar across the philtral dimple has minimal negative impact on the overall esthetic appearance.


  Conclusion Top


We describe a modification of Millard's rotation-advancement technique that reliably leads to a balanced Cupid's bow and excellent scars. After describing our operative technique and objectively assessing our outcomes, we find that performing a Z-plasty type rotation of the C-flap in unilateral cleft lip repair is a useful technique for leveling Cupid's bow and that the scars formed by this technique have minimal negative impact on the overall esthetic appearance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Millard DR Jr. Rotation-advancement principle in cleft lip closure. Cleft Palate J 1964;12:246-52.  Back to cited text no. 1
[PUBMED]    
2.
Randall P, Jackson O. A short history of cleft lip and cleft palate. In: Losee J, Kirschner R, editors. Comprehensive Cleft Care.2n d ed. Boca Raton: CRC Press; 2015:731-60.  Back to cited text no. 2
    
3.
Onizuka T. A new method for the primary repair of unilateral cleft lip. Ann Plast Surg 1980;4:516-24.  Back to cited text no. 3
[PUBMED]    
4.
Noordhoff MS. Reconstruction of vermilion in unilateral and bilateral cleft lips. Plast Reconstr Surg 1984;73:52-61.  Back to cited text no. 4
    
5.
Noordhoff M, Chen YR, Chen KT. The surgical technique for the complete unilateral cleft lip-nasal deformity. Oper Tech Plast Reconstr Surg 1995;2:167-81.  Back to cited text no. 5
    
6.
Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg 1987;80:511-7.  Back to cited text no. 6
    
7.
Cutting CB, Dayan JH. Lip height and lip width after extended mohler unilateral cleft lip repair. Plast Reconstr Surg 2003;111:17-23.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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