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 Table of Contents  
STATE OF THE ART
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 3-10

Reoperation of bilateral cleft lip deformity after primary Manchester or Veau III repair


1 European Face Centre, Universitair Ziekenhuis Brussel, Brussels, Belgium
2 Cleft Center, GZA Hospitals, Antwerp, Belgium

Date of Web Publication4-Feb-2019

Correspondence Address:
Prof. Maurice Y Mommaerts
European Face Centre, Universitair Ziekenhuis Brussel, VUB, Laarbeeklaan 101, B-1090, Brussel
Belgium
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_36_18

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  Abstract 


Residual bilateral cleft lip deformities are commonly attributed to neglect of oral sphincter reconstruction during primary repair. This report describes a straightforward technique for reoperation that is applicable for most patients. It also describes the results of a retrospective observational cohort study of 21 patients that underwent reoperation performed by the senior author (MYM) from 1991 to 2018. The patients had undergone primary lip repair at other institutions. Their mean age at reoperation was 17 years. Pre- and post-operative photographs (at 3.5 years' postoperation) were assessed for 15 parameters. Overall configuration, scar appearance, philtrum anatomy, Cupid's bow shape, and esthetic aspects of lip dynamics improved considerably. This procedure is the same as that used by the authors in 4-month-old children who have undergone a nasolabial adhesion procedure at 4 weeks of age. We discuss the rationale of using this procedure for primary lip repair, thus eliminating the need for reoperation.

Keywords: Bilateral cleft lip, cicatrix, esthetics, reoperation, retrospective studies


How to cite this article:
Mommaerts MY, Tache A, Loomans NA. Reoperation of bilateral cleft lip deformity after primary Manchester or Veau III repair. J Cleft Lip Palate Craniofac Anomal 2019;6:3-10

How to cite this URL:
Mommaerts MY, Tache A, Loomans NA. Reoperation of bilateral cleft lip deformity after primary Manchester or Veau III repair. J Cleft Lip Palate Craniofac Anomal [serial online] 2019 [cited 2019 Jun 19];6:3-10. Available from: http://www.jclpca.org/text.asp?2019/6/1/3/251473




  Introduction Top


Staged repair of bilateral cleft lip, closing one side first and the other side at a later date was advocated in earlier times to avoid wound dehiscence or spreading of the scar because of tension over a protuberant premaxilla. With this approach, nasolabial asymmetry was almost unavoidable [Figure 1]. Staged repair is still used by many surgeons who do not use presurgical orthopedic alignment.
Figure 1: Result of a staged primary closure performed at another institution. Note the extremely wide and flat philtrum, devoid of muscle support; the chapped area in the central vermilion with parakeratosis; the asymmetrical scars and nostril asymmetry; and the bulging orbicularis oris muscle stumps in the lateral lip segments

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Other surgeons perform synchronous bilateral repair after early orthopedic repositioning of the premaxilla, using a straight-line lip repair (“Veau III”) without muscle reconstruction.[1],[2] This procedure preserves nearly all of the prolabial skin and patchy vermilion and results in a wide central segment without a white roll, a lateral “orbicularis bulge” on smiling and whistling, and a tethered oral sulcus behind the prolabium [Figure 2]. The central segment will not grow vertically; it will widen during infancy and remain unchanged during the pubertal growth spurt [Figure 3]. This strategy, which was common in the first half of the 20th century, was used by surgeons who were concerned about a tight upper lip after resection of the entire prolabium (and premaxilla) [Figure 4].
Figure 2: Synchronous left and right lip repair after presurgical orthopedic alignment and early secondary orthopedic/orthodontic expansion, performed at another institution. (a) Wide central lip segment without white roll. (b) Lateral “orbicularis bulge” on kissing. (c) Nonexistent oral sulcus in the premaxilla area. (d) After lip reoperation, sulcoplasty, and Burian flaps obtained from the cheek mucosa to close the alveolar clefts before bone grafting during another procedure. Premaxilla repositioning by osteotomy was performed at the time of bone grafting

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Figure 3: Synchronous bilateral cleft lip repair without muscle reconstruction. (a) Frontal view with the lip at rest (aged 7 years). Note the paucity of prolabial vermilion with excess on the lateral lip elements and a wide philtrum with straight lateral borders. (b) Frontal view with the lip in a whistling position (aged 7 years). Bilateral muscle bulges in the lateral lip segments are clearly visible (arrows). (c) Frontal view with the lip at rest (aged 16 years). The secondary growth spurt during puberty did not lead to any changes

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Figure 4: A tight upper lip after resection of all of the prolabium

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Technique of secondary repair

In patients, who desire revision after unsatisfactory primary bilateral cleft lip repair, we use the following technique. The skin and mucosa incision designs are essentially the same as the designs used when performing primary repair after a lip adhesion procedure and presurgical orthopedic treatment [Figure 5].[3] Indeed, the situation is as if the initial surgeon performed bilateral lip adhesion (staged or synchronous) and offered this procedure for primary definitive lip repair. A central philtrum plastron is marked; its tip may have curved or straight edges. The lateral red lip segments are mirrored, using the narrower segment as a reference, while keeping the segments as wide as possible. The height of the vermilion is equalized on both sides with respect to the distance from the free border to the white roll and from the red line to the white roll. The incisions above the white roll equal the edges of the plastron/philtral flap tip in width and free up the medial white roll-vermilion-mucosal flaps so they can be united under the philtrum. Subtalar wedge excisions are necessary to avoid the upper lip becoming excessively long [Figure 6].
Figure 5: External incision design. The lateral lip segments also provide the central tuberculum. Sometimes it is necessary to create a step-off at the mucocutaneous border

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Figure 6: Subtalar wedge resections are marked (arrows). these help to balance lip height and nasal sill position. a) marking b) post operative

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The skin scars, embryonic undifferentiated mesoderm in the midline, subtalar wedges, and parakeratinized central vermillion are discarded, but the prolabial nonkeratinized mucosa behind the red line and in front of the gingiva is retained [Figure 7]. Bilaterally, the peripheral and marginal muscle orbicularis and nasolabial muscles are freed from their skin, mucosa, and bony attachments [Figure 8]. The nonkeratinized mucosa in the midline is stretched over the denuded periosteum of the premaxilla and centrally sutured to the periosteum covering the nasal spine [Figure 9] and [Figure 10].
Figure 7: Internal incision design. The dry vermilion of the prolabium is discarded. The wet vermilion is used to deepen the sulcus

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Figure 8: Freeing of the marginal and peripheral orbicularis oris muscle bundles over a distance of 5 mm

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Figure 9: The stretched prolabial mucosa covering the premaxilla and the joined mucosal lining and muscle bundles in front form a functional oral sulcus

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Figure 10: The small area of nonkeratinized mucosa left centrally in an obliterated sulcus is stretched over the periosteum of the premaxilla after it is freed from embryonic scar tissue

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The mucosal edges of the lateral lip segments are joined in the midline [Figure 11] and create an oral sulcus, which can accommodate an orthodontic appliance. The United muscle stumps [Figure 12] help achieve normal movement of the central lip. Rounding for vowels and proper positioning for bilabial (p, b, m) and labiodental consonants (f, v) becomes possible. The mouth can be closed, which helps prevent gingivitis. Whistling also becomes possible.
Figure 11: The lateral mucosal edges are joined in the midline behind the reconstructed lip muscle

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Figure 12: Muscle reconstruction in the midline with a tuck-down suture to the anterior nasal spine

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The resulting scars are minimal and hidden in the alar-facial groove or border the aesthetic units and mimic ridge transitions (white roll and philtral columns) [Figure 13]. The vertical scars become white and mimic light reflections on the philtral ridges. The lateral bulges disappear, and the lip becomes more pouty. Salient aspects are the central cupid bow morphology, height of the lip in relation to tooth exposure on smiling (the incisors often have cervical enamel lesions), and functional lip width and suppleness. Nevertheless, the greatest challenge persists–the creation of a median tubercle. Often the central vertical scar in the sulcus and vermillion mucosa contracts and acts as a curtain cord. Furthermore, the marginal orbicularis oris muscle stumps are often difficult to distinguish, dissect, and suture.
Figure 13: Scars are shown in red. They are located in inconspicuous locations

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  Materials and Methods Top


This is a retrospective observational cohort study comprising all of the first author's secondary lip correction cases between 1991 and 2018. The records of 21 patients (13 males and 8 females) were compiled for analysis. All patients underwent primary lip repair (Manchester or Veau III) at other institutions. The mean age at reoperation was 17 years (range, 9–39). Follow-up photographs were taken at a mean of 3.5 years (range, 1–13) after reoperation.

After obtaining informed consent from the patients or their parents, we created a questionnaire for each patient containing photographs before and after the reoperation, as well as a list of research questions [Figure 14] and [Table 1]. Two surgeons independently completed the questionnaires; one was a PhD student conducting research in outcomes of primary cleft lip, alveolus, and palate surgery (AT), and the other was an experienced cleft surgeon (NL).
Figure 14: Photographs used for before and after secondary repair assessments. In 6 of the 21 case reports, photographs in the kissing pose were lacking. (a and b) Before reoperation. (c-e) After reoperation

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Table 1: Questionnaire items

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  Results Top


The questionnaire results are shown in [Table 2]. The Cupid's bow shape improved in 81% of patients [Figure 15]. Scabby mucosa could not be eradicated in all patients [Figure 16]. Orbicularis oris bulges responded well to muscle reconstruction, from a mean visible score of 33% before reoperation to 10% after surgery. The assessors agreed that the lip became too tight in 57% of patients [Figure 17]. After surgery, the upper lip was judged as pouty in 14% of patients [Figure 18] and perfect in 52% of patients. In contrast, the upper lip was judged as too flaccid in 33% of patients before surgery. The philtral elements were graded as79.5 on a visual analog scale (VAS) after reoperation [Figure 19]. The VAS improvements in scar and overall appearance after reoperation were 78.8 and 82.0, respectively.
Table 2: Results of questionnaires completed by two assessors for 21 patients who underwent reoperation

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Figure 15: Creating a Cupid's bow and restoring lip height, oral competence, and a two-dimensionally normal philtrum occur in conjunction with creating a deep anterior sulcus. (a) After primary repair (performed at another institution). (b) Five years after upper lip reoperation and 1 year after lower lip reduction surgery. (c) One year after reoperation, while whistling. (d-f). The premaxilla had escaped vertically. Expansion with a quad-helix device. (g-i) After premaxilla osteotomy and bilateral alveolar osteoplasty. After orthodontic finishing and reshaping of the upper lateral incisors

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Figure 16: Nonkeratinized mucosa below the red line remains visible (arrow). However, this is not residual parakeratinized mucosa of the prolabium, and scabs do not develop. (a) Before reoperation. (b) After reoperation

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Figure 17: Vertical growth of the prolabium, devoid of muscle, did not occur. Secondary muscle reconstruction created a lip that was slightly tight but aesthetically superior (this surgery was performed in1994). (a) This patient was fortunate to have hair follicles in the central lip, but the hair could not camouflage the massive incisor show at rest.(b) Without a moustache. (c) While kissing. (d) Subtalar wedge excisions were not performed. (e) A lip that is slightly tight, with an unequal lip height. (f) Central dip at the red line upon smiling. Lack of a central lip tubercle and a circumferential vertical scar often lead to this outcome, which is resistant to filler injection

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Figure 18: One of three patients who both assessors agreed had a lip that was slightly too voluminous. The prolabium had been resected during primary surgery (performed at another institution). (a-c) Before any secondary reconstruction. Note the unaesthetic cervical area of the upper incisors. (d-f) After Le Fort-I advancement osteotomy (Dr. C. Declercq). (g-i) After muscle reconstruction, rhinoplasty, and prosthodontic work. It is important to avoid shortening the lip too much, so as not to expose the cervical region of the upper teeth and irregular gingival margins

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Figure 19: A balanced philtrum can be created, but only two-dimensionally. Even with fillers or cartilage grafts, the narrow ridges of the columns and the central dimple cannot be created. (a-c) Before reoperation. (d-f) After secondary lip correction, primary rhinoplasty, and genioplasty

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  Discussion Top


Adolescents and young adults with the stigma of a distorted cleft lip suffer from low self-esteem. However, even today, many European cleft centers do not offer primary orbicularis oris muscle reconstruction when dealing with bilateral complete cleft lip, alveolus, and palate. Parents tend to be content with what has been offered in the first year of their child's life, and cleft surgeons tend to disregard the lip deformity during consequent palatal and alveolar repairs because they created the deformity themselves. Often the lip receives no secondary attention until the child becomes a self-conscious member of society or the family moves to another geographic location and meets another cleft team.

A plethora of surgical techniques is utilized to repair secondary bilateral cleft lip deformities. However, the principles are well established: symmetry, muscle continuity, proper philtral size and shape, and an adequate median tubercle.[4] Kinnebrew mentioned that an Abbé flap is only indicated in selected patients with a significant cleft lip deformity.[5] Indeed, the vast majority of patients with bilateral cleft do not require an Abbé flap to correct their secondary deformity.

Subtalar wedge excisions avoid inappropriate lengthening of the lip. The initial fear of producing a too-short lip is a reflex persisting from the primary surgery. A long lip is aesthetically less pleasing than a short lip, especially in women. In patients with bilateral clefts, the lateral incisors are often missing, and central teeth are frequently discolored. The marginal gingiva is usually very irregular in contour and may exhibit persistent inflammation and scars. Careful height adjustment of the free lip border is mandatory.

A peaked tubercles is impossible to create using our technique. Central notching, however, can be corrected by a Z-plasty in the labial mucosa.[6] Residual nonkeratinized mucosa below the red line can be replaced by keratinized mucosa of the lower lip using a simple full-thickness graft.[7]


  Conclusion Top


The proposed technique for secondary correction is the same technique the authors (MM and NL) utilize for primary repair of the bilateral cleft lip at the age of 4 months. Patients with secondary deformities presenting for reoperation can be considered the same as children who have undergone a nasolabial adhesion procedure, but not received second-stage surgery at the appropriate age.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Veau V, Borel S. Division Palatine: Anatomie, Chirurgie, Phonétique. Paris: Masson; 1931.  Back to cited text no. 1
    
2.
Manchester WM. The repair of bilateral cleft lip and palate. Br J Surg 1965;52:878-82.  Back to cited text no. 2
    
3.
Nagy K, Mommaerts MY. Lip adhesion revisited: A technical note with review of literature. Indian J Plast Surg 2009;42:204-12.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Mokal NJ, Desai MF. A novel technique using a subcutaneously pedicled islanded prolabial flap for the secondary correction of bilateral cleft lip and nasal deformity. Indian J Plast Surg 2017;50:251-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Kinnebrew MC. Use of the abbé flap in revision of the bilateral cleft lip-nose deformity. Oral Surg Oral Med Oral Pathol 1983;56:12-9.  Back to cited text no. 5
    
6.
Stal S, Hollier L. Correction of secondary cleft lip deformities. Plast Reconstr Surg 2002;109:1672-81.  Back to cited text no. 6
    
7.
Mommaerts MY. Cleft lip vermilion: Below the red line. Br J Oral Maxillofac Surg 2018;56:561-2.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19]
 
 
    Tables

  [Table 1], [Table 2]



 

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