|Year : 2017 | Volume
| Issue : 3 | Page : 113-117
Cheiloplasty by Pfeifer's Technique
Rayadurgam Venkata Kishore Kumar1, Y Sivanagendra Reddy2
1 Department of Oral Maxillofacial Surgery, Narayana Dental College, Nellore, Andhra Pradesh, India
2 Department of Oral Maxillofacial Surgery, Anilnerukonda Institute of Dental Sciences, Visakhapatnam, Andhra Pradesh, India
|Date of Web Publication||21-Nov-2017|
Rayadurgam Venkata Kishore Kumar
Department of Oral Maxillofacial Surgery, Narayana Dental College, Chinthareddy Palem, Nellore - 524 002, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Cleft lip repair is done usually between the ages of 3rd–5th month of life. Millard's and Tennison techniques are usually used worldwide which are modified Z-plasty techniques at the superior and inferior ends of the philtrum, respectively. Wave-line incision method was introduced by Pfeifer (1970) and the available literature shows that it is an easy technique, applicable to almost all types of clefts. Hence, the study was undertaken to evaluate the results of this method. Patients and Methods: The study was carried out in a total of 701 patients, of which 572 were unilateral cleft lips and 129 were bilateral lips. According to this method, the lip skin incision modified into a wavy line, thus making it less conspicuous using the concept of “morphological order.” The basis of this is that a skin incision between two points can be lengthened if both points are joined in a curve or wavelike manner rather than in a straight line. Results: The results were evaluated for white roll match, vermilion match, cupids bow, and nasal symmetry after cleft repair and found to be excellent with 93.5%, 92.4%, 94%, and 81%, respectively, in unilateral cleft lip variety, good with 75.9%, 71%, 82%, and 87.5%, in bilateral cleft lip variety. Conclusion: This method is not a new technique, but the literature is not available. The technique is found to be good and useful in all clefts, also in revision surgeries and also found to be clinically as well as statistically significant.
Keywords: Cleft lip repair, pfeifer's method, wave line incision
|How to cite this article:|
Kumar RV, Reddy Y S. Cheiloplasty by Pfeifer's Technique. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:113-7
| Introduction|| |
With an incidence of 1/1000–3/1000, clefts are one of the most common repaired congenital malformations. The etiology of clefts appears to be multifactorial, and some cases demonstrate a strong hereditary component. Recent research has focused on the role of cellular messengers in the gestational fusion of facial structures leading to cleft formation. However, application of these findings to alter facial growth and development is not yet a clinical reality, and surgical repair remains the treatment of choice.
Cleft repair is usually done with either Millard or Tennison methods. Pfeifer's method is less commonly known and practiced worldwide. The aim of the study was to evaluate the results of cleft lip repair by Pfeifer wavy incision method and the objectives being (1) to assess the continuity of white roll match, vermilion match, symmetry of cupid's bow of the lip postoperatively and (2) to assess the nostril symmetry postoperatively.
| Patients and Methods|| |
A total of 701 patients having unilateral and bilateral cleft lips were included in the study. The duration of the study was 6 years from December 2010 to December 2016. Consent from the patients and parents (in minors below the age of 12 years) and ethical committee approval were taken before the study. Unilateral and bilateral cleft lip with/without cleft palate and nonsyndromic patients were included in the study. Syndromic patients, those who are not fit for general anesthesia, and those who would not give consent for the study were excluded from the study. Preoperative evaluation of all the patients performed with necessary investigations. All cases were done under general anesthesia except in adults where lip repair was done under local anesthesia.
Pfeifer technique involves changing the lip skin incision to a wavy line using the concept of “morphological order,” i.e., a skin incision between two points can be lengthened if both points are joined in a curve or wave-like manner. The incisions on cleft and noncleft sides are made of equal lengths by incorporating a series of shortwaves leading to a final incision line that should follow the lateral line of the philtrum. This incision also frees the excess mucosa located lateral to the columella and medial to the base of the ala.
Operative technique for unilateral cleft lip repair is as follows. Under anesthesia, measurements of noncleft side were recorded and translated to the cleft side using calipers. Marking points are sketched, and series of short waves made along the marked incision line of skin and mucosa [Figure 1] and [Figure 2]. Then, the soft tissue adjacent to the cleft is infiltrated with a local anesthetic solution. The skin and mucosal incisions are made along the planned wave lines. In incomplete clefts, incision lines converge and join inside the nasal entrance. The tissue of the lip that lies between the skin and mucosa of the cleft is completely excised and discarded. In complete clefts, the incision is extended medially onto the lower edge of the vomer till vomero-maxillary suture, laterally below the lower nasal concha for nasal floor preparation. The orbicularis muscle is freed from the skin and the mucosa on both sides. All false insertions of this muscle are taken down. The periosteum is now taken down from the leading edge of the pyriform aperture together with the nasal mucosa to create mucoperiosteal flaps, one for the nose, and the other for alveolar processes. A long supporting suture is placed at the vermillion lip border (can be stretched if required), the nasal mucosal flap is sutured. The suture to position the ala, shaping of the nostril, and the adapting of the paranasal muscles is placed to obtain symmetry of the nostrils. The final result of the corrected side should be symmetrical to the noncleft nostril. Then, subsequent realignment of the orbicularis muscle is performed and sutured. Now, the mucosa is sutured, beginning at the vermillion border, and proceeding inward. While doing this, minor corrective incisions and excisions can be done as required and skin is sutured [Figure 2].
This method is also suitable for all types of bilateral clefts and is as follows: the positioning of the symmetric marking points done. The width of the philtrum has to be adapted to the physiognomy of the population. After positioning of the typical marking points, the wave line is sketched on the skin and mucosa on the lateral lip stumps to acquire symmetry of both the sides. Over the prolabium, multiple short waves are sketched in. The wave lines should have the maximum distance to each other at the level of the nostrils. This will ensure a cranial elongation of the philtrum and the columella during the skin closure. Incisions are made along the planned wave lines and extended depending on the type of cleft either below the nasal entrance or extended to vomer medially and lower nasal concha laterally, bilaterally to create flaps for nasal floor [Figure 3] and [Figure 4].
Preparation of the lateral segments and prolabium was done. From the base of the ala, blunt dissection done toward alar dome to free the nasal mucosa from the cartilage on both sides so that nose can be reshaped to make it more symmetrical on both sides. Then, prolabium lifted up with skin hook; orbicularis oris muscles were brought below the philtrum and sutured in the center. Prolabium replaced over the repaired muscular bed and sutured. Mucosa sutured on the inner surface of the philtrum. Small 5–7 mm of cut pieces of nasogastric tube (No. 14 or 17) are placed inside the nostril and secured with two or three silk sutures. Regular postoperative care is followed. Shifting of waves into/out of nostril leading to stretching of the skin or mucosa is the main concept of this technique.
| Results|| |
Out of 701 cases in the study, in unilateral variety, 572 cases were included and in bilateral variety, 129 cases were included in the study. Age of the patients ranged from 4 months to 60 years. Majority of the children were below 10 years of age, i.e., 76.3% in unilateral variety and 80% in bilateral variety. Males were more affected (unilateral - 411 [71.8%] and bilateral - 98 [75.9%]) than females (unilateral - 161 [28%] and bilateral - 31 [24%]). In unilateral variety, left side is 69.4% (397 cases) involved than right (175 cases) side which constitutes 30.4%.
Analysis of results shows that almost 70%–80% of the patients showed significant improvement in lip and nose parameters [Table 1], could be because of young growing age at the time of surgery, elasticity of the tissues, and where the cleft width was <10 mm. Ten percent of cases showed average results because of increased age at the time of surgery, no preoperative nasoalveolar molding (NAM), decreased elasticity of tissues, and cleft width more than 10 mm could be the reasons.
| Discussion|| |
Cleft lip repair has evolved largely in the past 100 years to modern form. Millard's rotation advancement technique revolutionized the cleft lip repair. Throughout literature, there are numerous methods of repairing a cleft lip are available (more than 36 methods) since the fact that one method cannot reach the ideal result in repairing clefts, which are widely variant in severity and morphology. In general, surgical methods of repairing a cleft lip have been classified into under four groups: (1) straight-line incision group, (2) angular line incision group, (3) curved line incision group, and (4) diverse line incision group., Pfeifer described a wave line repair that allowed downward rotation as the curves were approximated into the straight line, the natural elasticity of the skin allows for the stretching the incision in the direction of a shallow curved margin. Corresponding to the skin incision, an additional lengthening of the lip stump is achieved if the falsely inserted muscles are repositioned and sutured. This offers numerous possibilities of variations which allow it to be individually adapted to the form of the cleft lip.
For evaluation of the surgical results, the assessment was done on the photographs. Two different photographic views were used for the analysis, a frontal view and basal view. Frontal view was taken to assess the white roll match, vermilion match, and Cupid's bow and basal view was taken to assess the nostril symmetry. In this study, all four parameters were compared both preoperatively and postoperatively and evaluated on a 3-point scale – poor, average, and good. For lip, the parameters considered poor before surgery, good when vertical discrepancy between the two sides is <2 mm and average if the discrepancy is >2 mm. For nasal parameters, poor preoperatively, good if the cleft side nostril after surgery is similar or near similar to the noncleft nostril three dimensionally and poor if the cleft nostril is no way similar to noncleft nostril. In bilateral lips as there is no normal side for comparison, assessment was done arbitrarily, i.e., equal nostrils are considered as good and unequal nostrils are considered as average or less than average.
In unilateral cleft lips, lip parameters improved better than nose parameter; in bilateral cleft lips since the landmarks not available, the percentage of results will come down comparative to unilateral variety, but nasal parameters such as nostril symmetry improved over unilateral variety because nose is not affected much in bilateral cleft lips.
The skin incision varies depending on the extent of retraction and elasticity of the skin and characteristics of the white roll. The peculiarity of this procedure is the simple identification of the same anatomical points without the need for measurements, which would have little meaning in relation to the tissues that are retracted as a result of cleft. The skin on the both sides of the cleft appears to be dome like due to lack of proper insertions of the underlying muscles. The skin, however, after surgery becomes distended and becomes thinner and assumes normal dimensions once the normal muscle activity is achieved.
It is anatomically difficult to reconstruct accurately the deficient vermillion and white roll with straight-line incision, but with wave-line incision, the postoperative results were good, the possible reasons were already mentioned. Similar results were observed with vermillion match and Cupid's bow. This indicates that the parameters have almost reached the normalcy after the surgery indicating the success of Pfeifer technique.
The nostril symmetry showed overall good result with statistical significance, especially in children below 6–12 months of age as alar cartilage is highly flexible, vulnerable, and adaptable into new position. The placement of the nasogastric tube cut pieces into the nostrils at the completion of operation will also aid in acquiring nostril symmetry [Figure 5] and [Figure 6].,
Outcome of primary surgery for cleft lip is judged by its effects on the quality of orofacial function and development which is dependent on good muscular repair of perioral and perinasal muscles, that is possible with this method. Presurgical orthodontics utilizing NAM plays a major role in easier surgery so that the tension over the mobilized soft tissue will be reduced so that the soft tissue results can be improved. Here, in this study due to nonaffordability of the patients and lack of cooperation for follow-ups, presurgical orthodontics could not be done. However, good lip symmetry was achieved.
Pfeifer incision consists of short curved waves which are subsequently approximated in a straight line, which helps in expanding the length and width of the tissue. The versatility of the Pfeifer incision is that this method is used to correct Tessier clefts and palatal repair with promising results. These incisions helped in tension-free closure of the cleft tissues, especially in wide clefts. The technique helps to properly align the orbicularis oris and the white roll which help in achieving adequate lip length, symmetry of the philtrum, Cupid's bow, with a better scar not crossing the philtrum. The only disadvantage of this technique is that the final closure line is placed directly over the philtrum and a negative aspect is the temporary postoperative shortening of the lip scar, which spontaneously improves within a few months by the regained function of the muscles of the lip. Combination of Pfeifer's incision on cleft side and Millard's incision on noncleft side area also in practice.
| Summary and Conclusion|| |
The cleft lip and palate is one of the most common birth defects that need long rehabilitation between birth and adulthood. Over the years, a number of techniques of cleft lip repair have been proposed and practiced. Almost all these techniques are concentrated on designing and cutting flaps of various dimensions and geometry. Although the technique is not new, the literature available for the Pfeifer's technique is less either in books or internet. In this study, good results were seen clinically and statistically, but as many surgeons are not following this technique, many intricacies and finer details are not available.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]