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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 139-143

Comparison of soft-tissue changes after the surgical repair of unilateral cleft lip side to noncleft lip side: An anthropometric study


1 Consulting Orthodontist, Private Practice, Hyderabad, Telangana, India
2 Consulting Orthodontist, Private Practice, Mumbai, Maharashtra, India
3 Department of Orthodontics and Dentofacial Orthopedics, Saraswati Dental College, Lucknow, Uttar Pradesh, India
4 Department of Oral and Maxillofacial Surgery, Babu Banarsi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India
5 Department of Oral and Maxillofacial Surgery, Meghna Institute of Dental Sciences, Nizamabad, Telangana, India

Date of Web Publication21-Nov-2017

Correspondence Address:
Rohit Kulshrestha
Private Practice, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_52_17

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  Abstract 

Aim: The aim of this article was to compare the tissue contraction after the surgical repair of unilateral cleft lip side to noncleft lip side. Materials and Methods: Forty patients with unilateral cleft lip only were used as subjects. They were divided into two groups based on gender (20 males and 20 females). Measurements of soft-tissue landmarks of cleft side and noncleft side were compared after surgical repair of the lip to check for soft-tissue contractions. A vernier caliper was used to measure the linear measurements, and all the measurements were measured directly on the patients' lips. Results: When gender comparison was done, it was found to be significant only for oral commissure to the peak of Cupid's bow for both cleft and noncleft sides (P < 0.05). When comparison between the two sides (left and right) was done, a significant difference was observed only for subalar to peak of Cupid's bow measurement which was found to be significantly larger at noncleft as compared to cleft side in overall assessment (P = 0.005) and in females (P = 0.046); however, this difference was not statistically significant when evaluated for males alone (P = 0.060). Conclusion: Marked soft-tissue contraction was seen after surgical repair of the unilateral cleft lip, more was seen in females. This indicates that adequate planning and accurate surgical techniques and measurements should be taken while approximating the two lip flaps both in vertical and in horizontal direction before planning the surgery to get the best esthetic result for the patients.

Keywords: Cleft lip surgery, soft-tissue contraction, unilateral cleft lip


How to cite this article:
Wajid MA, Kulshrestha R, Rastogi R, Kumar D, Singh K, Ateeq MA. Comparison of soft-tissue changes after the surgical repair of unilateral cleft lip side to noncleft lip side: An anthropometric study. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:139-43

How to cite this URL:
Wajid MA, Kulshrestha R, Rastogi R, Kumar D, Singh K, Ateeq MA. Comparison of soft-tissue changes after the surgical repair of unilateral cleft lip side to noncleft lip side: An anthropometric study. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:139-43. Available from: https://www.jclpca.org/text.asp?2017/4/3/139/218873


  Introduction Top


Patients with cleft lip or palate require a multidisciplinary team that focuses on the patients' form, function, and physiological and psychosocial development.[1] Unilateral cleft lip scar is a common phenomenon occurring due to either tension in the repair or improper suturing of the orbicularis muscles.[2] Trauma and infection may be rarer causes. Scarring on the repair side depends on the three factors: intrinsic strain, which depends on the tightness of the suturing; extrinsic strain, which is the tension with which the tissues are brought together; and the inherent reaction of the individual to surgical trauma.[3],[4],[5],[6] The surgeon has control over the first two factors, but not over the third. In the early period following the repair, most children exhibit a scar contracture with a pulled up Cupid's bow and a vermillion notch on the cleft side. Vermillion notching is a discontinuity in the free border of the vermillion. This may be central (“whistle deformity”) or seen laterally along the line of the scar, the latter is more common in unilateral lips.[7]

Cheiloplasty for cleft lip defects often results in severe scar formation, which, in turn, markedly affects facial esthetics. Furthermore, it has considerable influence on the anterior occlusion, such as lingual inclination of the maxillary anterior teeth in unilateral cleft lip patients with or without cleft palate.[8],[9] The assessment of scar tissue distribution and soft-tissue contraction postsurgery in the repaired lip is of great importance for orthodontic diagnosis, treatment planning, and prognosis. The severity of the primary deformity is generally proportional to the difficulty of surgical reconstruction and subsequently with scar formation in the palate and lip.[10],[11],[12] Furthermore, cleft lip/palate is known to be a key factor in maxillary growth retardation both in the vertical and horizontal directions.[13] However, little is known about the changes seen in the soft-tissue after the surgery following lip repair. The aim of this anthropometric study was to compare the tissue contraction after the surgical repair of unilateral cleft lip side to noncleft lip side.


  Materials and Methods Top


This study was conducted at Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, India. Forty patients with unilateral cleft lip were taken and were divided into two groups based on gender (20 males and 20 females). Primary cleft lip repair was carried out between the age of 3 and 6 months (mean age 4.3 months). The study was approved by the Institutional Ethical Committee of Swami Vivekanand Hospital and Research Centre, Lucknow, India. Informed consent was obtained from each subject's parents after appropriate explanation about the surgery involved and the study.

Measurements of soft-tissue landmarks of cleft side and noncleft side were compared after surgical repair of the lip to check for soft-tissue contractions. All of the anthropometric lip measurements were taken using a vernier caliper. The vertical height and transverse length measurements of both the cleft and noncleft sides of the lips were recorded to the nearest 0.5 mm. The anthropometric points used for the measurement were as follows:

  • Right vermillion border – it is the edge (border) of the red (vermilion) of the lip on the right side
  • Peak of Cupids bow right – highest point on the double curve of the human upper lip right side
  • Base of columella left – lower most point at the base of the columella on left side
  • Base of columella right – lower most point at the base of the columella on right side
  • Junction between dry and wet lip – the line demarcating the dry vermillion from the wet vermillion
  • Left vermillion border – it is the edge (border) of the red (vermilion) of the lip on the left side
  • Base of alar left – lower most point at the base of the nostril medially of left side
  • Subalar base left – lowermost point of the nostril laterally of left side
  • Lateral alar base left – most lateral point at the base of the nostril of left side.


Medial lip heights were measured from the midline of the labiocolumellar groove (subnasale) to the peaks of the cupid's bow. Lateral lip height of the noncleft side was measured from the lowest point of the alar base to the peak of the cupid's bow. Height of the cleft lip side was measured from the lowest point of the alar base (subalar) to the proposed peak of cupid's bow. The proposed peak of cupid's bow was the vermilion cutaneous junction where the cutaneous roll and the vermilion mucosal junction (red line) begin to converge medially [Figure 1]. The lateral lip transverse length of noncleft side was measured from the oral commissure to the peak of cupid's bow. The lateral lip transverse length of the cleft side was measured from the oral commissure to the proposed peak of cupids bow at Noordhoff's point.[14],[15],[16] Noordhoff's point can be seen along the lateral lip where the vermillion height is at its greatest and the white roll is well formed. This becomes less distinct as we go toward the cleft side.
Figure 1: Anatomical landmarks

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Statistical analysis

A master file was created with all the data, and it was statistically analyzed using the Statistical Package for the Social Sciences software (version 17) (SPSS Inc. Released 2008. Chicago, IL, USA). The data were subjected to descriptive analysis for mean, standard deviation, and 95% confidence interval. P < 0.05 was considered statistically significant association. For comparison of gender groups, independent samples t-test was performed. Paired t- test was used for comparison between cleft and noncleft side. To identify the errors associated with the linear measurements, all the measurements were repeated 8 weeks postsurgery. A paired sample t-test was applied to the first and second measurements, and the differences between measurements were insignificant.


  Results Top


When gender difference was compared, it was found to be significant only for oral commissure to the peak of cupid's bow for both cleft as well as noncleft sides (P < 0.05) [Table 1]. Between two sides, a significant difference was observed only for subalar to peak of cupid's bow measurement which was found to be significantly larger at noncleft as compared to cleft side in overall assessment (P = 0.005) and in females (P = 0.046); however, this difference was not significant statistically when evaluated for males alone (P = 0.060). All the measurements are shown in [Graph 1].
Table 1: Summary of anthropometric data

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  Discussion Top


The patients who were included in this study were inhabitants of a particular geographic region of India (northern part of India). Their ethnicity was Asian Indian. There are several factors that influence the optimum timing for closure of a cleft lip.[2],[5],[6],[17] In young infants, it is practically impossible to distinguish between the individual muscle fiber bundles which due to lack of function, are underdeveloped, weak and unable to adequately support sutures.[12],[15],[18] It is therefore advised to wait until the end of the 4th month for surgery. By this time, the labial musculature has developed significantly as a result of both growth and function, the function imparted by sucking, crying, and other facial activity.[15] Early reconstruction of the lip further reduces forward growth of the smaller fragment in unilateral clefts, which results in retrusion of the dentoalveolar segment and underdevelopment of the premaxilla.[8],[17] After cleft lip surgery, the ideal line of repair should have the following features:[19],[20]

  • Ascends from cleft side of cupid's bow
  • Mirrors the noncleft side philtrum column
  • Reach base of the nose
  • Continue superolaterally
  • Border lip-columellar crease which ascends to the nostril still.


This study attempts to compare the soft-tissue changes after surgery in unilateral cleft lip patients. The results of our study show differences in the measurements of the soft-tissue landmarks involving the lip structures between male and female groups and left and right sides. When gender difference was compared, it was found to be significant only for oral commissure to the peak of Cupid's bow for both cleft and noncleft sides. Singh et al.[21] did a 3-dimensional (3D) study of the facial morphology after surgical repair of unilateral cleft lip after nasoalveolar molding. They found that 3D facial morphology was virtually indistinguishable from the noncleft mean and clinically the apparent improvement in the facial soft-tissues may be the masked dysmorphic skeletal growth. Males at birth are generally larger in size than females. Rate of retraction of soft-tissue in females must have been higher in females than in males. There was no significant difference between the values before the surgery and on the contralateral side. Hence, it can be stated that the soft-tissue retraction after the surgery was higher in females. Holst et al.[22] found that patients with cleft lip who were treated with a standardized treatment concept had adequate craniofacial jaw relationships. Despite a measured skeletal Class I in both male and female patients with cleft lip and palate regardless of cleft type, there was a slight tendency toward a skeletal Class III. This shows that due to deficient maxilla, the soft-tissue over this region may not have developed fully. The maxillary bone support would be inadequate for the proper development of the lip.

When both the sides were compared (cleft and noncleft side), a significant difference was observed only for subalar to peak of cupid's bow measurement which was found to be significantly larger at noncleft as compared to cleft side in overall assessment and in females. In this result, again, we can see that there has been higher soft-tissue contraction after the surgery in females. This should be kept in mind while planning for cleft lip surgeries in females. Liao and Mars[2] concluded that adverse effects of clefts on the growth of the maxilla in patients with unilateral cleft lip and palate (UCLP) are restricted to the basal maxilla in size. The reduced growth in unoperated patients with UCLP might be primarily attributed to intrinsic effects and secondarily to functional effects. Further studies are required to find the exact effect of the intrinsic and the functional factors on the growth of the soft-tissue following cleft lip surgery.


  Conclusion Top


Marked soft-tissue contraction was seen after surgical repair of the unilateral cleft lip, more was seen in females. This indicates that adequate planning and accurate surgical techniques and measurements should be taken while approximating the two lip flaps both in vertical and in horizontal direction before planning the surgery to get the best esthetic result for the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hagerty RF, Hill MJ. Facial growth and dentition in the unoperated cleft palate. J Dent Res 1963;42:412-21.  Back to cited text no. 1
    
2.
Liao YF, Mars M. Long-term effects of lip repair on dentofacial morphology in patients with unilateral cleft lip and palate. Cleft Palate Craniofac J 2005;42:526-32.  Back to cited text no. 2
    
3.
Mars M, Houston WJ. A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J 1990;27:7-10.  Back to cited text no. 3
    
4.
Ross RB, Johnston MC. Cleft Lip and Palate. Baltimore, Md.: Williams & Wilkins; 1972.  Back to cited text no. 4
    
5.
van Zuijlen PP, Angeles AP, Kreis RW, Bos KE, Middelkoop E. Scar assessment tools: Implications for current research. Plast Reconstr Surg 2002;109:1108-22.  Back to cited text no. 5
    
6.
Christofides E, Potgieter A, Chait L. A long term subjective and objective assessment of the scar in unilateral cleft lip repairs using the Millard technique without revisional surgery. J Plast Reconstr Aesthet Surg 2006;59:380-6.  Back to cited text no. 6
    
7.
Ritter K, Trotman CA, Phillips C. Validity of subjective evaluations for the assessment of lip scarring and impairment. Cleft Palate Craniofac J 2002;39:587-96.  Back to cited text no. 7
    
8.
Singh GD, Levy-Bercowski D, Santiago PE. Three-dimensional nasal changes following nasoalveolar molding in patients with unilateral cleft lip and palate: Geometric morphometrics. Cleft Palate Craniofac J 2005;42:403-9.  Back to cited text no. 8
    
9.
Johnson N, Williams A, Singer S, Southall P, Sandy J. Initial cleft size does not correlate with outcome in unilateral cleft and palate. Eur J Orthod 2000;22:93-100.  Back to cited text no. 9
    
10.
Will LA. Growth and development in patients with untreated clefts. Cleft Palate Craniofac J 2000;37:523-6.  Back to cited text no. 10
    
11.
Prasad CN, Marsh JL, Long RE Jr., Galic M, Huebener DV, Bresina SJ, et al. Quantitative 3D maxillary arch evaluation of two different infant managements for unilateral cleft lip and palate. Cleft Palate Craniofac J 2000;37:562-70.  Back to cited text no. 11
    
12.
Fara M. The anatomy of cleft lip. Plast Reconstr Surg 1975;2:205-14.  Back to cited text no. 12
    
13.
Cosman B, Crikelair GF. The shape of the unilateral cleft lip defect; a speculative report. Plast Reconstr Surg 1965;35:484-93.  Back to cited text no. 13
    
14.
Lindsay WK, Farkas LG. The use of anthropometry in assessing the cleft-lip nose. Plast Reconstr Surg 1972;49:286-93.  Back to cited text no. 14
    
15.
Nakamura N, Suzuki A, Takahashi H, Honda Y, Sasaguri M, Ohishi M, et al. A longitudinal study on influence of primary facial deformities on maxillofacial growth in patients with cleft lip and palate. Cleft Palate Craniofac J 2005;42:633-40.  Back to cited text no. 15
    
16.
Bardach J. The influence of cleft lip repair on facial growth. Cleft Palate J 1990;27:76-8.  Back to cited text no. 16
    
17.
Capelozza Filho L, Normando AD, da Silva Filho OG. Isolated influences of lip and palate surgery on facial growth: Comparison of operated and unoperated male adults with UCLP. Cleft Palate Craniofac J 1996;33:51-6.  Back to cited text no. 17
    
18.
Kapucu MR, Gürsu KG, Enacar A, Aras S. The effect of cleft lip repair on maxillary morphology in patients with unilateral complete cleft lip and palate. Plast Reconstr Surg 1996;97:1371-5.  Back to cited text no. 18
    
19.
Li Y, Shi B, Song QG, Zuo H, Zheng Q. Effects of lip repair on maxillary growth and facial soft tissue development in patients with a complete unilateral cleft of lip, alveolus and palate. J Craniomaxillofac Surg 2006;34:355-61.  Back to cited text no. 19
    
20.
Ercan E, Celikoglu M, Buyuk SK, Sekerci AE. Assessment of the alveolar bone support of patients with unilateral cleft lip and palate: A cone-beam computed tomography study. Angle Orthod 2015;85:1003-8.  Back to cited text no. 20
    
21.
Singh GD, Levy-Bercowski D, Yáñez MA, Santiago PE. Three-dimensional facial morphology following surgical repair of unilateral cleft lip and palate in patients after nasoalveolar molding. Orthod Craniofac Res 2007;10:161-6.  Back to cited text no. 21
    
22.
Holst A, Holst S, Nkenke E, Fenner M, Hirschfelder U. Vertical and sagittal growth in patients with unilateral and bilateral cleft lip and palate – A retrospective cephalometric evaluation. Cleft Palate Craniofac J 2009;46:514-9.  Back to cited text no. 22
    


    Figures

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    Tables

  [Table 1]


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