Introduction
Cleft lip and palate (CLP) is the most common congenital craniofacial deformity. The prevalence of CLP is estimated at 16.86 per 10 000 live births in the USA [
1], and 13.4 per 10 000 live births in China [
2]. The etiology of non-syndromic CLP is complex, involving both environmental and genetic factors [
3]. Maternal periconception smoking has a dose-response relationship with orofacial clefting [
4,
5], and maternal alcohol consumption is also considered risky [
5]. Other environmental factors include maternal diabetes, periconception nutrition intake (e.g., vitamin A and folic acid), and anticonvulsant consumption [
6]. At the same time, numerous “candidate” genes/loci have been proposed based on linkage and/or association studies, including TGF-α, TGF-β3, MSX-1, and IRF-6 [
7-
10].
Millard’s rotation-advancement technique has long been recognized as the standard for unilateral cleft lip repair [
11,
12]. However, some residue deformities are observed despite the satisfactory outcome of this technique [
13,
14]. The most common deformity is the insufficient downward rotation of the christa philtri on the cleft side. Holtman [
15] reported shorter vertical lip lengths on the cleft side in 20% of cases repaired by Millard’s technique, and the vertical lip length has been observed to be relatively stable after surgery [
15-
17]. Thus, this method is important for restoring the symmetric labial vertical length in primary cheiloplasty. As a result, various modifications [
18-
22] have been proposed to better level the christa philtri. A small triangular flap on the white skin roll just above the christa philtri is most often suggested for such modifications [
13,
19,
20], but the resultant scar can be unacceptable to non-Caucasians. In this study, we introduce our modification for the better downward rotation of the christa philtri on cleft side without using an extra triangular flap.
Patients and methods
Sixty non-syndromic unilateral complete cleft lip and palate patients treated in the Department of Cleft Lip and Palate Surgery, West China College of Stomatology, Sichuan University between July 2011 and September 2012 were included. All patients had their lips repaired by our modified technique at about 4 months old, and their palate was repaired at about 12 months old. All included patients were from the same ethnic group in southwest China, and none of them received any orthopedic intervention, trauma, or other surgical operation in the oral maxillofacial region.
Surgical technique
Most markings were similar to those in the original Millard’s technique, except for points 5 and 8 (Fig. 1A). Point 5 was always located on the bisecting line of the angle formed by points 2, 1, 3, and the medial to the philtral column on the non-cleft side. The principle of this design was to ensure an equal distance from point 5 to points 2 and 3. In this way, when point 5 was corrected to the facial middle line, point 3 was also brought downward to the horizontal level as point 2 (Fig. 1A). Point 8 (the end of rotation incision) was located at the cleft one-third of the collumella base. The horizontal location of this point decided the shape of the cutaneous suture line but had nothing to do with the amount of downward movement.
The surgical area was infiltrated by 1% lidocaine with 1:200 000 epinephrine. The rotation incision on the non-cleft side and the advancement incision on the cleft side were made as shown in Fig. 1A. The depth of these incisions was limited to the skin to maintain the integrity of the underlying orbicularis oris muscle.
The orbicularis oris muscle was sharply dissected from both skin and mucosa at 3 mm to 4 mm from the cleft margin. On the cleft side, the attachment of orbicularis oris muscle on the maxilla was released, and for most of the cases, a branch of facial artery indicated the end of dissection (Fig. 2A). On the non-cleft side, the upper margin of the orbicularis oris muscle was freed from the anterior nasal spine to rotate the displaced muscle into a normal position. Similar to the skin rotation incision, the dissection of the upper margin of the orbicularis oris muscle was extended to the bisector line of angle 213 (Fig. 2B).
If the downward rotation of point 3 was limited by oral mucosa limits, a horizontal mucosa release incision was made at the level of the vermilion border, which still ended on the bisector line of angle 213. However, we made the incision after suturing the muscle and skin when necessary because the mobility and flexibility of the oral mucosa was much better. Thus far, sufficient downward rotation on the cleft side was achieved in skin, muscle, and mucosa in a “step rotation downward” manner.
Before muscle reconstruction, the vomer mucoperiosteum flap was elevated and sutured to the mucosa flap of the oral vestibule and the flap of nasal vestibule to form the roof of the oral vestibule and floor of nasal vestibule (Fig. 3A). The muscle on the cleft side was then advanced to the rotation defect of the muscle on the non-cleft side and secured to the anterior nasal spine with 5-0 PDS (Fig. 3B). The orbicularis oris ring was restored with a horizontal mattress suture to mimic the ridge of the philtral column.
After muscle reconstruction, the columella-based skin flap (C flap in the Millard technique) was moved upward to fill the rotation defect (Figs. 4C-4E). The lateral edge of the flap was sutured to the edge of the nasal vestibule skin flap on the cleft side to form the floor of the nasal vestibule.
Vermillion reconstruction was similar to Noordhoff’s technique [
23]. McComb’s method [
24] was used for primary rhinoplasty. The alar rim on the cleft side was elevated with a hook. The skin envelope of the lateral crus of the lower lateral cartilage was undermined through the nasal base and columella, with the cleft side alar rim lifted by a single hook (Figs. 4A and 4B). The three internal fixation sutures were then inserted to shape the nostril: the low lateral cartilage was suspended to the ipsilateral upper lateral cartilage and contralateral low lateral cartilage; and the alar groove on cleft side was accentuated (Figs. 4C-4E).
Measurements
Regional facial plaster casts were used for analysis. The casts were taken at three time points, i.e., before cheiloplasty (T1), immediately after cheiloplasty (T2), and before palatoplasty (T3). Endocanthion (En/En’: the inner commissure of the palpebral fissures), christa philtri (Cph/Cph’: the peaks of the Cupid’s bow), subalae (Sa/Sa’: the most inferior point at the junction of the alar base and the upper lip), and cheilion (Ch/Ch’: the labial commissure) were marked for measurements (Fig. 5). The distance between the bilateral endocanthion (
L), the distance between christa philtri and bilateral endocanthion (
L3,
L4), bilateral lip height (
L5,
L6), and bilateral lip length (
L7,
L8) were measured with a digital caliper. Then, the relative height of the christa philtri (
L1 for the non-cleft side and
L2 for the cleft side) can be calculated through the trigonometric function:
The height of the christa philtri (
L1 and
L2) was standardized by
L to minimize the influence of facial growth. The relative height of the christa philtri (
l1 and
l2) was acquired as follows:
and
Measurements from both sides were compared using paired-sample t-test with SPSS Version 17.0. The threshold of significance was set at 0.05.
Results
Lip length and lip height
Immediately after cheiloplasty, greater lip length (P = 0.000) and lip height (P = 0.000) on the non-cleft side were observed, but this asymmetry was relieved at about 10 months after cheiloplasty (P = 0.121 for lip length and 0.104 for lip height) (Table 1).
Relative height of the christa philtri
Immediately after cheiloplasty, no significant difference was observed between the bilateral relative height of the christa philtri either immediately (P = 0.214) or 10 months (P = 0.344) after lip repair (Table 2).
Discussion
Insufficient downward rotation of the cleft-side christa philtri was frequently noticed in Millard’s technique, and such shortcoming was overcome by our modification. The most important geometrical theory used in the technique was the angle bisector line principle. Normally, the bilateral alar base, peaks of Cupid’s bow, and columella base form a W shape, and the columella base and bilateral peaks of Cupid’s bow form an isosceles triangle. In unilateral complete cleft patients, the W shape is interrupted and the isosceles triangle is distorted. Therefore, the goal of unilateral cleft lip repair can be simplified into restoring the W shape. Points 2 and 3 form an isosceles triangle with any point on the bisector of angle 213; thus, the bisector of angle 213 is considered as the deviated midline in cleft patients. When the bisector of angle 213 is restored to the middle, point 3 also comes down to the horizontal level of point 2, and the midmost position of the isosceles triangle of the upper lip can be recovered (Fig.1A). In our modification, the peak of Cupid’s bow on the cleft side is designed to equalize the bilateral distances from the ala to the peak of Cupid’s bow and the distances from the columella base to the peak of Cupid’s bow instead of only matching the lengths of bilateral cleft edge incisions.
Another important feature of our technique is to separately rotate the skin, muscle, and mucosa downward. Thus, we suggest making rotation incisions of the skin, muscle, and mucosa at different levels. The columella-based C flap was used to fill the rotation defect and restore the nasal floor instead of elongating the columella. The incision on the muscle was made on its misattachment to the anterior nasal spine. The incision on the mucosa went horizontally through point 3 and terminated on the angular bisector. The amount of downward rotation on the skin, muscle, and mucosa were the same as all rotation incisions that ended on the angular bisector line (Fig. 6).
In previous studies, postoperative lengthening of the lip was mostly noticed in Tennison’s method and its variations [
25,
26]. Brauer and Wolf [
27] ascribed such postoperative lengthening of lip to the vertical growth of tissue, which normally grew horizontally before the rotation. For Millard’s technique and its variations, such lengthening of the lip was rarely noticed, but our data suggested that postoperative lengthening of the lip height and lip length can be expected using our modification.
Conclusions
Through skin, muscle, and mucosa separation to the bisecting line of angle 213, our modification has potential for producing sufficient downward rotation of the cleft side christa philtri.
Compliance with ethics guidelines
Yi Xu, Jingtao Li, and Bing Shi declare that they have no conflict of interest. This study was approved by the Institute of Health Studies Research Ethics Committee of Sichuan University. Informed consents were acquired from the parents of all patients.
Higher Education Press and Springer-Verlag Berlin Heidelberg
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