Principles and techniques of bilateral complete cleft lip repair

Important principles for repair of bilateral complete cleft lip are symmetry, primary orbicularis continuity, proper prolabial size and shape, median tubercle and mucocutaneous ridge formation from lateral lip tissue, and early construction of nasal tip and columella with anatomic placement of the alar cartilages. A two-stage repair employing techniques based on these concepts is described. At the initial procedure, the lateral crura are positioned and a tiny biconcave prolabium is shaped in anticipation of the changes with growth. The second stage (nasal correction) includes apposition of the alar genua, medial crural relocation, and intranasal transposition of banked forked flaps without disjunction of the columella-labial angle. The complete bilateral cleft lip is a four-dimensional problem.     

Bilateral cleft lip and nasal repair

SUMMARY: The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.     

Long-term results following velopharyngoplasty with a cranially based pharyngeal flap.

Between 1980 and 1989, 82 velopharyngoplasties have been carried out in the Department of Oral and Maxillofacial Surgery at the Medical University of Hannover. Speech results of 51 of these patients, including 39 patients with cleft lip and palate, could be followed up in the context of a clinical follow-up examination. Besides evaluation of speech results by two senior speech pathologists and two untrained listeners, a frequency analysis of the speech results with a sonograph was obtained. Nasal air loss was documented with a fogged-mirror test and computer aerometry. Whereas in 37 of 51 patients a normal or almost normal colloquial speech could be demonstrated, 30 of 39 patients with cleft lip and palate showed a normal or almost normal realization of the test sentences. Thirty of the 37 patients (81.08 percent) with normal or almost normal colloquial speech showed extensive mobility of the lateral pharyngeal wall. Symmetry of the velopharyngeal flaps seemed to have no influence on the speech result. With a fogged-mirror test, an average reduction of mirror fogging from 2.0 rings preoperatively to 0.9 rings postoperatively could be shown. In 31 patients, there was no longer any air loss postoperatively. Besides one rupture of a flap, two flaps had to be diminished in their lateral dimensions because of excessive size. We regard the cranially pedicled pharyngeal flap as an important operative procedure for improving speech results, especially in cleft lip and palate patients.     

Lip and vermilion reconstruction with the facial artery musculomucosal flap

The lips are a complex laminated structure. When lost through injury or disease, they present a complex reconstructive challenge. The facial artery musculomucosal (FAMM) flap is a composite flap with features similar to those of lip tissue. In this article, the anatomy, dissection, and clinical applications for the use of the FAMM flap in lip and vermilion reconstruction are discussed. A series of 16 FAMM flaps in 13 patients is presented. Seven patients had upper-lip reconstruction and six had lower-lip reconstruction. Superiorly based FAMM flaps were used in eight patients, and eight inferiorly based flaps were performed in five patients. Three patients had bilateral, inferiorly based flaps. In summary, the FAMM flap is a local flap that can be used for lip and vermilion reconstruction. Although not identical to the lip, it has many similar features, which make it an excellent option for lip reconstruction.     

Bilateral vermilion flaps for lower lip repair

A more natural reconstructive procedure of the lower lip using bilateral vermilion flaps was applied in five patients with excellent results. The vermilion defects were about two-fifths to three-fifths. In three patients, the vermilion defect was repaired using bilateral vermilion flaps alone. In the remaining two patients, a narrow horizontal lip defect was repaired by bilateral vermilion flaps and a subcutaneous V-Y advancement flap of the lower lip. A single vermilion flap or bilateral vermilion flaps are considered to be of great value for vermilion reconstruction because of the inherent elasticity and common anatomic unit. The postoperative scars are not remarkable at all. A long and narrow horizontal lip defect (perhaps within 1.5 cm downward from the vermilion border) may be effectively repaired by the combination of vermilion flap(s) and a V-Y advancement flap without sacrificing any additional healthy tissue.     

Staged sequential flap reconstruction for large lower lip defects

A method for the reconstruction of total or nearly total defects of the lower lip is described that utilizes a staged sequence of flaps that are familiar to most plastic surgeons. The recommended sequence is an extended Karapandzic flap to reestablish the oral sphincter, then two sequential Abbé flaps from the upper lip to restore balance and augment the central lower lip, and finally a commissureplasty using a sliding myomucosal flap in conjunction with final revision of the scars. Intervals of 3 weeks separate the surgical procedures. Using this strategy, essentially normal lip function and a relatively normal appearance have been obtained in four patients with large lip defects.     

Formation of philtral column using vertical interdigitation of orbicularis oris muscle flaps in secondary cleft lip

The philtrum in the lip has an important aesthetic significance and is a mark of individual distinction. For patients who have undergone cleft lip surgery, the construction of the philtrum is crucial for restoring a normal appearance to the upper lip. A total of 13 patients with unilateral cleft lip nose deformities were treated for the creation of a philtral column between January of 1998 and February of 1999. Eight of the patients were male and five were female with an age range of 10 to 40 years old. The scar on the philtral column is excised and a full-thickness incision is made down to the orbicularis oris muscle and mucosa. The medial and lateral muscle flaps are then exposed and split into two leaves. The two leaves of each muscle flap are sutured together to create a vertical interdigitation. Any excess skin is not excised but rather closed with 7-0 nylon. The follow-up period ranged from 6 to 15 months, with an average of 10 months. Ten of 13 patients were satisfied with their good surgical results. Two had fair results. One patient experienced a widening of the scar and no improvement in the philtral column. A possible cause for this lack of improvement was a partial disruption of the interdigitated muscle flaps due to the early active movement of the muscle before wound healing. In conclusion, the advantages of this procedure include the creation of an anatomically natural philtrum through preserving the continuity and function of the muscle, sufficient augmentation of the philtral column by the vertical interdigitation of the muscle, relief of skin tension, and no donor-site morbidity.     

One-stage closure of the entire primary palate

Timing of the closure of the anterior palate and alveolus is a subject of debate. Late repair of this defect is complicated by high fistula formation and subjects the patient to the problems of palate fistula for extended periods of time. We have utilized a single procedure performed when the child is 3 months of age that completely closes the anterior hard palate and alveolus along with the cleft lip. Our series consisted of 61 consecutive patients with unilateral clefts of the primary and secondary palate. Mucosal turnover flaps from the vomer along with lateral nasal mucosal flaps provide the nasal lining. A buccal sulcus flap with a Veau flap completes the oral repair. Ninety-five percent (58 of 61) of the patients had complete and stable closure of their anterior palate and alveolus after 1 year. The incidence of fistula formation in our series (3 of 61) is much lower than that reported with the utilization of other protocols. Excellent exposure of the anterior palate and alveolar defect during lip repair, early restoration of anatomic relationships, establishment of a good nostril floor and sill, and very low fistula formation are among the benefits of this procedure. The increase in operative time is considered minimal in light of aforementioned advantages.     

Nine-year experience with extended use of the commissure-based buccal musculomucosal flap

This study reports on the extended use of the commissure-based buccal musculomucosal (CBMM) flap. Large lip defects and medium-size intraoral defects have the general problem of being too large for primary closure to avoid a major functional and aesthetic impairment. Elaborate free flaps, such as axial flaps, although excellent in large defects, may not provide mucosa-equivalent sensitivity, motility, volume, and texture to replace lost tissue with a similar kind of tissue. A total of 60 flap procedures were performed with bilateral and unilateral flaps up to 7.5 x 4 cm in size. The partial and total upper and lower vermilion, gingivobuccal sulcus, floor of the mouth, lateral tongue margin, oropharynx, and hard and soft palates were reconstructed. Partial necrosis was seen in four flaps; all patients recovered with good oral function in speech and swallowing, good aesthetics, and prosthetic rehabilitation if necessary. The donor site could be closed primarily. In flaps with dorsal advancement, the mucosal excess above and below was closed, creating two small dog-ears. Facial expression and mouth opening returned to normal after less than 2 months. The parotid duct had to be marsupialized in large flap preparations, but this did never provoke stasis or infection. The two-point sensitivity of the flaps was, on average, equal to that of the nonoperated mucosa in intraindividual correlation, and the flaps lost, on average, 15 percent of their original size. In the authors' estimation, the results indicate a reliable and technically easy option for intraoral, medium-size defect reconstruction that yields sensitivity and facilitates the rehabilitation of oral function in speaking and ingestion.     

Lower lip suspension using bilateral temporalis muscle flaps and fascia lata grafts

Oral incompetence following composite reconstruction of total and subtotal lower lip defects without any functioning lower lip muscle is a difficult problem for reconstructive surgeons. The authors retrospectively reviewed the use of a novel bilateral temporalis suspension technique for oral incompetence following lower lip reconstruction over a 10-year period. The timing of the reconstruction, cause of the defect, period of follow-up, and any complications were noted. Three cases of lower lip resuspension using bilateral temporalis flaps and fascia lata grafts were performed from 2000 to 2010. Two cases were secondary to burn trauma and one was from ballistic trauma. All patients underwent traditional means of reconstruction using free microvascular composite tissue transfer with and without fascial slings. All three patients presented with persistent lower lip incompetence. The average interval between the initial reconstructive operations and the resuspension operations was 1.6 years. All patients achieved dynamic oral competence at the first postoperative visit. At a mean follow-up of 3.6 years, all patients had maintained lower lip function. Dynamic lower lip resuspension with bilateral temporalis flaps and fascia lata grafts is an option for refractory lower lip drooping following total and subtotal loss, especially after conventional static reconstruction and without any functional orbicularis muscle. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.     

Bilateral cleft lip reconstruction

Over a period of 8 years 140 bilateral cleft lips were operated using a muscle-repositioning banked fork-flap cheiloplasty. The use of buccal mucosal flaps in the intercartilaginous incision is helpful to decrease scarring and contracture by facilitating alar cartilage repositioning and wound closure without tension. Adding mucosa from the inferior turbinate makes complete wound closure relatively easy without tension. A lateral lip orbicularis muscle flap with white skin roll and vermilion is recommended for reconstruction of the Cupid's bow. Muscle continuity by freeing the muscle in one sheet and repositioning in front of the premaxilla with creation of a buccal alveolar sulcus is stressed to prevent the necessity of reentering the lip in a second procedure. The elongation of the columella is done at 1 to 6 years of age by advancing nasal floor tissue onto the columella and repositioning the alar cartilages superiorly and medially. When nasal floor tissue is inadequate, columellar lengthening is done by the use of a composite free ear graft.     

The taxonomy of Tylenchorhynchinae (Nematoda: Tylenchida) with longitudinal lines and ridges

Summary The taxonomy of those Tylenchorynchinae which have longitudinal lines or ridges on the cuticle is discussed. Dolichorhynchus is restricted to species with four incisures in the lateral field, lateral vulval flaps and a terminally notched bursa. D. prophasmis n. sp. is described. Neodolichorhynchus n. g. is erected for those species previously in Dolichorhynchus which have no lateral vulval flaps and a normal bursa, including: N. microphasmis (Loof, 1959) n.comb., N. judithae (Andrássy, 1962) n.comb., N. sulcatus (de Guiran, 1967) n.comb., and N. gladiolatus (Fortuner & Amougou, 1973) n.comb. Tessellus n.g. is proposed for T. claytoni (Steiner, 1937) n.comb. and T. pachys (Thorne & Malek, 1968) n.comb. the only remaining Tylenchorhynchus species with longitudinal cuticular lines. They are characterized by a rounded non-offset lip region, four incisures in the lateral field and a cuticular annulation divided into prominent blocks by deep longitudinal cuticular lines.     

Functional reconstruction using a depressor anguli oris musculocutaneous flap for large lower lip defects, especially for elderly patients

Described here is a new technique to reconstruct large lower lip defects using one or two musculocutaneous island flaps, which includes an innervated depressor anguli oris muscle and has a facial artery in its pedicle. Vermilion is simultaneously reconstructed using a mucosal transposition flap. Three patients who had a total lower lip defect and five patients who had a defect larger than one-half of the lower lip were treated by our procedure. All the flaps survived completely without any signs of vascular stasis. In six patients, sphincter function and sensation appeared within 3 months after surgery. In one patient who needed a total lower lip reconstruction, the depressor anguli oris muscle was atrophic and the motor nerve could not be found. This patient could not regain motion. One other patient complained of a sialorrhea accompanied by sensory loss; however, his sensation improved within 6 months after surgery. All of the reconstructed lower lips were large enough to enable the patient to wear dentures and were of a cosmetically acceptable appearance 1 year after surgery.     

Reconstruction of concomitant lip and cheek through-and-through defects with combined free flap and an advancement flap from the remaining lip

Massive facial defects involving the oral sphincter are challenging to the reconstructive surgeon. This study presents the authors' approach to simultaneous reconstruction of complex defects with an advancement flap from the remaining lip and free flaps. From January of 1997 to December of 2001, 22 patients were studied following ablative oral cancer surgery. Their ages ranged from 32 to 66 years. Nineteen patients had buccal cancer, two patients had tongue cancer, and one patient had lip cancer. In all cases, the disease was advanced squamous cell carcinoma. Nine patients underwent composite resection of tumor with segmental mandibulectomy, and seven patients underwent marginal mandibulectomy. Cheek defects ranged from 15 x 12 cm to 4 x 3 cm, and intraoral defects ranged from 14 x 8 cm to 5 x 4 cm in size. One third of the lower lip was excised in nine patients, both the upper and lower lips were excised in 10 patients, and only commissure defects were excised in three patients. An advancement flap from the remaining upper lip was used for reconstruction of the oral commissure and oral sphincter. Then, the composite through-and-through defect of the cheek was reconstructed with radial forearm flaps in 13 patients, fibula osteocutaneous flaps in five patients, double flaps in three patients, and an anterolateral thigh flap in one patient. The free flap survival rate was 96 percent, and only one flap failed. With regard to complications, there were two patients with cheek hematoma, six patients with orocutaneous fistula or neck infection, and one patient with osteomyelitis of the mandible. All but one patient had adequate oral competence. All patients had an adequate oral stoma and could eat a regular or soft diet; two patients could eat only a liquid diet. For moderate lip defects, immediate reconstruction of complex defects took place using an advancement flap from the remaining lip to obtain a normal and functional oral sphincter; the free flap can be used to reconstruct through-and-through defects. This simple procedure can provide patients with a useful oral stoma and acceptable cosmesis.     

Congenital isolated absence of the nasal columella: reconstruction with an internal nasal vestibular skin flap and bilateral labial mucosa flaps

Congenital aplasia of the nasal columella is a very rare anomaly. The deformity is characterized by the isolated absence of the columella from the nasal tip to the root of the philtrum, including the medial crura of the alar cartilages; surrounding structures such as the septum, nose, and upper lip are normal. To the best of our knowledge, only four such cases have been described to date. The embryopathogenesis for this uncommon disease is presently unknown. Our report describes a 14-year-old girl with congenital agenesis of the columella as an isolated anomaly. Her family history was positive for the presence of the same congenital deformity, which also affected her older brother; there was, however, no consanguinity between the parents. The columella defect was reconstructed with an internal nasal vestibular skin flap and bilateral upper labial mucosa flaps. There are many techniques available to repair columella defects, including free grafts from the ear, local flaps from the forehead, face, upper lip, and nose, distant flaps such as tube pedicle flaps, and free flaps from the ear. Each of these techniques has advantages and disadvantages. Because of this, the treatment of columella defects should be individualized.     

Tongue-flap reconstruction of the lip vermilion in hemifacial atrophy

The lips are key features to be considered in facial balance. Correction of lip atrophy in Romberg's disease, therefore, contributes significantly to restoration of facial symmetry. Along with other ancillary surgical procedures used for facial reconstruction in hemifacial atrophy, tongue flaps provide an excellent means of correction of the lip deformity with minimal morbidity and good results.     

Advanced squamous cell carcinoma involving both upper and lower lips and oral commissure with simultaneous reconstruction by local flap: a case report

Introduction

Squamous cell carcinoma is one of the most common malignant tumors of the skin and oral mucosa. However, squamous cell carcinoma involving near total upper and lower lip and oral commissure is rarely seen in the English literature. Simultaneous reconstruction of the upper and lower lips has been inconclusive and presents a challenge to the surgeon. We report such a case and outline our simultaneous reconstruction with local flaps. To the best of our knowledge this has never been reported.

Case presentation

A 73-year-old Thai woman presented with a large rapidly growing squamous cell carcinoma involving the upper lip, lower lip, left oral commissure and left cheek. En bloc resection of upper lip, lower lip, left oral commissure and buccal region was performed. Left radical neck dissection and right modified neck dissection were performed. Reconstruction of the upper lip with a left nasolabial-cheek cervicofacial rotational-advancement flap and right cheek advancement with perialar crescent flap was performed. The lower lip was reconstructed with bilateral labiomental advancement flaps.

Conclusions

Squamous cell carcinoma can grow rapidly and spread along the orbicularis oris muscle and across the oral commissure to the opposite lip. In advanced cancer, multimodal treatment is necessary. No gold standard in the reconstruction of both upper and lower lips has been established. We report the case of an advanced squamous cell carcinoma involving both the upper lip, lower lip, left oral commissure and buccal area and simultaneous reconstruction with local flap coverage that, to the best of our knowledge, has never been reported.     

New technique for correction of the microform cleft lip using vertical interdigitation of the orbicularis oris muscle through the intraoral incision

A microform cleft lip has three major components: (1) a minor defect of the upper vermilion border with loss of the mucocutaneous ridge; (2) a narrow ridge of tissue, resembling an exaggerated philtral column extending to the nostril sill; and (3) a deformity of the nostril. To attain the muscle continuity without an external scar on the upper lip, the author introduced a new method for the correction of a microform cleft lip deformity using vertical interdigitation of the orbicularis oris muscle through the intraoral incision to create the philtrum. Through the intraoral incision, a full-thickness incision is made down to the mucosa and the posterior portion of the muscle. Then, the remaining portion of the muscle is dissected. The medial and lateral muscle flaps are also detached from the oral mucosa and completely exposed and split into two leaves. The upper leaf of the lateral muscle flap is sutured to the dermis on the philtral dimple and base of the upper leaf of the medial muscle flap. Two leaves of each muscle flap are sutured together to create a vertical interdigitation to increase the thickness of the philtral column and to provide continuity of the muscle. A total of 12 patients with microform cleft lip were treated between August of 2001 and October of 2002. Seven of the patients were male and five were female, with an age range of 1 to 43 years. The follow-up period ranged from 6 months to 15 months, with an average follow-up of 9 months. The results of vertical interdigitation of the muscle were examined. All patients were satisfied with their results. The orbicularis oris muscle provided continuity and preserved good function. In all cases, the operation scar was not visible on the depressed philtral groove on the cleft side. Correction of cleft lip nasal deformity was performed in four patients and alar base advancement was performed in two patients. The advantages of the proposed procedure include the creation of an anatomically natural philtrum without an external visible scar through the intraoral incision, preservation of the continuity and function of the muscle, and sufficient augmentation of the philtral column by the vertical interdigitation of the muscle.     

The elastic flap for lip repair

These cases illustrate a new concept in lip repair. This approach recognizes the great inherent elasticity of the oral cavity and takes advantage of the florid blood supply of the region. Recent laboratory studies of Taylor et al., as well as the works of Manchot and Salmon, are combined with anthropologic observations of tribal customs to formulate another way of looking at lip reconstruction. Triangularization of surgical defects, lip switching, and mobilization of distant flaps are avoided by taking advantage of stretched local tissues. Preoperative expansion is discussed as a future option.     

A method with three triangular flaps as a secondary operative procedure after reconstruction of the lower lip by Estlander's method.

We have devised a new method for secondary commissuroplasty after reconstruction of the lower lip using Estlander's method with both aesthetically and functionally satisfactory results. This method consists of forming two equilaterally triangular mucosal flaps on the vermilion and a small triangular skin flap in the new position of the commissure and transposing these three flaps to reconstruct the commissure. In the present paper, we reported the procedure and the results. This method produces extremely good results, obtaining favorable commissure form and reconstruction of the mucosa of both upper and lower lips without leaving an unnatural-looking color change in the mucosa or a step deformity in the vermilion. It can be expected that our method will improve the results of Estlander's operations after tumor resection in the lower lip.