Journal of Cranio-Maxillofacial Surgery (1998) 26, 1%21 © 1998 European Association for Cranio-Maxillofacial Surgery

Secondary correction of bilateral cleft lip deformity with simultaneous Abb6 flap and nasal repair

Yohko Yoshimura, Tatsuo Nakajima, Yuji Nakanishi, Kei Yoneda

Department of Plastic and Reconstructive Surgery (Head." Prof. T. Nakajima), School of Medicine, Fujita Health University, Toyoake, Japan

SUMMARY. For secondary repair of a bilateral cleft lip deformity with a short columella and defective upper lip, simultaneous correction of the lip and nose is ideal. We perform a nasal repair through a bilateral reverse-U incision and columella elongation using the upper lip. An Abb6 flap is then transferred to the upper lip defect. This procedure enables total reconstruction of characteristic bilateral cleft lip deformities in one stage. We have applied this method to 15 patients (9 males and 6 females) with an average age of 18.7 years. Although some patients need jaw surgery, all have been satisfied with the results.

INTRODUCTION

The characteristics of secondary bilateral cleft lip deformity are: imbalance in tissue volume of the upper and lower lip, short columella, inadequate nasal tip, increased columello-labial angle and so-called whistling deformity due to tissue deficiency of the central vermilion.

For cases in which upper lip volume is markedly deficient, we have applied a one-stage reconstruction of the nose and the upper lip simultaneously. A nasal repair is done through a bilateral reverse-U incision. A central white lip flap based on the columella base is utilized for columella reconstruction, and the resul- tant upper lip defect is covered by an Abb6 flap. We report the details of this method of secondary correc- tion of bilateral cleft lip.

SURGICAL PROCEDURE

Surgery is performed under local anaesthesia. The white lip skin surrounded by scar is elevated and uti- lized for columella formation. The incision is then con- tinued up to the bilateral reverse-U incision, allowing wide exposure of the nasal cartilages. The shape of the white lip flap depends on the shape of the existing scar (like a fork flap in some instances and rectangular in most other cases) which directly connects to the col- umella (Fig. l a). As there usually exists a transverse scar crossing the columella base, care should be taken not to compromise the blood supply to the flap. For this reason, it is wise to elevate the soft areolar tissue between the bilateral alar cartilages along with the flap. To elevate the tip of the nose, this areolar tissue will be placed back on the alar cartilages after they are sutured to each other. The areolar tissue sometimes makes a flap by itself (Harashina, 1995), but in most of our cases the areolar tissue is elevated together with

17

the dorsal skin of the nose. In most Japanese patients, a cartilaginous strut (as described by Kinnebrew 1983, and Tessier and Tulasne 1984, is not needed because their noses are flatter than those of Caucasians.

To make a well-defined nasal dorsum and to avoid a round nose, two to three transverse mattress sutures of 44) clear monofilament nylon are placed subcuta- neously over the nasal tip and dorsum. The knot of the suture is buried through a stab incision. Some through- and-through sutures are added between skin and carti- lage of the ala along the alar groove (Fig. lb, lc).

The white lip flap is moved to the columella and the distal end of the flap is fixed to the anterior nasal spine (ANS). When the ANS is hypertrophied, it is trimmed to make a sharp columello-labial angle.

An Abb6 flap is inserted into the lip defect created by the nasal correction. The Abb6 flap is designed not to fill the defect but to match the normal aesthetic unit of the philtrum, given the age and sex of the patient. We use a measurement of the philtrum in a normal individual of the same age and gender as a guideline. Usually the width of the vermilion lip is 10-13 mm and the length of the white lip is 15-18 ram. A relatively narrow flap gives a better cosmetic result (Fig. ld).

For a defined philtral dimple, the skin incision for harvesting the Abb6 flap is inclined 45 ° from upper- lateral to deep-medial. The tip of the Abb6 flap is denuded and secured to the ANS. One or two buried sutures of 3-0 clear monofilament nylon are placed between the bilateral alar bases or between the alar base and the columella base to avoid flaring of the alar base (Fig. le).

To restrict jaw movement postoperatively, a Barton bandage is applied. When necessary, one or two wires for intermaxillary fixation are added.

The pedicle of the Abb6 flap is divided 5 to 7 days postoperatively. At that time, small irregularities of the vermilion border, which usually occur during fixation of the jaw, are accurately corrected.

18 Journal of Cranio-Maxillofacial Surgery

A

B

O

j areolar tissue

CASES

From July 1989 to March 1997, we applied this method in 15 patients with secondary deformities of bilateral cleft lips. Nine were male and six were female. Their ages ranged from 11 to 26 years (mean 18.7). In all cases, primary repair had been performed at another institute. Representative cases are presented below.

Case 1

A 17-year-old woman had had her bilateral cleft lip repaired, one side at a time. Details of the surgical procedure and the date of surgery were not available. Her alveolar examination revealed that her original deformity had been an asymmetric cleft. The Abb6 flap was divided 7 days postoperatively in this patient (Fig. 2).

The result 2 years and 8 months after surgery is shown in Figure 2f. Although we recommended an

suture

D

E

Fig. 1 - Schematic drawing of the surgical procedure. (a) Design of the incision (thin solid line indicates the incision). (b) Elevation of the white lip flap and nasal repair. (c) Transverse mattress sutures over the nasal dorsum, buried through stab incisions. (d) Lip defect after nasal repair and design of the Abb6 flap. (e) After surgery.

additional revision of the columella scar, the patient was satisfied with this result and refused further surgery.

Case 2

An 18-year-old man presented with a typical postoper- ative deformity of bilateral cleft lip and palate. His dental occlusion was good following orthodontic treatment. Our method was applied to correct his nasal deformity and to improve his profile. The pedicle of the Abb6 flap was divided 7 days later. The postop- erative contour of the nose and the relationship between the upper and lower lips were satisfactory (Fig. 3).

DISCUSSION

Much progress has been made in the field of cleft lip repair (Nakajima et al., 1991). However, in bilateral

Secondary correction of bilateral cleft lip deformity 19

Fig. 2 -Case 1: A 17-year-old woman. (a) Preoperative frontal (left) and lateral (right) views. (b) Design of the incision. Central portion of the lip vermilion was turned inwards to make a deep oral vestibule. (c) Elevation of the white lip flap. Note the wide exposure of the nasal cartilages. (d) Elevation of the Abb6 flap. (e) Immediately after surgery. The pedicle was divided 7 days later. (f) Two years and 8 months postoperatively.

cleft lip repair, numerous p rob lems still remain. Millard publ ished his forked-f lap technique in 1958 and Converse et al. (1970) repor ted a c o m b i n e d nose- lip repair in bi lateral cleft lip deformity, which mus t be considered to be a p ro to type for our me thod . As we repor ted previously (Nakajima and Yoshimura, 1990), some cases can be t reated successfully by a combina t i on o f a shor t - fork flap and a bi lateral

reverse-U incision (Fig. 4). However , in cases o f severe nasal deformi ty with m a r k e d insufficiency o f the uppe r lip volume, an Abb6 f lap is needed to add vo lume to the uppe r lip (Millard, 1970). In such a case, the procedure repor ted here can be effectively per fo rmed . O f course, there are some pat ients in w h o m maxi l la ry o s t eo tomy is indicated. In such cases, we use this p rocedure to release the uppe r lip

20 Journal of Cranio-Maxillofacial Surgery

Fig. 3 - Case 2: An 18-year-old man. (a) Frontal view before (left) and 8 months after (right) surgery. (b) Lateral view before (left) and 8 months after (right) surgery.

A

Fig. 4 - Our method of secondary correction of bilateral cleft lip with a short fork flap and bilateral reverse-U incision (Nakajima and Yoshimura, 1990). (a) Schematic drawing of the procedure. (b) A patient who underwent this procedure. Frontal view before (upper) and after (below) surgery. (c) Lateral view of the same patient.

tension in prepara t ion for the maxil lary osteotomy. In fact, many of these patients in w h o m maxil lary os teo tomy was indicated were highly satisfied with the result o f this procedure alone, and did no t want to undergo the osteotomy. It is understandable, con- sidering their age, that patients do no t wish to disturb their daily activity for a longer period by undergoing an osteotomy.

C O N C L U S I O N

We report a me thod of secondary correct ion o f bilat- eral cleft lip deformity using an Abb6 flap with nasal repair th rough a combinat ion o f bilateral reverse-U incision and columella elongat ion with a white lip flap based on the columella. This me thod is indicated only in cases o f severe deficiency of upper lip volume.

Secondary correction of bilateral cleft lip deformity 21

References

Converse, J.M., VM. Hogan, C C. Dupuis: Combined nose-lip repair in bilateral complete cleft-lip deformities. J. Plast. Reconstr. Surg. 45 (1970) 109 118

Harashina, T.: Secondary correction of bilateral cleft lip and nose deformities with special reference to the use of an Abbe flap and open rhinoplasty. Jap. J. Plast. Reconstr. Surg. 38 (1995) 475-485

Kinnebrew, M.C.: Use of the Abb6 flap in revision of the bilateral cleft lip-nose deformity. Oral Surg. 56 (1983) 12-19

Millard, 1). R.." Columellar lengthening by a forked flap. J. Plast. Reconst. Surg. 22 (1958) 454-460

MilIard, D.R.: Cleft Craft II. Little Brown Co., Boston 1976 Nakajima, T., Y Yoshirnura, Y. Nakanishi, M. Kuwahara, T. Oka:

Comprehensive treatment of bilateral cleft lip by multidisciplinary team approach. Brit. J. Plast. Surg. 44 (1991) 486-494

Nakajima, T., Y Yoshimura: Secondary correction of bilateral cleft lip nose deformity. J. Cranio-Maxillofac. Surg. 18 (1990) 63-67

Tessier, P., ~ F Tulasne. Secondary repair of cleft lip deformity. Clin. Plast. Surg. 11:4 (1984) 747-760

Yohko Yoshimura MD Department of Plastic and Reconstructive Surgery School of Medicine Fujita Health University 1 98 Dengakugakubo Kutsukake Toyoake Aichi 470-11 Japan

Paper received 1 September. 1997 Accepted 22 December. 1997

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