In this article, three incomplete and one complete unilateral cleft lip patients are presented. This study was approved by the Ethics Committee of Seoul National University Graduate School of Dentistry (IRB no. S-D20150022).
Incomplete unilateral cleft lip
The case 1 was a 9-month-old boy with incomplete unilateral cleft lip on his right side (Fig. 1 d–g). Although the length of tissue supposed to form philtral ridge on affected side is deficient, the difference of lip lengths between affected side and non-affected side was not huge. The lateral and medial side tissue were enough on affected side, and nasal deformity was relatively small. The case 2 was a 6-month-old boy with incomplete unilateral cleft lip on his left side (Fig. 1 h, i). His prolabium and nasal deformities were greater than case 1. He had asymmetric nares, deviated collumella, and cleft side subnasale was located in lower position than normal side. The discontinuity of orbicularis oris muscle cause bulging of prolabium area. Case 3 was a 5-year-old boy with incomplete unilateral cleft lip which was limited on his vermilion area (Fig. 1 j, k). His nasal deformity was not severe, and tissue seems to be enough. The difference of length between medial and lateral lip was slight. His philtrum was also located in the middle of face.
Surgical procedure
All the procedures are up to the patient’s condition, but basically it was like below;
Surgical field preparation, routine double head draping was done, and presurgical photographs were taken. The key landmarks and surgical incision line was designed with marking stick and gentian violet dye solution. Local anesthetics were infiltrated on labium and nasal area with 2% lidocaines with 1:100,000 epinephrine. Injection of marked landmarks could make tattooing effect, to facilitate preserving landmarks effectively during surgical procedure. The incision on the medial segment was carried on with a no. 15 blade and redundant cleft marginal tissue was discarded. The skin on the medial segment was undermined from the skin and mucosa to separate orbicularis oris muscle for about 1 mm distal from cut edge. The incision on the lateral segment was carried on with a no. 15 blade, and excess marginal tissue was discarded. Dissection between skin and muscle on lateral element was done as same manner as medial side. The mucosal incision was closed with 5-0 Vicryl®. Upturned orbicularis oris muscle at the alar base of cleft side was approximated to anterior nasal spine with 4-0 PDS®. Orbicularis oris muscle was overlapped and sutured with 5-0 Ethilon®. Medial and lateral lip flaps were approximated at the junction of red vermilion and cutaneous roll and then submucosal closure was done with 5-0 Vicryl®. Skin was closed with 6-0 Ethilon®. Upper vermilion flap was rotated and was sutured with 6-0 Vicryl®. Lip was closed with 5-0 Vicryl®. Infraorbital nerve block anesthesia was done with 2% lidocaine with 1:100,000 epinephrine to reduce postoperative pain. Dressing was done using antibiotic ointment and Steri-strip®.
Complete unilateral cleft lip
The case 4 was a 3-month-old girl with complete unilateral cleft lip on her right side (Fig. 2). The principle of skin design is the same with incomplete case. However, in complete cases, more considerations should be addressed to achieve equal circumferential nares and symmetric alar base than in incomplete cases. The circumferential length of noncleft side nare is calculated to determine uppermost point of lateral flap on cleft side. An inferior turbinate releasing incision was done to reduce the buckling effect of lesser segment. In addition, intraoral vestibular incision was made and subperiosteum dissection was carried out superiorly to infraorbital nerve, moreover releasing incision on periosteum was performed to mobilize the lateral flap without tension. The nasal floor was reconstructed by medial, and lateral flap on the base of nose was approximated with 5-0 Vicryl®. The misoriented orbicularis oris muscle toward the columella was dissected and re-orientation was done. Later approximation of medial and lateral flap procedure was similar to the incomplete cases.
Orbicularis oris muscle overlapping suture
Natural philtral ridge is a key point in rehabilitation of cleft lip patients. The flattening of philtral ridge resulted from failure to reconstruct natural orientation of orbicularis oris muscle during surgery. However, sometimes, even after the approximation of orbicularis oris muscle, we could observe that the outcome of philtral ridge is not prominent enough.
Orbicularis oris muscle overlapping suture can reproduce the natural balanced appearance by making elevated philtral ridge on the cleft side. After dissecting orbicularis oris muscle from skin for about 1 mm distal from the cut edge, lateral segment muscle was overlapped on medial segment of muscle. And then, several 5-0 nylon sutures were made in the manner of deep to superficial and superficial to deep [4] (Fig. 2 i, k).
Primary rhinoplasty
The abnormal insertion of orbicularis oris muscle into base of columella in cleft lip creates unfavorable forces to pull columella and caudal nasal septum to the non-affected side. Furthermore, insertion of orbicularis oris muscle into the subalar cartilage forces the cleft side of the nose to retract laterally and inferiorly, which results in flattening of the lower lateral alar cartilage. Correction of these anatomic displacement is indispensable to restore normal nasal structure. It is bound up with dissecting, releasing, and repositioning of lower lateral alar cartilage from the margin of medial and lateral flaps on the base of nose. After completion of lip nose skin suture, trans alar cartilage suture initiates from intranasal mucosa and passes lower lateral cartilage and anchors to dermis of nasal skin with 4-0 PDS® [4] (Fig. 2e).