Modified Fisher method for unilateral cleft lip-report of cases

Rehabilitation of normal function and form is essential in cleft lip repair. To attain this goal, various methods have been developed and advocated. Among them, rotation advancement technique, so called Millard method, has been widely used because of lengthening effect and preserving more adequate Cupid’s bow dimple component than previous triangular flaps [1]. However, flap design curving under the columella base might create unfavorable scar line across the philtral ridge especially in some people who have tendency to make hypertrophy and keloid.

In 2005, Dr. David M. Fisher [2] introduced an innovative method, named “an anatomical subunit approximation technique” in unilateral cleft lip repair (Fig. 1 a–c). According to this method, circumferential incision along the columella on cleft side of the medial flap is continued to the planned top of the Cupid’s bow in straight manner, which runs parallel to the unaffected philtral ridge. This incision line is made on the cleft side coinciding with the non-cleft side, and the simulated philtral ridge of the cleft side. The proposed peak of the Cupid’s bow on the lateral lip element is Noordhoff’s point on vermilion-cutaneous junction where the cutaneous roll and the vermilion-mucosal junction lines start to converge medially [3]. Usually, small inlet incision is needed to lengthen the cleft side of medial flap. On lateral flap, small triangle (smaller than traditional triangle technique) just above the cutaneous roll is used to prevent unesthetic shortening of upper lip on medial flap. This allows better continuity of the Cupid’s bow and ideal distribution of tension on the lip. In addition to this, muscle overlapping suture is applied to make the elevated philtral ridge.

Fisher’s method has some advantages. First of all, it provides very natural and esthetic columella and philtral ridge due to its symmetric design and lack of incision line across the philtrum. Secondly, cleft side lateral lip element can be lengthened by small triangular flap and Rose-Thompson effect which means slightly concave excision of the cleft margins providing additional length when closing in a straight line (Fig. 1 c). Furthermore, this small triangular flap has not only scar breaking effect but also accentuation effect on the pout of the lip by providing small amount of tension. In our cases, subtle modification of Fisher’s method was introduced to improve lip contour on the philtral ridge; orbicularis oris muscle overlapping. Through this commonly applied modification reconstructed philtral ridge can be augmented to mimic the elevated normal side of the ridge.

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).

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.

Historically, there are numerous surgical techniques to repair cleft lip from simple cutting to current microscopic rehabilitation. The variety of skin designs were used and were published in cleft lip surgery according to surgeon’s concept. The majority of oral and maxillofacial surgeons in Korea use Millard’s method and its modifications due to advantages in advancement of lateral flap and acceptable outcome. Despite of some modifications, Millard’s method still has weakness because the course of incision line below nostril is almost vertical to the philtral ridge. Although it is positioned just below the nostril side, scar could be visible due to its direction crossing the philtrum [5]. Fisher’s method which was published in 2005 seems to overcome this drawback. It forms exact mirror image of normal side of philtrum to the cleft side philtrum. Some surgeons might doubt about its lengthening effect. They might argue that it is not sufficient to get enough tissue from lateral flap due to limitation of straight method. However, straight method quite overcome its weakness through various modifications, and Fisher’s method also showed its usefulness and esthetic results [6].

Furthermore, adequate approximation of orbicularis oris muscle plays important role in reconstruction of natural philtral ridge which is composed with the philtral groove and the flanking ridges [7]. According to this need, various methods were introduced to repair discontinued orbicularis oris muscle. Cakir et al. [8] reported ‘jack-like eversion by splitting the orbicularis oris muscle’ and Cho [9] reported vertical interdigitation of the orbicularis oris muscle. These methods may not be easily applied to the cleft lip patients because the orbicularis oris muscle is very thin and small especially in 3-month-old babies.

The cleft nasal deformity is not only present at birth, but also proceeds over growth. Most of the surgeons agree that aggressive surgery is not necessary in primary surgical intervention of cleft lip [10]. However, repositioning of cleft side dome and lateral crus of lower lateral cartilage could be performed in minimally invasive manner during primary surgery as we presented here.

In this report of cases, the skin designs were basically followed by Fisher’s proposal, but some modifications were performed. First, acute triangular flap incision line on the vermilion is replaced by broad-based triangular flap to minimize the visible scar line. This wide triangular shaped flap on the vermilion contained some fibers of orbicularis oris muscle to reinforce the vermilion height which can be trimmed and adjusted during approximation procedure. Second, orbicularis oris muscle overlapping suture was applied to make natural looking elevated philtral ridge and to obtain more esthetic outcomes. Finally, we added alar web correction in the case of complete cleft lip to generate symmetrical nostrils.

Cleft lip repair necessarily follows some principles. Most of all, reconstruction of natural appearance with esthetic scar is mandatory in considering flap design. In addition, functional rehabilitation by muscle reorientation should be obtained through complete understanding of anatomical structures. In these points of view, Fisher’s method presents excellent capability and can be applied for treating unilateral cleft lip patients regardless their extensiveness.