Bilateral cleft lip repair has been continuously improved in order to achieve good results. Previously, a two-stage operation was used to be performed on the severe side, considering the blood circulation of the prolabium. However, since the second half of the twentieth century, most clefts have been reconstructed with a single operation on both sides [8]. The surgical scope has also evolved from skin-based closure surgery to a three-dimensional concept that separates muscle and nasal cartilage. Concerns have been raised about not only improving the overall esthetics of the nasolabial complex but also minimizing secondary deformities.
In accordance with several previous techniques of scholars, such as Veau, Bauer–Trusler–Tondra, Millard, Wynn, Manchester, Mulliken, and Noordhoff, the current surgical methods are based on the straight-line methods such as Millard, Mulliken [6], and Fisher [9] based on the techniques by Mulliken or Chen and Noordhoff [10], rather than the triangular flap or the square flap which requires complicated construction. Although each surgeon’s technique differs slightly, the philtrum flap is obtained from the prolabium. When the lateral lip flap is placed, forked flaps are formed on both sides to increase the columella length, or de-epithelialized strips are formed to raise the philtral margin. The rest of the prolabium is discarded. The lateral vermilion flap is used to make the medial tubercle. Additionally, oral mucosa is created with a lateral lip advancement flap through the vestibular incision and sufficient dissection extending from the labial sulcus. The lateral lip flap may be curved to extend to the lower lateral side of the nasal wing, or the lower lateral cartilage may be accessed via a nostril rim incision (Fig. 3). However, most surgeons access it through a flap incision and do not require additional intranasal incisions to dissect the alar cartilage. In addition, interdormal or transdormal suturing of the lower alar cartilage to support and define the tip of the nose or cinch suturing at the alar base for narrowing may be performed. The orbicularis oris muscle with abnormal insertion is dissected and sutured to restore continuity. If there is a vertical deficiency, a small triangular flap or vermilion unilimb Z-plasty may be added. In addition, based on the results of many studies on growth, slow-growing structures, such as the columella and nasal tip, are made slightly larger than normal, whereas the fast-growing structures, such as the philtrum, are made smaller. As an exceptional structure, the median tubercle usually grows rapidly, but this is not the case in patients with bilateral cleft lip after surgery; hence, the median tubercle should be as long as possible [11].
Despite these efforts, unanticipated results emerge after surgery, such as a pointed Cupid’s bow, a flat prolabium, the absence of a philtral dimple, a wide philtrum, a tight upper lip, and the absence of a tubercle. In particular, unlike the philtrum, a slow-growing artificial tubercle forms a secondary deformity gradually due to the inadequate bulk provided by the lateral segment vermilion. Nevertheless, the lateral segment vermilion is used to construct the tubercle because Mulliken’s principle [4], which is the basis of modern surgery, is still followed. (1) Cupid’s bow of the prolabium is rounded; (2) white roll is indistinct and absent in the prolabium; (3) the color of central the vermilion is not the same as that of the lateral lip vermilion; (4) it is difficult to obtain an accurate approximation of vermilion for a good esthetic outcome. The prolabium in the bilateral complete cleft lip is essentially made up of collagenous connective tissue without muscle fibers, and the normal philtrum and Cupid’s bow are also absent. The white roll is not clearly distinguished, and the vermilion color of the prolabium is more red than the vermilion color of the lateral lip. As a result, in conventional techniques, all remaining tissues, except the prolabial flap used to create the philtrum, are discarded. However, efforts are being made to gradually improve the results by making the use of vermilion of the prolabium from part to whole [12,13,14,15]. The rationale behind doing this is as follows. The majority of natural lips have gentle curves and do not form an angle, as seen in conventional surgery outcomes. Mulliken et al. described that the white roll prominence is caused by the underlying marginalis orbicularis oris muscles [16]. In contrast to before surgery, the white roll of prolabium placed on the repairing marginalis orbicularis oris shows clearly visible results after surgery. The color of the median vermilion differs from that of the lateral lip vermilion. Proliferated blood vessels, decreased melanin, and increased non-keratinized tissue give a more reddish hue to the vermilion of the prolabium. Histopathologically, it showed marked vascularity with thick-walled and congested blood vessels similar to erectile tissue [14]. This is rather a part that contributes to creating a natural tubercle.
The patient in this case had high skin sensitivity and could not use any dressings, such as compression or steri-strip, after surgery. It is unfortunate that the scar was accentuated by surgical site irritation. However, the prolabial flap was extended to the premaxilla hinge and placed on the orbicularis oris muscle, which had gained continuity, to achieve a white roll, a gently curved vermilion line, and a protruding tubercle and volume. This finding is different from previous surgical results and closer to normal appearance (Fig. 4). Other reports using this method also show better esthetic outcomes and good long-term follow-up results.
In the present case, only the C-flaps that were formed on both sides of the prolabial flap were excised. This approach is consistent with the Mulliken’s report[8] stating that forked flaps are not required to increase the length of the columella. However, they play a role in maintaining blood flow to the prolabial flap as a stable base for manipulation during surgery and in creating a natural U-shaped columellar base by proper trimming at the end. The remaining tissues were elevated as medial vermilion flaps and fully utilized for the oral lining, which contributed to the reduction of tension caused by tissue securing.
The technique of attempting to achieve close to “normal” appearance by preserving the tissue and reflecting the patient’s unique characteristics is similar to Millard's principle, which is “concerned with describing in intricate details a logical way of finding the missing pieces and carefully fitting them into the puzzle so that the final picture is complete, normal, and happy in function and appearance”[17]. The surgical method is applied based on the situation of various cases and each surgeon’s experience. This method, which preserves and utilizes tissue as much as possible and reflects the patient's unique structural characteristics, has a low level of difficulty but a higher esthetic outcome than conventional surgery and shows good long-term results. We believe that in the future, this method will be supported and accepted by more surgeons as the standard.
