Clinical andAnatomicCorrelations FREDERICK R. HECKLER, …

The Minimal Cleft Lip Revisited:

Clinical and Anatomic Correlations

FREDERICK R. HECKLER, M.D.

LARRY G. OESTERLE, D.D.S.

MICHAEL E. JABALEY, M.D.Jackson, Mississippi 39216

Minimal cleft lip has been defined as a cleft which does not extend past the vermilion.A study was undertaken to delineate more clearly several features of this entity withinthe overall cleft spectrum. Eight patients with minimal cleft lip were studied.

Despite the minimalnature of the lip cleft, all patients had some degree of dental andnasal deformity. Serial microscopic sections of tissue taken from the cleft region werestudied and a comparison made between the degree of muscle pathology and the varyingdegrees of clinical deformity in each patient.

Varying proportions of orbicularis muscle fibers were directed cephalically along thepotential cleft line, as is seen in more complete clefts. Patients with greater amounts ofmuscle fiber misdirection in the intact lip segments also showed more severe nasaldeformities and formed vertical furrows on pursing the lips.

Findings suggest that the patients exhibiting the clinical triad of minimal cleft lip,obvious nasal deformity, and linear lip furrow on puckering can be presumed to havegreater underlying muscle abnormalities. Patients showing these findings therefore requiredefinitive orbicularis muscle reconstruction during surgical repair in order to assuredynamic as well as static rehabilitation of the lip.

The term "minimal cleft lip" is used in this

paper to describe a congenital lip cleft extend-

ing into but not past the vermillion. Other

features said to be regularly found with min-

imal cleft lip include: (1) a minor defect in

the mucocutaneous border, (2) either a nar-

row ridge of tissue or a depressed groove

extending from vermilion to nostril, and (3) a

nostril deformity (Lehman and Artz, 1976)

(Figure 1). A variety of of other names have

been given to this entity in the past including

vermilion notch, rudimentary cleft, micro-

form cleft lip, and congenital lip scar. We

present clinical and histologic observations

gleaned from studying eight patients with this

congenital deformity and offer recommenda-

tions for a selective approach to the surgical

management of this problem.

Dr. Heckler and Dr. Jabaley are affiliated with TheDepartment of Surgery, Division of Plastic Surgery, Uni-versity of Mississippi Medical Center, Jackson, Missis-sippi. Dr. Heckler is an Assistant Professor and Dr.Jabaley is Professor and Chairman. Dr. Oesterle is aMajor in the United States Air Force stationed at MisawaAir Base. ,

Paper presented at Annual Meeting ofAmerican Cleft

Palate Association, Atlanta, Georgia, April 5, 1978

240

Materials and Methods

Eight patients ranging in age from seven

months to 37 years were studied. Each patient

had a minimal cleft lip as defined above, and

all clefts were unilateral. Co

Each patient was evaluated by a plastic

surgeon and an orthodontist, and a specific

search was made for the presence or absence

of cleft palate, alveolar ridge and dental ab-

normalities, and cleft lip nasal deformity.

Note was also made of the presence or absence

of a vertical furrow or groove extending along

the philtral column line from the vermilion to

the nostril floor, formed upon puckering or

pursing the lips (a finding previously de-

scribed by Stenstrom, 1965). A simple scale

was used to grade the severity of the dento-

alveolar and nasal deformity, with each being

scored minimal, moderate, or marked.

Each patient underwent rotation-advance-

ment cleft lip repair. A single full thickness

section of upper lip extending over the entire

vertical height of the lip was removed during

the procedure (Figure 2). The width of this

excised tissue varied according to the age of

the patient and corresponded to tissue usually

241Heckler et al., minimar cLeer LtP

FIGURE 1A & B. Patient with minimal cleft lip, demonstrating (1) vermilion notch, (2) minor defect inmucocutaneous border, (3) narrow ridge of tissue extending from vermilion to nostril (this may also appear as adepressed groove), and (4) nostril deformity.

FIGURE 2. A full thickness section of upper lip wasremoved and serially sectioned. The tissue removed wastissue usually excised and discarded during lip repair.

excised and discarded during the repair. The

biopsies were carefully oriented and fixed,

sectioned serially, stained with hematoxylin

and eosin, and then examined for muscle fiber

quantiy, orientation, and direction. Approxi-

mately 50 sections of each specimen were

examined. The histologic specimens were

graded according to their degree of variation

from the normal, regular, parallel arrange-

ment of orbicularis muscle fibers in the upper

lip. Comparisons were then made among the

various clinical and histologic parameters to

see if any useful correlations could be found.

Results (Table 1)

All eight patients with minimal cleft lip

had some degree of dental deformity demon-

strated clinically or by x-ray (Table 2). The

youngest patient (7 months) did not have

sufficient dentition for evaluation at the time

of lip surgery and was evaluated at late fol-

lowup. The severity of the dento-alveolar de-

formity did not seem to have any correlation

with the severity of the nasal deformity or the

amount of vermilion notching.

All of the patients also showed evidence of

cleft lip nasal deformity regardless of how

minimal the vermilion abnormality (Figure

3). The configurations of the nasal deformities

generally demonstrated the classical features

of the cleft lip nasal deformity as described by

Huffman and Lierle (1949). The area of the

nostril sill and nasal floor seemed to have the

greatest abnormalities, with less severe

changes in the alar base, caudal septum, col-

umella, and alar cartilage. Only one patient

had a cleft palate, and this was limited to the

soft palate.

Results of Histologic Examinations

In all patients, there was continuity of or-

bicularis muscle fibers across the cleft locus.

Some muscle fibers ran in the normal hori-

zontal plane across the lip, and some fibers

turned in a cephalic direction as they ap-

proached the cleft locus (Figure 4). The his-

tologic picture was one of muscle fiber dis-

array at the potential cleft line with absence

of the usual homogeneous pattern of fiber

orientation (Figure 5). The nostril sill and

242 Cleft Palate Journal, July 1979, Vol. 16 No. 3

TABLE 1. Clinical and histologic findings on minimal cleft lip patients.

pt muscle lip j;unrmw nasal dental |* abnormality puckering deformity abnormality

1 Minimal No Minimal Supernumerary deciduous incisor

2 Marked Yes Marked Incomplete erupted, hypoplastic

permanent lateral incisor, hia-

tus between central and lateral

incisor

3 Marked Yes Marked Supernumerary lateral incisor

4 Marked Yes Marked Rotated, hypoplastic lateral inci-

sor, delayed eruption central in-

cisor

5 Minimal No Minimal Rotated lateral deciduous incisor

6 Moderate No Moderate Hypoplastic pits on lateral per-

manent incisor, incomplete

eruption central incisor

7 Minimal No Moderate Malformed lateral incisor

8 Moderate No Moderate Lateral incisor rotated, hiatus be-

TABLE 2. Dental anomalies associated with cleft lip.

. Congenitally Missing Teeth

. Supernumerary teeth

. Fused teeth and irregularities of tooth size

. Malformed Teeth

. Malpositioned teeth

. Delayed Eruption of Teeth

. Overeruption of Mandibular Anterior Teeth~IG)rBG

ND!~

From: Olin, W. H. in Cleft Lip and Palate:Grabb, W. C., Rosenstein, S. W., Bzoch,K. R., Little, Brown and Company, Bos-ton, 1971, Page 602.

upper lip area showed more muscle abnor-

malities than did the vermilion region, with

proportionally greater numbers of misdi-

rected muscle fibers, and sometimes a sugges-

tion of a decrease in total muscle mass (Figure

6).

The greatest amount of muscle fiber mis-

direction and disarray was seen in patients

who had the most severe cleft lip nasal de-

formities, and who also formed a furrow from

the vermilion to the nasal floor on puckering

the lips. No correlation was noted between

the degree of orbicularis muscle abnormality

and either the severity of the dental defects or

the size of the vermilion notch.

Discussion

Several authors have clearly demonstrated

that, in cleft lip patients, the orbicularis oris

tween lateral incisor and canine

muscle fibers diverge from their normal hori-

zontal pattern and turn in a cephalic direction

to parallel the cleft margins (Fara et al; 1965;

Fara, 1968; Pennisi et al; 1969) (Figure 7).

The functional importance of re-orienting

these muscle bundles during cleft lip repair

has also been emphasized (Randall, 1974).

Our studies demonstrate that, in the minimal

cleft lip, varying proportions of orbicularis

fibers proceed normally across the cleft area,

while other fibers turn in a cephalic direction

paralleling the potential cleft line. This cha-

otic histologic picture is consistent with pre-

vious studies (Pennisi et al., 1969).

Of note in our specimens was the relative

increase in muscle misdirection and disarray

seen in sections from the superior lip and

nasal floor areas. Cosman and Crikelair

(1965) have hypothesized from clinical obser-

vations and measurements that "the locus of

the cleft defect is in the floor of the nose, the

upper lip, and the alveolar arch, rather than

on the free border of the lip." Our histologic

findings lend support to their hypothesis. The

observation that the degree of muscle fiber

disarray varied from minimal cleft lip to min-

imal cleft lip is consistent with the graded

teratological order noted by Karsten et al.

(1977).

Cosman and Crikelair (1966) also observed

a lack of parallelism in the degree of clinical

deformity of the nose as compared to the

243Heckler et al., minimar. cuert up

FIGURE 3. Patient with very minimal cleft lip. A. Slight elevation of the left apex of the Cupid's bow and minimalasymmetry of the alar bases. B. Nostril asymmetry and deficiency of the left nostril sill. C. Supernumerary tooth onthe cleft side. D. No furrow or groove is formed on puckering. Despite the very minimal lip deformity, all features ofa cleft of the primary palate are present.

alveolar arch from one minimal cleft lip pa-

tient to another. Our patients, too, showed no

clear-cut relationship between the size of the

vermilion notch and the nasal and dento-al-

veolar deformities. There was parallelism,

however, between the severity of muscle fiber

misdirection and disarray, the degree of nasal

deformity, and the presence or absence of a

vertical lip groove on puckering. Our observa-

tions indicate that minimal cleft patients who have

more severe nasal deformities and who also form a

vertical furrow on pursing the lips can be presumed

to have more marked oribcularis muscle abnormalities

(Figures 8, 9A, B, C, D, 10A, B, C, D, 10A, B,

C, D).

This last observation can be useful in se-

244 Cleft Palate Journal, July 1979, Vol. 16 No. 3

[

FIGURE 4. Diagrammatic representation of orbicularis muscle fibers in normal and minimal cleft lips. A.Minimal Cleft Lip-Some fibers run in normal horizontal direction, and some fibers turn upward in cephalic directionas they approach cleft locus. B. Normal Lip-Muscle fibers are directed in regular, parallel direction, transverselyacross upper lip.

FIGURE 5. Histologic section from minimal cleft lip,cut in sagittal plane. Some fibers are cut longitudinally,some tangentially, and some are seen in cross section.There is lack of the normal, regular muscle fiber pattern.This section is from the vermilion end of the lip.

lecting an appropriate surgical approach to

minimal cleft lip patients. It is sometimes

assumed that patients with vermilion notches

should be treated with limited and local sur-

FIGURE 6. Section from nasal end of lip (same pa-tient as Figure 5). There is even more marked irregularityof pattern, with muscle fibers running at right angles toeach other.

gical techniques designed to align the muco-

cutaneous junction and fill out the vermilion

border, thereby avoiding a lip scar running

the full height of the upper lip. This approach

may be adequate orly in minimal cleft lip

Heckler et al., minimar cuerT Lip 245

Z S C CS

SHS

MINIMAL - incompuete - COMPLETE

FIGURE 7. Muscle fiber orientation in cleft lips of varying severity.

Tm

FIGURE 8. Diagrammatic representation of orbicularis oris fiber orientation in two types of minimal cleft lips.Lip on left has minimal nasal deformity and forms no furrow on puckering. Relatively few fibers turn in cephalicdirection. Lip on right has more marked nasal deformity and forms vertical furrow on puckering. Proportionally moremuscle fibers are misdirected.

FIGURE 9. A. Patient with minimal cleft lip. B. Minimal nasal deformity with only slight nostril sill deficiency.C. No lip furrow formed on puckering.

246 Cleft Palate Journal, July 1979, Vol. 16 No. 3

patients who do not have marked orbicularis

oris abnormalities. Patients who exhibit the

triad of a vermilion notch, obvious cleft lip

nasal deformity, and a vertical lip crease on

puckering, will additionally require muscle

reconstruction to achieve dynamic as well as

static rehabilitation of the lip.

As our patients demonstrate, the minimal

FIGURE 9. D. Histologic specimen (Sagittal section)showing quite regular pattern with only a few longitu-dinally cut, misdirected fibers.

cleft lip might more accurately be termed a

minimal cleft of the primary palate, consist-

ently involving all structures derived from this

embryologic locus. Like Millard (1976), we

have found that adequate correction of all of

the pathologic features of the minimal cleft

generally requires a full-skin incision on the

FIGURE 10. D. Histologic specimen shows majormuscle fiber bundles cut longitudinally and transverselylying adjacent to each other; an irregular, chaotic micro-scopic appearance.

FIGURE 10. A. Patient with minimal cleft lip. Vermilion notch is similar in magnitude to that of patient inFigure 9. B. More marked nasal deformity, particularly in the nostril sill area. C. Lip furrow on puckering.

lip. In our hands, the rotation-advancement

technique has best allowed simultaneous cor-

rection of the lip deformity, nasal deformity,

and muscle abnormality. Regardless of which

skin incision is chosen, the abnormal segment

of muscle underlying the lip crease should be

excised. This will allow reconstitution of the

dynamic oral sphincter by approximation of

the adjacent, normal orbicularis muscle bun-

dles.

Acknowledgment: The authors are grateful to

Dr. Somprasong Songcharoen for permitting

us to include one of his patients in this series.

References

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Cosman, B., and CrRricKkELAIR, G. F., The minimal cleftlip, Plast. Reconstr. Surg., 37, 334-340, 1966.

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Heckler et al., MINIMAL CLEFT LIP 247

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