Unilateral Microform Cleft Lip Repair .5

Unilateral Microform Cleftof Muscle Tension L

Ningbei Yin, MD, Tao Song, MD, Jiajun Wu, MD, Bo CYongqian Wang, MD, Haidon

Background: In microform cleft lip repair, reconstructing the elaboratestructures is difficult. We describe a new technique of unilateral micro-form cleft lip repair that is based on themuscle tension line group theory.Methods: According to the shape of Cupid bow, a different small in-cision is used without creating an obvious cutaneous scar. First, thenasolabial muscle around the nasal floor (the first auxiliary tensionline group) is reconstructed, and then the orbicularis oris muscle aroundthe philtrum (the second auxiliary tension line group) is reconstructedbased on the muscle tension line group theory.Results: From June 2006 to June 2012, the technique was used in 263

ORIGINAL ARTICLEfor reconstructing the tension line. The unilateral microform cleft lip isrepaired through small incisions on the Cupid bow andmucosa to recon-struct the nasolabial muscle. The results have been favorable.

PATIENTS AND METHODS

This work was supported by the Capital Medical Development Fund of China(grant 20093012).

The authors report no conflicts of interest.Supplemental digital contents are available for this article. Direct URL citations

appear in the printed text and are provided in the HTML and PDF versionsof this article on the journals Web site (www.jcraniofacialsurgery.com).of China; E-mail: [email protected], including the philtrum, depressed nasal floor, deformity of the nasalalar, discontinuity of the orbicularis oris muscle, misplacement of theCupid bow, and the notch of vermillion, without obvious skin incisions,we used the concept of the tension line groups and applied a newmethod

Accepted for publication December 1, 2014.Address correspondence and reprint requests to Ningbei Yin, MD, Center for

Cleft Lip and Palate Treatment, Plastic and Surgery Hospital, ChineseAcademy of Medical Science, Peking Union Medical College, No. 33,Ba-Da-Chu Rd, Shi Jing Shan District, Beijing 100144, Peoples Republicunilateral microform cleft lip repairs. For 18months, 212 patients werefollowed up. The appearance of the nasal alar, nasal sill, philtrum, andCupid bow peak improved.Most patients had a satisfactory appearance.Conclusions: Based on the muscle tension line group theory, usingthis technique offers the ability to adduct the nasal alar effectively toform a good nasal sill and philtrum.

Key Words: Lip muscle, nasal muscle, nasolabial muscle complex,muscle tension line, microform cleft lip

(J Craniofac Surg 2015;26: 343346)

C linical manifestations of microform cleft lip include disruption ofthe Cupid bow, elevated Cupid bow peak, deformity of the phil-trum, deficiency of the orbicularis oris muscle, and nasal deformity.

What Is This Box?A QR Code is a matrix barcode readable byQR scanners, mobile phones with cameras,and smartphones. The QR Code links tothe online version of the article.

From the Center for Cleft Lip and Palate Treatment, Plastic Surgery Hospital,Chinese Academy of Medical Sciences and Peking UnionMedical College,Beijing, Peoples Republic of China.

Received October 21, 2014.Copyright 2015 by Mutaz B. Habal, MDISSN: 1049-2275DOI: 10.1097/SCS.0000000000001460

The Journal of Craniofacial Surgery Volume 26, Number 2, March

Copyright 2015 Mutaz B. Habal, MD. UnauthoLip Repair: Applicationine Group Theory

hen, MD, Hengyuan Ma, MD, Zhenmin Zhao, MD,g Li, MD, and Di Wu, MD

Patients or their parents usually have a high expectation because thedeformities look mild.

Traditionally, an incision was made on the upper lip and some-times even on the nasal floor. An obvious scar was left.1 Recently, somesurgeons reported making a small incision on the mucosa to repair uni-lateral microform cleft lip.2,3 However, the operative field was insuffi-cient. With this technique, it is difficult to suture the muscle accuratelyand to reconstruct the elaborate structures, such as the position of the na-sal alar, nasal sill, and philtral column. Reconstructing these structures ef-fectively poses a dilemma when repairing unilateral microform cleft lip.

Since 2006, we have studied the anatomy of the nasolabialmuscle and have performed microcomputed tomography scanningof nasolabial tissues.4 The results are shown. The pars peripheralishas a flat-fan shape and is located in the deep level of the upper lip.It originates from one side of the modiolus and diffuses outward likea fan. We found that it was divided into 3 different branches withdifferent directions (A1, A2, A3). A1 terminated at the tissue belowthe ipsilateral anterior nasal spine, continued with the depressor septimuscle, and was relevant to the lip movements. A2 crossed themidlineand continued with the alar part of nasalis, which originated from thelateral crus of alar cartilage at the contralateral nasal bottom. A2 is re-lated to the shape of the nasal bottom and nasal alar. The fibers of A3went across the same group of muscle fibers from the opposite side inthe midline. Most of the fibers terminated at the skin of the contralat-eral philtrum ridge region.Moreover, some of the muscle fibers termi-nated at the lateral skin of the contralateral philtrum ridge region,which is relevant to the shape of the philtrum. The connected musclefibers in bundles are called the tension line. Because of the involve-ment of the levator labii superioris alaeque nasi, the tension lines indecussation are called the tension line group.We divide the orbicularisoris muscle tension of the upper lip into 3 tension line groups: maintension line group, first auxiliary tension line group, and second aux-iliary tension line group (Fig. 1). The shape of the nose and lip relieson the tension line groups. We believe that the microform cleft lip de-formity is related to the first auxiliary tension line group and secondauxiliary tension line group.

It is commonly known that it is nearly impossible to repair the ab-normal orbicularis oris muscle anatomy to the same appearance as a nor-mal human, but it is possible to restore the muscle tension line to thenormal level. To repair the deformities of the unilateral microform cleftFrom June 2006 to June 2012, the technique was used in 263unilateral microform cleft lip repairs (158 male and 105 female). Thepatients ages ranged from 3 months to 36 years. The average age

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was 37.8 months. There were 148 patients on the left side, and 117patients on the right side. The surgical technique is described as follows:

Design of IncisionThe incision was designed according to the shape of the Cupid

bow, vermillion, and tubercle. If the Cupid bow was jagged, Z-plasty

continues to the secondary branch of the pars peripheralis (A2) fromthe contralateral modiolus at the nasal floor, and makes the strengthtransfer backward, called tension line L2. A1 originates from themodiolus, terminates at the tissue below the ipsilateral anterior nasalspine, and continues with the depressor septi muscle, called tensionline L1. These 2 tension lines from different directions and the alarcartilage are connected into a whole ring structure and form a criss-cross structure at the nasal floor, called the first auxiliary tension linegroup. Thus, this step is called the reconstruction of the first auxiliarytension line group (Fig. 2).

Reconstruction of the Orbicularis Oris MuscleAround the Philtrum (Reconstruction of theSecond Auxiliary Tension Line Group

The medial orbicularis oris muscle was sutured with the deeplayer of the lateral orbicularis oris muscle. The superficial layer ofthe lateral orbicularis oris muscle was sutured to the deep dermis of

FIGURE 1. The orbicularis oris muscle tension of the upper lip is divided into3 tension line groups. Purple line: main tension line group; red line: first auxiliarytension line group; green line: second auxiliary tension line group.

Yin et al The Journal of Craniofacial Surgery Volume 26, Number 2, March 2015was used to restore the continuity of Cupid bow and descend the ipsi-lateral Cupid bow peak. If some skin was inserted into the vermillion,we performed a fusiform excision of the extra skin to restore the con-tinuity of the Cupid bow. If the ipsilateral Cupid bow peak was muchhigher than the unaffected Cupid bow peak, a small triangle skin flapwas inserted medially, or a curved incision was made to restore thecontinuity of the Cupid bow and descend the ipsilateral Cupid bowpeak. Simultaneously, a mucosal incision was made to expose theorbicularis oris muscle. The skin of the upper lip was intact.

Reconstruction of the Nasolabial Muscle Aroundthe Nasal Floor (Reconstruction of the FirstAuxiliary Tension Line Group

The orbicularis oris muscle was dissected from the mucosa andskin. The abnormal muscular attachments from the inferior and lateralmargins of the piriform aperture and the anterior segment of the max-illa were released. According to the direction of the muscle fiber, thelateral muscle was divided into 2 parts: the alar part of the nasalis flapand orbicularis oris muscle flap. The medial orbicularis oris muscleflap at the root of the columella was elevated and sutured with the lat-eral alar part of the nasalis flap. The lateral orbicularis oris muscle flapcovered the 2 muscle flaps mentioned above and was fixed at the an-terior nasal spine. We believe that the alar part of the nasalis originatesfrom the lateral part of the lateral crus of alar cartilage, runs along theedge of the piriform aperture from the deep to the superficial layer,FIGURE 2. Reconstruction of the first auxiliary tension line group. A, A medialorbicularis oris muscle flap at the root of the columella is elevated and sutured withthe lateral alar part of the nasalis flap. B, Tension line L2 is reconstructed.C, The lateral orbicularis orismuscle flap covers the 2muscle flapsmentioned aboveand is fixed at the anterior nasal spine. D, The first auxiliary tension line group isreconstructed.

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Copyright 2015 Mutaz B. Habal, MD. Unauthorthe philtrum to form a philtral dimple and philtral ridge. We believethat the third branch of pars peripheralis (A3) originates from one sideof the modiolus, runs upward and medially, crosses the midline, andinserts into the skin of the philtrum and its lateral areas. The firstbranch of the levator labii superioris alaeque nasi (B1) enters the up-per lip from the lateral and top directions, moves inward, and insertsinto the dermis inside of the ipsilateral philtrum ridge. In the axialplane of the upper lip, the directions of A3 and B1 cross each other,and their muscle fibers interact with each other, which is known asthe second auxiliary tension line group (Fig. 3). Thus, this step is calledreconstruction of the second auxiliary tension line group (see Supple-mental Digital Content, Video, http://links.lww.com/SCS/A104, whichdemonstrates the complete procedure). We repaired the deformity ofthe nasal alar when patients were older than 6 years.

AssessmentTwo plastic surgeons, who were not part of our team, assessed

the nasal floor fullness, abduction of the nasal alar, and shape of thenasal sill and philtrum using a 3-point visual analog scale. If the shapeof the nasal floor, nasal alar, nasal sill, and philtrum were similar tonormal, the result was rated as 3; if the shape was improved, but notas good as normal, it was rated as 2; if the shape was not improved,it was rated as 1.

RESULTSAll the patients healed well. After the surgery, the fullness of

the nasal floor was attained; the nasal alar was symmetrical; the

FIGURE 3. Reconstruction of the secondary auxiliary tension line group. A,The medial orbicularis oris muscle is sutured with the deep layer of the lateralorbicularis oris muscle. The superficial layer of the lateral orbicularis oris muscleis sutured to the deep dermis of the philtrum. B, The philtral ridge isreconstructed using mechanical traction. C, The second auxiliary tension line

group is reconstructed.

2015 Mutaz B. Habal, MD

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deviation of the columella was improved; the nasal sill was similarto normal; the tubercle was obvious; and the philtrum was not obvi-ously twisted.

For 18 months, 212 patients were followed up. None of thepatients had obvious scars. In 37 patients, they had a thicker vermil-lion than the unaffected side. Secondary revision was performed on33 patients. In 27 patients, the lateral lips were bulging, and in 25 ofthose, the lips improved obviously after 18 months. The other 2 patientsrefused further treatment. After 18 months, 16 patients had philtrumsthat became shallow. The appearance of the nasal alar, nasal sill,philtrum, and Cupid bow peak improved (Table 1) (Figs. 46). Mostpatients had a satisfactory appearance.

TABLE 1. Long-term Results of Microform Cleft Lip Repair

Assessment 3 2 1

Fullness of nasal floor 132 74 6

Nasal sill 122 73 17

Abduction of nasal alar 139 64 9

Height of cleft-side philtral ridge 175 33 4

FIGURE 5. Typical case: A 3-year-old girl with left microform cleft lip. 1A, 1B, 1C:The clinical manifestation included asymmetrical nostril, left depressed nasal floorand nasal alar, and a jagged Cupid bow. 2A, 2B, 2C: Twelvemonths after surgery ,the philtral dimple was very depressed. The philtral ridge was obvious. The rightvermillion was thick.

The Journal of Craniofacial Surgery Volume 26, Number 2, March 2015 Application of Muscle Tension Line Group TheoryDISCUSSIONWith years of clinical experience, methods of repairing micro-

form cleft lip have greatly improved. The high expectations of patientshave driven the need for a more minimally invasive technique.

Mulliken5 designed a double unilimb Z-plasty to correct thevertical asymmetry and notch of vermillion while limiting the scarto the lower one-half of the lip. When the distance from the cleft sidepeak of the Cupid bow to the midline is shorter than on that from thenoncleft side, using a conventional cheiloplasty approach results in anasymmetrical Cupid bow with an unnatural philtrum that is difficultto correct. Koh et al6 modified the design of the cleft-side Cupidbow to avoid causing this secondary deformity. Oyama et al7 modifiedMullikens method to maintain the natural curve and obtained a sym-metrical and natural-looking Cupid bow. Oyama et al7 emphasized theimportance of preserving the remaining normal structure, particularlythe curve of the white roll on the lateral lip, and suggested that thepeak of the curve should be defined as the Cupid bow peak of the cleftside. In fact, the Cupid bow in microform cleft lip was various. Only 1FIGURE 4. Typical case: A 5-month-old boy with right microform cleft lip. 1A, 1B,1C, The clinical manifestation included asymmetrical nostril, right depressed nasalfloor and nasal alar, a notch of vermillion, and a jagged Cupid bow. The rightCupid bow peak was 1.5 mm higher than the left peak. 2A, 2B, 2C: Six monthsafter surgery, the bilateral nasal alar was symmetrical; the right nasal floor wasslightly higher; the right upper lip was bulging, and the philtral dimple was verydepressed. The philtral ridge was obvious. The right vermillion was thick. 3A, 3B,3C: Two years later, the bilateral nasal alar, nasal floor, and upper lip weresymmetrical. The philtrum was natural. The right vermillion was a little thick.

2015 Mutaz B. Habal, MD

Copyright 2015 Mutaz B. Habal, MD. Unauthomethod was difficult to meet the clinical requirements. A differentmethod should be used based on the different appearances of theCupid bow. The surgeon should use caution when making an incisionin the upper lip. When we started to repair microform cleft lip, wechose small incision only to reduce scar of lip. Now, we believe smallincision is an inevitable choice, if the second auxiliary tension linegroup is reconstructed. When the abnormal skin of microform cleftlip is removed, the upper lip is too tight to form philtral ridge.

Some authors reported that the nasal floor of the cleft lip isrepaired by a skin flap or mucosa flap.8 When the nasal floor is recon-structedwith a flap, which is only a layer of skin or mucousmembranecover, and its bottom is hollow, the postoperative result may be stable,but the deformity easily relapses.

We believe that the alar part of the nasalis originates from thelateral part of the lateral crus of the alar cartilage, runs along the edgeof the piriform aperture from the deep to the superficial layer, con-tinues to the secondary branch of the pars peripheralis (A2) fromthe contralateral modiolus at the nasal floor, and makes the strengthtransfer backward, called tension line L2. A1 originates from themodiolus, terminates at the tissue below the ipsilateral anterior nasalspine, and continues with the depressor septi muscle, called tensionline L1. These 2 tension lines from different directions in combinationwith the alar cartilage are connected in awhole ring structure and forma crisscross structure at the nasal floor, which is called the first auxil-iary tension line group.

Using this technique, we advocate restoring the continuity ofthe nasolabial muscle complex. A medial orbicularis oris muscle flapat the root of columella is elevated and sutured with the lateral alar partof the nasalis flap. The lateral orbicularis oris muscle flap covers theFIGURE 6. Typical case: A 13-month-old girl with left microform cleft lip. 1A, 1B,1C: The clinical manifestation included asymmetrical nostril, left depressed nasalfloor and nasal alar, and a notch of vermillion. 2A, 2B, 2C: Eighteen months aftersurgery, the philtral dimple was depressed. The philtral ridge was obvious. Theright vermillion was a little thick.

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Yin et al The Journal of Craniofacial Surgery Volume 26, Number 2, March 20152 muscle flaps mentioned above and is fixed at the anterior nasalspine. The technique simulates the physical structure to adduct the na-sal alar, elevate the nasal floor, form a nasal sill, and correct the devi-ation of the columella. The medial orbicularis oris musclelateral alarpart of the nasalis structure supports the skin-like bridge-building withthe tension to simulate the nasal sill. Fixation of the lateral orbicularisoris muscle flap is involved in the formation of the nasal sill and pre-vents the lateral vermillion from ptosis. A stable nasal sill can bemain-tained. The balanced muscle strength can restore the dislocated nasalseptum to the middle position. Because the patients received the fullnasal floor, raised nasal sill, columella in the middle, and arched nose,they were often very satisfied with the operations results.

The philtrum should be reconstructed using the orbicularis orismuscle. To repair microform cleft lip, Desrosiers et al9 combined thefollowing 3 techniques: the Mulliken microform cleft lip repair withno cutaneous scar, the Furlow complete cleft lip repair with interdigi-tating muscle, and the Cutting cleft nose repair. With Desrosiers andcolleagues9 technique, the orbicularis oris muscle was divided intosome bundles and sutured together to form the philtral ridge. Cho andBaik10 split the medial and lateral muscle flaps into 2 leaves. The 2leaves of each muscle flap were sutured together to create a vertical in-terdigitation to form the philtral ridge. In Kim and colleagues11 report,the abnormally inserted orbicularis musclewas freed and realigned in anormal horizontal orientation. The muscle was vertically incised andrepaired with vertical mattress sutures, spreading out the muscle to in-crease the thickness of the philtral ridge. The philtral ridge was accen-tuated by deepening the dimple with a dermal suture at the midline.

We believe that the third branch of the pars peripheralis (A3)originates from 1 side of the modiolus, runs upward and medially,crosses the midline and inserts into the skin of the philtrum and its lat-eral areas. The first branch of the levator labii superioris alaeque nasi(B1) enters the upper lip from the lateral and top directions, moves in-ward, and inserts into the dermis inside of the ipsilateral philtrumridge. In the axial plane of the upper lip, the directions of A3 andB1 cross each other, and their muscle fibers interact with each other.It is known as the second auxiliary tension line group. Because thestrength of the muscle fibers of B1 and A3 pulls the skin on bothsides of the philtral ridge in opposite directions, the bevels perpendic-ular to the direction of the muscle fibers on both sides are formed,which constitute the contour of the philtral ridge. With our technique,the orbicularis oris muscle on the lateral side of the cleft is divided into2 layers. The muscle fibers of the deep layer are sutured obliquely tothe muscle fibers on the medial side of the cleft to simulate the musclestrength of A3. The muscle fibers of the superficial layer are suturedobliquely to subcutaneous tissue on the medial side of the cleft to sim-ulate the strength of B1. Then, the orbicularis oris muscle on both sidesof the philtral ridge forms a cross structure in the 3-dimensional space,and under the influence of its strength, the philtral dimple is formedwith a narrow top and wide bottom, and the philtral ridge is raised.We advocate the adoption of mechanical traction rather than the vol-ume accumulation to reconstruct the cleft lip patients philtral ridge.12,13

Haddock et al14 observed the long-term effect of primary cleftrhinoplasty in patients with unilateral cleft lip and believed that pri-mary nasal reconstruction performed with cleft lip repair made the na-sal tip more symmetric and required less complex intervention at thetime of definitive secondary rhinoplasty. Guyuron15 stated that pri-mary rhinoplasty could not reduce the ratio and difficulty of secondaryrhinoplasty. Yuzuriha and Mulliken16 performed primary rhinoplasty insevere microform cleft lip patients. We repaired the nasal alar defor-mity when patients were older than 6 years. We believe that the nasaldeformity becomes increasingly more severe because of the abnormalmechanical traction from the muscle. With our technique, the firstauxiliary tension line group is built, which simulates the physical346

Copyright 2015 Mutaz B. Habal, MD. Unauthorstructure. Over time, the nose may develop properly under normalpermanent mechanical traction. So, we recommend allowing the nat-ural development of the cleft lip nose until the patient is 6 years old.

After surgery, 17.5% of patients had thick vermillion. Possiblereasons are scar, edema of vermillion flap, and prolapse of vermillion,which is caused by dissection and detachment of vermillion fromorbicularis oris muscle. We think the main reason of permanent thickvermillion is prolapse of vermillion. So we reattached the dissectedvermillion and mucosa to orbicularis oris muscle recently. And the re-sults were better than before. There is more skin of the upper lips thannormal in some cases. After reconstruction of the second auxiliarytension line group, lateral lip is bulging because of extra skin. Usually,extra skin shrinks, and bulging lip becomes normal in 1 year.

We believe that the shape of the lip depends on the balancedmuscle tension on both sides instead of upon themuscle volume. Oncethe muscle tension line is disrupted, the deformity occurs. Here, werepaired unilateral microform cleft lip according to the muscle tensionline group theory and obtained favorable results.

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