Dr. Alireza Ghassemi

1. Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Acellular Dermal Graft in Secondary Cleft Lip
Deficiencies: Assessment of Results With a Reproducible
Quantitative Technique
Bijan Movahedian Attar, DMD, OMFS,Ã
Abbas Haghighat, DMD, OMFS,Ã
Navid Naghdi, DMD,y
Saman Jokar, DMD, OMFS,y
Reyhaneh Nazem, DDS, MSc,z
and Alireza Ghassemi, MD, PhD§
Purpose: Considering the little evidence around acellular dermal
graft application in secondary lip reshaping, this study is aimed to
quantitatively examine the effect of acellular dermal graft in
combination with Z-plasty technique in secondary defects of cleft
lip.
Methods: In this clinical investigation, patients with secondary
unilateral cleft lip deformity were selected. Standard photographs
were prepared for each patient. Subsequent to scar revision,
submucosal tunneling and Z-plasty, implantable human acellular
dermal graft was placed and fixed in submucosal pocket.
Quantitative parameters included angle of symmetry , dimension
of symmetry (DS), defect height (DH), parallel lines, and lip
thickness were measured presurgically and 1 year after
treatment. Pre and post-operative pictures were compared and
the changes were documented according to the criteria. P value
less than 0.05 were considered as significant.
Results: Eighteen patients were included in this study. The difference
of ‘‘DS’’ between normal side and cleft side was 3.1Æ 1.5mm
presurgically and 1.1Æ 1.8mm postsurgically. The change was
significant (P value< 0.05). The difference between pretreatment
and posttreatment measures of ‘‘DS’’, ‘‘DH’’, and ‘‘Lip Thickness’’
were 2.75Æ 4.55, 3.43Æ 4.82, and 2.66Æ 3.04mm, respectively. The
results were significant (P value<0.05).
Conclusions: Based on the results, acellular dermal graft in
combination with Z-plasty was able to improve lip deformity in
patients with secondary defects of cleft lip. Further studies are
recommended regarding the application of this technique in patients
with bilateral cleft lip and severe ‘‘DH.’’
Key Words: Acellular dermal graft, cleft lip, secondary lip
deformity, z-plasty
(J Craniofac Surg 2016;27: 313–316)
Orofacial clefts are the most common types of congenital
malformations in head and neck area. Numerous compli-
cations including facial deformities, dental disorders, inappropriate
occlusion, and functional problems have been identified in these
patients.1–3
Secondary lip deformity, also called as whistle deform-
ity or vermillion notching,4
is a disorder commonly seen in patients
with previous surgical revision of upper lip.5
The fullness and free
border of lip, which consists of orbicularis oris muscle, submucosa,
vermilion, and labial mucosa, play important roles in aesthetic and
integrity of lip.5,6
The most common techniques used in secondary
lip revision include Z-plasty, V-Y advancement flap, mucosal
transposition flaps,7
and Kapetansky double pendulum flaps.8
Although the problem can be resolved by rearrangement of
tissues, deformities can be occurred by tissue contraction because of
scar formation. Thus, application of other tissues or alloplastic
materials is required to obtain satisfactory results.4,9
Recent inves-
tigations showed that acellular dermal graft is an appropriate
material for revision of secondary lip deformities; the results of
acellular dermal graft is comparable with temporoparietal fascia in
managing severe deformities.9
Considering the relatively high prevalence of cleft lip and palate
and significant aesthetic requirements of patients, a closer evaluation
should be done regarding the novel techniques for lip reformation.
Little evidence is available around acellular dermal graft application
in secondary lip reshaping.9–11
Current study was aimed to quanti-
tatively examine the effect of acellular dermal graft in combination
with Z-plasty technique in secondary defects of cleft lip.
MATERIALS AND METHODS
This study is registered and approved by the Regional Bioethics
Committee of Isfahan University of Medical Sciences, Iran. Eigh-
teen patients with secondary unilateral lip deformity were chosen.
Selected patients had undergone a primary surgery previously. All
of the patients had mild to moderate lip deficiency (this value is
obtained according to ‘‘defect height’’ which is explained sub-
sequently). The patients with bilateral cleft lip or midline cleft
lip, history of numerous surgeries on the upper lip, systemic
problems, cleft not in the mild to moderate range, and pregnant
women and patients without informed consent, were excluded from
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From the ÃTorabinejad Dental Research Center; yOral and Maxillofacial
Surgery, Department of Oral and Maxillofacial Surgery, Isfahan Uni-
versity of Medical Sciences, Isfahan; zDental Materials Research Center
and Department of Operative Dentistry, School of Dentistry, Qazvin
University of Medical Science, Qazvin, Iran; and §Department of Oral,
Maxillofacial and Plastic Facial Surgery, University Hospital of Rhei-
nisch-Westfa¨lische Technische Hochschule, Aachen, Germany.
Received February 11, 2015.
Accepted for publication October 12, 2015.
Address correspondence and reprint requests to Saman Jokar, DMD,
Department of Oral and Maxillofacial Surgery, Isfahan University of
Medical Sciences, Hezar Jerib St., Isfahan 81746-73461, Iran;
E-mail: saman.jokar@yahoo.com
The authors report no conflicts of interest.
Copyright # 2016 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000002324
ORIGINAL ARTICLE
The Journal of Craniofacial Surgery Volume 27, Number 2, March 2016 313

2. Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
the study. The surgery procedure was completely explained to
patients and informed consent was taken from them.
Presurgical Proceedings
Standard photography was carried out for each patient. The
photographs were taken by digital single-lens reflex professional
camera (Sony, Tokyo, Japan). The patient’s distance to the camera
was constant in all of the cases. To adjust the horizontal axis, 2
photographs were taken from the patient in natural head position.
Also, the patient’s cervicomental angle was measured and recorded
to obtain a higher accuracy. To adjust the vertical axis, the lines
passing through the patient’s pupils and upper border of earlobe
were matched with parallel horizontal lines on background. To
eliminate the environmental light, all photographs were taken by a
50 mm lens with f 22, ISO 100, and flashlight.
Presurgical photographs were saved in the patient’s file and
intended parameters were measured. Also the estimated size of
defects was determined. There are limited parameters used to
evaluate the indices of symmetry and aesthetic of lip before and
after surgical procedure. In current study, a new series of parameters
were applied for quantitative assessment of results.
Symmetry Indices
The line from the highest point of cupid bow to the intersection
point of facial midline and intercommissure line is named as A-line.
The angle between A-line and facial midline is called as angle of
symmetry (AS), and the distance of A-line (from cupid bow to the
intersection of midline and intercommissure line) is called as
dimension of symmetry (DS) (Fig. 1).
Defect Height
Size of upper lip defect in cleft region, which is determined
through the difference between upper lip thickness (the distance
from inter-commissure line to cupid bow point) and vermillion
thickness (the distance from the cupid bow point to lower vermillion
border) (Fig. 2). Less numerical value indicates less defect size in
lip (Table 1).
Parallel Lines
In normal condition, the line crossed from 2 labial commissures
(intercommissure line) and the line crossed from 2 cupid bow
points, are relatively parallel. In patients with cleft lip, because
of abnormal position of cupid bow in cleft side, a small angle is seen
between the lines (Fig. 3). It is more favorable if the size of this
angle is numerically smaller.
Lip Thickness
The length of perpendicular line drawn from the highest point
of cupid bow to intercommissure line (Fig. 2), which was compared
in normal side and the side with defect. To eliminate the few
photographic errors, this number was measured compared with
interpupillary distance, which is always constant.
To control the results of this study, the half with lip defect was
restored by Adobe Photoshop (Adobe, San Jose, CA) based on the
mirror image of healthy side. The ideal lip state was hypothetically
designed on the affected side and used as reference for analyzing the
results of treatment.
Surgical Procedure
Surgical procedure was performed under local or general
anesthesia in all of the patients. The area with defect was deter-
mined and decisions were made about submucosal pocket site.
Subsequent to scar tissue excision, submucosal pocket was created
in combination with Z-plasty technique, resulting in sufficient space
with minimum tissue tension. The Z incision was created in moist
labial mucosa just behind the whistle notch, so that the upper and
lower edges of Z were parallel with wet-dry junction of lip.
Therefore, the height of mucosa adjacent to the defect increased
because of soft tissue releasing. The pocket was made a little larger
than estimated size to compensate the changes following gradual
resorption of material.
Implantable non-meshed acellular dermal graft (Tissue Regen-
eration Corporation, Kish, Iran) with suitable thickness and dimen-
sions was used. The sheet was cut in a triangle form and then was
twisted to form a tube. The lateral edge and vertices were sutured by
absorbable suture to preserve the shape. The implant was placed in
FIGURE 1. Symmetry indices. A, The highest point of cupid bow in cleft side. B,
The highest point of cupid bow in normal side. C, The intersection point of facial
midline and inter-commissure line. AS, angle of symmetry is the angle between
AC and facial midline in cleft side or between BC and facial midline in normal
side; DS, dimension of symmetry is the distance between A and C (in cleft side)
or B and C (in normal side).
FIGURE 2. Defect height and lip thickness. A, Lower vermilion border in cleft
side; the distance between A and inter-commissure line called as ‘‘Defect
Height.’’ B, The highest point of cupid bow in cleft side; the distance between B
and intercommissure line called as ‘‘Lip Thickness.’’
TABLE 1. Classification of Lip Defect Based on Defect Height
Defect Height
Mild 0–2 mm
Moderate 2–5 mm
Severe 5 mm
Attar et al The Journal of Craniofacial Surgery Volume 27, Number 2, March 2016
314 # 2016 Mutaz B. Habal, MD

3. Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
the submucosal pocket and fixed on the pocket floor by absorbable
suture (Fig. 4). Finally the flap was closed by absorbable suture.
The amount of used acellular dermal graft was recorded for each
patient. Postsurgical follow-ups were performed 1 week, 1, 3, 6, and
12 months after surgery; final photographs were taken from each
patient in 1 year postsurgical appointment. Pre and post-operative
pictures were compared and the changes were documented accord-
ing to the criteria. The obtained data were analyzed by SPSS 16.0
statistical software using paired T and x2
tests. P values less than
0.05 were considered as significant.
RESULTS
Eighteen patients were included in this investigation. Patients’ ages
ranged between 8 to 27 years. Firmness and bulging of grafted area
remained until 3 months follow-up appointments, but were
improved in 6 months visits and were disappeared 12 months
postsurgically. All of the patients were satisfied in final recalls
and no complaints were reported (Fig. 5)
Angle of Symmetry
The approaching of the side with cleft to the normal side is
estimated through the index. Because the mean difference between
normal side and defected side before treatment was 5.2 Æ 22.6 and
after treatment was 1.58 Æ 12.28, it can be concluded that the
difference between both sides has become smaller after treatment.
The difference, however, was not significant (Table 2). The differ-
ence between pretreatment and posttreatment measures in cleft side
was averagely 2.758 Æ 17.478, which also was not statistically
significant (Table 3).
Dimension of Symmetry
The difference between normal side and cleft side was averagely
3.1 Æ 1.5 mm presurgically. After treatment, the difference was
changed to 1.1 Æ 1.8 mm, which indicated that the amount of defect
side was shifted to the normal side. The results were statistically
significant (Table 2). Pretreatment and posttreatment values of
‘‘DS’’ in cleft side had a difference of 2.75 Æ 4.55 mm, which
was statistically significant (Table 3). In all of the samples, a slight
difference was observed in pre and postsurgical values of normal
side.
Defect Height
The potential of treatment to improve lip defect is characterized
with defect height criteria. After treatment, the amounts of defective
height were significantly changed in deficient sides, but not in
normal sides. Smaller values were obtained postsurgically in cleft
side, which indicated that the defect height was decreased and
inclined to normal situation (Table 3).
Parallel Lines
The ability of treatment in leveling the cupid bows is estimated
through the index. After treatment, there was a difference in
terms of paralleling the line passing through cupid bows with
FIGURE 3. Parallel lines. In patients with cleft lip, a small angle is seen between
the line crossed from 2 labial commissures (lower line) and the line crossed from
2 cupid bow points (upper line).
FIGURE 4. Acellular dermal graft was shaped as a tube and implanted in
prepared pocket.
FIGURE 5. Six-year-old girl with unilateral right cleft lip. Primary lip closure was
done at 2 months. A, preoperation picture shows lip deformity and vermillion
notching in right side. After scar tissue excision, Z-plasty and submucosal
tunneling, acellular dermal graft was implanted and fixed in created pocket. B, 1
year after treatment. The defect has been resolved with satisfactory results.
TABLE 2. Pretreatment and Posttreatment Differences in ‘‘Angle of Symmetry’’
and ‘‘Dimension of Symmetry’’ Criteria Between Normal Side and Cleft Side
Before
Treatment
After
Treatment
P Value
(Paired t-Test)
‘‘AS’’ difference
between normal side
and cleft side
5.2 Æ 22.68 1.5 Æ 12.28 Pv ¼ 0.566
‘‘DS’’ difference
between normal side
and cleft side
3.1 Æ 1.5 mm 1.1 Æ 1.8 mm Pv ¼ 0.01
AS, angle of symmetry, DS, dimension of symmetry.
The Journal of Craniofacial Surgery Volume 27, Number 2, March 2016 Secondary Cleft Lip Defects
# 2016 Mutaz B. Habal, MD 315

4. Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
intercommissure line. Although the changes were close to signifi-
cant levels, the results were not statistically significant (Table 3).
Lip Thickness
Lip thickness was increased in both normal and deficient sides;
however, the increase was not statistically significant in normal
side. The change in lip thickness indicated more increase in
deficient side, which was statistically significant (Table 3).
DISCUSSION
Nowadays acellular dermal graft is a known biomaterial in soft
tissue revision procedures. Application of acellular human dermis
as an allograft material has advantages, such as reducing the need
for donor site in which pain, scar, and infection may probably occur.
Shortening of operation time and less use of anesthetics and con-
sequently less possible complications. Ease of surgeon to prepare
the required graft.
Application of acellular dermal graft in lip revision is a safe
technique with predictable results. Lee and Koh compared the
results of acellular human dermis graft with temporoparietal fascia
in secondary cleft lip deficiencies. The study showed that acellular
dermal graft combined with V-Y advancement flap is an appro-
priate option in secondary cleft lip defects; as reported, acellular
dermal graft is as effective as temporoparietal fascia in long-term
and no major complication was reported subsequently.9
Similarly,
in current investigation, treatment outcomes were satisfactory in all
of the patients; no complications including infection, graft rejection,
or hypersensitivity reactions were observed during follow-up
period.
What distinguishes the current study is the method through
which the standard photographs were prepared and the systematic
and replicable measurement method for facial rations was used to
analyze them. Altering an aesthetic qualitative index of upper lip to
various quantitative components is a novel idea that increases the
precision of data analyzing in many cosmetic or reconstructive
surgeries.12
Application of quantitative components combined with
measuring software reduces the bias of evaluation. The points
considered in the current study were quite specified and researcher
was not involved in determining them. To avoid bias in study, the
points were placed on photographs by a software engineer.
Hypothetical reconstruction of lip defect is valuable in assess-
ment of treatment outcomes. The ideal shape of lip, which is
designed based on healthy side, was used as a reference to evaluate
the results of treatment; thus the biases resulted from researcher
opinions were reduced.
Based on the results, current surgical procedure using acellular
dermal graft in combination with Z-plasty was able to remarkably
improve the size and shape of lip in patients experiencing secondary
defects of cleft lip. Significant reduction of defect size measured by
defect height, suggests that the technique is favorably able to
augment the deficiency of secondary cleft lip. In addition the
significant changes in ‘‘DS’’ and ‘‘parallel lines’’ angle indicate
that the form of lip in deficient side was approached to normal side
after treatment; thus the symmetry of lip improves subsequent to the
treatment process. The nonsignificant difference reported by other
indices, however, may be because of low number of samples. Many
samples were excluded from the study because of patients’ dis-
affiliation in follow-up period, precise inclusion, and exclusion
criteria intended for the study and high dispersion of data.
According to the first hypothesis of study, no changes were
considered in normal side. In all of the samples, slight changes in
normal side, however, were observed after treatment. Increasing the
lip thickness in normal side was occurred in all of the patients, but it
was not statistically significant. Although these changes were
expected to increase the overall thickness of lip, it was one of
the factors that made the comparative results nonsignificant.
Because this technique can be carried out as chair side through
local anesthesia and the donor site is removed to perform this graft,
it can be performed as an outpatient operation. Based on the
advantages of this surgical technique and low number of conducted
investigations, the findings of this study are suggested to be
reassessed in more comprehensive studies. The long-term results
of this surgery should be evaluated in patients with cleft lip. Further
studies are recommended in patients with bilateral cleft lip and
higher defect height.
ACKNOWLEDGMENTS
The authors thank Mehdi Moradi (computer and software engineer)
who kindly helped in picture processing.
REFERENCES
1. Shprintzen RJ, Siegel-Sadewitz VL, Amato J, et al. Anomalies
associated with cleft lip, cleft palate, or both. Am J Med Genet
1985;20:585–595
2. Olin WH. Dental anomalies in cleft lip and palate patients. Angle Orthod
1964;34:119–123
3. Milerad J, Larson O, Hagberg C, et al. Associated malformations in
infants with cleft lip and palate: a prospective, population-based study.
Pediatrics 1997;100:180–186
4. Patel IA, Hall PN. Free dermis-fat graft to correct the whistle deformity
in patients with cleft lip. Br J Plast Surg 2004;57:160–164
5. Farmand M. Secondary lip correction in unilateral clefts. Facial Plast
Surg 2002;18:187–196
6. Mulliken JB, Pensler JM, Kozakewich HPW. The anatomy of Cupid’s
bow in normal and cleft lip. Plast Reconstr Surg 1993;92:395–403
7. Robinson DW, Ketchum LD, Masters FW. Double V-Y procedure for
whistling deformity in repaired cleft lips. Plast Reconstr Surg
1970;46:241–244
8. Kapetansky DI. Double pendulum flaps for whistling deformities in
bilateral cleft lips. Plast Reconstr Surg 1971;47:321–323
9. Lee KN, Koh KS. Acellular human dermis, a good option for correcting
the free border deficiency in secondary cleft lip deformity. J Plast
Reconstr Aesthet Surg 2012;65:356–361
10. Castor SA, To WC, Papay FA. Lip augmentation with AlloDerm
acellular allogenic dermal graft and fat autograft: a comparison with
autologous fat injection alone. Aesthetic Plast Surg 1999;23:218–223
11. Tobin HA, Karas ND. Lip augmentation using an Alloderm graft. J Oral
Maxillofac Surg 1998;56:722–727
12. Wakami S, Harada T, Muraoka M, et al. Rectangular mucosal flap with
artificial dermis grafting for vermilion deformity in cleft lips. J Plast
Reconstr Aesthetic Surg 2010;63:22–27
TABLE 3. Difference Between Pretreatment and Posttreatment Measures in
Cleft Side
Difference Between
Pretreatment and
Posttreatment in Cleft Side
P Value
(Paired t-Test)
‘‘AS’’ 2.75 Æ 17.478 Pv ¼ 0.67
‘‘DS’’ 2.75 Æ 4.55 mm Pv ¼ 0.03
‘‘Defect height’’ 3.43 Æ 4.82 mm Pv 0.001
Angle of ‘‘Parallel lines’’ 14.76 Æ 12.618 Pv ¼ 0.07
‘‘Lip thickness’’ 2.66 Æ 3.04 mm Pv ¼ 0.01
AS, angle of symmetry, DS, dimension of symmetry.
Attar et al The Journal of Craniofacial Surgery Volume 27, Number 2, March 2016
316 # 2016 Mutaz B. Habal, MD