Secondary cleft lip deformities

1. Secondary cleft lip deformity

4. Lip deformities
Five broad areas:
• scarring,
• lip,
• vermillion,
• muscle,
• buccal sulcus

5. Scarring
1. signs of immaturity (redness, firmness),
2. contour changes,
3. distortion of local structures.
• Severe and worsening scarring: - an acute
intervention (steroid injections)
• Stable or improving scars: - close monitoring
until full maturation

7. Lip dimensions
1. short lip (philtral column on the cleft side is
vertically shorter than the noncleft side),
2. a long lip (philtral column on cleft side is
vertically longer than the noncleft side),
3. tight upper lip (decreased width between
cupid’s bow peaks and/or disparity in
anteroposterior projection of the upper lip in
relation to lower lip),

8. 4. wide upper lip (increased horizontal width
between cupid’s bow peaks),
5. short lateral lip (cleft-side lateral lip segment is
horizontally shorter than the lateral lip
segment on the normal side),
6. philtral column distortion,
7. cupid’s bow distortion

9. Vermilion
1. thin or thick lip segments,
2. vermillion mismatches (between the wet and
dry vermillion),
3. vermillion notching or border malalignment
(between the white roll and vermillion),
4. whistle deformity (median tubercle paucity
resulting in nonapposition of upper and lower
lip segments at rest)

10. Muscle
• Inadequate muscle re approximation
– bulging on either side of the lip repair
– short and widened lip scar.
• Incomplete dissection of aberrant attachments
leads to more mild deformities
– tethering of the nasal ala,
– subtle relapse to the prior classic cleft appearance

11. Buccal sulcus
• deep aspect of sulcus should extend up to the
region of the columella–lip junction.
• If the lip is tethered, this can result from scar
contracture or from a true paucity of tissue
related to the initial deformity.

12. Timings
• for secondary surgery at the age of 4 or 5 before
the start of kindergarten
• 87–93% of growth-related changes in labial
landmarks occur by age 5

13. Short lip
• scar contraction,
• primary deficiency of prolabial soft tissues,
• Inadequate primary rotation and advancement

14. • <2–3 mm
• Diamondshaped scar
excision
• unilimb Z-plasty
• >2–3 mm
• Standard Z-plasty to
lengthen the philtral
column
• entire repair should be
taken down and
repeated

15. Long lip
• Cause: overrotation of the medial lip segment
• Not recommended:
– simply to excise lip tissue from beneath the alar base
in an effort to “hitch up” the elongated cleft side
– suspension with permanent sutures fixed to bone

16. • take down the entire repair and excise tissue in
all dimensions to correct the deformity.

17. Tight lip
1. fat injections to the upper lip
2. reduction of the lower lip through a wedge
excision of inner lip tissue
3. Abbé flap

19. Abbe flap:
1. decreased anteroposterior projection of the upper
lip (particularly helpful in reducing the disparity in
tissue volume between the upper and lower lip);
2. excess scarring of the central aesthetic unit
3. a significantly narrowed or shortened central
aesthetic unit.
4. Pseudodimple for the philtrum,
5. a tuft of hair in males
6. continuity of surface landmarks

20. Wide lip
1. in bilateral clefts where the prolabial philtral
segment was designed too wide at the time of
initial operation
2. persistent tension across the neophiltrum,
secondary to a protruding maxilla or
underlying orbicularis muscle function causes
horizontal expansion of the prolabial soft tissue

21. • Excision of the excess philtral tissue
• meticulous approximation of orbicularis oris
• accurate approximation of philtral landmarks.
• (philtrum should be made smaller than the final
desired size - subsequent stretching)

22. Short lateral lip
• results after excision of its diminutive medial
portion

23. Philtral column distortion
• scarring,
• short length,
• lack of prominence

24. To recreate the philtral column
1. Fat grafts (free or dermal)
2. “vest-over-pants” closure
3. mattress sutures to reapproximate and evert
the orbicularis
4. vertical interdigitation of the orbicularis

27. Cupid’s bow distortion
• result of misalignment or notching
• diamond excisions and Z-plasties
• take down the previous lip repair and to repeat
rotation advancement
• Abbé flap

28. Thin lip
• free fat injections
• dermal fat graft

29. Thick lip
• relative excess adjacent
to an area of relative
paucity, (inadequate
advancement rotation
following the initial
repair)
• the lateral lip element
should be redistributed
or readvanced to reduce
the disparity
• thick lip exists alone
• direct excision, via an
incision on the inner
aspect of lip

30. Vermillion mismatch
• color mismatch involves the
median tubercle and
adjacent structures
• Excision of mucosa with
subsequent medialization of
adjacent, bilateral,
undermined vermillion flaps
can be used to close the
defect
• involves just the central
tubercle and there is an
adjacent lateral excess of
vermillion
• the wet and dry vermillion
of the lateral elements can
be used to recreate the
central tubercle after it is
excised

31. Vermillion notching/vermillion
border malalignment
• Scar management,
• diamond excisions,
• Z-plasties,
• as well as local tissue rearrangement techniques
(backcuts, M-plasties, V-Y advancements)

32. Whistle deformity
1. secondary to scar contracture across the
vermillion,
2. failure to fill the central tubercle with lateral
vermillion tissue,
3. diastasis of the orbicularis muscle at the base
of the nose (resulting in an upward pull on the
central tissue),
4. combination of these

33. • If central deficiency with concomitant lateral
excess:
– procedures to reposition and reorient the lateral
tissue as advancement flaps (V-Y advancements and
Kapetansky’s pendulum flaps)
• If no disparity in vermillion bulk between the lip
segments:
– augmentation using free fat grafting, fillers, palmaris
longus grafts, temporoparietal fascial grafts, dermal
fat grafts

34. • If central tubercle vermillion bulk is deficient and
no locally available tissue:
– an Abbé flap – the workhorse for significant
deformities.
– the tongue flap can provide additional “nonlike”
tissue

35. Orbicularis muscle deformities
• reopening the repair, dissecting the orbicularis
from the overlying skin for several millimeters in
the subdermal plane, and subsequent suture
reapproximation

36. Buccal sulcus deformities
• Excess of tissue in
gingivobuccal sulcus
• excise the excess
• and retack the mucosa to
the nasal spine or the
periosteum in
• the region of the
columellar–lip junction
• Deficiency
• to reconstruct the sulcus
• local flaps (mucosal
upper lip flap based
inferiorly),
• mucosal grafts,
• split-thickness and full-
thickness skin grafts