Augmentation of the Median Tubercle with Dermis-Fat Graft in Children with Repaired Cleft Lip

Introduction: Surgical outcomes for patients with complete cleft lips are not as ideal as those achieved for milder phenotypes. We hypothesized that in addition to the greater width of the cleft, patients with complete cleft lip and palate exhibit a greater degree of hypoplasia and asymmetry. Methods: Stereophotographs of 14 infants with unrepaired unilateral complete and 14 with incomplete cleft lips were measured using Vectra imaging software (Canfield Imaging). Unpaired t tests were used to compare measured asymmetry between groups. Measurements included nasion to endocathion, sn-sbal, subnasale to alare (sn-al), subnasale to crista philtra, subalare to crista philtra (sbal-cphi), chelion to crista philtra, lateral lip element fullness, medial lip element fullness (mef), and non-cleft lip fullness. Duplicate measurements allowed Pearson correlation to be used to determine intra-rater reliability. Statistical significance was set at P < .05. Results: Degree of asymmetry of the nasal base, sn-al, and sn-sbal was significantly greater for patients with complete clefts ( P = .0001, P = .0001). Hypoplasia of the lateral lip element was seen when comparing lateral and mef ( P = .04, P = .004) and lateral lip height (sbal-cphi’’; P = .002). The degree of cupid’s bow asymmetry did not differ between groups ( P = .23). Intrarater reliability was high for all facial measures, ranging from 0.70 to 0.99. Conclusions: More severe, complete cleft lips demonstrate statistically significant greater asymmetry in surgically relevant dimensions. There was greater width of the nasal base. Vertical asymmetry of cupid’s bow was unaffected by cleft severity, but that asymmetry was greater in patients with complete clefts due to hypoplasia of the lateral lip element. This may contribute to the less favorable results in these patients.

Section: Discussionmentioning

confidence: 99%

Degree of Asymmetry Between Patients With Complete and Incomplete Cleft Lips

Jodeh

Soni

Cray

et al. 2020

“…Therefore, if the vermilion fullness on the cleft side is excised, it may be preferable that a small amount of vermilion fullness was left intact and subsequently monitored upon follow-up. The excess vermilion fullness can then be used to translocate tissue volume to the center in any flaps 3,7 to supply median weakness or create a median tubercle. Considering the changes in the mucosal free margin through the 4 points of growth, the prevalence of recessed margins significantly increased from 10 years of age to the end of growth.…”

Section: Discussionmentioning

confidence: 99%

Longitudinal Morphological Changes in the Mucosal Free Margin After Unilateral Cleft Lip Repair

Nakajima

Yuzuriha

Nagai

2022

Weakness of the mucosal free margin is common in secondary cleft lip deformities. However, the incidence is rarely reported after a long-term follow-up. We evaluated the evolution of patient mucosal free margin after primary repair and until the end of growth. Blinded retrospective study (photography and chart reviews). Tertiary care hospital; private practice. Forty-eight patients with unilateral cleft lip with or without cleft palate who underwent primary nasolabial repair between 1996 and 2004 were followed up until their end of growth marked at 18 and 16 years of age for male and female patients, respectively. Primary nasolabial repair using a straight-line closure without a triangular flap on the vermilion was performed; if needed, a revision surgery was performed at 5 years of age (85%). The contour of the mucosal free margin was classified into nodular, smooth, and recessed types at 1, 5, and 10 years and at the end of growth. At 1 year of age, the nodular type was more common (58%). However, the recessed type was more common (75%) at the end of growth. The mucosal free margin continued to change after 10 years of age. At the end of growth, half of the patients with incomplete cleft experienced center weakness, and the others had cleft-side weaknesses. Patients with incomplete clefts showed favorable results at early ages. However, two-thirds of the patients with complete and incomplete clefts showed focal weakness at the end of growth.

“…Our preferred method is placement of a dermis-fat graft to augment the deficient lip, chosen for the minimal donor site morbidity, speed, and ease of execution. Previous publications have described the use of sutures attached to a Keith needle (Steinbacher et al, 2009; Resnick et al, 2018) or a tendon passer (Patel & Hall, 2004) to insert the graft into the submucosal pocket. The senior author has developed the technique presented here to expedite the delivery of the graft after observing that passing a needle directly into the pocket with the aid of a retractor is likely to catch soft tissue and alter the graft placement.…”

Section: Discussionmentioning

confidence: 99%

“…Grafting the deficient area with either aspirated fat ( Jones et al, 2017; Koonce et al, 2018) or a dermis-fat graft (Richards et al, 1997; Patel & Hall, 2004; Staebel &Verheyden, 2009; Steinbacher et al, 2009; Resnick et al, 2018) has been described to correct the tissue deficit as an alternative to a number of local flap options (Abbe, 1968; Robinson et al, 1970; Kapetansky, 1971; Matsuo et al, 1993; Gudis & Patel, 2015). While fat injection is becoming more popular for cosmetic lip augmentation, it is generally not utilized following cleft lip repair, as the area that needs maximum augmentation is simultaneously the area of maximum scar following cleft repair and is thereby less conducive to the survival of injected fat.…”

Section: Introductionmentioning

confidence: 99%

Novel Passage of Dermis-Fat Graft for Augmentation of Vermilion Deficiency Following Cleft Lip Repair

Sasson

Turin

Gosain

2020

Despite timely repair of cleft lip, secondary deformities such as vermilion notching or “whistle deformity” often require further surgical treatment. The use of dermis-fat graft for soft tissue augmentation of the upper lip is an established technique. We propose an innovation on this technique, by which the dermis-fat graft can be placed reliably and with minimal dissection by use of a soft red rubber sheath to protect the Keith needle while delivering the graft through the submucosal pocket in the dry vermilion, thereby avoiding the needle inadvertently catching soft tissue inside the pocket. We recommend using an 8F red rubber catheter, cutting the catheter to be just shorter than a 2.5-inch Keith needle. This provides a sheath through which the Keith needle can be passed within the submucosal vermilion tunnel. We believe this to be much more reliable for vermilion augmentation than other techniques, including fat injection, and makes graft inset more predictable, faster, and simpler.