Abstract
In unilateral cleft lip and palate, the orbicularis muscle, the alveolar bone, the floor of the nose, and the hard and soft palate are interrupted, creating an open communication between nasopharynx and oropharynx. Patients with a cleft lip and palate are treated in specialized cleft centers by a multidisciplinary team. Having cleft lip and/or palate has a noteworthy impact on quality of life and psychosocial functioning. Surgical scars are in the center of the face and can be quite noteworthy. Postoperative scarring is a common cause of patient dissatisfaction.
Here, we describe a patient with an unpleasing esthetic result after surgical correction of unilateral cleft lip and palate in China. After careful surgical planning, scar excision and a single Z-plasty were performed to achieve scar lengthening. Pre- and postoperative images are shown.
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Keywords
A 11-year-old male visited the outpatient clinic with his parents because of unpleasing esthetic result after surgical correction of unilateral cleft lip and palate in China. There are no additional operative data available. The cleft palate and lip were not part of a genetic syndrome. There were no other comorbidities.
He stated that he was not pleased with the aesthetic result of the cleft surgery and that the main problem for him was asymmetry of the perioral area. There were no functional complaints in the domains of speech, eating, and/or drinking.
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Q1. Define the problem in terms of anatomy
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Q2. What is the Rose–Thompson effect?
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Q3. What would be the surgical approach to this problem?
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Q4. What (non)surgical methods can be chosen to optimize postoperative scarring?
Immediate postintervention situation: Correction of these deformities in children is best performed under general anesthesia. Intubation is performed using an RAE (Ring-Adair-Elwyn) tube , which is a prebent tube that facilitates adequate reach of the operative area. The operative area is marked using skin marker that does not wash away or fade out during sterile exposition and surgery. The operative region is infiltrated with a mix of lidocaine and adrenalin.
The scar was excised using a concave excision pattern, making use of the Rose–Thompson effect. With one additional Z-plasty , adequate scar length was achieved. Reconfiguration of misaligned lip mucosa was achieved in the same session. The subcutaneous plane was closed using resorbable sutures. The skin was closed using skin glue.
Argumented answers and explanation according to the five references (cited later): 20 lines
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Q1. Define the problem in terms of anatomy.
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A1. Postoperative scar contracture of philtral scar with subsequent effect on nose and lip esthetics. Also, misalignment of lip mucosa was observed.
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Q2. What is the Rose–Thomson effect ?
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A2. The effect of scar lengthening by using concave excisions of the scar, which is subsequently closed in a straight line
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Q3. What would be the surgical approach to this problem?
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A3. Use of the Rose–Thompson effect in combination with one or multiple Z-plasties or a combination of these strategies. An alternative approach might be using fat grafting of the scar; however, this probably provides a less predictable result.
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Q4. What (non)surgical methods can be chosen to optimize postoperative scarring?
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A4. Injecting the orbicularis oris with botulinum toxin , silicon application in the postoperative phase, using glue instead of sutures for tissue approximation.
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Cleft lip scars influence lip, philtrum, and nose aesthetics.
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In secondary lip correction, cleft surgeons typically make use of the Rose–Thompson effect, one or multiple Z-plasties, or a combination of these strategies.
Suggested Reading
Deshmukh M, Vaidya S, Deshpande G, Galinde J, Natarajan S. Comparative evaluation of esthetic outcomes in unilateral cleft lip repair between the Mohler and fisher repair techniques: a prospective, randomized, observer-blind study. J Oral Maxillofac Surg. 2019;77(1):182.e1–8.
Farmand M. Secondary lip correction in unilateral clefts. Facial Plast Surg. 2002;18(3):187–95.
Mulliken JB, Zhu DR, Sullivan SR. Outcomes of cleft lip repair for internationally adopted children. Plast Reconstr Surg. 2015;135(5):1439–47.
Stal S, Hollier L. Correction of secondary cleft lip deformities. Plast Reconstr Surg. 2002;109(5):1672–81.
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van der Sluis, W.B., Don Griot, J.P.W. (2020). Secondary Lip Correction in a Cleft Lip Patient. In: Téot, L., Mustoe, T.A., Middelkoop, E., Gauglitz, G.G. (eds) Textbook on Scar Management. Springer, Cham. https://doi.org/10.1007/978-3-030-44766-3_64
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DOI: https://doi.org/10.1007/978-3-030-44766-3_64
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