Vermillion Notch After Millard Repair of Unilateral Cleft Lip - ESPRS

280 Vol. 33, No. 2 / Vermillion Notch After Millard Repair of Unilateral Cleft Lip
The objective of this article is to analyze different
factors responsible for vermillion notching
and assess the results of labial revisions addressing
these factors.
MATERIAL AND METHODS
Twenty children with vermillion notching after
Millard repair of unilateral cleft lip were included
in this study. Age of the patients ranged from 2-
12 years with a mean of 4.3 years. Six patients
were males while 14 were females. They were
operated upon for their secondary lip deformity
by the authors at the Children’s Hospital, Cairo
University (Aboul Reesh), during the period from
January 2006 till December 2008.
All patients had had their previous lip repair
performed using the classic Millard rotationadvancement
flap technique. Preoperative assessment
was performed clinically together with preoperative
standard photography. Assessment included
lip length as compared to the non-cleft side
(short/equal), integrity of Cupid’s bow (smooth/
tented), vermillion fullness on either side of the
notch (near normal fullness/deficient), the severity
of the notch (mild/severe) and the quality of the
scar (masked/obvious) (Table 1).
Table (1): Results of preoperative assessment.
Item
Short Lip
Tented Cupid’s Bow
Deficient Vermillion
Severe Notching
Obvious Scar
Number
Percentage
All corrective procedures were performed under
general anesthesia. The technique was tailored
according to pre and intra-operative findings. Intraoperative
assessment included the bulk of muscle
fibers at the lower lip margin. Surgical techniques
used included muscle re-approximation, revision
of medial segment rotation and modification of
the paring point on the lateral lip segment. Scar
revision was done in cases with obvious scars.
Patients were followed-up weekly during the
first month, then monthly thereafter. Postoperative
assessment using both clinical and photographic
documentation was performed after a minimal of
15
15
11
6
8
75
75
55
30
40
3 months of corrective surgery. Follow-up period
ranged from 3 to 34 months with a median of 16
months.
RESULTS
Preoperative assessment revealed short lip with
tented Cupid’s bow in 15 cases (75%), deficient
vermillion in 11 cases (55%), severe notching in
6 cases (30%) and obvious scar in 8 cases (40%)
(Table 1). Intra-operative assessment showed deficient
muscle fibers at the lower lip border in all
20 cases (100%) (Fig. 1). Patients with deficient
vermillion (n=11) included two different groups,
those with hypoplastic medial segments (n=2) and
those with medially placed paring point on the
lateral lip segment (n=9). This latter group retained
cleft tissue in their previous repairs that accounted
for the hypoplastic appearance of the vermillion
at the site of notching.
Surgical technique included dissection of the
muscle bulk and re-approximation at the lower lip
border in all cases. In 15 cases (75%), total revision
was performed to increase the rotation of the medial
lip segment. Back cuts were used in these cases to
gain enough length. In 9 cases (45%), lateral displacement
of the paring point was done on the
lateral lip segment with excision of excess cleft
tissue available at the lateral aspect of the vermillion
notch (Fig. 2). Too medial placement of the paring
point was the only case in 5 cases, while 4 cases
had both inadequate rotation in addition to lateral
paring point displacement. These 4 cases therefore
needed total lip revision to improve rotation of the
medial segment, in addition to lateral displacement
of the paring point on the lateral segment. Although
the old scar was obvious only in 8 cases, however,
a total of 17 cases (85%) had their scar revised.
Those included the 15 total lip revisions in addition
to 2 cases with obvious scars that did not need
total revision (Table 2).
Table (2): Surgical techniques.
Technique
Re-approximation of muscle at the
lower lip margin
Total Lip Revision with adequate
rotation of the medial segment
Lateral Displacement of the paring
point on the lateral segment
Scar revision (including total lip
revisions)
Number
20
15
9
17
Percentage
100
75
45
85