Correction of secondary vermilion notching deformity in unilateral cleft lip patients: Complete revision of two errors

Abstract

Background

Vermilion notching deformity is one of the most common secondary deformities in unilateral cleft lip patients. Two errors during primary cheiloplasty seem to cause notching deformity. The first one is insufficiently lengthened oral lining of the medial lip compared to the cutaneous surface, and the other is medialized marking of the height of cupid’s bow on cleft side rather than marking it at the thickest portion of the vermilion. The authors were able to obtain satisfactory results after revising notching deformities by correcting these two errors.

Methods

A total of 104 patients (median age: 13) with secondary notching deformity underwent revision surgery from 1987 to 2009. After the new height of cupid’s bow on the cleft side was marked on the white roll with the greatest vermilion fullness, the notched vermilion including the cutaneous scar was elevated. For sufficient lengthening of the oral lining, the elevated tissue was interposed as an inferior pedicled flap into a relaxing incision of the central portion of the oral sulcus.

Results

The follow-up period ranged from 1 year to 12 years. The patients were satisfied with the aesthetic outcomes. Seven patients experienced lateral vermilion bulging which was easily corrected by an elliptical excision.

Conclusion

Complete revision by lengthening the oral lining of the central lip portion, and lateralizing the height of cupid’s bow of cleft side to the region where vermilion is thickest, is an effective method for correction of secondary notching deformity.

Introduction

Secondary deformities in cleft lip patients who have undergone primary cheiloplasty are not uncommon. Recent advances in clinical research and surgical techniques have reduced the need for secondary revision procedures; however, secondary deformities of cleft lip are still prevalent (Mommaerts and Nagy, 2008, Schwenzer-Zimmerer et al., 2008). Notching deformity (whistle deformity) is one of the most common secondary deformities (Stal and Hollier, 2002) after primary cheiloplasty. Notching deformities are often thought to be confined to the vermilion, and surgeons tend to restrict their efforts by correcting them within the vermilion using a local mucosal flap. Dermofat grafts or fascia grafts on a notching area may also be attempted (Chen et al., 1995, Patel and Hall, 2004, Wakami et al., 2010). However, these procedures may cause unwanted scars or otherwise produce suboptimal outcomes.

The authors assumed that notching deformities arise because of two errors during primary cheiloplasty, and that notching can be corrected by revision of these errors. First, vermilion notching may occur when the oral lining of the medial flap is lengthened insufficiently. This occurs when the symmetry of the cupid’s bow is achieved by rotation and sufficient lengthening of cutaneous side, but the lengthening of the oral lining is relatively shorter. This causes a tethering of the mucosal flap of the oral lining, creating a notch.

The second error is medailly deflected marking of the height of cupid’s bow. When the height of cupid’s bow is determined on cleft side, the marking should be at the thickest point of the vermilion. If the location of marking of the height of cupid’s bow on the cleft side is determined by using the same length as measured between the oral commisure and the height of cupid’s bow on the noncleft side, the vermilion of the lateral flap usually becomes thinner than the medial flap, creating a notching deformity.

The authors have obtained satisfactory results after complete revision of notching deformities in unilateral cleft lip patients by correcting the two errors.