REPAIR OF THE UNILATERALLY CLEFT LIP
Normal Upper Lip
high points of Cupid's bow are symetrical and situated along the horizontal
*The two philtral crests are parallel and equal
*The axis of symetry is perpendicular to the arc.
*The cutaneomucuous lines ( A3-B4
) are symetrical and of the same length.
*The cleft is localized on the philtral column ( left ), and the medial
side is hypotrophied.
*Cupid's bow is lopsided, the left high point is
split ( along 4 & 4'
) and is situated higher than its equivalent on the healthy side.
*The axis of symetry is skewed towards the cleft
*The wing of the nose is spread out.
*The cutaneomucuous lines remain of the same length
but are not symetrical.
A priory the plasty of such an anomaly
can be remedied through the excision of the cleft
and of the distrophic tissues fringing it ( hatched areas in figs. 1a &
Nevertheless the final result is
not satisfactory , the arc is still not horizontal and the labial asymetry
is still present : the cupidal tip ( 4') remains high. Suppressing this flaw
has meaning only if the requirement to achieve facial symetry is taken into
Therefore rendering both sides of the of the lip
symetrical requires lowering the cupidal tip on the cleft side to
the point where it becomes level with the corresponding healthy
The solutions devised to this end are illustrated on the above canvas
where the main reference points of the lip are takento be in the
condition described above.
We will use the terms "medial side" and "lateral
side" to refer to the two segments of the lip parted by the
Lowering the cupidal tip
on the cleft side from a height "h" corresponding to
the denivellation can be achieved one of two ways:
*The first type of artifice transforms a curvilinear
-drawn from one extremity of the philtral crest to the other-into
a rectilinear incision.
A slice of philtral tissue is then excised thereby exerting traction
on the free end
of the lip ( hatched area 3a).
*The second type of artifice consists
of cutting through the philtrum transversally,
the traction applied to the free end of the lip on the medial side
brings the arc to the horizontal position and results
in a triangularly shaped loss of tissue ( fig.4b).
The incision's length (5-x) corresponds to height (h).
In fact, the focus is on making the scar resulting from the surgery
as unnoticeable as possible by hiding
the philtral notch.
*Single and distal, and present a right or reduced angle with
the axis of symetry (5a-5b),
*Single and beneath the collumella, or
*Double: the philtrum is notched starting from the the extremities
of the philtral crest (5d).
Regardless of the procedure used,
the gain in labial height comes at the cost of some amount of philtral tissue,
which in turn will eventually have to be compensated for at the expense
of the lateral side. In other words, getting the arc to lie along a horizontal
axis takes precedence over allowances madeto correct the labial cleft. Therefore
one ought to first concentrate on the philtrum prior to moving on to the
lateral side the remodelling of whichis a function of what has been attained
at the medial level.
These two distinct steps will
be sketched out in a series of drawings which will present the methods used
to bring Cupid's bow to lie horizontally.
Let us go back to figure
*As a result of the excision
of a crescent shaped area of philtral tissue,
the traction exerted on the free end of the medial side transforms
the section slice from curvilinear to rectilinear thereby bringing
Cupid's bow to lie along the horizontal axis. At this point the
same procedure is also carried out on the lateral side to join the
two sections. This method was devised by Rose & Thompson.
*One ought to bear in mind that the sacrifice of tissue made necessary
by this procedure results in a narrowing of the philtrum.
*The second possible inconvenient is attributable to the rectilinear
outline of the scar and the fact that it can retract following the
Let us go back to figure 5;
*The philtral notch (5-x)
is made starting from the cupidal tip, the traction exerted on the
free end of the medial side allows for the arc to be positionned
horizontally. This leads to a loss of tissue (5-x-5) which is triangularly
shaped and will eventually be filled in using a flap of tissue of
the same dimensions cut out from the lateral side.
*Starting from point 4"
a triangular flap (4"-5- 6) corresponding to the loss of philtral
tissue is outlined. The delineation of the flap requires the excision
of the tissue area located above it (hatched area in figure 5c).
The flap is then freed and mobilized around its base (4"-6)
until it is positionned into the philtrum.
*This principle of plasty is known as the triangular flap of rotation
method, the original procedure is the work of Tennison
Let us go back to figure
*The philtral notch is perpendicular
to the axis of symetry.
The loss of tissue takes the shape of a right angle and
its hypotenuse represents the lip's deficit in height.
Starting from point 4' a right rectangular flap is
Its dimensions are equivalent to those of the area of philtral loss,
and its mobilization
and repositionning obviously require a sacrifice of tissue (hatched
This method developped by Lemesurier is a variant
here the difference lies with with the complexity of the flap's outline
the amount of labial tissue sacrificed.
* Making two cuts instead of
one reduces the size of philtral tissue loss to the point where
the scars resulting from the surgery are little noticeable. The
length of each cut -at an angle with the vertical- does not exceed
half the deficit in height of the lip.
* Preparation of the two
flaps necessitates the excision of a relatively more extended
area of tissue.
This procedure devised by Skoog is in fact a
variant of the triangular flap of rotation method;
*An incision is made beneath
the columella and allows for the lowering of tip (4').
*The loss of tissue is compensated
for by a flap cut into the lateral side by performing a transversal
counter-incision below the nostril.
*The lateral flap is then mobilized and forwarded into the area
of tissue loss below the columella.
The advantage -among others- of this plasty devised by R.
Millard and known as the " flap of advancement "
method lies with the fact that it exploits the lateral side without
incurring any sacrifice of tissue.
At the conclusion of this overview of the technical basis of
the unilateral labial pasty
emphasis should be placed on the following points:
*The first step requires setting
Cupid's bow along the horizontal axis.
*This procedure necessarily creates a loss of philtral tissue which is to
be filled in from the previously modelled lateral side.
*Compensating for the sacrifice of philtral tissue requires a loss of tissue
from the lateral side to the exception of the plasty relying on the flap of