The Operation Rainbow Canada Technique for Unilateral Cleft Lip Revision

Introduction

Cleft lip (with or without cleft palate) varies in incidence from one in 450 live births among Asian and Native American populations, to one in 2000 live births in African Americans. ¹ Primary cleft lip repair is typically repaired in North America at 3 months of age. ² There are many techniques used to get ideal results in unilateral cleft lip repairs.

The authors are part of the volunteer medical mission organization, Operation Rainbow Canada (ORC). The mandate of ORC is to provide free reconstructive surgery and related health care for cleft lip and cleft palate deformities to impoverished children and young adults in developing countries. The focus is on surgical care for patients in countries who would not normally receive care. The group has provided care to patients in countries such as India, China, Cambodia, Mexico, and Philippines.

During ORC missions, it was noted that in addition to performing primary cleft surgery for patients, there were high volumes of patients presenting for cleft lip revision.

Many of the patients encountered on these missions who are seeking revision surgery have had primary Millard type repairs. With this repair, patients tended to have a cleft side lip that is either too long or too short or the “c” flap scar from the Mallard repair has descended down the columella.

There were also many patients seen on these missions with a previous straight line repair. These straight line repairs look favourable immediately after surgery because of the low scar burden but with time and patient growth, the scar contracts leading to a short lip from a deficient philtral column height on the cleft side.

The cleft nose deformity is typically surgically addressed with a definitive open rhinoplasty at a separate surgery when the patient is an adolescent. ² When doing these cleft lip revisions, we realized we had an opportunity to improve the overall cosmesis of the patients’ lip and nose aesthetic unit by correcting the cleft nose deformity at the same time of the lip revision.

Typically, patients presenting for assessment and possible revision have one of or a combination of the following surgical issues:

The philtral column on the cleft side is either too long or too short. This causes the lip to look too “short” as exemplified by excessive red lip show (“notching”) or the lip being too long and looking “bulky.”

The surgical technique used by the ORC team combines the principles of the anatomic subunit repair technique for primary cleft lip repair as described by Fisher ³ and the correction of cleft nose deformity as described by McCombs ⁴ and applies them to unilateral cleft lip revision at one sitting.

This technique has been used on multiple missions and it is efficient and effective in treating the array of revision maneuvers needed for cleft lip patients seen for consideration of cleft lip repair. We have found that during the revision surgery, our technique can revise the previous scar, either lengthen the white lip skin with a lateral white lip triangle or augment the vermilion mucosa with a lateral vermilion mucosal triangle or both if needed. Repair of the orbicularis oris muscle at the same time allows access for correction of the nasal deformity with McCombs sutures. We have used this technique over the last 10 years on approximately 18 to 19 missions.

Surgical Technique

The summation description of this surgical technique is to either take a previous rotation advancement scar ^5,6 or a straight line repair scar and convert it to a anatomic subunit repair technique ³ while improving the cleft lip nose deformity with McCombs ⁴ suture technique.

From the existing scar, markings are done to avoid any further new scars, on the lip and nose. Markings and technique follow the original anatomic subunit repair as published previously. ³ The existing scar should be marked laterally and medially far enough that normal skin will be re approximated and that all the old scar will be excised.

The nasal alar domes are aligned first with a temporary 4-0 PDS suture using McCombs technique. ⁴ This is used to “tent” the nose into the correct position during the lip repair portion of the surgery. This “stay” suture is left connected to the patients’ head drapes during the correction of the lip and then taken out at the end of the surgery and replaced with permanent sutures.

If lengthening of the lip is necessary, a triangular flap is incorporated in the markings from the lateral side of the white lip skin. A triangular flap is positioned just above the vermilion border on the short cleft side of the lip scar to lengthen it. The philtral column on the non-cleft side is measured and compared to the philtral column on the cleft side. The difference measured in millimetres is the distance of the base of the triangle designed on the lateral white lip skin to be inset into the philtral column. Generally, these triangles are designed to be equilateral. A back cut is made on the medial side of the scar just above the white roll to incorporate the triangle from the lateral white lip skin. ³

A second triangular flap is placed on the lateral cleft side vermilion and is inserted medially. This triangular mucosal flap is incorporated to increase the height of the vermilion part of the lip to match the normal side. ³ The height of the triangle is the difference in height of the red vermilion lip on the non-cleft side and the vermilion on the cleft side vermilion. The triangle is inserted into a back cut made along the wet dry junction of the red lip medially on the cleft side lip. ³

Next the orbicularis oris muscle of the lip are isolated and repaired. About 2 to 3 mm of muscle is dissected from the overlying tissue. The muscle is then repaired so continuity is restored.

After the lip incision has been made, the lower lateral cartilage of the nose on the cleft side is freed from the dome skin medially. Then the lateral part of the lower lateral cartilage is released at the alar base. This frees the cartilage from the overlying skin and nasal ala lining and allows the cartilage to be repositioned by the McComb’s suspension sutures.

These suspension sutures are placed by entering the cleft side nasal lining and going thru the lower lateral cartilage towards the exterior skin but stopping prior to going through the skin and then tunnelling subcutaneously to the contra lateral alar dome and coming out through the skin on the ala non-cleft side. The suture, on a straight needle, is then passed back through the same exist hole on the skin and passed back to the cleft side so that it catches a bite of the alar dome on the non-cleft side. The suture is then tunnelled and brought out back down through cleft side lower lateral cartilage and then out through the ala nasal lining skin. The knot is tied here. This series of suspension sutures repositions the inappropriately “buckled” nasal ala. Thus, the slumped alar dome on the cleft side is elevated and suspended to the non-cleft side of the alar dome of the nose with suspension sutures. ⁵ Finally the skin layer of the lip is repaired, incorporating the 2 triangular flaps as described above.

Case Series

The following case series illustrate the different applications of the technique (Figures 1 –14). The patients all had previously repaired unilateral cleft lips and were seen for revision 2 to 10 years after primary surgery. The primary surgeries were done by various visiting volunteer organizations, performing cleft lip and palate procedures prior to our group’s arrival.

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Figure 1.

Case 1—This patient had a previous left cleft lip repair at a younger age. The existing lip scar is curved towards the midline at the columella base and has a lateral extension around the lateral alar base indicating that the previous repair was a Millard type repair. The scar from the Millard “c” flap has descended down the philtral column. This scar is quite low and is visible on frontal view. The philtral column on the cleft side is too short. This causes excessive red lip (vermilion) show and looks asymmetric compared to the non-cleft side. The previous repaired scars have widened with time as the patient has grown. The patient also displays a typical cleft nose deformity which involves the nostril being too wide at its base and the lower lateral cartilage being “buckled” or flattened.

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Figure 2.

For the repair, the nasal alar domes are aligned with a temporary suture using McCombs technique. This is used to “tent” the nose into the correct position during the lip repair portion of the surgery. To lengthen the philtral column of the lip, a triangular flap is incorporated in the markings from the lateral side of the white lip skin. Another triangular flap is placed on the cleft side vermilion and inserted towards medially deficient vermilion to provide fullness to match the vermilion of the non-cleft side.

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Figure 3.

The skin is closed incorporating the 2 triangular flaps both in the lip above the vermilion border on the cleft side and the second flap on the vermilion to provide fullness on the deficient cleft side volume. The temporary McComb’s sutures are removed and replaced by permanent McComb’s sutures.

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Figure 4.

Final result.

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Figure 5.

Case 2—This adult male had a left-sided cleft lip. The existing lip scar has a lateral extension around the lateral alar base indicating that the previous repair was a Millard repair. The most noticeable issue is the vermilion (red lip) notching. The lower lip vermilion is asymmetric compared to the non-cleft side. The deficient vermilion notch is noticeable with lack of fullness of the lip. The orbicularis oris muscle is not intact. A deep groove (valley) seen along the scar which indicates that the muscle was either not initially repaired or if it was repaired it has separated secondary to growth after the initial repair. Also, the typical cleft nose deformity is seen which involves the nostril being too wide at its base and the lower lateral cartilage being “buckled.” The old scars have widened as the patient has grown.

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Figure 6.

Post-operative result. Lengthening of the white lip was accomplished by designing a triangular flap from the lateral side of the white lip skin. Another triangular flap was designed from the lateral cleft side vermilion mucosa and inserted into the central vermilion to provide fullness to match the vermilion of the non-cleft side. The orbiculas oris muscles of the lip have been repaired and are now in continuity. The previous groove along the vertical scar is now gone. The medially and lateral parts of the lower lateral cartilage has been released at the alar base and the cartilage has been repositioned and held in place by the McComb’s sutures. The slumped alar dome on the cleft side is elevated and suspended to the non-cleft side of the alar dome of the nose.

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Figure 7.

Case 3—The existing lip repair scar is evaluated. The philtral column on the cleft side (right side) is too short. This causes the lip to look too “notched” as exemplified by excessive red lip show. A typical cleft nose deformity is seen, the nostril is too wide at its base and the lower lateral cartilage are flattened or “buckled.”

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Figure 8.

The skin has been repaired after incorporating the 2 triangular flaps both in the lip above the vermilion border on the cleft side and a second flap on the vermilion to provide fullness to the deficient red lip volume. The nasal deformity has been addressed by dissecting the lower lateral cartilage, releasing them at the alar base and repositioning them by the McComb’s sutures. This repositions the nose correctly.

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Figure 9.

Case 4—This adult female had a left-sided cleft lip repair at a younger. The existing lip scar is relatively smooth. The lip is long and the cupid bow peaks are asymmetric. The typical cleft nose deformity is seen. The asymmetry is noticeable as the nostril openings are asymmetric in both position and shape.

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Figure 10.

Post-operatively, the nasal alar domes are aligned with McCombs suture technique. The alar domes are “tented” into the correct position. The dimpling on the skin from placement of the McCombs sutures typically resolves after a couple of months. The Cupid bow peaks are now symmetrical.

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Figure 11.

Case 5—The scar is curved towards the midline and has a lateral extension around the lateral alar base indicating that the previous repair was a Millard repair. This scar has descended down with time. The scar is low on the lip, it is quite visible. The philtral column on the cleft side is too short. This causes the lip to look too “short” as exemplified by excessive red lip show. There is also a notch in the red lip which indicates deficient red lip bulk. The typical cleft nose deformity is shown. The nostril is too wide at its base and the lower lateral cartilage are “buckled.” The previous repaired scars can widen as the patient has grown.

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Figure 12.

The nasal alar domes are aligned using McCombs suture technique. This is used to “tent” the nose into the correct position. Lengthening of the lip was necessary and a triangular flap was incorporated from the lateral side of the white lip skin. A triangular flap is positioned just above the vermilion border on the short cleft side of the lip scar to lengthen it. Another triangular flap is placed on the lateral cleft side was inserted towards the deficient vermilion to provide fullness to match the vermilion of the non-cleft side. This second triangular mucosal flap is incorporated into the deficient vermilion to increase the height of the vermilion.

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Figure 13.

Case 6—This adult male had a left-sided microform deformity. There is vermilion notching and deficient fullness of the vermilion on the cleft side lower lip. The orbicularis oris muscle is not intact.

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Figure 14.

Patient is shown post-operatively. Lengthening of the white lip was accomplished by designing a triangular flap from the lateral side of the white lip skin. Another triangular flap was designed from the lateral cleft side vermilion mucosa and inserted into the central vermilion to provide fullness to match the vermilion of the non-cleft side. The orbiculas oris muscles of the lip have been repaired and are now in continuity. The previous groove along the vertical scar is now gone.

Discussion

We have taken Fisher cleft lip repair principles and applied them to lip revisions. During revision, we have also aligned the nose with McComb’s principles for cleft nose correction. These 2 techniques give improved the aesthetic outcomes in previous Millard and straight line lip repairs. These modifications have been introduced by our senior author and been used over 12 years.

When the senior author started doing high volumes of surgeries on missions, he encountered a surprisingly large number of adult patients requiring primary cleft lip repair ⁷ and a large number of non-infant patients requiring revisions of previously repaired cleft lips. At the same time, the anatomic subunit repair as described by Fisher was rising in popularity in Canada. It was recognized that the surgical technique and principles for the primary anatomic subunit repair could be applied in the setting of revision and this principles translated well for addressing revisional issues.

Most of the patients seen for revisions by our organization during missions were initially treated by Millard repairs. We were surprised with the amount of straight lip repairs that we encountered. For these patients, the straight lip repair can be corrected again incorporating triangular flaps to lengthen the lip in the line of repair and to also add fullness to the red lip.

At the same time of lip revision, realignment nose gives the patient a better facial appearance and better results. ⁸ Fixing the patients cleft nose deformity at the same time as revising the lip is unfortunately the only chance that many patients in these underserviced countries will have to receive surgical care. McCombs sutures are a well-known technique and works well during lip revision.

The technique described in our article has been used successfully on many ORC missions to address the aesthetic needs of patients presenting for revision after previous cleft lip repair at a younger age. The fact that both the lip is revised and the nose is being corrected at the same operation is ideal for patients seen on these surgical missions.