by Erin M. Taylor, MD (@ErinTaylor_Surg)
The article in the August edition of #PRS entitled “Direct Anthropometry of Repaired Bilateral Complete Cleft Lip: A Long-Term Assessment” by David C. Kim, M.D. and John B. Mulliken, M.D. provided an in-depth examination of changes in nasolabial features of complete bilateral cleft lip repair over time.
The article used anthropometry measurements in patients undergoing complete bilateral cleft lip repair with the goal to understand nasolabial changes over time and incorporate this knowledge into an operative strategy. Anthropometry measurements were performed preoperative and immediately postoperative in 174 patients who underwent bilateral complete cleft lip nasolabial repair by the senior author (J.B.M.) between 1990-2014. Serial anthropometry measurements were recorded in 66 Caucasian patients (46 male, 20 female) between the ages of 6 months to 6 years old, which were compared to respective age and sex-matched Farkas’ controls. Because upper philtral width was not included in Farkas’ controls, philtral width measurements were performed in 454 non-syndromic Caucasian male and female subjects, aged 1 to 18 years.
The operative technique sought to design fast-growing nasolabial features to be smaller than normal and slow-growing features to be larger than normal, with the exception of the medial tubercle, which was made as full as possible at the time of primary repair. Results demonstrated that inter-medial canthal width was above average and remained within normal limits through puberty, interalar width was narrowed initially and slightly wider through adolescence, columellar height and nasal projection both were made slightly long and paralleled normal growth, cutaneous philtral length was made from the available length in primary repair but remained short, and the philtrum was made narrow and matched normal values throughout adolescence. The normal inferior/superior philtral width ratio was 1.60 in females and 1.59 in males, which interestingly was close in value to the divine ratio (1.618). The median tubercle was made as full as possible on primary repair, with 18% (31/174) of patients requiring secondary augmentation with dermal graft.
Based on this retrospective analysis, the following recommendations were made for the primary repair of bilateral complete cleft lip: design the philtral flap 2 to 2.5mm at columellar-labial junction (cphs-cphs) and 4 to 4.5mm between peaks of Cupid’s bow (cphi-cphi), use full height of cutaneous prolabium (sn-ls) with 7-8mm if available, build median tubercle (ls-sto) as full as possible, construct the columella (sn-c) at least 4-5mm in length but no longer than 7mm, and narrow the interalar distance (al-al) to 24mm or less.
In conclusion, the proposed operative strategy was to design fast-growing features on a small scale and slow-growing features on a large scale at the time of primary repair, except for the median tubercle, which should be made as full as possible. In particular, nasal width, philtral height, and median tubercle size deserve special attention in primary nasolabial repair of bilateral complete cleft lip.
- Kim, David C., Muliken, John B. Direct Anthropometry of Repaired Bilateral Complete Cleft Lip: A Long-Term Assessment. Plast Reconstr Surg. 2017;140(2):326E-332E.