Mohler and Tennison Randall

Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e10
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Journal of Cranio-Maxillo-Facial Surgery

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Variation trends of the postoperative outcomes for unilateral cleft lip

patients by modified Mohler and TennisoneRandall cheiloplasties
Liqi Li, Lishu Liao, Yuxiang Zhong, Yuangui Li, Li Xiang, Wanshan Li*
Oral Department, Children's Hospital, Chongqing Medical University, Chongqing, PR China
a r t i c l e i n f o a b s t r a c t
Article history: Purpose: To evaluate postoperative variation trends of unilateral cleft lip by stages, and to analyze
Paper received 21 July 2015 influential factors of nasolabial symmetry.
Accepted 31 August 2016 Materials and methods: A total of 145 patients with unilateral cleft lip were treated by the modified
Available online xxx
Mohler or TennisoneRandall technique, and received routine anti-scarring treatment postoperatively.
Photogrammetry was applied to respectively measure 5 indices by stages preoperatively, the first week
Keywords:
(1 w), the third month (3 m), the sixth month (6 m), and the first year (1 y) postoperatively. Then we
Unilateral cleft lip
calculated the symmetry ratio and drew line charts. Student t tests were used for any group differences;
Nasolabial symmetry
Variation trend
linear regression analysis was used to examine which postoperative stage correlated best with the
Influential factors preoperative stage; cluster analysis was used to classify the severity of the cleft according to preoperative
Modified Mohler technique SRsn-cphi, which was used to predict the operative difficulty and to select an appropriate technique.
TennisoneRandall technique Results: The Mohler technique yielded a more symmetric result. With the TennisoneRandall technique,
the alar base was more lateral and downward, and the lip height on cleft side seemed longer. A stable
effect emerged around 1 year after surgery with both techniques. Conspicuous scars appeared at 3
months, most scars gradually fade at 6 months, and the total evolution took around 1 year. Scars from the
Mohler technique fluctuated across a larger range. Preoperative SRsn-cphi of the two techniques had
statistical significance and was adopted as the basis for cluster analysis. The critical value was 0.670. The
Mohler technique attained an almost identical effect in each interval, whereas the TennisoneRandall
technique was better in the interval that SRsn-cphi <0.670.
Conclusions: Preoperative SRsn-cphi can be the evaluation index of severity; the modified Mohler
technique is more broadly applicable to differences in severity than is the TennisoneRandall technique.
© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.
1. Introduction seen both revolutionary changes and subtle technical refinements,

and enables surgeons to evaluate both function and aesthetics
Unilateral cleft lip (UCL) is one of the most common oral cleft (Demke and Tatum, 2011). Even though the surgeons endeavor to
deformity. Recently, a slang expression that “It's a face-judging minimize growth disturbances as well as unsightly scars and con-
world” is so prevalent in China that people often use a “Face tour irregularities, many children still show some disfigurement in
Score” to appraise one's features. Apparently, children with clefts the nasolabial area (Fudalej et al., 2009), which attracts consider-
may be hindered from full participation in social life, while their ably more attention than it would without a cleft (Meyer-Marcotty
parents, long for an improved appearance to relieve social pressure et al., 2010). Hence, surgeons endeavor to lengthen the width of the
and feelings of guilt (Xing et al., 2008). A natural-appearing vermilion, lip height, and philtrum height on the affected side
functional repair is crucial for UCL patients. The UCL repair has (Chou et al., 2013).
Until now, the two commonly used techniques for UCL repair
have been Millard's rotation-advancement and TennisoneRandall's
triangular flap repairs (Lee, 1999). These techniques have been
* Corresponding author. Oral Department, Children's Hospital, Chongqing Med- repeatedly used and have withstood the test of time; however,
ical University, 136 Zhongshan Er Road, Yuzhong District, Chongqing, 400014, PR
overall consideration should include the range of application, the
China. Fax: þ86 023 63632433.
E-mail address: cqlwsam2622@163.com (W. Li). scar size and restoration speed, and the influence on nasolabial
http://dx.doi.org/10.1016/j.jcms.2016.08.025
1010-5182/© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Li L, et al., Variation trends of the postoperative outcomes for unilateral cleft lip patients by modified Mohler
and TennisoneRandall cheiloplasties, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.08.025
2 L. Li et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e10
tissue growth. Based on the current findings, nasolabial appearance respectively. Make an incision is made along the lines 6e5e3, 3e9
may be affected more by the nasolabial symmetry and the presence and 4e10 deep to the orbicularis oris, and the rectangular flap and
of residual scar than by the underlying skeletal asymmetry C-flap are respectively formed on the medial segment. Undermine
(Urbanova et al., 2013). Furthermore, subjective evaluation is vital, sharply to free the orbicularis oris from the skin and mucosa, and
but symmetry is easier to evaluate objectively (Komori et al., 2009). cut down its abnormal upturned attachment in the region of the
The measurement data provide a fundamental basis for presurgical alar base, columellar base, and alveolar cleft margin. On the medial
consultation, surgical planning, and postoperative assessment, and segment, the rectangle skin flap and the orbicularis oris rotate at
may serve as a predictor for treatment outcome (Chou et al., 2013). point 6 as the rotational pivot point until points 3 and 1 are at the
Mohler's technique was represented to be one of the currently same horizontal level. Pull the columella upward, move the C-flap
modified techniques in advanced Millard's, but still has some dis- to the non-cleft side, and close the tissue defects caused by
advantages (Cutting and Dayan, 2003). In our clinical experience, removing the rectangle flap downward. The height of the philtral
we have tried to gain symmetric postoperative outcomes by ridge on the cleft side equals the sum of the distance of the straight
continuously reviewing and improving surgical techniques. Hence, lines 5e6 and 3e5. On the lateral segment, advance the orbicularis
the modified Mohler technique (Li et al., 2015) came into being, superio-medially and fill the triangular space, which formed by the
although the TennisoneRandall technique (Randall, 1959), which is orbicularis on the medial segment pulled downward. Move the skin
still representative, has not been completely replaced. In this study, flap 4e10 medially; a new peak of Cupid's bow is formed after
the varied trends of postoperative outcomes in UCL patients were points 3 and 4 are sutured together. To rebuild the continuity of the
evaluated by photogrammetry. Patients underwent repair by the red line and to restore the symmetry of the vermilion, a triangle
modified Mohler and TennisoneRandall techniques, and factors muco-muscular flap from dry vermilion on the lateral segment is
influencing surgical outcomes were comprehensively analyzed, inserted into the triangular space under point 3; similarly, another
such as surgical techniques, scarring, and severity of deformity. triangular muco-muscular flap from wet vermilion on the medial
segment is inserted into the lateral segment, and then the suture is
2. Materials and methods completed.
The TennisoneRandall technique was first proposed by Randall
2.1. Patient selection and study design (Randall, 1959), Fig. 1D shows its operative design. Line 3e11 is
extended medially at a right angle with the line 3e9. Point 11 is
A retrospective study was conducted in patients with UCL usually on about the midline of the philtrum. Its position varies
deformity who underwent primary repair at our department from depending on the size of lateral triangular flap; it should never be
January 2009 to March 2014. The inclusion criteria for the placed beyond the opposite philtral ridge. Points 7 and 8 are usually
study were as follows: 1) UCL patients (except microform) who at the midpoint of the transverse incisions. The difference between
received the modified Mohler technique (Li et al., 2015) or Tenni- 9 and 7 and the length of the philtral ridge on the non-cleft side
soneRandall procedure (Randall, 1959) by the same surgeon; 2) the should equal the distance across the lateral triangular flap (8e4), or
same ethnic group (Han nationality) in the southwest of China; 3) the distance on the cleft side of the Cupid's bow must be brought
no other craniofacial malformations or system diseases; 4) no or- down to bring it into a normal position. The incisions on the medial
thodontic management before or after cheiloplasty; 5) no history of segment cut completely through; point 3 can then be dropped
oral maxillofacial trauma; and 6) no family history of hyperplastic down to a same level with point 1; 9e3 equals 10e16. The location
scar. Patients were excluded if their clinical data were incomplete of point 16 is adjusted according to the distance between 4 and 8.
or if photographs were not available. Postoperatively, the duration Point 15 will vary depending on the tissue available and the size of
of follow-up was 1 year or more, and they were required to return the flap desired, 15e4 equals 15e16. Points 15 and 16 are the most
at appointed times; many of them still participated in outpatient indefinite points in the design and therefore frequently the most
follow-up visits at irregular intervals afterward. The variation difficult to find.
trends of the surgical outcomes at different stages were evaluated
as described below, and values were compared with each other. To
promote the scar softening as quickly as possible, since the third 2.3. Data acquisition
week after surgery, a prednisolone suspension was injected into the
local scar on the affected side, once a week for 4 consecutive weeks, Data were obtained by photogrammetry, which performed on a
and scar massage was performed more than 30 min a day until the personal computer (PC) using Digimizer 4.2.0, an image analysis
scar was completely softened. software developed by MedCalc Software. Frontal facial photo-
Ethical approval was obtained from the Children's Hospital, graphs are the best suited to the analysis of nasolabial symmetry
Chongqing Medical University. Parents of the patients received an (Al-Omari et al., 2005). At the preoperative (pre), the first week
information sheet and signed a consent form. (1 w), the third month (3 m), the sixth month (6 m), and the first
year (1 y) or even longer after surgery, numerous photographs in
2.2. Surgical technique the standard frontal view were respectively taken for each patient
with the same digital camera and the same researcher. Some
The incision design and postoperative result of the modified photos with clearly anatomic landmarks and no significant
Mohler technique are shown in Fig. 1AeC (Li et al., 2015). L is the deformity were selected. Fig. 2 shows the anthropometric points
vertical distance between the points 1 and 3, and represents the and measured distances on both sides. To eliminate the influence of
amount that the lip needs to be lengthened on the cleft side. The photographed parameters and to minimize the comparison errors
straight incision lines are formed by sequential and straight caused by the year-long facial growth (Zhang et al., 2012), the
connection of the points 3, 5 (subnasale, the midpoint on the symmetry ratio (SR) (Li et al., 2015) for each variable was selected to
columellar base), and 6 (the intersection point between the philtral evaluate the outcomes, and SR ¼ cleft counts/non-cleft counts. The
ridge of the non-cleft side and the arc, which is drawn by point 5 as closer the value of SR is to 1, the more symmetrical the area is. Each
the center of the circle and L as the radius). The other two arc picture was measured three times, and the mean value was
incision lines are also formed by connecting points 3 with 9, and obtained to reduce error. All data were obtained and analyzed by a
points 4 with 10 along the white skin roll on the cleft side, single researcher.
L. Li et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e10 3
Fig. 1. Schematic diagram of the incision design and postoperative status with the modified Mohler (AeC) and TennisoneRandall techniques (D, E) for unilateral cleft lip (UCL)
patients. Point 1: the peak of Cupid's bow (cphi) on the non-cleft side; point 2: the midpoint of Cupid's bow; point 3: cphi on the medial segment, and the distances of the lines 1e2
and lines 2e3 are equal; point 4: cphi on the lateral segment, where the vermillion is widest and starts to converge medially; points 9 and 10, at the muco-cutaneous junctions of
the nostril floor of the medial and lateral cleft sides, respectively, ensure equal widths of nasal floor on both sides. (See text for the detailed definition of the other points.)
2.4. Statistical analysis differences between the two techniques and groups or among
different stages with the same technique or in the same group,
All data analyses were performed with SPSS 18.0 (SPSS, Inc., the group Student t test for independent samples or paired
an IBM Company, Chicago, IL, USA). Variation trends from the samples was used. A P value <0.05 was used to indicate statistical
different surgical methods were depicted by line charts. For any significance.
Fig. 2. Anthropometric points and measured distances on the cleft side and the non-cleft side. Among them are the following: sn, subnasale; cphi, the peak of Cupid's bow; sbal,
subalare, the most inferior point of the alar base; ch, cheilion; sn-cphi, distance between cphi and sn; ch-sbal, the distance between sbal and ipsilateral ch; ch-cphi, distance
between cphi and ipsilateral ch; cphi-sbal, distance between cphi and ipsilateral sbal; vh, vermilion height.
Fig. 3. Photographs of complete cleft lip patients based on the Mohler technique preoperatively and in the first week, third month, sixth month, first year, and around the fifth year
postoperatively.
In the clinic, we found that the reconstruction of lip height was 3. Results
more difficult than the closure of cleft, and also the key of the
cheiloplasty. Therefore cluster analysis was used to divide all of the In our study, 145 UCL patients met the inclusion criteria.
preoperative SRsn-cphi into two groups and produce a cutoff value Among them, 91 patients underwent the modified Mohler
that made the two groups have a remarkable gap. Then the char- technique (51 males and 40 females; 42 complete and 49
acteristics of the modified Mohler and TennisoneRandall technique incomplete clefts; age 2.33 monthse17.00 months, average 3.89
were evaluated by two series of variation trends. months), and the remaining 54 patients underwent the classical
Simultaneously, to identify the most likely recovery stage after TennisoneRandall procedure (28 males and 26 females; 15
surgery, and to evaluate the correlation between preoperative complete and 39 incomplete clefts; age 2.43 monthse12.43
SRsn-cphi and the other SRsn-cphi at different postoperative months, average 3.94 months). The patients who underwent repair
stages, linear regression analysis was used to probe into the most with the modified Mohler or TennisoneRandall technique are
relevant stage. depicted in Figs. 3e5.
Fig. 4. Photographs of complete cleft lip patients based on the TennisoneRandall technique preoperatively and in the first week, third month, sixth month, first year, and around the
fifth year postoperatively.
Fig. 5. Photographs of patients with incomplete cleft lip based on the Mohler and TennisoneRandall techniques preoperatively and in the first week, third month, sixth month, and
first year postoperatively.
Conspicuous polymorphic scars appeared at period 3 m; most presented shorter except 3 m after surgery, and SRsbal-cphi also
scars faded approximately 6 months later, and scar evolution took had apparent differences except pre. SRcphi-ch and SRvh had no
around 1 year. Scars from the Mohler technique fluctuated across a difference except 3 m after surgery. Statistical results are shown in
larger range. Fig. 6 visually represents the general trends with the Fig. 6. Under the modified Mohler, sn-cphi on the cleft side seemed
two techniques at the different stages. Table 1 shows a pairwise longer at 1 w and became shorter at 3 m. From 6 m to 1 y, it was
comparison of the different intervals of each index under the two increasingly equal to the non-cleft side in comparison to 1 w.
techniques. Sn-cphi on the cleft side with the Tennison technique Sbal-ch was shorter at 1 w and even shorter at 3 m; from 6 m to 1 y
was longer than with Mohler, and SRsn-cphi all had statistical it became longer, but showed no significant difference with that at
significance at each time point. Although sbal-ch was opposite 1 w. Sbal-cphi was always shorter; at 3 m it stayed the shortest and
except pre- and SRsbal-ch, all had no statistical significance except at 6 m it was superior to 1 w; at 1 y it was closest to the non-cleft
1 w after surgery. Moreover, sbal-cphi on the cleft side in Tennison side. Cphi-ch was even longer at 3 m; since 6 m it began to recover,
Fig. 6. The two techniques (red: modified Mohler; blue: TennisoneRandall): general trends of SRsn-cphi, SRsbal-ch, SRsbal-sphi, SRcphi-ch, and SRvh shown visually by line charts.
Table 1 Cupid's bow (Schendel, 2000). In our study, through contrasting the
Pairwise comparison in the different intervals of each index under the two tech- modified Mohler and TennisoneRandall techniques, SRsn-cphi had
niques (M: modified Mohler; T: TennisoneRandall).
statistical significance at each time point, whereas SRsbal-ch was
P value sn-cphi ch-sbal cphi-sbal ch-cphi vh the opposite except 1 w after surgery; SRsbal-cphi also had an
Pre vs 1 w PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 e apparent difference except pre, and SRcphi-ch and SRvh had no
PT ¼ 0.000 PT ¼ 0.000 PT ¼ 0.000 PT ¼ 0.000 difference except 3 m after surgery.
Pre vs 3 m PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 e SRsn-cphi is the symmetry ratio of the distances between cphi
PT ¼ 0.000 PT ¼ 0.027 PT ¼ 0.756 PT ¼ 0.000
and sn on both sides, and indirectly reflected the height of the
Pre vs 6 m PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 e
PT ¼ 0.000 PT ¼ 0.000 PT ¼ 0.001 PT ¼ 0.000 philtral crest on the affected side. The surgical plan will decide the
Pre vs 1 y PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 e height of the lip (LeMesurier, 1949). The vertical height of the lip
PT ¼ 0.000 PT ¼ 0.000 PT ¼ 0.001 PT ¼ 0.000 can become too long due to faulty design rather than abnormal
1 w vs 3 m PM ¼ 0.000 PM ¼ 0.005 PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000
growth (Sawhney, 1972). Cutting and Dayan (2003) found that the
PT ¼ 0.000 PT ¼ 0.049 PT ¼ 0.000 PT ¼ 0.958 PT ¼ 0.000
1 w vs 6 m PM ¼ 0.000 PM ¼ 0.323 PM ¼ 0.004 PM ¼ 0.001 PM ¼ 0.000
outcomes after repair using the Millard technique tended to result
PT ¼ 0.008 PT ¼ 0.325 PT ¼ 0.247 PT ¼ 0.646 PT ¼ 0.001 in an unacceptably short lip on the cleft side (Li et al., 2015; Xing
1 w vs 1 y PM ¼ 0.000 PM ¼ 0.113 PM ¼ 0.000 PM ¼ 0.099 PM ¼ 0.002 et al., 2008). Chou et al. (2013) held the view that symmetry in
PT ¼ 0.000 PT ¼ 0.236 PT ¼ 0.082 PT ¼ 0.313 PT ¼ 0.008 the lip height was more important than that of the lateral lip length,
3 m vs 6 m PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000
and their original surgical techniques had been modified. To over-
PT ¼ 0.053 PT ¼ 0.119 PT ¼ 0.000 PT ¼ 0.769 PT ¼ 0.000
3 m vs 1 y PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 PM ¼ 0.000 come these shortcomings, we modified the Mohler technique
PT ¼ 0.765 PT ¼ 0.026 PT ¼ 0.000 PT ¼ 0.388 PT ¼ 0.006 based on geometric principles (Li et al., 2015). In the operation, the
6 m vs 1 y PM ¼ 0.001 PM ¼ 0.948 PM ¼ 0.001 PM ¼ 0.134 PM ¼ 0.000 uppermost point of the rotation incision (point 5) is marked as sn. L
PT ¼ 0.183 PT ¼ 0.040 PT ¼ 0.179 PT ¼ 0.510 PT ¼ 0.755 is the vertical height difference between the cphi on both sides
Comment: paired t-test was applied to pairwise compare every two time intervals, (points 1 and 3). The lowermost point (point 6) is related to the L
which were aimed at significant change. value; the intersection point is between the normal philtral column
and the arc, of which point 5 is the center and L is the radius; the
and it returned to the 1 w level at 1 y. Vh became the most serious
rotation incision runs straight from point 6 upward to point 5, and
at 3 m and until 1 y, as it still failed to recover to the 1 w level (the
turns down to point 3. The A-flap rotates at point 6 to be the
most symmetrical state). With the TennisoneRandall technique,
rotational pivot point until points 3 and 1 stay at the same hori-
sn-cphi on the cleft side seemed longer at 1 w, and since 3 m it
zontal level, and its remaining tissue defects are filled by the C-flap
became shorter but was still a little longer than the non-cleft side
moving medially, then equally long bilateral philtral columns are
and was similar at 6 m and 1 y (P > 0.05). Sbal-ch was shortest at
obtained (Li et al., 2015). The characteristics of marking accurately
3 m; since 3 m it began to recover, but was slightly shorter than that
and less flexibly can ensure stable outcomes, and the less experi-
on the non-cleft side; there were no significant difference among
enced surgeons can utilize this technique skillfully. Nevertheless,
1 w, 6 m, and 1 y. Sbal-cphi was also similar to sbal-ch. Cphi-ch was
under the TennisoneRandall technique, the height of philtral ridge
in relative steady state, and there was no significant difference
on the cleft side equals the sum of 9e7 and 10e8, and the points 7
except pre; although until at 1 y vh still failed to recover to the level
and 8 are located respectively at the midpoint of the transverse
of 1 w, it avoided drastic changes like the modified Mohler's
incisions 3e11 and 15e16. Moreover, points 11, 15, and 16 are the
technique.
most indefinite points in the design. Point 11 varied depending on
Cluster analysis showed that 145 values of preoperative
the size of lateral triangular flap, point 16 is adjusted according to
SRsn-cphi were divided into two parts, of which the critical value
the distance between 4 and 8, and point 15 will vary depending on
was 0.670. SRsn-cphis less than 0.670 were classified as Group a,
the tissue available and the size of the flap desired (Randall, 1959).
which seemed more severe; those greater than 0.670 were
In our study, even for a surgeon with more than 20 years' experi-
classified as Group b. With the modified Mohler technique,
ence, marking these points is not easy. Postoperatively, we found
whether preoperative SRsn-cphi is more or less than 0.670, a nearly
the outcomes were unsatisfactory: the lip height with the Tenni-
identical surgical effect can be attained, except that the index
soneRandall technique is always too long. It was similar to the
SRsbal-ch is better in Group b. With the TennisoneRandall tech-
results reported by Xing et al. (2008). Simultaneously, when
nique, the index SRsn-cphi and SRsbal-cphi both demonstrate that
comparing with modified Mohler technique, the oblique nasal
the technique is well done in Group a (SRsn-cphi <0.670); Group b
columella still existed due to the orbicularis oris ring not having
seemed to present with an overly long lip height. The general
been rebuilt (Randall, 1959) and point Sn was located more toward
trends of each index by the different techniques are displayed in
the non-cleft side. This may be the partial reason that Sn-cphi was
Fig. 7. Statistical differences between groups are listed in Table 2.
longer on the cleft side, and SRsn-cphi was larger than achieved
Linear regression analysis found that SRsn-cphi at period 1 y
with the modified Mohler technique postoperatively. However,
was the most positively relevant to the preoperative period than
other authors did not observe any major difference in the overall
other periods by both techniques, and a stable effect emerged
postoperative appearance (Chowdri et al., 1990; Fudalej et al., 2009;
around 1 year after surgery. It also shows that the preoperative
Holtmann and Wray, 1983; Raschke et al., 2012) except for a greater
SRsn-cphi was nearer to 1 the better the postoperative effect was.
incidence of hypertrophic scars after the rotation-advancement
Results are shown in Figs. 8 and 9. The modified Mohler technique
technique (Chowdri et al., 1990; Holtmann and Wray, 1983).
yielded a more symmetric result.
Subalare (sbal) mainly affects the ch-sbal and cphi-sbal. The
ch-sbal depends on the locations of sbal and ch, but the cheilion
4. Discussion (ch) is stationary. Preoperatively, we found that the alar base on the
cleft side was located laterally and downwardly. Postoperatively,
4.1. Surgical techniques' impact on the postoperative outcomes SRsbal-ch in the TennisoneRandall technique was smaller than
that obtained with the modified Mohler technique. The
Although lack of direct outcome and unequivocal conclusions, modified Mohler technique can promote point sbal moving
Schendel still noted that surgical techniques might affect the superior-medially (Li et al., 2015), but the TennisoneRandall
position of the scar, length of the reconstructed lip, or shape of technique cannot correct the abnormal attachment of musculus
Fig. 7. The two techniques (left: modified Mohler; right: TennisoneRandall) general trends of SRsn-cphi, SRsbal-ch, SRsbal-sphi, SRcphi-ch and SRvh after cluster analysis.
orbicularis oris and malpositioning of nasal alar cartilage (Randall, The cphi on the cleft side will affect ch-cphi and sbal-cphi on the
1959), which resulted in the position of the alar base being more cleft side and the fullness of the vermilion. In our study, the point is
normal after the Millard repair, while the alar base was laterally uniformly marked on the Noordhoff point where the vermilion is
displaced by the triangular flap repair (Cutting et al., 1989). It had widest and starts to converge medially with the two techniques (Li
been generally accepted that muscle repair was vital in order to et al., 2015; Randall, 1959). Postoperatively, SRsbal-ch, SRcphi-ch
mould the distorted premaxilla back into proper position by the and SRvh have no difference, except for individual time point.
repaired lip (Kim et al., 2011). Yamada et al. (2002) concluded that However, compared with the modified Mohler, SRsbal-cphi in the
the rotation-advancement method produced somewhat better re- TennisoneRandall technique was shorter due to the alar base being
sults: notably, the shape of the nose and nostril was more favorable. more lateral and downward. We obtained the same results as other
authors (Chou et al., 2013; Schendel, 2000; Yamada et al., 2002).
Table 2
The statistical difference between the groups after cluster analysis under the two
techniques.
4.2. Impact of scars on postoperative outcomes
Index P value in different measurement time interval

The process of scar formation and evolution is one of the main
Pre 1w 3m 6m 1y reasons that each measured index under the two techniques at
sn-cphi Mohler 0.000 0.890 0.238 0.228 0.114 different stages changes. Except for fetal scarless wound healing
Tennison 0.000 0.760 0.336 0.438 0.017 (Walmsley et al., 2015), scar is an inevitable complication of post-
sbal-ch Mohler 0.271 0.277 0.090 0.312 0.017 operative wound healing (Zhu and Li, 2011). Clinical appearances
Tennison 0.053 0.341 0.025 0.270 0.522
manifest as an aberrant color, increased thickness, irregular surface,
sbal-cphi Mohler 0.004 0.003 0.671 0.066 0.532
Tennison 0.548 0.817 0.055 0.364 0.048 loss of elasticity, and contraction (Van de Kar et al., 2005). Multiple
cphi-ch Mohler 0.222 0.480 0.666 0.233 0.601 factors lead to the typical features of a postoperative scar, which
Tennison 0.894 0.992 0.262 0.982 0.239 include location, size, tension, suture, wound care, and individual
vh Mohler e 0.433 0.537 0.525 0.719 age, race/ethnicity, and genetic predisposition, among other factors
Tennison e 0.074 0.065 0.291 0.201
(Frans et al., 2012; Knapp, 1986; Tamada and Nakajima, 2010).
Fig. 8. Regression analysis results of SRsn-cphi between the preoperative period and the period 1 year after surgery in modified Mohler techniques.
Certainly, for UCL patients, other factors will also affect the scarring crease (Li et al., 2015). Moreover, the TennisoneRandall technique
on the repaired side, such as the surgical design, anatomically would produce a Z-shaped scar above the white roll on the cleft
appropriate muscle reconstruction, traumatic severity and extent, side, which was the most protuberant location of the upper lip
and surgeon experience, among others (Tamada and Nakajima, (Randall, 1959) and easily attracted people's attention. The
2010). photographs and objective data of the UCL patients also supported
Various surgical techniques produce various scars. Christofides these results.
et al. (2006) evaluated postoperative scars from the Millard pro- Scars evolve over time, and amelioration of the scar continues
cedure by dividing the scar into three portions, and concluded that with increasing age (Bond et al., 2008; Frans et al., 2012). After
more complications involved the upper and lower portions than injury, initially good results begin to deteriorate over time, typically
the middle one. Tamada and Nakajima (2010) observed that the from 14 to 21 days, and a mature scar is formed after 3e4 months.
Millard technique left a conspicuous scar at the alar base and across Most scars fade after approximately 7 months, and scar evolution
the philtrum. In our study, the modified Mohler technique resulted takes at least 12 months. Hypertrophic scars have a rapid growth
in two longitudinal scars and one transverse scar. Among them, one phase over a period of 1e3 years (Walmsley et al., 2015). The
vertical scar was shorter, and was hidden in the philtral dimple process of contraction is also considered beneficial for obtaining
underneath the nasal columella; the other vertical scar was longer, rapid wound closure (van Zuijlen et al., 2002). In our study, the
and almost consistent with the normal philtral column, and variation trend of each index was also mainly connected with the
simulated the unaffected philtral edge; the transverse one scar contraction, fading, and regression. Scar contraction was most
crossed the philtral column slightly. We also avoid the Millard obvious at the third month after operation, and resulted in
technique-associated unattractive horizontal scar around the alar conspicuous and polymorphic scars and the cphi on the cleft side
Fig. 9. Regression analysis results of SRsn-cphi between the preoperative period and the period 1 year after surgery in TennisoneRandall techniques.
moving upwardly, after which SRsn-cphi and SRsbal-cphi became 5. Conclusions

smaller, SRch-cphi and SRvh became larger. Presumably, scar
contraction on the nasal base may be beneficial for SRsbal-cphi; By evaluating postoperative variation trends of modified Mohler
that is, as time went by, it showed increasing symmetry, and TennisoneRandall technique results with photogrammetry, we
especially with the Mohler technique. Due to the straight scar of draw the following conclusions. (1) Preoperative SRsn-cphi can be
the modified Mohler technique and the Z-shaped scar of the selected as evaluation index of severity, with 0.670 as the critical
TennisoneRandall technique, the scar contraction was significantly value. (2) The modified Mohler technique can be applied to defects
greater than the latter. Significant differences existed between of any degree of severity, whereas the TennisoneRandall technique
Mohler and Tennison technique at the third month after surgery, is suitable for the interval that SRsn-cphi <0.670. (3) Conspicuous
except SRsbal-ch, as scars of Mohler appeared fluctuated across a scars appear at 3 months postoperatively, most scars gradually fade
larger range, which was distributed on the white roll as well as at 6 months, and the total evolution takes around 1 year. (4)
mucosa, alar base, and philtrum. Problems with SRsn-cphi being longer on the cleft side invariably
Intralesional injection of prednisolone suspension can influence arise when using the TennisoneRandall technique.
collagen synthesis in scars (Knapp, 1986; Walmsley et al., 2015). To accurately see the mistakes and the successes that different
Massage and stretching over the long term may relieve contracture, surgical techniques may offer, we should further expand the
break the line of scar tension, and improve collagen cross-linking sample size to increase the evaluation methods available.
(Davis, 1931). To promote scar softening as quickly as possible, Moreover, in our study, the longest assessment interval was only 1
since the third week after surgery, the prednisolone suspension year postoperatively; this should be extended in order to eliminate
was injected into the local scar on the affected side, once a week for the influence of maxillary and mid-face growth.
4 consecutive weeks, and scar massage was done more than 30 min
a day until the scar was completely softened. Treatment of the scar Sources of support in the form of grants
has also included reoperation, irradiation, and so forth (Walmsley
et al., 2015). None.
4.3. Selection of surgical techniques and lip height difference References
Johnson et al. (2000) investigated the importance of initial cleft Al-Omari I, Millett DT, Ayoub AF: Methods of assessment of cleft-related facial
deformity: a review. Cleft Palate Craniofac J 42: 145e156, 2005
severity in determining patient outcome, and Tamada and
Bond JS, Duncan JA, Mason T, Sattar A, Boanas A, O'Kane S, et al: Scar redness in
Nakajima (2010) found that the type of cleft will affect the humans: how long does it persist after incisional and excisional wounding.
long-term stability of the nasal contour, the vermilion symmetry, Plast Reconstr Surg 121: 487e496, 2008
and the maxillary profile. However, Hurwitz et al. (1999) found a Chou PY, Luo CC, Chen PK, Chen YR, Samuel NM, Lo LJ: Preoperative lip measure-
ment in patients with complete unilateral cleft lip/palate and its comparison
weak direct correlation between severity of deformity and with norms. J Plast Reconstr Aesthet Surg 66: 513e517, 2013
outcome. To examine excellent or poor postoperative results, Chowdri NA, Darzi MA, Ashraf MM: A comparative study of surgical results with
important determinants should be carefully analyzed based on rotation-advancement and triangular flap techniques in unilateral cleft lip. Br J
Plast Surg 43: 551e556, 1990
specific features. So far, however, there are no widely accepted Christofides E, Potgieter A, Chait L: A long term subjective and objective assessment
quantitative indices to accurately evaluate the severity of the of the scar in unilateral cleft lip repairs using the Millard technique without
patients with UCL deformity. revisional surgery. J Plast Reconstr Aesthet Surg 59: 380e386, 2006
Cutting CB, Bardach J, Pang R: A comparative study of the skin envelope of the
In the clinic, we found that the reconstruction of lip height is unilateral cleft lip nose subsequent to rotation-advancement and triangular flap
more difficult than the closure of cleft, and it is also the key to lip repairs. Plast Reconstr Surg 84: 409e417, 1989 discussion 418e419
cheiloplasty. In the modified Mohler technique, no matter how Cutting CB, Dayan JH: Lip height and lip width after extended Mohler unilateral
cleft lip repair. Plast Reconstr Surg 111: 17e23, 2003 discussion 24e26
complete or incomplete the clefts, once the height difference of
Davis JS: The relaxation of scar contractures by means of the Z-, or reversed Z-type
bilateral philtral crests exceeds 5 mm, a simple C-flap cannot incision: stressing the use of scar infiltrated tissues. Ann Surg 94: 871e884,
completely fill the defect. In order to completely close the 1931
Demke JC, Tatum SA: Analysis and evolution of rotation principles in unilateral cleft
defect, we must extend the C-flap to the inner aspect of the
lip repair. J Plast Reconstr Aesthet Surg 64: 313e318, 2011
columella and rotate outwardly (Li et al., 2015). Based on these Frans FA, van Zuijlen PP, Griot JP, van der Horst CM: Assessment of scar quality after
clinical characteristics, we adopt the preoperative SRsn-cphi cleft lip closure. Cleft Palate Craniofac J 49: 171e176, 2012
(indirectly reflect the height difference of bilateral philtral Fudalej P, Katsaros C, Bongaarts C, Dudkiewicz Z, Kuijpers-Jagtman AM: Nasolabial
esthetics in children with complete unilateral cleft lip and palate after 1- versus
crests) as an indicator to evaluate the cleft severity in UCL 3-stage treatment protocols. J Oral Maxillofac Surg 67: 1661e1666, 2009
patients, rather than the type of cleft. In our study, the Holtmann B, Wray RC: A randomized comparison of triangular and rotation-
SRsn-cphi of patients with partial incomplete cleft was smaller advancement unilateral cleft lip repairs. Plast Reconstr Surg 71: 172e179, 1983
Hurwitz DJ, Ashby ER, Llull R, Pasqual J, Tabor C, Garrison L, et al: Computer-assisted
than in patients with complete cleft. Cluster analysis was an anthropometry for outcome assessment of cleft lip. Plast Reconstr Surg 103:
effective statistical method to distinguish the severity, which 1608e1623, 1999
produced a critical value. We found that the critical value was Johnson N, Williams A, Singer S, Southall P, Sandy J: Initial cleft size does not
correlate with outcome in unilateral cleft lip and palate. Eur J Orthod 22:
0.670, and preoperative SRsn-cphi less than 0.670 seemed more 93e100, 2000
severe. In order to test each technique's range of application in Kim JB, Strike P, Cadier MC: A simple assessment method for auditing multi-centre
regard to different cleft severity, the UCL patients undergoing unilateral cleft lip repairs. J Plast Reconstr Aesthet Surg 64: 195e200, 2011
Knapp TR: Plastic surgery: keloid and hypertrophic scar. West J Med 145: 507e508,
the two techniques were divided into two groups according to 1986
the preoperative SRsn-cphi; Group a contained patients with Komori M, Kawamura S, Ishihara S: Averageness or symmetry: which is more
more severe clefts and Group b the less severe. Data and important for facial attractiveness. Acta Psychol (Amst) 131: 136e142, 2009
Lee TJ: Upper lip measurements at the time of surgery and follow-up after modified
statistical analysis demonstrated that for the Tennison technique,
rotation-advancement flap repair in unilateral cleft lip patients. Plast Reconstr
the patients in Group a performed better based on SRsn-cphi Surg 104: 911e915, 1999
and SRsbal-cphi, and Group b had an overly long lip height. LeMesurier AB: A method of cutting and suturing the lip in the treatment of
The Mohler technique had a wider application rage. For complete unilateral clefts. Plast Reconstr Surg (1946) 4: 1e12, 1949
Li L, Liao L, Zhong Y, Li Y, Xiang L, Li W: A modified Mohler technique for patients
SRcphi-ch and SRvh, both were not only affected by severity of with unilateral cleft lip based on geometric principles e a primary report.
cleft, but also surgical techniques over time. J Craniomaxillofac Surg 43: 663e670, 2015
Meyer-Marcotty P, Gerdes AB, Reuther T, Stellzig-Eisenhauer A, Alpers GW: Van de Kar AL, Corion LU, Smeulders MJ, Draaijers LJ, van der Horst CM, van
Persons with cleft lip and palate are looked at differently. J Dent Res 89: Zuijlen PP: Reliable and feasible evaluation of linear scars by the patient and
400e404, 2010 observer scar assessment scale. Plast Reconstr Surg 116: 514e522, 2005
Randall P: A triangular flap operation for the primary repair of unilateral clefts of van Zuijlen PP, Angeles AP, Kreis RW, Bos KE, Middelkoop E: Scar assessment tools:
the lip. Plast Reconstr Surg Transplant Bull 23: 331e347, 1959 implications for current research. Plast Reconstr Surg 109: 1108e1122, 2002
Raschke GF, Rieger UM, Bader RD, Schultze-Mosgau S: Lip reconstruction: an Walmsley GG, Maan ZN, Wong VW, Duscher D, Hu MS, Zielins ER, et al: Scarless
anthropometric and functional analysis of surgical outcomes. Int J Oral wound healing: chasing the Holy Grail. Plast Reconstr Surg 135: 907e917, 2015
Maxillofac Surg 41: 744e750, 2012 Xing H, Bing S, Kamdar M, Yang L, Qian Z, Sheng L, et al: Changes in lip 1 year after
Sawhney CP: Geometry of single cleft lip rapair. Plast Reconstr Surg 49: 518e521, modified Millard repair. Int J Oral Maxillofac Surg 37: 117e122, 2008
1972 Yamada T, Mori Y, Minami K, Mishima K, Sugahara T: Three-dimensional facial
Schendel SA: Unilateral cleft lip repairestate of the art. Cleft Palate Craniofac J 37: morphology, following primary cleft lip repair using the triangular flap with or
335e341, 2000 without rotation advancement. J Craniomaxillofac Surg 30: 337e342, 2002
Tamada I, Nakajima T: Detailed assessment of cleft lip scar following straight line Zhang R, Li J, Zheng Q, Shi B, Li S, Wang Y, et al: Symmetry in nasolabial area of UCCL
repair. J Plast Reconstr Aesthet Surg 63: 282e288, 2010 patients one year after primary lip repair with modified Millard technique. Oral
Urbanova W, Brudnicki A, Strydom H, Bronkhorst EM, Katsaros C, Fudalej PS: Surg Oral Med Oral Pathol Oral Radiol 114: S11eS18, 2012
Nasolabial aesthetics correlates poorly with skeletal symmetry in unilateral Zhu Q, Li J: A combined candidate therapy for the scar-free repair of cleft lip based
cleft lip and palate. J Plast Reconstr Aesthet Surg 66: e1e7, 2013 on inhibitors of TGF-beta. Med Hypotheses 76: 86e88, 2011

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Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e10

Contents lists available at ScienceDirect

Journal of Cranio-Maxillo-Facial Surgery

Variation trends of the postoperative outcomes for unilateral cleft lip

1. Introduction seen both revolutionary changes and subtle technical reﬁnements,

Index P value in different measurement time interval

moving upwardly, after which SRsn-cphi and SRsbal-cphi became 5. Conclusions

4.3. Selection of surgical techniques and lip height difference References

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