|Year : 2021 | Volume
| Issue : 2 | Page : 163-168
Triangular flap technique for unilateral cleft lip deformity
Ramesh Kumar Sharma
Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||05-May-2021|
|Date of Acceptance||05-May-2021|
|Date of Web Publication||7-Jun-2021|
Dr. Ramesh Kumar Sharma
Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
The triangular flap lip repair is one of the two main techniques used for the correction of a cleft lip deformity worldwide. Many surgeons in Indian subcontinent and Europe use the triangle flap technique as their first choice. This CME article describes the details of the triangular flap technique as modified by Dr. C P Sawhney. The rationale of the technique, lip markings, planning of incisions, and the detailed operative steps are described. The merits and demerits of this versatile technique are also discussed.
Keywords: Cleft lip, complete and incomplete, repair, triangular flap technique
|How to cite this article:|
Sharma RK. Triangular flap technique for unilateral cleft lip deformity. J Cleft Lip Palate Craniofac Anomal 2021;8:163-8
| Introduction|| |
The cleft of the lip is a birth blemish that stares us in the face and is a major social stigma. Its management has always been incredibly challenging. It has taxed the ingenuity of the reconstructive surgeons, and many innovative methods have been described for its management. The earlier techniques simply aimed at pairing the edges of the defect and suturing which resulted in suboptimal outcomes. In later years, the various components of the lip defect were analyzed, and attempts were made to match the repaired lip with the normal side. It was also felt that there is deficiency of tissue in the region of the cleft that needs to be replaced by bringing in extra tissue from the other side. Today, various methods of lip repair can be categorized as either modifications of triangular flap or rotation advancement techniques or as hybrid techniques that are inspired by both. Majority of the surgeons today use Millard's rotation advancement technique or its variants. However, Tennison's triangular flap technique is also used by a large number of the surgeons, especially in the Indian subcontinent. There have been recommendations that rotation advancement should be reserved for the narrow clefts, and the triangular flap technique should be used for wider clefts. However, the author feels that any of these two techniques can be used for correction of the whole spectrum of cleft lip defects. Holtmann and Wray concluded that the overall appearance of lip and nose postoperatively has been almost similar in both the rotation advancement and triangular flap methods. Any of these standard techniques can give acceptably pleasing esthetic results if executed properly. The choice of technique in clinical practice is primarily guided by the surgeon's training during the formative year.
| Anatomy of Unilateral Cleft Lip Deformity|| |
The normal lip consists of well-formed cupids bow that has highest points called “peak” on either side of midline (points “1, 3”;) and a “beak” or trough in the midline of the bow (point “2”). This cupid bow is symmetrical both in its height and transverse dimensions [Figure 1], left]. However, cleft lip can be visualized as “split” into two segments, namely the medial and the lateral segment, each carrying the “cupids peak.” These “peak” points can be identified on both these segments by locating the “thickest point of the white roll just before thinning.” It can be noted very clearly that this “peak” on the medial segment is located at a higher level than its counterpart on the normal side [Figure 1], right]. Moreover, the Cupid's bow is displaced toward the cleft side and rotated superiorly into a position that is oblique to the horizontal facial plane.
|Figure 1: Anatomy of the normal and cleft lip. Landmarks of the cupids bow are marked. On left side figure, point 1, 3 are cupids peaks and point 2 is cupids beak in a normal lip;on right side figure the cupids peak is marked at point 3 on medial and lateral segment|
Click here to view
There is discontinuity of the underlying orbicularis muscle in the presence of a complete cleft. The discontinuous muscle is abnormally attached along the pyriform margin on medial and lateral segment of the cleft lip. In incomplete lip, the muscle discontinuity is not complete. The free edges of the muscles can be seen as bulges in both the cleft segments. The ala tends to sag and displaced inferiorly and posteriorly. This can get further accentuated because of associated cleft of the upper alveolus. The columella is deviated to the normal side, presumably because of the pull of orbicularis and deviated septum. These findings are illustrated both in complete and incomplete lip in [Figure 2].
|Figure 2: The abnormal anatomy in cleft lip in a complete (upper row) and an incomplete (lower row) cleft case|
Click here to view
| Execution of Triangular Flap Technique|| |
The preliminary step in any cleft repairs is to define the cupids peak on the normal side as well as on the medial and lateral segment of the cleft side of the lip. The aim of any lip repair technique is to bring down the vertically short medial segment so that its “cupids peak” point matches the “cupids peak” on the normal side. However, doing so will create a defect in the medial segment at a location depending on where a back cut is made. In triangular flap technique, this defect is created at the lower part of the lip. The defect so created in the medial segment would need to be filled up by importing tissue from the lateral segment. A full-thickness triangle is designed on the lateral segment which can then be used to fill the defect on the medial segment. In 1952, Tennison described his stencil method, in which he “preserved” the Cupid's bow and used a segment of wire to develop the surgical measurements. This method was subsequently modified by Randall in 1958 and Hagerty in 1959. Cardosa recommended the use of calipers instead of wire. Cronin also suggested some modifications in the Tennison repair in 1966. Subsequently, Sawhney described precise geometrical basis of this technique. Goulian et al. made further refinements in 1987. This CME article is based upon Dr. Sawhney's modification of the Tennison-Randall's technique.
The technique essentially consists of calculating the vertical deficiency in the medial segment of the cleft lip. The shorter medial segment of the lip is brought down by creating a back cut. This would create a defect in the medial segment which is filled by a triangle designed on the lateral segment.
The following description will discuss the exact planning and execution of the triangular flap technique.
| Markings in Complete Cleft Lip|| |
Marking the key landmarks
- The peak of the cupid's bow is also marked on the normal side (point “1”;)[Figure 3]
- The midpoint of the columella is marked “a.” The marking can be facilitated if the deviated columella is brought to normal position by pushing the lip or using a skin hook to lift the affected alar rim. Point “2” is marked at the lowest point of the cupids bow (also called as “beak”). The line “a-2” joining these two points will be the midline of the lip. It is important that no incision should cross this line
- The white line is followed from midline along the medial segment, and a point “3” is marked where it is thickest just before thinning. A similar point is marked on the lateral segment white line where it is thickest just before thinning
- Alar basal points “b” are marked both on the medial and lateral side of the cleft. These points are marked at a place where the alar rim joins the lip on the medial and lateral part of the cleft, respectively.
|Figure 3: Markings in a complete cleft lip. The area marked in green shadow will form “M” and “L” flaps|
Click here to view
Calculating the drop needed on the medial segment
The drop required in the medial segment is determined by drawing perpendiculars from point “3“ and point “1.” The point “3” needs to be dropped by a distance equal to “x” to match the height of the peak of cupids bow on the normal side at point “1”; of the lip.
Creating a drop in the medial segment
The line “;3–4” represents the back cut that will be required to drop the point “3” to the level of point “1.” It should be noted that line “3–4”; does not cross the midline, otherwise the lip on the normal side will also get lengthened. It is suggested to keep line “3–4” as a 90° horizontal to midphiltral line “a-2.”
Calculation of the triangle on the lateral segment
We need to create a triangle on the lateral segment in such a manner that it has a base which is equal to the drop “x” and has two sides with dimensions of line“3-4” which let us say is designated as “y.” The distance “b-3” on the medial segment is measured with calipers, and an arc is drawn on the lateral segment from point “b” on the lateral ala. Next, distance “x” is measured on the medial segment, and an arc is drawn from point “3” on the lateral segment. This will cut the previous arc to create the point “5.” Now, the distance “3-4” (“y”) is measured and two arcs are drawn from point “3” and point “5” and these arcs meet to create a new point “4.”
The final incision line is drawn in solid blue [Figure 3], right].
The shaded areas in light green will be raised as “M” and “L” flaps on the medial and lateral segments, respectively.
| Markings for Incomplete Lip|| |
The markings are essentially the same as for the complete cleft lip. The area shaded in green is, however, discarded as “M” and “L” flaps are not required in incomplete lip [Figure 4].
|Figure 4: Markings in incomplete lip. The area marked in green shadow will be excised|
Click here to view
| Tissue Dynamics in Triangular Flap Repair|| |
Sawhney in 1972 concluded that adequate drop of the medial segment can be achieved even if the back cut was limited till the midline. He also suggested that the back-cut should be in the form of a perpendicular drawn from the thickest point just before thinning on the white line (i.e. line “3–4”) on the medial segment. A full-thickness cut along this line will open a triangular area into which a triangle with a base equal to the drop required can be inserted from the lateral segment [Figure 5], upper row].
|Figure 5: Dynamics of incisions on the medial and lateral segment. The upper row depicts the medial segment and the lower row depicts the lateral segment|
Click here to view
The triangle which is created on the lateral segment has a base equal to the drop required (“x”) and has two arms equal to the length of back cut (“y”) [Figure 5], lower row]. The insertion of this triangle into the medial segment defect will maintain the drop.
The movement of triangle from the lateral segment to the medial segment and the final suture line are depicted diametrically in [Figure 6].
|Figure 6: Feeding triangle from lateral segment into the back cut defect on medial segment. The “M” and “L” flaps have also been shown in light green color|
Click here to view
| Incisions|| |
The incision lines are marked in solid blue, both on the medial and lateral segments of the cleft lip [Figure 3]. The skin incisions are made initially with number 15 blade and then deepened to full thickness with a number 11 blade. The “M” and “L” flaps that have been highlighted in light green shade are raised superiorly on the medial and lateral aspect, respectively. The “M” Flap consists of vermillion and some skin tissue from the medial segment and is based on the alveolar margin and base of columella. The “L” flap consists of extra tissue on the lateral segment left behind after completion of the full-thickness incision. It is based on the alveolar margin and the lateral alar base. The “M” and “L” flaps will provide tissue for deepening of the sulcus or as a second layer for the anterior palate repair. On the lateral side, the “L” flap has sufficient tissue that can also be easily used for providing additional lining in the region of pyriform region.
The green shaded area in incomplete lip [Figure 4] is excised as the “M” and “L” flaps are not needed in this situation.
As noted in [Figure 3] and [Figure 4], the incision on the medial segment is placed along the future philtral column in the upper part; in the lower part, a back cut 3–4 is made from the thickest point on the white line to the midphiltral line. This triangular defect created on the medial segment will be filled by a triangular flap from the lateral segment (marked in pink in [Figure 5] and [Figure 6] with the exact dimensions of this defect.
The incision on the lateral segment is also made initially with 15 blade and then with 11 blade. As can be seen in [Figure 3] and [Figure 4], a triangle with a base exactly equal to the drop required on the medial segment has been created. This triangle [shown in pink in [Figure 5] and [Figure 6] has two limbs exactly equal to the limbs of the defect created on the medial segment after execution of the back cut. The feeding of this triangle from the lateral segment will maintain the drop achieved in the medial segment after the back cut.
The mucosal incision continues into the gingivobuccal sulcus both on medial and lateral segment. The further dissection is carried out in the supraperiosteal plane so that both the medial and lateral segments are adequately lifted off the maxilla. Some surgeons perform this dissection in the subperiosteal plane; this may be helpful if one is also planning the septal work the same time. All the abnormal attachments of the orbicularis muscle to the skin and mucosa are freed on both sides of the cleft. All the abnormal fibrofatty tissue near the lateral alar base is also excised. Some surgeons may also like to perform limited septoplasty through the medial incision.
The nasal chondromucosal layer is dissected off the overlying skin envelope using sharp dissection with scissors through a closed approach via the medial and lateral incisions. This helps in repositioning of the abnormally located nasal framework.
| Anterior Repair|| |
In case of complete cleft of the lip and plate, the anterior part of the palate is closed by vomerine flap and the lateral nasal mucosa flap. The second layer in this case can be provided by the “L” and “M” flaps. The excess of these flaps can then be trimmed. The lateral “L” flap is also very handy in providing the mucosal lining deficiency seen after the abnormal placed alar structures have been released and repositioned forwards.
| Suturing of the Lip Tissue|| |
The lateral and the medial lip elements are placed appropriately; the triangle on the lateral segment exactly fits into the defect created on the medial segment following back cut. Once the nostril sill is sutured, all the other points fall into place. The suturing is done in layers. Special care is taken to suture the orbicularis muscle at three points in the upper, middle, and lower third of the lip. One should carefully take a suture in the vermillion muscle to create a nice pout. Care should also be taken to match the red line on the lateral and medial segments accurately. If any discrepancy in vermillion thickness is noted, some local tissue adjustment is performed using unequal Z plasty in the vermillion. There is always availability of the more dry vermillion on the lateral segment and it can be used at this time. If a major discrepancy in the dry vermillion is noted beforehand, one can incorporate Noordhoff et al.'s vermillion flap at the time of marking of lip. The skin is closed with 5-0 nylon suture; some surgeons prefer the use of Vicryl rapid for the same.
| Nasal Tie Over Bolster|| |
The nasal framework has already been dissected off the skin. These are kept in accurate position with the use of two ties over bolster sutures. Alternatively, internal cartilage sutures can be placed using Poly Diaxanone Suture (PDS).
| Suture Removal|| |
The sutures are removed on day 6. The lip scar is managed with gentle massage using an emollient. We try to keep an indigenously fabricated nostril retainer for a few weeks.
[Figure 7] shows a case of complete unilateral cleft lip and palate operated with this technique in a 6-month-old baby. Immediate postoperative and 6-month postoperative appearance is also shown.
[Figure 8] shows results in a case of incomplete cleft lip; [Figure 9] and [Figure 10] show late results in complete cleft.
|Figure 10: Late postoperative results in another case of complete cleft lip|
Click here to view
| Discussion|| |
The triangular flap technique is very versatile and can be employed for repair of a broad spectrum of clefts ranging from incomplete to very wide complete cleft defects. This method is, however, very technique sensitive and mandates precise measurements at the beginning of the operation. A miscalculation at the time of initial measurements can result in a situation of no return. However, a meticulous marking and planning can easily avoid this mishap.
One of the common arguments against the Tennison's triangular flap is that the lower triangle invades the philtral region and is therefore unsightly. However, the experience of most of the surgeons conversant with this technique feels that the scar line and the lip esthetics are excellent with this method of repair. Unlike the Millard's' rotation advancement technique, the scar settles very well and does not have any tendency to hypertrophy. The scar being in a zig-zag line is easily camouflaged. Some authors, have also described the use of an upper triangle taken from the lateral segment to avoid invasion of the philtral column; however, this modification is not very popular as it does not provide adequate lengthening of the medial segment. The Tennison's technique is particularly useful for very wide clefts with severe rotation of the cupids bow peak.
Any cleft lip repair results should be analyzed by looking at adequate position of the cupids bow, symmetry of the nostril and alar base, midline vermillion tubercle and pout, fullness of the vermillion, and adequate length and symmetry. The triangular flap technique scores very high on all these points. Liberal dissection of the nasal cartilages and the paranasal region and incorporation of the “M” and “L” flaps help in achieving adequate paranasal fullness and proper nasolabial contours.
| Conclusion|| |
The triangular flap technique is a very versatile method of clip repair. It is easy to teach and learn the execution as it is based upon precise geometrical design. It can be easily used for correction of the whole spectrum of cleft lip cases ranging from minor incomplete clefts to very wide complete clefts. The scar line has minimal tendency to hypertrophy. The final scar with a zig-zag outline is almost imperceptible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Millard DR Jr. A primary camouflage in the unilateral harelip. In: Transactions of the International Congress of Plastic Surgeons, Baltimore USA: Williams and Wilkins 1957. p. 160.
Tennison CW. The repair of the unilateral cleft lip by the stencil method. Plast Reconstr Surg (1946) 1952;9:115-20.
Sidman JD. Triangular flap repair of the unilateral complete cleft lip. Facial Plast Surg 1993;9:184-7.
Holtmann B, Wray RC. A randomized comparison of triangular and rotation-advancement unilateral cleft lip repairs. Plast Reconstr Surg 1983;71:172-9.
Randall P. A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast Reconstr Surg Transplant Bull 1959;23:331-47.
Hagerty RF. Unilateral cleft lip repair. Surg Gynecol Obstet 1958;106:119-22.
Cardosa AD. New technique for harelip. Plast Reconstr Surg 1952;10:92-5.
Cronin TD. A modification of the Tennison-type lip repair. Cleft Palate J 1966;3:376-82.
Sawhney CP. Geometry of single cleft lip repair. Plast Reconstr Surg 1972;49:518-21.
Goulian D, Lesesne CB, Antell DE. Further refinements on the triangular flap closure of the cleft lip. Plast Reconstr Surg 1987;80:29-36.
Noordhoff M, Chen Y, Chen K, Hong K and Lo L. The surgical technique for the complete unilateral cleft lip-nasal deformity. Oper Tech Plast Reconstr Surg 1995;2:167-74.
Aranmolate S, Aranmolate SO, Zeri RS, Gbeneol T, Ajani AO. Upper Triangular Flap in Unilateral Cleft Lip Repair. J Craniofac Surg 2016;27:756-9.
Koh KS, Oh TS, Song JW. Upper triangular flap method for primary repairs of incomplete unilateral cleft lip patients: Minor to two-thirds way defects. Ann Plast Surg 2015;74:318-23.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]