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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 170-176

Review of two cutaneous closure methods for Tessier 7 repair: Straight-line versus Z-plasty

Guwahati Comprehensive Cleft Care Centre (GC4), Mission Smile, Mahendra Mohan Choudhary Hospital, Guwahati, Assam, India

Date of Submission23-May-2022
Date of Acceptance02-Jul-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Dr. Anhad Mehra
Guwahati Comprehensive Cleft Care Centre (GC4), Mission Smile, Mahendra Mohan Choudhary Hospital, M. G. Road, Fancy Bazaar, Guwahati - 781 001, Assam
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_11_22

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Aim of the Study: The aim of this study is to retrospectively analyze the surgical outcomes of patients who were treated for Tessier 7 cleft deformity, over a period of 10 years and compare the two cutaneous closure methods used for the treatment of the same in our cleft center. Patients and Methods: This is a retrospective audit of all the patients who had undergone Tessier 7 cleft repair from 2010 to 2020 in our center. Relevant details from recorded case histories were extracted and the surgical technique (Straight-line closure or Z-plasty technique) used for the closure of each case was analyzed. The benefits and drawbacks of linear closure and geometric closure methods were also studied. The preoperative, postoperative, and follow-up records and photographs were assessed for the results. Results: Of the 40 patients, 23 patients had skin closure done using Z-plasty technique while 17 patients had the closure done using the straight-line method. The average age at repair was 10.6 months and the follow-up period was unto 1.5 years. Visual Analog Scale and Scar assessment scales revealed Z-plasty skin closure scars were more conspicuous than straight-line closure ones. Lateral migration of the commissure was not an evident finding. Conclusion: Z-plasty or W-plasty can be avoided in repair of transverse facial clefts. Closure of the orbicularis oris muscle is the critical step to provide a counterforce to the contraction of the cutaneous scar and no lateral migration or hypertrophic scarring is present after straight-line cutaneous closure.

Keywords: Cosure, cutaneous, straight-line, Tessier-7, Z-plasty

How to cite this article:
Mehra A, Sarma H. Review of two cutaneous closure methods for Tessier 7 repair: Straight-line versus Z-plasty. J Cleft Lip Palate Craniofac Anomal 2022;9:170-6

How to cite this URL:
Mehra A, Sarma H. Review of two cutaneous closure methods for Tessier 7 repair: Straight-line versus Z-plasty. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Dec 8];9:170-6. Available from: https://www.jclpca.org/text.asp?2022/9/2/170/354287

  Introduction Top

Lateral facial clefts or commissural clefts are unique developmental defects of the facial region caused due to failure of proper fusion of the maxillary and mandibular processes of first brachial arch of the embryo to form the optimal commissures of the mouth.[1] Associated clinical findings commonly include pretragal skin tags, defective auricle and external ears, agenesis of the  Eustachian tube More Detailss and abnormal temporomandibular joints, and zygomatic arches.[2],[3] Tessier 7 cleft or Macrostomia is a rare oro-facial congenital defect with an incidence of 1/80,000–1/300,000 live births or 0.3%–1.0% of the cleft spectrum.[4],[5]

The main objectives in treating commissural clefts are to achieve (1) Symmetrical mouth opening, (2) Accurately functioning and naturally appearing commissure, (3) Satisfactorily positioned and functioning orbicularis oris muscle, (4) Minimal external scarring, and (5) Avoidance of contracture leading to lateral commissural migration.[6],[7] Skin closure using either straight line, Z-plasty or W-plasty technique is considered to be a crucial step in the repair of the defect along with correcting the abnormally positioned orbicularis oris muscle, carrying out commissuroplasty and conducting a layered closure from deep to superficial tissues.[4],[5],[6],[7],[8],[9],[10] Linear closure of the cutaneous layer using the straight line technique is considered to be one of the earliest methods but is also believed to be generally associated with contracture and lateral displacement of the commissure.[11],[12] In order to counteract the same, various geometric methods such as Z-plasty,[13] double Z-plasty,[14] or W-plasty[15] were introduced.

Since its commencement, our center has been carrying out both straight-line closures and Z-plasties for the treatment of Tessier-7 clefts. The major objective of this study is to compare the two techniques along with their benefits and the associated complications and to also understand why straight-line closure is more or less sufficient to achieve the desired results without scar contracture or lateral migration of repaired commissures, which are generally anticipated with the linear closure method.

  Patients and Methods Top

Retrospective analysis of patients treated in our Center for Tessier 7 cleft deformity over a period of 10 years (2010–2020) was done. The total number of patients were 40, of which 23 (57.5%) had skin closure using Z-plasty while 17 (42.5%) had closure done using straight-line method. Clinical preoperative and follow-up records were taken into consideration for this study. Follow-ups were carried out at 1 week, 3 months, 6–8 months, and 1.5 years.

The inclusion criteria involved nonsyndromic unilateral and bilateral soft-tissue Tessier 7 cleft patients and whose complete case histories and follow-up records for the time periods were available while cases of Treacher-Collins syndrome, malnourished or underage patients and those diagnosed with associated bony abnormalities such as involvement of mandibular ramus, were excluded from this study.

Bütow and Botha's classification system was used to stratify the patients based upon the placement and appearance of the transverse cleft.[16] Parameters considered to explore the postoperative outcomes were scar hypertrophy, migration of commissure, scar contracture, visibility of scar during movement of oral commissure, and functional continuity of the commissure. The anthropometric landmark majorly taken into account for the same was the distance from labiale superius, i.e., the midpoint of Cupid's bow at the vermilion-cutaneous junction to the chelion. In the case of Bilateral Tessier 7 patients, the midpupilary line and cleft papillae helped determine the symmetry of the commissures.

Postoperative assessment of the results and complications was carried out using Scar Assessment scales – Manchester Scar Scale adjunct with Visual Analog Scale (VAS). The visual assessment was done by two surgeons apart from the operating one and 1 from nonmedical department. The patients' parents' assessment was also considered and the average scoring was used to determine the outcome. Inter-assessor reliability was maintained by including assessors whose assessments scores were consistent for the same patient.

Surgical technique

A four-layered surgical repair is done. Surgical markings are done on the cleft side of the lip along with the important landmarks.

  1. Excision of the cleft tissue along with removal of the excess mucosa. A straight-line closure of the mucosa is done
  2. Vermillion mucosal flaps are raised from the upper and lower lips to remove the excess cleft tissue
  3. Orbicularis muscle fibers of the upper and lower lips are dissected and reconstruction of the sphincter function is done
  4. Skin closure is done using straight-line closure or Z-plasty method [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d.
Figure 1: (a) Surgical markings and landmarks. (b) Vermillion mucosal flaps are raised and excess cleft tissue removed. (c) Orbicularis oris muscle fibres dissected and sutured along with sphincter reconstruction. (d) Cutaneous closure – Straight-line or Z-plasty

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  Results Top

Of the total number of patients, 22 were female patients while 18 were male. The average age at the time of repair was 10.6 months (range, 6–36 months). Skin tags were a common finding.

Scar hypertrophy was noted in 11 of the patients, on whom skin closure was done using Z-plasty while 5 out of 17 straight-line cutaneous closures had evident hypertrophy. Lateral migration of the scar was not a very evident finding, with only 2 of the total repaired clefts showing mild migration and both of them were repaired using Z-plasty. Scar visibility was more conspicuous in Z-plasty treated patients as compared to straight-line closure ones in whom the scars were thinner, flatter and less significant. Eighteen of the Z-plasty and 6 of the linear closure patients had visible scars postoperatively. Commissural symmetry as determined by comparing the anthropometric measurements of the repaired and unrepaired sides was well within the esthetic boundaries of 0.5–1 mm in all the patients. Under group of straight-line skin closure, the results majorly ranged from “excellent” to “good” under VAS assessment and had a score range of 5–7 under the Manchester scale. While under the group of Z-plasty, the results ranged from “good” to “acceptable” under the VAS scale and had a score range of 6–9 under the Manchester scale [Table 1] and [Table 2] and [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 4]a, [Figure 4]b, [Figure 4]c, [Figure 4]d.
Table 1: Cutaneous closure methods and postoperative outcomes in Tessier number 7 cleft patients

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Table 2: Scar assessment: Straight-line closure versus Z-plasty

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Figure 2: (a) Preoperative photograph of unilateral Tessier 7 cleft. (b) Repaired Tessier 7 cleft using straight-line closure method. (c) Follow-up photograph after 1 week. (d) Follow-up photograph after 6 months

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Figure 3: (a) Preoperative photograph of bilateral Tessier 7 cleft. (b) Repaired Tessier 7 cleft using straight-line closure method. (c) Follow up photograph after 6 months. (d) Follow up photograph after 1.5 years

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Figure 4: (a) Preoperative photograph of unilateral Tessier 7 cleft. (b) Repaired Tessier 7 cleft using Z-plasty showing evident puckering of cheek. (c) Follow up photograph after 6 months. (d) Follow-up photograph after 1.5 years

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  Discussion Top

Significant variation has been noted and recorded in the clinical presentation of transverse facial clefts over the years. A classification system established by Bütow and Botha[16] is largely followed- (a) T7.1– Superiorly rotated, subdivided into T7.1a (without bone involvement) and T7.1b (with bone involvement) (b) T7.2– Middle positioned (most common with 45% incidence) subdivided into T7.2a (with soft tissue involvement only) and T7.2b (with additional bone involvement) (c) T7.3– Inferiorly rotated and (d) T7.4– Agenetic lateral facial cleft. Our cleft study involved all cases, which were middle positioned and had only soft-tissue involvement (T7.2a).

Among the first surgical techniques described for the repair was the use of an Estlander flap with a full-thickness vermillion lined flap. However, focus was not placed on appropriate adaptation and adequate joining of the separated elements of orbicularis oris muscle, which is a critical step in achieving oral continence.[10] Boo-Chai[13] described the importance of correct placement of the orbicularis oris muscle as close to the commissure of the lip as possible to prevent a cutaneous-vermillion web formation, producing a deformity called “goldfish mouth.” Several authors suggested surgical techniques to enhance the repair of transverse clefts such as Skoog,[17] who recommended the extensive repairing of the buccinator muscle to avoid a depression in the cheek while May[10] mentions about the layered closure of orbicularis oris muscle to restore muscular balance and prevent the lateral displacement of the commissure and the scar. Reconstructing the normal anatomy of the commissure is a challenging task as it is unique and delicate and cannot be looked upon as just a corner of the mouth, but rather a smooth and continuous segment of vermilion.[18] The outermost edge of the upper and lower lip vermillion appear to be two opposing triangles which are noncontiguous with the mouth closed, as described by Onizuka.[19] Verheyden[20] found the vermillion of the commissure to be more similar to mucosa than the lip due absence of rugae while Wall et al.[21] explained the reason for natural overlapping of upper and lower lip segments and in folding of vermillion in the depth of the commissure caused due to the vermillion of commissure forming a smaller anterior web with upper lip and a larger posterior web with lower lip. Positioning of the reconstructed oral commissure is equally important and this can be achieved by using intraoperative anthropometry,[7],[22] which is more precise as compared to the methods suggested by Ross and Carless[11] in 1898 who described small papilla on both upper and lower lips as the area of detachment of orbicularis oris muscle bundles and Astute surgeons who noted that vermillion of cleft region is lighter than the normal lip and should be considered as a landmark for commissure.[13],[17],[19],[23] However, both these methods have been underscored.[6],[13] In the case of intraoperative anthropometry, measurements are taken on the normal side, middle of Cupid's bow to the commissure are transposed to cleft side using a caliper. In the case of bilateral clefting, the position can be determined using either cleft papillae or placing the commissures at midpupillary line.[15] Initially, authors used straight closure of vermillion and mucosa but was later discouraged as it often resulted in fissuring and contracture at the commissure.[7],[17],[24],[25] To avoid this unnatural appearance, some surgeons started constructing the commissure using small triangular cutaneous flaps[19],[26] and others using rectangular vermillion mucosal flaps.[7],[22],[23] A four-layered closure technique along with its variations is a commonly suggested method by several authors including Kaplan, who modified the closure using superiorly based vermillion mucosal flap. He suggested the overlapping of upper muscle bundles on lower muscle bundles to facilitate the natural overhang appearance of upper lip to lower lip.[27]

According to the literature, straight-line closure is considered to be suitable for minimal postoperative scarring[12],[25],[26] while geometric techniques such as Z-plasty[13],[19],[23] or W-plasty[6],[7],[10] prevent scar contracture. Functional and esthetic outcomes are the key goals expected from any cutaneous closure method of choice, along with avoidance of lateral migration of the scar.[25],[27],[28],[29],[30] Straight-line skin closure has been castigated for being a technique, which promotes scar formation, allows migration of scar, causes lateral displacement of the reconstructed commissure, stimulates scar contracture, and provides poor esthetic results.[6],[22],[23],[27],[28],[29],[30] However, very little data is present to support this belief and actual studies have not proven this yet. Studies put forth by Chen and Noordholff[23] described lateral commissural migration in about six cases on which linear closure was performed. In their series, two out of three patients had shown features of postoperative commissural asymmetry secondary to scar contracture but the same features were also found in patients on whom Z-plasty cutaneous closure was carried out. Hence, proving the fact that the lateral displacement was not technique driven and could easily be prevented by a constant medially directing dynamic “counterforce” produced by the sphincter function of an adequately repaired orbicularis oris muscle.[10],[25] There are very few studies described in the literature that actually advocate poor functional and esthetic outcomes of straight line skin closure. Rogers and Mulliken[25] observed that no lateral commissure migration was evident after straight-line closure and found geometric techniques such as Z-plasty and W-plasty to be unnecessary and prerequisite for conspicuous scar formations. Kajikawa et al.[31] supported the same theory and recommended horizontal linear closure medial to nasolabial fold and to add a very small Z-plasty lateral to nasolabial fold only if the defect is very long. The skin tension-relaxation lines are disparate in the regions medial and lateral to the nasolabial fold and to prevent scar formation, Kajikawa et al.[31] prefers to remain medial to the landmark with a linear closure. Yoshimura et al.[32] noted significant scars in their study of five patients who were repaired with Z-plasties and hence started promoting the use of linear cutaneous closure to achieve improved results. Eguchi et al.[7] supported the fact that Z-plasty has the tendency of producing a scar which shall not be invisible despite meticulous suturing. They believed that using straight-line closure or a lazy W-plasty will have an advantage when further revision or correction is required rather than using Z-plasty.

However, a vast majority of studies in the literature support geometry cutaneous closures such as Z-plast or W-plasty. They are used to break or redirect cutaneous scars to prevent hypertrophic scar formations and contractures, which are liable to cause lateral migration of the oral commissure following linear cutaneous closure.[6],[13],[20],[22],[23],[33],[34] Longacre[9] preferred applying the Z-plasty technique along the margins of the oral fissure while Oniuka[19] produced Z-plasty using a small triangular flap that would be inserted into the mucosa at the lower part of the corner of the mouth. These techniques are helpful as they help prevent contraction of the oral cavity but have a tendency to place a scar at the angle of the mouth, which becomes conspicuous over a period of time.[7],[18] Fukuda and Takeda[35] shifted from preferring Z-plasty to W-plasty cutaneous closure because the scar of a Z-plasty was discernible and most of the patients required revision. The size of Z-plasty also affects the final esthetic outcome of the surgery, as debated by several authors.[25] Sugihara et al.[36] suggested using double Z-plasty technique in which 16 patients with transverse facial cleft were repaired with multiple cutaneous Z-plasties. However, they found that large Z-plasties (>10 mm triangles) resulted in more thicker and significant scars than small Z-plasties (<6 mm triangles) and recommended producing smaller triangles for Z-plasties.[36] Chen and Noordholff[23] also mentioned about problems with the orientation of the cutaneous Z-plasty in their patients. They cautioned about careful design and placement of the Z-plasty limbs to avoid hypertrophic scars and distortion of the commissure, which were evident in their upturned and downturned Z-plasty procedures. To avert these complications, some authors have suggested hiding the central limb of Z-plasty in the melolabial fold or by keeping the Z-plasty lateral to the nasolabial fold.[27],[34],[37] However, Eguchi et al.[7] put forth the fact that accurate placement of the limbs of Z-plasty is difficult to achieve in children and adults as the furrow of melolabial fold is poorly defined and the technique can distort the fold.

Some authors argue that that the migration of the commissure is not due to poor skin closure but rather poorly sutured muscular and vermillion closure and a good closure of the muscle layer is sufficient to produce a counterforce to prevent lateral displacement.[8],[25],[27] Rogers and Mulliken recommends approximating the muscle bundles in a side to side manner with suturing end to end exclusively of the pars marginalis in a linear fashion.[25] We agree with this method as it has helped us achieve the required stability of the commissure.

We prefer inferiorly based vermillion mucosal flaps for the reconstruction of the commissure, as the scar formation at the insertion point in the upper lip is inconspicuous, the color and thickness of the vermilion and mucosa remains constant and minimal change is noted in the shape of the commissure during opening of the oral cavity. Orbicularis oris muscle bundles are approximated and sutured in a linear fashion and the lower labial flap is inserted into the upper lip with the mouth fully open. The mucosal suturing is also done in a linear fashion. The reconstruction of the modioulus as described by Bütow and Botha[16] and duplication of muscle, as put forth by Kaplan[27] is not performed in our cases. Our center has been carrying out both straight-line closures and Z-plasties since the beginning but lately our follow-up cases have been showing significant scar formations in Z-plasty patients and have been achieving comparatively better results with linear closures. Hence, a shift has been noticed in the cutaneous closure choice of our surgeons.

  Conclusion Top

Our study puts forth a conclusion that both straight-line cutaneous closure and Z-plasty have their own benefits and drawbacks and the choice of the technique majorly depends upon the surgeon and the unique anatomy of each cleft. However, our research did confirm that linear skin closure methods are sufficient to achieve long-term oral symmetry, minimal scarring, and pleasant esthetic results as any tendency for scar contracture and lateral commissural migration is counteracted by the functioning of an adequately repaired and approximated orbicularis oris muscle.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


The authors would like to thank Guwahati Comprehensive Cleft Care Center, Mission Smile and our team for the encouragement and facilities provided.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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