British Journal of Phic Suryery (1985) 38, 89-92 %I 1985 The Trustees of British Association of Plastic Surgeons

Primary columella lengthening and lip adhesion

D. E. TOLHURST

Department of Plastic Surgery, Academisch Ziekenhuis Rotterdam Dijkzigt, The Netherlands

Summary-A technique is described for lengthening the columella during the lip adhesion procedure in bilateral cleft lips.

Bilateral complete cleft lip and palate in its extreme form is characterised by unrestrained anterior projection of the premaxilla, a prolabium that is broader than the normal infant philtrum and a columella that is so short that it appears to flatten the tip of the nose and tether it to the premaxilla. Following repair and as the child grows there is some improvement in the length of the columella but, without correction, the nose tip will remain too flat (Fig. 1A).

Secondary columella lengthening operations have not proved altogether satisfactory and McComb (1975) attempted to overcome the objec- tions to the secondary forked flap procedure by using the principle to lengthen the columella before the primary lip repair was undertaken. This idea carried with it the additional benefit that the prolabium was narrowed to a width approaching that of a normal infant philtrum. About 6 weeks after the preliminary columella lengthening McComb carried out a definitive repair of the lip.

Of all the many operations proposed for primary repair of the bilateral cleft lip there is almost universal agreement that Manchester’s technique (1970) is the best. Manchester himself never origin- ally narrowed the prolabium but he has now agreed that if there is one slight failing in his technique, it is the wide philtrum simulated by the vertical scars of his repair. For some time I have narrowed the prolabium and transposed the two lateral flaps to the nostril sill area. As my dissatisfaction with the secondary forked flap corrections of the columella and tethered nose tip continued unabated (Fig. 1B

and C), I sought an alternative solution and decided to adopt McComb’s idea of a primary columella lengthening operation but with one simple modification.

Since most of the children with a bilateral complete cleft will benefit from a lip adhesion (with or without pre-operative orthopaedic treatment) I have lengthened the columella at the time of the lip adhesion. This procedure enables one to close the donor areas on the prolabium with the lateral adhesion flaps. The benefits of combining the two procedures are obvious and the results to date appear satisfactory (Fig. 2).

Our patients do have the benefit of pre-operative orthopaedic treatment and the timing of the columella lengthening and lip adhesion is planned with the orthodontist. There is a feeling that if the lip adhesion in bilateral cases is carried out over the whole vertical length of the cleft, the premaxilla may be tipped into a class 3 relationship. For this reason some surgeons close only the nasal floor and upper part of the cleft during the adhesion, but I feel this only postpones the evil day which, if it is to dawn, will be far worse following definitive repair of the lip. I therefore perform a lip adhesion over the entire vertical length of the lip. When the relation- ship of the premaxilla to the lateral segments is satisfactory, the lip is repaired and the nasal floor and alveolar cleft is closed in the hope that this will retain the maxillary elements in a reasonable position. Of course this is not always so and later orthodontic treatment or an osteotomy may be needed.

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Figu broa

Fig. 1

we l-(A) Short columella in a repaired bilateral cleft. (B) and (C) Forked flap columella len Id columella and prominent lip scars.

lgthening at 6 years of age. Note the

PRIMARY COLUMELLA LENGTHENING AND LIP ADHESION 91

c

Fig. 2

Figure 2(A)-A pre-operative appearance of bilateral cleft hp. The child’s dislike of the orthopaedic plate is evident. (B) Lip adhesion and columella lengthening completed. (C) Appearance following definitive lip closure.

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References

McComb, H. K. (1975). Primary repair of the bilateral cleft lip nose. British Journal of Plastic Surgery, 28, 262.

Manchester, W. M. (1970). The repair of double cleft lip as part of an integrated program. Plastic and Reconstructive Surgery, 45, 207.

The Author

David E. Tolhurst, MB, FRCS, Academisch Ziekenhuis Rotter- dam Dijkzigt.

Requests for reprints to: D. E. Tolhurst, MB, FRCS, Academisch Ziekenhuis Rotterdam Dijkzigt, dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.

Fig. 2

Figure 2-Result at 2 years-of-age.