The Journal of Craniofacial Surgery
Correspondence
& Volume 25, Number 3, May 2014
TABLE 1. Clinical Information of 25 Patients With Cutaneous Angiomyolipoma Published in English Literature No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
20 21 22 23 24 25
Author Fitzpatrick et al
4
Year
Age
Sex
Size, cm
Site
Duration
Clinical Diagnosis
1990
77 63
M M
V V
V V
V 6 mo
50 59 52 33 48 39 67 49 58
M F M M M M M M M
V V V V V V 1.0 1.0 V 3.0 4.0
Head Elbow Hand Toe
Ear Ear Elbow
V V 1y 3y 2 mo V 40 y V 15 y
Lipoma vs cyst giant cell tumor of tendon sheath vs mucoid cyst Mass Nodule Lipoma Epidermal cyst Lipoma Subcutaneous nodule Epidermal cyst Epidermal cyst Unknown
49 38 36 54 75 43 56 44 38 16 50 26 37 3
M M M F M M M F F F F F F F
2.5 2.0 2.5 2.5 1.5 1.5 V V 0.4 0.6 0.5 443 2.5 1.5 3.0 2.5 1.0 0.9 1.7 1.6 1.0 2.5
Ear Ear Nose Nose Nose Ear Chin Ear Popliteal Buttock Thigh Ear helix Ear lobe Anterior abdominal wall
5y 10 y 3y 5y 10 y 6 mo V 3 mo 5y Unknown 5y V Several years V
Lipoma Unknown Unknown Cavernous hemangioma, Lipoma Lipoma Unknown Unknown Cyst Sarcoma Vascular tumor Epidermoid cyst, lipoma, leiomyoma Mucoid cyst Lipoma epidermal cyst Nodule
Argenyi et al5 Mehregan et al8 Rodriguez-Fernandez and Caro-Mancilla9 Val-Bernal and Mira10 Bu¨yu¨kbabani et al19
1991 1992 1993
Obata et al11 Tsuruta et al13 Beer14
2001 2004 2005 2005 2005 2005 2006 2006 2009 2012 2012
Hatori et al15 Makino et al16 Debloom et al12 Shin et al6 Mikoshiba et al17 Ammanagi et al18
1996 1998
method of treatment for cutaneous angiomyolipoma is complete surgical excision with a low recurrence rate. Hyung-Sup Shim, MD Dong-Hwi Kim, MD Ho Kwon, MD, PhD Sung-No Jung, MD, PhD Department of Plastic and Reconstructive Surgery College of Medicine, The Catholic University of Korea Uijeongbu, South Korea [email protected]
REFERENCES 1. Farrow GM, Harrison EG Jr, Utz DC, et al. Renal angiomyolipoma. A clinicopathological study of 32 cases. Cancer 1968;22:564 2. Hajdu SI, Foote FW. Angiomyolipoma of the kidney: report of 27 cases and review of the literature. J Urol 1969;102:396Y401 3. Weiss SW, Goldblum JR, Enzinger FM. Enzinger and Weiss’s Soft Tissue Tumors. 4th ed. St Louis, MO: Mosby, 2001:605Y607 4. Fitzpatrick JE, Mellette JR Jr, Hwang RJ, et al. Cutaneous angiolipoleiomyoma. J Am Acad Dermatol 1990;23:1093Y1098 5. Argenyi ZB, Piette WW, Goeken JA. Cutaneous angiomyolipoma. A light-microscopic, immunohisto-chemical, and electron-microscopic study. Am J Dermatopathol 1991;13:497Y502 6. Shin J-U, Lee K-Y, Roh M-R. A case of a cutaneous angiomyolipoma. Ann Dermatol 2009:21:217Y220 7. Roma AA, Magi-Galluzzi C, Zhou M. Differential expression of melanocytic markers in myoid, lipomatous, and vascular components of renal angiomyolipomas. Arch Pathol Lab Med 2007;131:122Y125 8. Mehregan DA, Mehregan DR, Mehregan AH. Angiomyolipoma. J Am Acad Dermatol 1992;27:331Y333 9. Rodriguez-Fernandez A, Caro-Mancilla A. Cutaneous angiomyolipoma with pleomorphic changes. J Am Acad Dermatol 1993;29:115Y116
1122
10. Val-Bernal JF, Mira C. Cutaneous angiomyolipoma. J Cutan Pathol 1996;23:364Y368 11. Obata C, Murakami Y, Furue M, et al. Cutaneous angiomyolipoma. Dermatology 2001;203:268Y270 12. Debloom JR, Friedrichs A, Swick BL, et al. Management of cutaneous angiomyolipoma and its association with tuberous sclerosis. J Dermatol 2006;33:783Y786 13. Tsuruta D, Maekawa N, Ishii M. Cutaneous angiomyolipoma. Dermatology 2004;208:231Y232 14. Beer TW. Cutaneous angiomyolipomas are HMB45 negative, not associated with tuberous sclerosis, and should be considered as angioleiomyomas with fat. Am J Dermatopathol 2005;27:418Y421 15. Hatori M, Watanabe M, Kokubun S Angiomyolipoma in the kneeVa case report. Ups J Med Sci 2005;110:245Y249 16. Makino E, Yamada J, Tada J, et al. Cutaneous angiolipoleiomyoma. J Am Acad Dermatol 2006;54:167Y171 17. Mikoshiba Y, Murata H, Ashida A, et al. Case of a cutaneous angiomyolipoma in the ear. J Dermatol 2012;39:808Y809 18. Ammanagi AS, Dombale VD, Shindholimath VV. Cutaneous angiomyolipoma. Indian Dermatol Online J 2012;3:40Y41 19. Bu¨yu¨kbabani N, Tetikkurt S, Oztu¨rk AS. Cutaneous angiomyolipoma: report of two cases with emphasis on HMB-45 utility. J Eur Acad Dermatol Venereol 1998;11:151Y154
A Marking for Repair of Complete Cleft Lip To the Editor: Management of unilateral cleft lip remains controversial.1 A large series lends support to the belief that no single technique of cleft lip repair is a panacea for all cases.2 After studying * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
incomplete cleft lips and mild cleft lips,3,4 we study 30 complete cleft lips. Complete cleft lip has a deviated philtrum dimple and a deviated nasal column. The deviated dimple and the nasal column are always toward the same direction and have the same angle to the middle line. Therefore, we have a hypothesis that the deformities of the deviated dimples and the nasal columns have the same physical reason that the asymmetric lip on the noncleft side is due to the unbalance power of the muscles. If the muscle of the noncleft side were out of power, the deformity of a cleft lip should only be a cleft with a symmetric cupid bow and right location of philtrum dimple and nasal column. We can observe the result on bilateral cleft lips, which can present evidence of the hypothesis. No matter how severe the clefts on bilateral cleft lips are, their nasal columns and the philtrums dimples are always on the middle line without severe deviation. Taking photograph is an important work for a plastic surgeon. While studying lots of the pictures, we found that there was a potential line on the noncleft side on the photograph of the complete cleft lip (Figs. 1 and 2). Therefore, we assumed that there was a nature marking on the cleft lip. Performing on more than 30 patients, we obtained favorable results. The longest follow-up period was 1 year.
PATIENTS AND METHODS Methods We mark the cleft-side lip as Figure 1. A, 2, B were marked according to Millard rotation-advanced principle. C is located on the top of the philtrum dimple. CB is a curve line with the same length of CA. D is located at the noncleft side of nasal column. E is marked according to D, which is located at the cleft side of the nasal column and CE = CD. Thus, we can obtain 2 triangles named $ABC and $DCE (Fig. 1). The cross point is located at the summit of the philtrum dimple. Because A, 2, B are marked according to Millard rotation-advanced principle, the distance from A to 2 is equal to the distance from 2 to B. $ABC can obtain a twisted philtrum dimple contour. The inverse triangle $DCE comprises a normal nasal column contour. When the ‘‘C’’ is secured to the middle line, the ‘‘B’’ will descent spontaneously. After muscle repair and nasal column and the philtrum dimple fixed at the middle line, we can obtain a symmetric cupid bow easily. The incision of cleft side is marked at the commissure of the skin and vermilion.5
FIGURE 1. There seems a shadow line on the noncleft side before doing nothing, when we studied many photographs.
Correspondence
FIGURE 2. Line ECB and HI are the incisions. Line E4 is a releasing incision to correct the nasal column to the middle line.
Case A 3-month-old boy was admitted with his parent’s complaint of complete unilateral cleft lip. After examination, the diagnosis of complete unilateral cleft lip was made (Fig. 2). Surgical repair was performed under general anesthesia associated with infraorbital lidocaine injected. In our design, noncleft side incision was made as a concave high curve line along the natural line, which is from the peak of the cupid bow of the noncleft side to the nasal column. A transverse incision in the nasal column base was made to reduce the deviated nasal column (Fig. 2). The incision of the cleft side was marked at the commissure of the skin and mucosa (Fig. 2). Of great care was to maintain the philtral dimple. Muscular repair began with the muscle from the tip of the lateral flap into the medial rotation defect according to the style of Stal et al.6 Taking muscular roll created a medial vector to rotate the cleft ala inward by Byrd and Salomon’s7 technique. Cleft-side alar base drift laterally was repositioned slightly and secured to nasalis.8 The lateral advancement flap was advanced together with the muscle released from the maxillary. Retrogression of C-flap was partly excised, and the rest was used to reconstruct the nostril sill. We performed simple interrupted sutures, working superior to inferior, until the incision was closed. One year later, we got the photograph while he was admitted to repair the cleft palate (Fig. 3).
FIGURE 3. The case on 12 months’ follow-up visit. The baby presented unnoticeable scar and a symmetric cupid bow.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1123
The Journal of Craniofacial Surgery
Correspondence
RESULTS The technique gets good result from 1-year follow-up response. The cupid bows present symmetrically (Fig. 4). Scars on the lips present slight curve line without noticeable contraction (Fig. 4).
DISCUSSION A method, recognized as rotation-advanced principle technique, was on the horizontal, which was destined to become even more popular.6 A study by Sitzman et al1 confirmed that rotationadvancement principle remained the most popular technique among cleft surgeons: 84% of respondents performed a rotation-advancement repair for complete unilateral cleft lip. However, almost half of those surgeons used a modified technique. Therefore, it confirmed that, with the wide usage of the Millard technique, lots of disadvantages were presented. The modifications of Millard technique such as back cut and inferior triangle flap always focus on obtaining enough length to reconstruct the cupid bow. Stal et al6 used an S-shaped ‘‘fleur de lis’’Ytype incision to add length to the labial element. In our design, skin rotation incision was made up of a concave high curve along the natural line, which is from the peak of the cupid bow of the cleft side to the nasal column. The technique of the concave high curve line is much easier to elongate the white lip than various rotations. Therefore, a symmetric cupid bow can be reconstructed easily instead of inferior triangular flaps, various rotation techniques, and back cut by Millard rotation-advancement principle. Reconstruction of philtrum ridges and philtrum dimples is also a problem in cleft lip repair. In our study, skin on the cleft side shifted down to maxilla and fused with mucosa, which form a low level of incision. The incision marked at the edge of the skin and mucosa can obtain a different lever between the incision and cleft-side lip. The philtrum ridges and the philtrum dimples will be spontaneously reconstructed without any technique because of the natural lever difference (Fig. 3). For Chinese babies undergoing surgery for this type of deformity, scarring on the nostril sill, alar base, and white lip plays an important role in postoperative aesthetics, which is different from the white-race babies. The present technique is less likely to necessitate secondary scar revision, as it minimizes primary surgical incisions. The whole incisions are according to the Langhans line, which is the principle of plastic surgery. It is reported nasal tip projection and columella length of
& Volume 25, Number 3, May 2014
Chinese people are fast-growing features by 5 years of age.2 Therefore, the technique cannot obtain a permanent outcome of nasal deformities. The new features of the technique are as follows. The first is that there are no incision and flap on the cleft side. The second is that the incisions of both sides have some curve orientation, which is easy to close. The third is that all of the markings are simple enough to understand by young doctors. The essentials of the technique are as follows. All of the incisions are around the cleft without any incisions in normal skin, which is to minimize iatrogenic damage. The main problem of Millard technique is to obtain the symmetric cupid bow. The incision of the technique can obtain the symmetric cupid bow easily. Chen Jianbing, PhD Weimin Shen, PhD Jie Cui, MD Department of Plastic Surgery Nanjing Children’s Hospital Affiliated to Nanjing Medical University Nanjing, Jiangsu, China [email protected]
REFERENCES 1. Sitzman TJ, Girotto JA, Marcus JR. Current surgical practices in cleft care: unilateral cleft lip repair. Plast Reconstr Surg 2008,121:261eY270e 2. Reddy GS, Webb RM, Reddy RR, et al. Choice of incision for primary repair of unilateral complete cleft lip: a comparative study of outcomes in 796 patients. Plast Reconstr Surg 2008;121:932Y940 3. Chen J, Shen W, Cui J. Modification of the rotation-advancement principle in cleft lip repair. J Craniofac Surg 2009:20: 2215Y2216 4. Chen J, Shen W, Jie C. An individual technique for mild incomplete cleft lip repairing. J Craniofac Surg 2012;23:1131Y1132 5. Koh KS, Choi JW, Kim H. Minimal paring of skin flaps for primary repair of incomplete unilateral cleft lip. Plast Reconstr Surg 2008;121:1382Y1385 6. Stal S, Brown RH, Higuera MS. Fifty years of the Millard rotation-advancement: looking back and moving forward. Plast Reconstr Surg 2009;123:1364Y1377 7. Byrd HS, Salomon J. primary correction of unilateral cleft nasal deformity. Plast Reconstr Surg 2000;106:1276Y1286 8. Mulliken JB, Labrie RA. Four-dimensional changes in nasolabial dimensions following rotation-advancement repair of unilateral cleft lip. Plast Reconstr Surg 2012;129:491Y498
Preventing Hair Interference During Ear Surgery
FIGURE 4. Photographs of some of our cases. The longest follow-up period is 1 year.
1124
To the Editor: During ear surgery, postauricular and scalp hair can cause an obstacle for the surgeon. Surgical drapes are preferred worldwide by wrapping them until an appropriate surgical field is settled. Easy dissection and surgical handling alongside the ear may be problematic unless an appropriate hairless field is achieved. Moreover, the hair around the surgical area can get stuck unwantedly, making the surgeon habitually struggling with this hair rather than the surgery itself. Even an assistant sometimes deals solely with this task to help the surgeon do his/her work. There are little data existing about this concern in the literature. Hede´n1 first described the use of elastic bands in hair restraint. Bovill and Wharton2 simply suggested using swimming caps for this purpose. I used a postauricular adhesive tape to prevent hair interference in the surgical field. After appropriate cleaning and preparation, a previously sterilized adhesive tape was fixed on the postauricular area (Fig. 1). With this maneuver, a surgical field without hair * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
& Volume 25, Number 3, May 2014
TABLE 1. Clinical Information of 25 Patients With Cutaneous Angiomyolipoma Published in English Literature No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
20 21 22 23 24 25
Author Fitzpatrick et al
4
Year
Age
Sex
Size, cm
Site
Duration
Clinical Diagnosis
1990
77 63
M M
V V
V V
V 6 mo
50 59 52 33 48 39 67 49 58
M F M M M M M M M
V V V V V V 1.0 1.0 V 3.0 4.0
Head Elbow Hand Toe
Ear Ear Elbow
V V 1y 3y 2 mo V 40 y V 15 y
Lipoma vs cyst giant cell tumor of tendon sheath vs mucoid cyst Mass Nodule Lipoma Epidermal cyst Lipoma Subcutaneous nodule Epidermal cyst Epidermal cyst Unknown
49 38 36 54 75 43 56 44 38 16 50 26 37 3
M M M F M M M F F F F F F F
2.5 2.0 2.5 2.5 1.5 1.5 V V 0.4 0.6 0.5 443 2.5 1.5 3.0 2.5 1.0 0.9 1.7 1.6 1.0 2.5
Ear Ear Nose Nose Nose Ear Chin Ear Popliteal Buttock Thigh Ear helix Ear lobe Anterior abdominal wall
5y 10 y 3y 5y 10 y 6 mo V 3 mo 5y Unknown 5y V Several years V
Lipoma Unknown Unknown Cavernous hemangioma, Lipoma Lipoma Unknown Unknown Cyst Sarcoma Vascular tumor Epidermoid cyst, lipoma, leiomyoma Mucoid cyst Lipoma epidermal cyst Nodule
Argenyi et al5 Mehregan et al8 Rodriguez-Fernandez and Caro-Mancilla9 Val-Bernal and Mira10 Bu¨yu¨kbabani et al19
1991 1992 1993
Obata et al11 Tsuruta et al13 Beer14
2001 2004 2005 2005 2005 2005 2006 2006 2009 2012 2012
Hatori et al15 Makino et al16 Debloom et al12 Shin et al6 Mikoshiba et al17 Ammanagi et al18
1996 1998
method of treatment for cutaneous angiomyolipoma is complete surgical excision with a low recurrence rate. Hyung-Sup Shim, MD Dong-Hwi Kim, MD Ho Kwon, MD, PhD Sung-No Jung, MD, PhD Department of Plastic and Reconstructive Surgery College of Medicine, The Catholic University of Korea Uijeongbu, South Korea [email protected]
REFERENCES 1. Farrow GM, Harrison EG Jr, Utz DC, et al. Renal angiomyolipoma. A clinicopathological study of 32 cases. Cancer 1968;22:564 2. Hajdu SI, Foote FW. Angiomyolipoma of the kidney: report of 27 cases and review of the literature. J Urol 1969;102:396Y401 3. Weiss SW, Goldblum JR, Enzinger FM. Enzinger and Weiss’s Soft Tissue Tumors. 4th ed. St Louis, MO: Mosby, 2001:605Y607 4. Fitzpatrick JE, Mellette JR Jr, Hwang RJ, et al. Cutaneous angiolipoleiomyoma. J Am Acad Dermatol 1990;23:1093Y1098 5. Argenyi ZB, Piette WW, Goeken JA. Cutaneous angiomyolipoma. A light-microscopic, immunohisto-chemical, and electron-microscopic study. Am J Dermatopathol 1991;13:497Y502 6. Shin J-U, Lee K-Y, Roh M-R. A case of a cutaneous angiomyolipoma. Ann Dermatol 2009:21:217Y220 7. Roma AA, Magi-Galluzzi C, Zhou M. Differential expression of melanocytic markers in myoid, lipomatous, and vascular components of renal angiomyolipomas. Arch Pathol Lab Med 2007;131:122Y125 8. Mehregan DA, Mehregan DR, Mehregan AH. Angiomyolipoma. J Am Acad Dermatol 1992;27:331Y333 9. Rodriguez-Fernandez A, Caro-Mancilla A. Cutaneous angiomyolipoma with pleomorphic changes. J Am Acad Dermatol 1993;29:115Y116
1122
10. Val-Bernal JF, Mira C. Cutaneous angiomyolipoma. J Cutan Pathol 1996;23:364Y368 11. Obata C, Murakami Y, Furue M, et al. Cutaneous angiomyolipoma. Dermatology 2001;203:268Y270 12. Debloom JR, Friedrichs A, Swick BL, et al. Management of cutaneous angiomyolipoma and its association with tuberous sclerosis. J Dermatol 2006;33:783Y786 13. Tsuruta D, Maekawa N, Ishii M. Cutaneous angiomyolipoma. Dermatology 2004;208:231Y232 14. Beer TW. Cutaneous angiomyolipomas are HMB45 negative, not associated with tuberous sclerosis, and should be considered as angioleiomyomas with fat. Am J Dermatopathol 2005;27:418Y421 15. Hatori M, Watanabe M, Kokubun S Angiomyolipoma in the kneeVa case report. Ups J Med Sci 2005;110:245Y249 16. Makino E, Yamada J, Tada J, et al. Cutaneous angiolipoleiomyoma. J Am Acad Dermatol 2006;54:167Y171 17. Mikoshiba Y, Murata H, Ashida A, et al. Case of a cutaneous angiomyolipoma in the ear. J Dermatol 2012;39:808Y809 18. Ammanagi AS, Dombale VD, Shindholimath VV. Cutaneous angiomyolipoma. Indian Dermatol Online J 2012;3:40Y41 19. Bu¨yu¨kbabani N, Tetikkurt S, Oztu¨rk AS. Cutaneous angiomyolipoma: report of two cases with emphasis on HMB-45 utility. J Eur Acad Dermatol Venereol 1998;11:151Y154
A Marking for Repair of Complete Cleft Lip To the Editor: Management of unilateral cleft lip remains controversial.1 A large series lends support to the belief that no single technique of cleft lip repair is a panacea for all cases.2 After studying * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
incomplete cleft lips and mild cleft lips,3,4 we study 30 complete cleft lips. Complete cleft lip has a deviated philtrum dimple and a deviated nasal column. The deviated dimple and the nasal column are always toward the same direction and have the same angle to the middle line. Therefore, we have a hypothesis that the deformities of the deviated dimples and the nasal columns have the same physical reason that the asymmetric lip on the noncleft side is due to the unbalance power of the muscles. If the muscle of the noncleft side were out of power, the deformity of a cleft lip should only be a cleft with a symmetric cupid bow and right location of philtrum dimple and nasal column. We can observe the result on bilateral cleft lips, which can present evidence of the hypothesis. No matter how severe the clefts on bilateral cleft lips are, their nasal columns and the philtrums dimples are always on the middle line without severe deviation. Taking photograph is an important work for a plastic surgeon. While studying lots of the pictures, we found that there was a potential line on the noncleft side on the photograph of the complete cleft lip (Figs. 1 and 2). Therefore, we assumed that there was a nature marking on the cleft lip. Performing on more than 30 patients, we obtained favorable results. The longest follow-up period was 1 year.
PATIENTS AND METHODS Methods We mark the cleft-side lip as Figure 1. A, 2, B were marked according to Millard rotation-advanced principle. C is located on the top of the philtrum dimple. CB is a curve line with the same length of CA. D is located at the noncleft side of nasal column. E is marked according to D, which is located at the cleft side of the nasal column and CE = CD. Thus, we can obtain 2 triangles named $ABC and $DCE (Fig. 1). The cross point is located at the summit of the philtrum dimple. Because A, 2, B are marked according to Millard rotation-advanced principle, the distance from A to 2 is equal to the distance from 2 to B. $ABC can obtain a twisted philtrum dimple contour. The inverse triangle $DCE comprises a normal nasal column contour. When the ‘‘C’’ is secured to the middle line, the ‘‘B’’ will descent spontaneously. After muscle repair and nasal column and the philtrum dimple fixed at the middle line, we can obtain a symmetric cupid bow easily. The incision of cleft side is marked at the commissure of the skin and vermilion.5
FIGURE 1. There seems a shadow line on the noncleft side before doing nothing, when we studied many photographs.
Correspondence
FIGURE 2. Line ECB and HI are the incisions. Line E4 is a releasing incision to correct the nasal column to the middle line.
Case A 3-month-old boy was admitted with his parent’s complaint of complete unilateral cleft lip. After examination, the diagnosis of complete unilateral cleft lip was made (Fig. 2). Surgical repair was performed under general anesthesia associated with infraorbital lidocaine injected. In our design, noncleft side incision was made as a concave high curve line along the natural line, which is from the peak of the cupid bow of the noncleft side to the nasal column. A transverse incision in the nasal column base was made to reduce the deviated nasal column (Fig. 2). The incision of the cleft side was marked at the commissure of the skin and mucosa (Fig. 2). Of great care was to maintain the philtral dimple. Muscular repair began with the muscle from the tip of the lateral flap into the medial rotation defect according to the style of Stal et al.6 Taking muscular roll created a medial vector to rotate the cleft ala inward by Byrd and Salomon’s7 technique. Cleft-side alar base drift laterally was repositioned slightly and secured to nasalis.8 The lateral advancement flap was advanced together with the muscle released from the maxillary. Retrogression of C-flap was partly excised, and the rest was used to reconstruct the nostril sill. We performed simple interrupted sutures, working superior to inferior, until the incision was closed. One year later, we got the photograph while he was admitted to repair the cleft palate (Fig. 3).
FIGURE 3. The case on 12 months’ follow-up visit. The baby presented unnoticeable scar and a symmetric cupid bow.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1123
The Journal of Craniofacial Surgery
Correspondence
RESULTS The technique gets good result from 1-year follow-up response. The cupid bows present symmetrically (Fig. 4). Scars on the lips present slight curve line without noticeable contraction (Fig. 4).
DISCUSSION A method, recognized as rotation-advanced principle technique, was on the horizontal, which was destined to become even more popular.6 A study by Sitzman et al1 confirmed that rotationadvancement principle remained the most popular technique among cleft surgeons: 84% of respondents performed a rotation-advancement repair for complete unilateral cleft lip. However, almost half of those surgeons used a modified technique. Therefore, it confirmed that, with the wide usage of the Millard technique, lots of disadvantages were presented. The modifications of Millard technique such as back cut and inferior triangle flap always focus on obtaining enough length to reconstruct the cupid bow. Stal et al6 used an S-shaped ‘‘fleur de lis’’Ytype incision to add length to the labial element. In our design, skin rotation incision was made up of a concave high curve along the natural line, which is from the peak of the cupid bow of the cleft side to the nasal column. The technique of the concave high curve line is much easier to elongate the white lip than various rotations. Therefore, a symmetric cupid bow can be reconstructed easily instead of inferior triangular flaps, various rotation techniques, and back cut by Millard rotation-advancement principle. Reconstruction of philtrum ridges and philtrum dimples is also a problem in cleft lip repair. In our study, skin on the cleft side shifted down to maxilla and fused with mucosa, which form a low level of incision. The incision marked at the edge of the skin and mucosa can obtain a different lever between the incision and cleft-side lip. The philtrum ridges and the philtrum dimples will be spontaneously reconstructed without any technique because of the natural lever difference (Fig. 3). For Chinese babies undergoing surgery for this type of deformity, scarring on the nostril sill, alar base, and white lip plays an important role in postoperative aesthetics, which is different from the white-race babies. The present technique is less likely to necessitate secondary scar revision, as it minimizes primary surgical incisions. The whole incisions are according to the Langhans line, which is the principle of plastic surgery. It is reported nasal tip projection and columella length of
& Volume 25, Number 3, May 2014
Chinese people are fast-growing features by 5 years of age.2 Therefore, the technique cannot obtain a permanent outcome of nasal deformities. The new features of the technique are as follows. The first is that there are no incision and flap on the cleft side. The second is that the incisions of both sides have some curve orientation, which is easy to close. The third is that all of the markings are simple enough to understand by young doctors. The essentials of the technique are as follows. All of the incisions are around the cleft without any incisions in normal skin, which is to minimize iatrogenic damage. The main problem of Millard technique is to obtain the symmetric cupid bow. The incision of the technique can obtain the symmetric cupid bow easily. Chen Jianbing, PhD Weimin Shen, PhD Jie Cui, MD Department of Plastic Surgery Nanjing Children’s Hospital Affiliated to Nanjing Medical University Nanjing, Jiangsu, China [email protected]
REFERENCES 1. Sitzman TJ, Girotto JA, Marcus JR. Current surgical practices in cleft care: unilateral cleft lip repair. Plast Reconstr Surg 2008,121:261eY270e 2. Reddy GS, Webb RM, Reddy RR, et al. Choice of incision for primary repair of unilateral complete cleft lip: a comparative study of outcomes in 796 patients. Plast Reconstr Surg 2008;121:932Y940 3. Chen J, Shen W, Cui J. Modification of the rotation-advancement principle in cleft lip repair. J Craniofac Surg 2009:20: 2215Y2216 4. Chen J, Shen W, Jie C. An individual technique for mild incomplete cleft lip repairing. J Craniofac Surg 2012;23:1131Y1132 5. Koh KS, Choi JW, Kim H. Minimal paring of skin flaps for primary repair of incomplete unilateral cleft lip. Plast Reconstr Surg 2008;121:1382Y1385 6. Stal S, Brown RH, Higuera MS. Fifty years of the Millard rotation-advancement: looking back and moving forward. Plast Reconstr Surg 2009;123:1364Y1377 7. Byrd HS, Salomon J. primary correction of unilateral cleft nasal deformity. Plast Reconstr Surg 2000;106:1276Y1286 8. Mulliken JB, Labrie RA. Four-dimensional changes in nasolabial dimensions following rotation-advancement repair of unilateral cleft lip. Plast Reconstr Surg 2012;129:491Y498
Preventing Hair Interference During Ear Surgery
FIGURE 4. Photographs of some of our cases. The longest follow-up period is 1 year.
1124
To the Editor: During ear surgery, postauricular and scalp hair can cause an obstacle for the surgeon. Surgical drapes are preferred worldwide by wrapping them until an appropriate surgical field is settled. Easy dissection and surgical handling alongside the ear may be problematic unless an appropriate hairless field is achieved. Moreover, the hair around the surgical area can get stuck unwantedly, making the surgeon habitually struggling with this hair rather than the surgery itself. Even an assistant sometimes deals solely with this task to help the surgeon do his/her work. There are little data existing about this concern in the literature. Hede´n1 first described the use of elastic bands in hair restraint. Bovill and Wharton2 simply suggested using swimming caps for this purpose. I used a postauricular adhesive tape to prevent hair interference in the surgical field. After appropriate cleaning and preparation, a previously sterilized adhesive tape was fixed on the postauricular area (Fig. 1). With this maneuver, a surgical field without hair * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
