British Journal of Plastic Surgery (I 976), 29, I I 3-1 I 5
AN ATTEMPT TO REDUCE THE VISIBLE SCAR IN PRIMARY CLEFT LIP REPAIR
By B. S. CRAWFORD, M.B., F.R.C.S. The Royal Hospital Annexe, Fulwood, Shefield IO MODERN cleft
lip surgery attempts to provide a nose and lip which are normal in function and appearance. Unfortunately the result is often marred by a noticeable scar, however fine it may be. In some patients the scar draws attention to the lip due to broadening, depression or a poor colour match with the adjacent skin. An attempt has been made to reduce the visible scarring in the repaired lip using an idea based on a simple observation made during the treatment of facial abrasions and lacerations: wounds confined to the epidermis and superficial layers of the dermis healed without visible scars but those which penetrated more deeply, particularly if they reached the fat, always left noticeable scars. It was considered that, if the repair of a cleft lip could be designed so that the only visible portion of the repair was confined to the superficial layers of the skin, it might be possible to hide the main scar. It was assumed that the skin of the lip would be sufficiently opaque to hide the scar and that a wedge-shaped strip of skin (without subdermal fat) would survive on the dermal plexus.
L
: _3 . ** ..:. ..** ...
l
l
l
l
l
FIG. I. The markings used in cleft lip repair. The parallel lines are 3 mm apart. 29/2-A
113
BRITISH
114
JOURNAL
OF PLASTIC
SURGERY
b dermis fat
FIG.
2.
Vertical section (not to scale) to show the lip (a) prepared for repair and (b) after closure.
The technique has been tried on a small series of cleft lip repairs carried out in the first few months of life. At first it was limited to partial clefts in order to avoid tension but it has now been tried on wider clefts. The early impression is promising but it is important to use an uncomplicated method such as that of Brown and McDowell, (1948) Or Millard (1960). TECHNIQUE
The usual lines are marked on the skin and are then replaced by double parallel lines drawn 3 mm apart on either side of the original lines (Fig. I). On one side the parallel lines demarcate what will be a wedge of skin with the base beneath its outer line; the very sharp apex of the wedge lies on the surface along the inner line. On the other side the parallel lines outline what will be a wedge-shaped dermal defect corresponding exactly to the skin wedge raised on the first side. When the skin wedge is raised it is important to use a very sharp scalpel which is initially held flat against the skin so that the free edge of the wedge cm the line nearer the cleft is translucent like a thin skin graft. As the knife penetrates it is angled to reach the junction of dermis and fat beneath the second of the 2 parallel lines. The fat, muscle and mucosa are now divided vertically in the usual way. On the opposite side a similar manoeuvre is carried out but the wedge-shaped skin strip is discarded with the other unwanted tissue. The 2 wound margins should now fit perfectly and are closed in layers. When the rest of the operation is complete a minimum number of fine “Dexon” (polyglycolic acid) sutures are inserted to coapt the muscles, the deep
REDUCTION
OF SCAR IN PRIMARY
CLEFT
LIP
REPAIR
II5
FIG. 3. An example of the result achieved z years after cleft lip repair by the method described.
layers of the dermis and the mucosa (Fig. 2). No sutures are applied to the skin which is held in place with perfect edge to edge contact by lengths of “Steri-Strip” which are peeled off after I week. RESULTS So far all the wedge-shaped strips of skin in this small series have survived and rapid skin healing has occurred. No cysts have developed in the buried dermis. The amount of visible scar seems to be reduced and sometimes it is almost invisible although minor blemishes can be detected (Fig. 3). The “stepped” design prevents depression of the scar and the avoidance of surface stitches eliminates the problem of cross-hatching. It is important to wait some years before the final result is assessed.
REFERENCES BROWN, J. B. and MCDOWELL, F. (1948).
56, 750.
MILLARD, D. R., Jr. (1960). Surgery, 25, 59s.
Surgical repair of cleft lips.
Archiwes of Surgery,
Complete unilateral clefts of the lip. Plastic and Reconstructive
AN ATTEMPT TO REDUCE THE VISIBLE SCAR IN PRIMARY CLEFT LIP REPAIR
By B. S. CRAWFORD, M.B., F.R.C.S. The Royal Hospital Annexe, Fulwood, Shefield IO MODERN cleft
lip surgery attempts to provide a nose and lip which are normal in function and appearance. Unfortunately the result is often marred by a noticeable scar, however fine it may be. In some patients the scar draws attention to the lip due to broadening, depression or a poor colour match with the adjacent skin. An attempt has been made to reduce the visible scarring in the repaired lip using an idea based on a simple observation made during the treatment of facial abrasions and lacerations: wounds confined to the epidermis and superficial layers of the dermis healed without visible scars but those which penetrated more deeply, particularly if they reached the fat, always left noticeable scars. It was considered that, if the repair of a cleft lip could be designed so that the only visible portion of the repair was confined to the superficial layers of the skin, it might be possible to hide the main scar. It was assumed that the skin of the lip would be sufficiently opaque to hide the scar and that a wedge-shaped strip of skin (without subdermal fat) would survive on the dermal plexus.
L
: _3 . ** ..:. ..** ...
l
l
l
l
l
FIG. I. The markings used in cleft lip repair. The parallel lines are 3 mm apart. 29/2-A
113
BRITISH
114
JOURNAL
OF PLASTIC
SURGERY
b dermis fat
FIG.
2.
Vertical section (not to scale) to show the lip (a) prepared for repair and (b) after closure.
The technique has been tried on a small series of cleft lip repairs carried out in the first few months of life. At first it was limited to partial clefts in order to avoid tension but it has now been tried on wider clefts. The early impression is promising but it is important to use an uncomplicated method such as that of Brown and McDowell, (1948) Or Millard (1960). TECHNIQUE
The usual lines are marked on the skin and are then replaced by double parallel lines drawn 3 mm apart on either side of the original lines (Fig. I). On one side the parallel lines demarcate what will be a wedge of skin with the base beneath its outer line; the very sharp apex of the wedge lies on the surface along the inner line. On the other side the parallel lines outline what will be a wedge-shaped dermal defect corresponding exactly to the skin wedge raised on the first side. When the skin wedge is raised it is important to use a very sharp scalpel which is initially held flat against the skin so that the free edge of the wedge cm the line nearer the cleft is translucent like a thin skin graft. As the knife penetrates it is angled to reach the junction of dermis and fat beneath the second of the 2 parallel lines. The fat, muscle and mucosa are now divided vertically in the usual way. On the opposite side a similar manoeuvre is carried out but the wedge-shaped skin strip is discarded with the other unwanted tissue. The 2 wound margins should now fit perfectly and are closed in layers. When the rest of the operation is complete a minimum number of fine “Dexon” (polyglycolic acid) sutures are inserted to coapt the muscles, the deep
REDUCTION
OF SCAR IN PRIMARY
CLEFT
LIP
REPAIR
II5
FIG. 3. An example of the result achieved z years after cleft lip repair by the method described.
layers of the dermis and the mucosa (Fig. 2). No sutures are applied to the skin which is held in place with perfect edge to edge contact by lengths of “Steri-Strip” which are peeled off after I week. RESULTS So far all the wedge-shaped strips of skin in this small series have survived and rapid skin healing has occurred. No cysts have developed in the buried dermis. The amount of visible scar seems to be reduced and sometimes it is almost invisible although minor blemishes can be detected (Fig. 3). The “stepped” design prevents depression of the scar and the avoidance of surface stitches eliminates the problem of cross-hatching. It is important to wait some years before the final result is assessed.
REFERENCES BROWN, J. B. and MCDOWELL, F. (1948).
56, 750.
MILLARD, D. R., Jr. (1960). Surgery, 25, 59s.
Surgical repair of cleft lips.
Archiwes of Surgery,
Complete unilateral clefts of the lip. Plastic and Reconstructive
