Wednesday, September 29, 2010

Comparison of Repair Incisions for Complete Unilateral Cleft Lip – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

For disclosure, I have not done a cleft lip repair in years.  The referrals of cleft lip patients in Arkansas funnel them to Arkansas Children’s Hospital where they get very good care.  That has not keep me from reading the articles in my journals.
This one (full reference below) with a following commentary caught my eye.  It offered a comparison of three incisions used for repair of unilateral cleft lip:  Millard incision, Pfeifer incision, and Afroze incision.
The Millard incision is based on a rotation flap on the noncleft side coupled with an advancement flap on the cleft side.   In one form or another, it is the most widely practiced method today. (photo credit)
The Pfeifer incision is a straight line repair for unilateral cleft lips.  The “straight-line” incisions on cleft and noncleft sides are made of equal lengths by incorporating a series of waves leading to a final scar that should follow the lateral line of the philtrum.
The Afroze incision is described in the article as a variant incision combining the Millard incision on the noncleft side (medial side) and the Pfeifer incision on the cleft side (lateral side).
The authors of the comparison study conducted a prospective cohort study of 1200 patients with complete unilateral cleft lip with or without cleft palate over a period of 4 years.  The first cohort of 400 patients was treated using the Millard incision between September of 2001 and October of 2002; the second cohort of 400 patients was treated using the Pfeifer incision between November of 2002 and January of 2004; and the last cohort of 400 patients was treated using the Afroze incision between February of 2004 and March of 2005.
Outcome assessments were performed 2 years postoperatively and consisted of assessment of the white roll, vermilion border, scar, Cupid's bow, lip length, nostril symmetry, and appearance of alar dome and base.
The authors concluded that the Afroze incision was superior:
With regard to white roll, vermilion border, scar, Cupid's bow, and lip length, the Afroze incision always gave superior results compared with the Millard or Pfeifer incision.
Depending on the cut-off for treatment success, the Afroze incision also showed better results regarding nostril symmetry.
With respect to the alar base and alar dome, all three incisions showed comparable outcomes.
I wish I could show you the photos included in the article as for me and Dr. Wolfe, the photos don’t agree with the authors conclusions. 
The patient with the bull's eye on his glabella preoperatively was operated on with a rotation advancement, and I feel he has the best result of the three. There is a very nice white roll and a discrete Cupid's bow, and the scar comes close to mirroring the normal philtral column on the noncleft side. …..
The second patient, with the “1” on his glabella, repaired with the Pfeifer incision, I think has the worst result of the three. The scar runs straight up into the nostril, giving him the appearance of having a runny nose, the lip on the cleft side is a bit short, there is no Cupid's bow, and there is a slight alar slump beneath the soft triangle.
The third, with the glabellar black spot, was repaired with the Alfroze technique. He has a nice Cupid's bow, but the lip scar wanders away from the desired area of the philtral column and is distracting. There is a very significant vestibular web, and the alar base on the cleft side lacks definition, as does the footplate area of the medial crus. The commissure-to–high point distance on the cleft side also appears a bit shorter than on the noncleft side.

Perhaps if they had chosen different photos for the article it would have been better.  The ones chosen, unfortunately, don’t back up the authors conclusions.

Comparison of Three Incisions to Repair Complete Unilateral Cleft Lip; Reddy, Srinivas G.; Reddy, Rajgopal R.; Bronkhorst, Ewald M.; Prasad, Rajendra; Kuijpers Jagtman, Anne Marie; Bergé, Stefaan; Plastic & Reconstructive Surgery. 125(4):1208-1216, April 2010;  doi: 10.1097/PRS.0b013e3181d45143
Discussion: Comparison of Three Incisions to Repair Complete Unilateral Cleft Lip; Wolfe, S. Anthony; Plastic & Reconstructive Surgery. 125(4):1217-1219, April 2010; doi: 10.1097/PRS.0b013e3181d45017
Unilateral Cleft Lip Repair; eMedicine article, June 19, 2009; Pravin K Patel, MD, Raja Ramaswamy, MS,  Mitchell F Grasseschi, MD, David E Morris, MD

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