The Comparison of Different Surgical Techniques Used for Repair of Complete Unilateral Cleft Lip

Up to now, many various techniques have been proposed for the repair of complete unilateral cleft lip. The aim of this study was to compare late results of three different surgical techniques (C. Tennison, R. Millard, and J. Olekas) used for the repair of complete unilateral cleft lip and to analyze their advantages and disadvantages. Material and Methods. Sixty-six patients with nonsyndromic complete unilateral cleft lip, alveolus, and palate were examined. For 19 patients (28.8%), cleft lip repair was performed using the Tennison technique; for 20 patients (30.3%), Millard technique; and for 27 patients (40.9%), Olekas technique. Results were assessed by score, which was given by analyzing standardized photographs of nasolabial triangles. For the assessment, the modified scale according to Mortier and Anastassov was used. Separate anatomical elements – red lip, white lip, scars, and nose – were assessed. Results. The best appearance of the red lip and white lip was found after the Tennison technique. Scars and nose looked the best after Olekas cheiloplasty. There were no significant differences in the evaluation of red lip and nose appearance comparing all three analyzed surgical techniques (P>0.05). Tennison technique showed significantly better results in the appearance of the white lip (P<0.05); the appearance of scars was significantly better after the Olekas repair (P<0.001). Conclusions. Height of white lip and symmetry of the Cupid’s bow were better restored by using the Tennison technique. The physiological configuration of the white lip and less visible scars were achieved by using the Olekas technique. All techniques were equal in red lip and nose formations.


Introduction
Cleft lip, alveolus, and palate are the most common congenital anomalies of the face.The ratio of these anomalies in different populations varies from 1:286 to 1:1235 (1,2).In Lithuania, this ratio was 1:544 during 1993-1997 (3).Up to now, many various surgical techniques are proposed for the repair of complete unilateral cleft lip.However, each and all these techniques have advantages and disadvantages (4)(5)(6).The comparison of results of different methods is complicated because of differences in patients' age at the time of surgery, measurements of the cleft, and time of evaluation.Evaluation of the results of surgery has been suggested to be performed at least some years after surgery.
The methods of evaluation in different studies are also inconsistent: some of them are based on subjective patient's or examiner's satisfaction, and others are based on more objective criteria or digital evaluation of residual deformities.Digital evaluation is performed by measuring postsurgical distances of angles of anatomical structures in standardized postoperative photographs (7,8), by computerized measurement of nose deformations on standardized photographs (9), or by using a scoring system for the subjective evaluation of postoperative appear-ance of the lip and nose (10)(11)(12).Another possible reason for a lack of comparative results is the evaluation of postsurgical outcomes in different cleft centers, in which different presurgical and postsurgical treatment protocols are used.The experience of surgeons is also different.
The aim of this study was to compare late results of three different surgical techniques -C.Tennison (triangle fl aps), R. Millard (rotations fl aps), and J. Olekas (modifi ed G. Pfeiffer or wave incisions with a small triangle fl ap above the red lip) -used for the repair of complete unilateral cleft lip and to analyze advantages and disadvantages of these three methods.

Material and Methods
This retrospective study was carried out at the Cleft Center, Vilnius University Hospital Žalgiris Clinics.All operations were performed from 1987 to 2000 by two experienced surgeons.In the case of complete unilateral cleft lip, alveolus, and palate, lip repair in this Cleft Center was performed according to the Tennison (from 1987 to 1992, Fig. 1), Millard (from 1990 to 1996, Fig. 2), and Olekas (after 1995, Fig. 3) techniques (13,14).Other parts of treatment protocol (preoperative and postoperative orthodontic treatment) were the same.
One hundred fi ve patients with nonsyndromic complete unilateral cleft lip, alveolus, and palate treated at the same Cleft Center were invited for the evaluation of postoperative results.Syndromic patients and patients who had undergone the secondary surgical correction of the lip and/or nose were excluded.Patients were divided into three groups according to the application of the type of surgical technique (Tennison, Millard, and Olekas).
All patients were photographed in standardized illumination and background using a digital camera Canon 400 D. Photographs in 4 standard projections -en face, left and right profi les, and from slightly below (nasomental view) -were taken.All patients and their photographs were coded.In all photographs, only nasolabial triangle (without eyes) was evaluated.The nasolabial areas were projected onto a white screen and estimated in the same illumination.The evaluation was performed using the modifi ed rating scale, which was proposed by Mortier et al. (10).This rating system is constructed based on the principle of giving points to each element characterizing both cleft and nasal deformities (11).The total sum of points demonstrated the level of correction of deformities.The more diffi cult correction of the secondary deformity of cleft lip or nose, the higher total score is.The rating scale consists of 4 different groups of anatomical elements of nasolabial triangle: red lip, white lip, scars, and nose (Table 1).
Statistical analysis was performed using the statistical program SPSS, version 14.0 (SPSS Inc., Chicago, IL, USA).
In order to verify the reliability of rating scale and to prevent inaccuracy during the rating procedure, nasolabial areas were evaluated independently by two investigators twice with a 10-day interval in the same illumination.The interexaminer reliability (kappa coeffi cient) was 0.89 and 0.92.In order to equalize results, the mean value and standard deviation were calculated in each group (red lip, white lip, scars, and nose).
The Kolmogorov-Smirnov test confi rmed that the null hypothesis (H 0 ) was true, i.e., the distribution of analyzed data in the interval scale did not differ from normal or Gaussian distribution.Mean values, standard deviation, and confi dence interval of difference were calculated.The level of significance for all tests was set at P<0.05.

Results
The follow-up period after cleft lip repair varied between 9 and 24 years.The response rate was 62.9% (66 of the 105 patients invited).In 19 patients (28.8%), the Tennison technique was used during cleft lip repair; in 20 patients (30.3%), the Millard technique; and in 27 patients (40.9%), the Olekas  Evaluated by points, the best appearance of red lip and white lip was found for patients with cleft, operated on using the Tennison technique.Scars and nose looked the best after surgeries according to the Olekas technique (Table 2).The distribution of scores with confi dence intervals of difference is shown in Figs.4-7.
However, the analysis revealed that despite better rating of the red lip by the Tennison technique or nose appearance by the Olekas technique, there was no signifi cant difference comparing all three investigated techniques (P>0.05).Tennison methodology showed signifi cantly better results in the appearance of the white lip and Olekas technique in the appearance of scars (Table 2).

Discussion
Different treatment protocols (preoperative and postoperative orthodontic treatment, different patient's age at the time of the surgery, different surgical techniques) might infl uence postoperative results (1,15).In the case of unilateral cleft lip, operations in different cleft centers were performed at the different patient's age varying from 1 month to 1 year, mostly from 3 to 6 months ( 16).In the present study, all operations were performed at the same Cleft Center, and only two experienced surgeons operated the patients using the same treatment protocol only applying different operative techniques.Therefore, these factors gave the better possibility to compare different operative techniques eliminating the infl uence of different treatment protocols, patient's age at the time of surgery, and surgeons' experience on the postoperative results.
Up to now, several different methods of the evaluation of cleft lip plasty have been proposed.For this purpose, cephalometric analysis (17), anthropometric studies (18), and subjective tests based on the appearance of cleft lip and nose components (19) are used.The rating scale, which was chosen in this study, is also based on the subjective evaluation of separate anatomical elements in the nasolabial triangle.This scale is closely related to the classifi cation of clefts by the American Cleft Palate-Craniofacial Association (11).Its validity has been already tested in other studies for the lip revision in bilateral clefts, comparing the severity of palatal cleft and the speech results and the results of the primary surgery for incomplete cleft lips (10,11).The same rating scale is being used in a prospective, randomized international multicenter study "Baltic Cleft Network" (Rostock, Ryga, Tartu, and Vilnius) (20).
Some authors separated wide clefts (8-10 mm and wider) from narrow; other authors incorporated all clefts in one group (12).In the case of wide clefts, cheiloplasty is performed in two steps in some centers.At fi rst, the preliminary lip adhesion (skin and mucosa sutures without muscles) is performed, and only a few months later, the true lip repair with mucosa and skin mobilization and orbicular muscle sutures is done (21).According to the Tennison technique, even very wide clefts are managed by single operation (22).In the present study, due to limited number of cases, patients were not divided into separate subgroups according to the cleft width.Therefore, the infl uence of cleft width on esthetic outcomes was impossible to evaluate.
After the assessment of red lip, there was no signifi cant difference comparing all three studied techniques (P>0.05);however, evaluation by separate scores revealed that the worst appearance of red lip was found for patients operated on by applying the Millard technique (Fig. 2).It might be determined by several factors.One of them is insuffi cient experience of surgeons at the beginning of the use of Millard technique.Until this time, all cleft lip plasties were performed only by applying the Tennison technique.The second factor is that in our center, all cleft lip plasties were performed by single operation, i.e., without preliminary adhesion of the mucosa and skin.
In the assessment of white lip, the patients operated on by applying the Tennison (triangular) technique, as might be expected, showed the best results.This is because symmetry of the Cupid's bow Linas Zaleckas, Laura Linkevičienė, Juozas Olekas, Nerijus Kutra and reconstruction of vertical lengths of the upper lip and upper vermilion contour are the classic characteristics of the triangular techniques (22).At the same time, the results of Millard and Olekas techniques in this group were almost equal (1.45±0.64 and 1.69±0.33 points, respectively).However, the height of white lip can be easily corrected by secondary plastic surgery, and the advantages of Tennison technique are valid only to this time.
Olekas technique showed the signifi cantly better results in the appearance of scars than other techniques (P<0.0001).This is because after cleft lip repair according to Olekas, scars occur directly on the philtrum border and they are less or no visible (Fig. 3).The change of scar confi guration from a triangular-shaped (Tennison technique, Fig. 1) or arch-shaped (Millard technique, Fig. 2) to a straight-line form is practically impossible.From this point of view, Olekas technique, used in our center, becomes an absolute advantage because scars after such operations are less visible, and the upper lip appears to be more physiological.
Lip symmetry in the case of unilateral cleft continues to improve with time after surgery and patient's age.Facial growth and the position of the alveolus process may also infl uence postoperative results.With regard to surgical outcome and facial growth, some changes in symmetry are very subtle and yet clinically signifi cant (23).However, the main bone growth of the middle third of the face is completed up to 9 years of age, and after this period, the proportions of the middle part of the face changes slightly.The mean age of patients operated on using the Olekas technique was 10.5±1.2 years, and we suppose that different patients' age at the time of evaluation does not have a great infl uence on the evaluation of results.In addition, according to other authors, despite the fact that a patient with extremely good results at a young age might look asymmetrical when he or she is older, good results more often remain good and poor results more often remain poor as a child ages (24).
One of the greatest aims in cleft lip surgery is avoidance of nasal deformities (25).There are some data that the Millard technique gives better results in the formation of the nostrils than the Tennison technique (6).The results of this study showed no signifi cant difference (P>0.05)comparing all three analyzed techniques despite the fact that the nose after Olekas technique was rated better.It might be concluded that each technique has advantages but none of these showed signifi cantly better results in the formation of the nostrils.
In the case of primary cleft lip plasty, it would be wise to separate such components as lip and nose.Cleft lip repair directly does not include rhinoplasty, but during primary cheiloplasty, new nostrils are formed, and the relationship of the nasal cartilages is also changed.There is ongoing discussion at what place skin incision in nostril area must be done to mobilize the alar cartilage during primary cleft lip plasty or it must be done during secondary surgery, how and wherewith to fi x mobilized cartilages, to use or not to use postoperative stents (26).Further studies are required in order to answer these questions.

Conclusions
Height of white lip and symmetry of the Cupid's bow were better restored by using the Tennison technique.The physiological confi guration of the white lip and less visible scars were achieved by using the Olekas technique.All techniques were equal in red lip and nose formations.

Statement of Conflict of Interest
The authors state no confl ict of interest.

Fig. 3 .
Fig. 3. Lip frontal view after cheiloplasty according to the technique by Olekas

Flat
's bow and philtrum too narrow or no Cupid's bow at all Cupid's bow and philtrum too wide base too wide Columellar base too narrow Insuffi cient wrapping of the ala Exessive wrapping of the ala Deformation of the upper part of the nostril rim Poor position of alar cartilage High position of the ala Low position of the ala the time of evaluation, the mean age of patients operated on according to Tennison, Millard, and Olekas techniques was 20.5±3.2 years, 15.2±2.7 years, and 10.5±1.2 y ears, respectively.

Table 1 .
Rating Scale

Table 2 .
Results of Evaluation of Different Anatomical Elements