Presurgical Unilateral Cleft Lip Anthropometrics

Sir: We would like to draw attention to the stair-step deformity of the vermilion-mucosa junction, which frequently occurs after cleft lip repair (Fig. 1). It has been our experience that failure to appreciate and correct vermilion height asymmetry at the time of primary lip repair will result in a stair-step deformity of the vermilion-mucosa junction and exposure of mucosa with the lips in repose. The exposed mucosa is visually conspicuous because of the color and texture mismatch. Furthermore, the exposed mucosa dries and chaps, and the patient will habitually lick the lip to moisten the mucosa. Although techniques exist to correct vermilion height asymmetry during primary lip repair,1,2 a minority of surgeons routinely employs them.3 Most surgeons instead perform straight-line closure of the vermilion, failing to address vermilion height asymmetry.Fig. 1: Secondary deformity from failure to correct vermilion height asymmetry. Note the stair-step deformity with exposure of oral mucosa on the outer lip surface, where it takes on a dry and red appearance. This distracts from an otherwise quite acceptable lip repair.We hypothesized that differences in vermilion height between the medial and lateral lip elements are a common occurrence in patients with unilateral cleft lip. We reviewed anthropometric measurements from 331 consecutive patients with unilateral cleft lip who underwent repair by the senior author (D.M.F.). We excluded patients with previous lip surgery or contralateral cleft variant. Measurements were obtained immediately before lip repair with the patient under general anesthesia. Vermilion height was measured as the distance from the vermilio-cutaneous junction to the vermilio-mucosal junction, taken along a line perpendicular to the vermilio-cutaneous junction. Vermilion height was obtained at the points of closure. For the medial lip element, this was the peak of the Cupid’s bow; for the lateral lip element, this was Noordhoff’s point.4 The Research Ethics Board at The Hospital for Sick Children approved the study. We found that the average vermilion height on the medial lip element was 2.5mm (SD 0.7mm), compared with 3.9mm (SD 0.8mm) on the lateral lip element. This difference was highly significant (p < 0.0001, Student’s t test) and represented a 36.9 percent deficiency in medial lip vermilion height compared with the lateral lip (Fig. 2). On average, the medial lip vermilion was 1.4mm (SD 0.7mm) shorter than the lateral lip. A height difference of at least 1mm was present in 88.5 percent of patients. A difference of at least 2mm was present in 31.4 percent of patients.Fig. 2: Vermilion height at the Cupid’s bow peak. The median is represented by a black box, the twenty-fifth to seventy-fifth percentiles are represented by a gray box, and all data are represented by a black line. Hollow circles indicate outliers (>2*interquartile range). For the lateral lip vermilion height, the fiftieth and seventy-fifth percentiles were both 4.0 mm.This study is the first to describe the incidence of vermilion height asymmetry in the unilateral cleft lip. We found that medial lip vermilion is significantly deficient relative to the lateral lip at the point of closure. This deficiency meets or exceeds the 1-mm threshold in 88.5 percent of patients. Failure to address vermilion height asymmetry during cleft lip repair will place a large majority of patients at risk of requiring secondary surgery. Primary lip repair is the ideal time to correct vermilion height asymmetry. When a straight-line vermilion closure is performed during primary cleft lip repair, the tissue from which to create a laterally based vermilion flap is forever discarded. The authors hope that describing the high incidence of vermilion height asymmetry will inspire cleft surgeons to routinely look for and address this asymmetry during primary cleft lip repair. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding support was received for the work, and no products, drugs, or devices were used in the research described within. Presented at the Annual Meeting of the American Cleft Palate–Craniofacial Association, in San Jose, California, April 17 through 21, 2012, and the Annual Meeting of the Canadian Society of Plastic Surgeons, in Toronto, Ontario, Canada, June 6 through 9, 2012. Thomas J. Sitzman, M.D. Division of Plastic Surgery Cincinnati Children’s Hospital Medical Center Department of Surgery University of Cincinnati Cincinnati, Ohio David M. Fisher, F.R.C.S.C., F.A.C.S. Division of Plastic Surgery The Hospital for Children Department of Surgery University of Toronto Toronto, Ontario, Canada

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