Abstract
Elimination of cosmetic deformity of lower lip pits and lower lip protrusion is the most common indication for lower lip repair in Van der Woude syndrome. 34 patients with lower lip pits that were operated on between 1982 and 2006 were reviewed. Surgical correction was performed with one of three different techniques: simple excision, vertical wedge resection, or inverted-T lip reduction. The aesthetic results were evaluated by two groups of raters. One group consisted of 10 medical professionals, and the other 10 lay people. A rating scheme was utilized, with a score of 3 for good, 2 for fair, and 1 for poor results. The final results were compared based on the mean score for each patient and inter-rater reliability was assessed using a weighted kappa coefficient. There was a fair agreement on the ratings between raters within groups. Inverted-T lip reduction received the best aesthetic result score from both groups of evaluators, with a mean score of 2.38 ± 0.30 in the professional group, and 2.43 ± 0.29 in the lay group. The results conclude that inverted-T lip reduction is a simple, safe and effective technique that achieves a better aesthetic result in lower lip repair of Van der Woude syndrome.
Van der Woude syndrome is an autosomal dominant malformation typically consisting of a cleft lip and/or cleft palate and distinctive pits of the lower lip. The most distinctive features of patients with Van der Woude syndrome are lower lip pits and lower lip protrusion. Since Demarquay first described the anomaly in 1845, lower lip pits have been reported under various names, such as lower lip humps, cysts, sinuses, and fistula. Elimination of cosmetic deformity is the most common indication for surgical correction of lower lip pits, although sometimes mucous secretions and the potential for chronic inflammation also warrant intervention. The ideal technique for the treatment of lower lip pits requires the complete excision of sinus tracts and optimal restoration of the orbicular ring for lip hypotonia and protrusion correction and lip function preservation. Prevention of secondary deformities such as whistling defects should also be a priority. In the past, the most common surgical technique was simple excision of the sinuses using horizontal or vertical methods. Due to unsatisfactory results, alternative surgical techniques have been proposed for correction of the deformity, such as vertical wedge resections, the split lip advancement technique (SLAT) or recently, resection with AlloDerm graft implantation. In 2007, the inverted-T lip reduction technique was introduced as an alternative method to treat lip pits, while addressing the issues stated previously.
There is no consensus on which type of technique is superior. The purpose of this study was to review and evaluate the aesthetic results between various techniques used for lip pits surgery, judged by medical specialists and non-medical lay people. A simplified rating system was used and the results given by the two groups of raters were evaluated.
Materials and methods
Between 1982 and 2006, 34 patients with lower lip pits requiring primary surgical intervention were treated at the craniofacial centre at Chang Gung Memorial Hospital. There were 18 male and 16 female patients, with a mean age of 3.77 years (range 3 months to 16 years). All cases were associated with cleft lip and/or palate except for two. 11 patients had a positive family history. Lower lip pits in all patients were a feature of Van der Woude syndrome. Operations were performed for aesthetic and functional indications, with no specific clinical complaints such as infections. Regarding surgical correction of lower lip pits, the 34 patients in this study underwent lip repairs including 16 simple excisions, 7 vertical wedge resections and 11 inverted-T lip reductions. The choice of surgical technique was established through chronological order, as unsatisfactory results with simple excision and vertical wedge resection led to the inverted-T lip reduction technique. All patients had regular follow-up visits and had good quality, colour photographs taken in a designated standardized format. The mean follow-up time after lower lip repairs was 5.6 years.
Surgical techniques
Simple excision began by marking the exterior margin of the pits. Longitudinally directed, elliptical incisions were made around each of the pits. The extent of sinus tracts was identified with a probe and methylene blue, followed by complete excision of sinus pits with their connecting tracts. The wound was closed with vicryl sutures ( Fig. 1 ).
For vertical wedge resection, two vertically directed, elliptical incisions were made, extending outward to the skin inferior to the margin of the vermilion and inward to the wet vermilion. After identification of tracts with a probe and methylene blue, the sinus pits were resected in full-thickness wedges. The transected orbicularis oris muscle was repaired, followed by wound closure with vicryl sutures ( Fig. 2 ).
For inverted-T lip reduction, the exterior margins of the two sinus openings were first marked out in a similar fashion to simple excision, but were connected in the middle. The lateral edges were extended further towards the angle of the mouth to form wedge shapes. The outer margin of the marking remained parallel to the white skin roll, maintaining a constant width of vermillion tissue anteriorly. A vertical half-wedge was marked, starting perpendicular to the inner margins of the sinus pits in the midline, beginning approximately at the most interior point of the lip pits, and converging interiorly at the midline of the labial mucosa. The size of the wedge was adjusted according to patient differences. Skin incisions were made according to the markings. The incisions were deepened into the labial mucosa to excise the sinuses in their entirety following the probe and methylene blue stains, including the outer rim of loose orbicularis marginalis and peripheralis muscles in the lower lip. The edges of the vertical wedge were undermined and brought together in the midline. By closing the median defect formed by sinus excision, the muscular continuity of the lip was restored. The edges of the wound were closed with vicryl sutures ( Figs. 3 and 4 ).
Surgical techniques
Simple excision began by marking the exterior margin of the pits. Longitudinally directed, elliptical incisions were made around each of the pits. The extent of sinus tracts was identified with a probe and methylene blue, followed by complete excision of sinus pits with their connecting tracts. The wound was closed with vicryl sutures ( Fig. 1 ).
For vertical wedge resection, two vertically directed, elliptical incisions were made, extending outward to the skin inferior to the margin of the vermilion and inward to the wet vermilion. After identification of tracts with a probe and methylene blue, the sinus pits were resected in full-thickness wedges. The transected orbicularis oris muscle was repaired, followed by wound closure with vicryl sutures ( Fig. 2 ).
For inverted-T lip reduction, the exterior margins of the two sinus openings were first marked out in a similar fashion to simple excision, but were connected in the middle. The lateral edges were extended further towards the angle of the mouth to form wedge shapes. The outer margin of the marking remained parallel to the white skin roll, maintaining a constant width of vermillion tissue anteriorly. A vertical half-wedge was marked, starting perpendicular to the inner margins of the sinus pits in the midline, beginning approximately at the most interior point of the lip pits, and converging interiorly at the midline of the labial mucosa. The size of the wedge was adjusted according to patient differences. Skin incisions were made according to the markings. The incisions were deepened into the labial mucosa to excise the sinuses in their entirety following the probe and methylene blue stains, including the outer rim of loose orbicularis marginalis and peripheralis muscles in the lower lip. The edges of the vertical wedge were undermined and brought together in the midline. By closing the median defect formed by sinus excision, the muscular continuity of the lip was restored. The edges of the wound were closed with vicryl sutures ( Figs. 3 and 4 ).
