Richard E. Kirschner, Oluwaseun A. Adetayo, Joseph E. Losee
○ Lip adhesion is a useful alternative to presurgical orthopedics in infants with complete unilateral or bilateral cleft lip.
○ In designing the lip adhesion, the incisions must be placed within tissues that will be discarded at the time of definitive lip repair.
○ To permit tension-free adhesion, the lateral lip and alar base should be released from their attachments to the maxilla through an upper buccal sulcus–piriform aperture incision.
○ Use of a permanent internal retention suture relieves tension on the adhesion and reduces the risk of dehiscence. The retention suture should encircle the orbicularis muscle on both sides of the cleft.
○ Careful flap placement ensures symmetrical positioning of the alar bases in both the vertical and horizontal planes.
○ Placement of a silicone nasal conformer at the time of lip adhesion allows for columellar lengthening and reshaping of the lower lateral cartilages before definitive lip repair.
The complete unilateral and bilateral cleft lip and nose deformity presents the reconstructive surgeon with the challenge of significant distortion of normal lip and nasal anatomy.1 Improvement or restoration of normal skeletal, cartilaginous, and soft tissue relationships before definitive lip and nose repair may offer significant benefits to overall outcome. To this end, numerous methods of presurgical intervention have been described, each with its own advantages and disadvantages and all with varying degrees of success. Latham popularized the use of an active pin-driven device for presurgical infant orthopedics (PSIO).2–4 Grayson et al5 described passive presurgical nasoalveolar molding (NAM) in infants with cleft lip and palate to assist in achieving improved lip and nasal symmetry after cleft repair. These methods invariably require active parental participation, frequent travel to the provider’s office for appliance fitting and adjustment, and financial resources. For families with time, economic, geographic, and other constraints, PSIO may present a very significant burden of care. For the infants of such families, a staged surgical approach, including preliminary lip adhesion, can be a practical and beneficial alternative.
Lip adhesion was originally described by Johanson in 1960 as a means to facilitate alveolar approximation in preparation for early primary bone grafting.6,7 The goal of the procedure was to convert the complete cleft deformity to an incomplete deformity, thereby restoring the normal compressive forces of the intact lip to realign the alveolar arches.8 In bilateral deformities, lip adhesion served to retract the protruding premaxilla, expand the soft tissues, elongate the deficient prolabium, and allow definitive repair to be completed with decreased tension and less likelihood of dehiscence.8,9 The potential of this procedure to facilitate primary lip and nose repair was clearly evident, and surgeons quickly adopted lip adhesion as a part of their treatment plan for patients with complete unilateral and bilateral cleft lip and nasal deformities. In 1965, Randall1 published his technique of lip adhesion using broad triangular flaps, and this became the foundation upon which many surgeons added variations and improvements. Walker and colleagues10,11 suggested the potential “physiologic molding” of the alveolar segments by a functionally intact lip in 1966. More recently, Van der Woude and Mulliken12 proposed repositioning the lower lateral cartilages at the time of the lip adhesion, naming the procedure a “lip-nasal adhesion.” They noted the potential advantages of lip-nose adhesion for wide unilateral and bilateral clefts to include not only molding of the alveolar segments, but also improved nasal contour, augmented orbicularis oris musculature, and increased vertical height of the lateral and medial lip elements.
Although the advantages of lip adhesion are numerous, some disadvantages exist as well, including the potential anesthetic risks, costs of an additional operation, dehiscence, and scarring.13–15 Dehiscence rates are reported to be less than 5% in experienced hands and may be higher in bilateral cases.12,13 When a dehiscence does occur, it is often partial in nature, and the final result is compromised little, if at all. Because lip adhesion results in unpredictable repositioning of the maxillary segments, passive alveolar molding is required if primary gingivoperiosteoplasty is planned.
In 1983, Osborn and Kelleher16 reported that only a small percentage of plastic surgery training programs routinely use lip adhesion as a part of their cleft lip treatment plan. Critics of lip adhesion note scarring as a disadvantage. Bardach and Salyer14 compared unilateral cleft lip repair with and without lip-nose adhesion and found that children who underwent single-stage repairs had superior outcomes in their series. They attributed this in part to the scarring that occurred after lip adhesion. Despite the arguments that lip adhesion introduces scar into the unrepaired lip, careful design and execution will ensure that such scars remain within tissues that would eventually be discarded at the time of definitive repair. In our experience, scarring has not been a major concern in most cases. The lip adhesion scar is simply excised at the time of definitive lip repair; it does not impede the dissection or affect the final aesthetic outcome.
Another advantage of lip adhesion is its molding effect on the alveolar segments in both unilateral and bilateral cleft deformities, with authors reporting approximately a 60% decrease in cleft gaps after preliminary adhesion.17–19 This facilitates closure in the definitive lip repair as well when gingivoperiosteoplasty is planned.17–20 Lip adhesion has also been shown to result in a measurable increase in the thickness of the orbicularis oris muscle in the unilateral cleft lip, thus facilitating definitive repair and providing additional bulk for constructing the philtral ridge.21
Infants with wide complete unilateral or bilateral clefts are good candidates for lip adhesion (Fig. 41-1). The procedure is performed under general anesthesia at 2 to 3 months of age.
Unilateral Lip Adhesion
After anesthesia is induced and the airway is secured, key points for the definitive cleft lip and nose repair are marked on the skin and tattooed with methylene blue. The key landmarks are delineated so tissues needed for the definitive repair are not violated during the lip adhesion procedure (Fig. 41-2). Of particular note, the alar base position and alar-facial grooves are marked. The lip-nose adhesion must be performed in such a way as to create both vertical and horizontal symmetry of these very important landmarks. If asymmetry of the alar base position exists at the completion of the lip adhesion, either in the vertical or horizontal dimension, the deformity will be harder to correct at the time of definitive lip and nose repair.
Fig. 41-1 Newborn infant with a complete left-sided cleft lip, nose, and palate.