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 Table of Contents  
SHORT COMMUNICATION
Year : 2014  |  Volume : 1  |  Issue : 2  |  Page : 114-116

The "True Triangle" in cleft lip repair: A novel technique


Department of Oral Maxillofacial Surgery, Prince Mohammed Bin Abdualziz City, Riyadh, Saudi Arabia

Date of Web Publication12-Aug-2014

Correspondence Address:
Dr. Abdullah I Al Atel
Department of Oral Maxillofacial Surgery, Prince Mohammed Bin Abdualziz City, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-6816.138487

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  Abstract 

The aim of this short communication is to describe the True Triangle (TT) technique for the repair of unilateral cleft lip (CL). A total of 309 patients were operated using the TT technique. The final cleft lip repair results showed positive outcomes. Conclusion: This technique may overcome some of the drawbacks of the previously described surgical techniques used for CL repair.

Keywords: Cleft lip, repair technique, true triangle


How to cite this article:
Al Atel AI. The "True Triangle" in cleft lip repair: A novel technique. Saudi J Oral Sci 2014;1:114-6

How to cite this URL:
Al Atel AI. The "True Triangle" in cleft lip repair: A novel technique. Saudi J Oral Sci [serial online] 2014 [cited 2019 Jul 23];1:114-6. Available from: http://www.saudijos.org/text.asp?2014/1/2/114/138487

Given the complex nature of cleft lip (CL) and the esthetic and functional characteristics associated with its repair, new surgical techniques may bring small changes in the CL repair. [1] This short communication describes the use of a "true triangle" for the surgical repair of CL.

This technique practiced in the last 6 years in the Oral and Maxillofacial Surgery Department at Prince Sultan Military Medical City, Riyadh, Saudi Arabia. A total of 309 patients were operated using the True Triangle (TT) technique (Al- Atel Technique) to repair the CL; the final cleft lip repair results showed positive outcomes.


  The True Triangle Cleft Lip Repair Technique (Al Atel Technique) Top


Surgical markings

The technique uses 24 unique surgical points and in keeping with other techniques these points are marked on the patient using methylene blue [Figure 1]. The points can be described as those on the medial lip (non-cleft side). Nasal floor, and medial lip (non-cleft side)
Figure 1: Surgical anatomical points of the flap design for the TT technique

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  • (Point 1) base of columella
  • (Point 2) at lip-collumella crease
  • (Point 3) at lip-collumella crease to mirror (point 2) relation to (point 1)
  • (Point 4) at mid of philtrum (tubercle), near the vermillion cutaneous junction
  • (Point 5) at peak of cupids bow
  • (Point 6) at peak of cupids bow, mirror point 5 relation to point 4 and 1 mm above the vermillion cutaneous junction
  • (Point 7) is 2 mm superior to (Point 6) and forms the base of triangle at non-cleft side
  • (Point 8) is the apex of the triangle as points 6, 7, and 8 form a triangle with 2 mm base
  • (Point 9) is 1 mm below the vermillion cutaneous junction and forms the base of triangle with point 11
  • Points 6 and 9 form a line perpendicular to the vermillion cutaneous junction and pass through the peaks of the cupids bow
  • (Point 10) at mid of vermillion form apex of triangle with points 9 and 11
  • (Point 11) at the vermillion mucus junction
  • (Point 12) commissure of non cleft side


Nasal floor (Non-cleft side)

  • (Point 13) at sub alare medial side
  • (Point 14) at sub alare lateral side, on the curve of the alar-lip junction


Lateral lip (Cleft side)

  • (Point 15) at sub-alare lateral side, on the curve of alar-lip junction
  • (Point 16) at sub-alare medial side
  • The distance between points 2 and 13 (nasal sell at non-cleft side) equal the distance between points 3 and 16 (nasal sell at cleft side)
  • (Point 17) medial tip of advancement flap
  • (Point 18) peak of cupids bow at cleft side (1 mm above the white roll )
  • (Point 19) is 2 mm superior to point 18 and forms with point 18 the base of the triangle
  • (Point 20) apex of the triangle
  • (Point 21) is 1 mm below vermillion cutaneous junction
  • (Point 22) midpoint of vermillion forming the apex of the triangle, base is formed by points 21, 23
  • (Point 23) vermillion mucus junction
  • (Point 24) commissure cleft side


The distance between points 5 and 12 (peak of cupids bow and commissure at non-cleft side) equals the distance between points 24 and 18 (peak of cupids bow and commissure at cleft side).

Surgical technique

While a detailed description of the surgical technique is beyond the scope of this short communication the technique utilizes marking skin and subcutaneous incisions, incision of the orbicularis oris muscle, tip rhinoplasty, closure of the nasal layer of the alveolar cleft, and location of the nasal floors followed by closure of the orbicularis oris muscle and skin closure. This is then followed by mucosal closure and finally active placement of the alar base and placement of the nasal sell. The repair diagrams for the rectangular shape of philtrum [Figure 2]a and shield type of philtrum [Figure 2]b are shown in this communication. At the time of preparation of this communication, 309 patients had been operated on using this technique. The pre and post-operative pictures are shown below [Figure 3]a-f. The detailed outcome as well as patient and parent satisfaction from the technique are beyond the scope of this communication.
Figure 2: (a) The True Triangle lip repair diagramming in the case of rectangular shape of philtrum where the cutback (the arrow) is used. (b) The True Triangle lip repair diagramming in the case of Shield type of philtrum where the rotation part (the arrow) is used

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Figure 3: (a) Right CL pre-operative. (b) Same patient one month post operative CL repair with TT CL repair technique. (c) Same patient Three months post operative. (d) Six months post operative, CL repair with TT CL repair technique. (e) One year post operative. (f) One year post operatively, notice the nostril near symmetrical result

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  Discussion Top


This technique is a combination of Millard [2] or Mohler [3] technique, depending on the philtrum shape of the non-affected side of the cleft, in addition to creating a modified true triangle used by Noordhoff. [4]

The purpose of using the rotation flap is to get the lengthening effect. The back cut is used to get the lengthening effect advocated by Mohler [3] , and it is used in rectangular-shape philtrums. The back cut and its associated lengthening effect has also been previously used by Randall. [5]

The two true triangles drawn at medial and lateral side of the cleft are placed 1 mm above the vermillion border to avoid the resultant irregular white roll which could result when the triangle is placed at the vermillion border. The triangle at the medial side of the cleft where the triangle base is 2 mm or less to avoid the obvious notching or discrepancy effect noted in Millard's technique [2] corrected by Thompson [6] and Fisher. [7] The triangle is directed toward the collemella, unlike Fisher (2005) where the triangle is directed medially in a horizontal direction. [7]

This technique may overcome some of the drawbacks of the previously described surgical techniques used for CL repair.

 
  References Top

1.Atack NE, Hathorn IS, Semb G, Dowell T, Sandy JR. A new index for assessing surgical outcome in unilateral cleft lip and palate subjects aged five: Reproducibility and validity. Cleft Palate Craniofac J 1997;34:242-6.  Back to cited text no. 1
    
2.Millard DR Jr. A primary camouflage in the unilateral harelook. In Transactions of the International Congress of Plastic Surgeons. Baltimore, MD, Williams & Wilkins; 1957. p. 160.  Back to cited text no. 2
    
3.Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg 1987;80:511-5.  Back to cited text no. 3
    
4.Noordhoff MS, Chen YR, Chen KT, et al. The surgical technique for the complete unilateral cleft lip-nasal deformity. Operat Tech Plast Reconstr Surg 1995;2:167-74.  Back to cited text no. 4
    
5.Randall P. A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast Reconstr Surg Transplant Bull 1959;23:331-47.  Back to cited text no. 5
    
6.Thomson HG. Unilateral cleft lip repair. Oper Tech Plast Reconstr Surg 1995;2:175-81.  Back to cited text no. 6
    
7.Fisher DM. Unilateral cleft lip repair: An anatomical subunit approximation technique. Plast Reconstr Surg 2005;116:61-71.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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