title: Repair of transverse facial cleft in hemifacial microsomia: long-term anthropometric evaluation of commissural symmetry.
abstract: BACKGROUND
  Cleft of the oral commissure is an uncommon malformation that results from incomplete mesenchymal merging of the mandibular and maxillary prominences of the first pharyngeal arch. Many operative techniques have been proposed to repair this cutaneous and muscular defect. Most authors recommend cutaneous closure by Z-plasty or W-plasty, but these geometric techniques cause additional cutaneous scarring; furthermore, the risk of commissural migration after repair of a transverse facial cleft is poorly documented.
  
  
  METHODS
  Anthropometry was used to evaluate the operative outcome in 13 patients with hemifacial microsomia who underwent repair of a transverse facial cleft by the senior author between 1980 and 2001. The procedure included (1) apposition of the orbicularis oris muscle; (2) linear cutaneous closure; and (3) construction of the commissure using an inferiorly based, rectangular vermilion-mucosal flap.
  
  
  RESULTS
  The average age at repair was 11 months, and the mean follow-up was 10.3 years. Comparing the cleft and noncleft sides, the position of the commissure was within 1 mm in all patients, whereas the melolabial fold was asymmetric in six patients. The average length of the scar was 17 mm, and the scar extended lateral to the melolabial fold in all but one patient. No patients were found to have had lateral commissural migration.
  
  
  CONCLUSIONS
  The authors conclude that Z-plasty or W-plasty is unnecessary in repair of a transverse facial cleft. Closure of the orbicularis oris muscular ring is the critical step in the procedure to provide oral continence and a counterforce to the contraction of the cutaneous scar. There is no lateral creep of the commissure or hypertrophic scarring after straight-line cutaneous closure.
authors: Boston, Mass. From the Craniofacial Center, Department of Plastic Surgery, Children's Hospital, Harvard Medical School.
authors: Gary F
authors: GF
authors: Rogers
authors: John B
authors: JB
authors: Mulliken
mesh_terms: D000886:Anthropometry; D001837:Body Weights and Measures; D002675:Child, Preschool; D005145:Face / Q000033:anatomy & histology* / Q000601:surgery*; D005146:Facial Asymmetry / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008297:Male; D019651:Plastic Surgery Procedures; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
references: Jawarski, S. Macrostomia: A modified technique of surgical repair. Acta Chir. Plast. 18: 117, 1976.
references: May, H. Transverse facial clefts and their repair. Plast. Reconstr. Surg. 29: 240, 1962.
references: Boo-Chai, K. The transverse facial cleft: Its repair. Br. J. Plast. Surg. 22: 119, 1969.
references: Converse, J. M., Wood-Smith, D., McCarthy, J. G., et al. Bilateral facial microsomia: Diagnosis, classification, treatment. Plast. Reconstr. Surg. 54: 413, 1974.
references: McCarthy, G. T., and West, C. M. Ablepharon macrostomia syndrome. Dev. Med. Child Neurol. 19: 659, 1977.
references: Chen, K.-T., and Noordhoff, S. M. Congenital macrostomia–transverse facial cleft. Chang Gung Med. J. 17: 239, 1994.
references: Stevens, C. A., and Sargent, L. A. Ablepharon-macrostomia syndrome. Am. J. Med. Genet. 107: 30, 2002.
references: Stark, R. B., and Saunders, D. E. The first branchial syndrome: The oral-mandibular-auricular syndrome. Plast. Reconstr. Surg. 29: 229, 1962.
references: Moore, K. L., and Persaud, T. V. N. The Developing Human, 7th Ed. Philadelphia: Saunders, 2003. Pp. 202–240.
references: Hawkins, D. B., Miles, J. W., and Selzer, D. C. Bilateral macrostomia as an isolated deformity. J. Laryngol. Otol. 87: 309, 1973.
references: Keith, A. Concerning the origin and nature of certain malformations of the face, head, and foot. Br. J. Surg. 28: 173, 1940.
references: Bauer, B. S., Wilkes, G. H., and Kernahan, D. A. Incorporation of the W-plasty in repair of macrostomia. Plast. Reconstr. Surg. 70: 752, 1982.
references: Eguchi, T., Asato, P. H., Takushima, A., et al. Surgical repair of congenital macrostomia: Vermilion square flap method. Ann. Plast. Surg. 47: 629, 2001.
references: Rose, W., and Carless, A. Manual of Surgery for Students and Practitioners. New York: William Wood, 1898. P. 660.
references: Blackfield, H. M., and Wilde, N. J. Lateral facial clefts. Plast. Reconstr. Surg. 6: 68, 1950.
references: Fogh-Anderson, P. Rare clefts of the face. Acta Chir. Scand. 129: 275, 1965.
references: Powell, W. J., and Jenkins, H. P. Transverse facial clefts: Report of three cases. Plast. Reconstr. Surg. 42: 454, 1968.
references: Millard, D. R. Cleft Craft: The Evolution of Its Surgery, Vol. 1. Boston: Little, Brown, 1977. Pp. 769–779.
references: Longacre, J., DeStefano, G. A., and Holmstrand, K. E. The surgical management of first and second branchial arch syndromes. Plast. Reconstr. Surg. 31: 507, 1963.
references: Grabb, W. C. The first and second branchial arch syndrome. Plast. Reconstr. Surg. 36: 485, 1965.
references: Onizuka, T. Treatment of the deformities of the mouth corner. Jap. J. Plast. Reconstr. Surg. 8: 132, 1965.
references: Skoog, T. Plastic Surgery: New Methods and Refinements. Philadelphia: Saunders, 1974. Pp. 146–154.
references: Aketa, J., Nodai, T., Kuga, Y., et al. Method for the repair of transverse facial clefts. Cleft Palate Craniofac. J. 17: 245, 1980.
references: Kaplan, E. N. Commissuroplasty and myoplasty for macrostomia. Ann. Plast. Surg. 7: 136, 1981.
references: Fukuda, O., and Takeda, H. Advancement of oral commissure in correcting mild macrostomia. Ann. Plast. Surg. 14: 205, 1985.
references: Weatherley-White, R. C. A. Developmental defects of the lips and chin. In R. B. Stark (Ed.), Plastic Surgery of the Head and Neck, Vol. 2. New York: Churchill Livingstone, 1987. Pp. 172–173.
references: McCarthy, J. G. Oral commissure repair. In B. Brent (Ed.), The Artistry of Reconstructive Surgery: Selected Classic Case Studies. St. Louis: Mosby, 1987. Pp. 267–271.
references: Verheyden, C. N. Anatomical considerations in the repair of macrostomia. Ann. Plast. Surg. 20: 374, 1988.
references: McCarthy, J. G., Grayson, B. H., Coccaro, P. J., and Wood- Smith, D. Craniofacial microsomia. In J. G. McCarthy (Ed.), Plastic Surgery, Vol. 4. Philadelphia: Saunders, 1990. Pp. 3085–3086.
references: Yoshimura, Y., Nakajima, T., and Nakanishi, Y. Simple line closure for macrostomia repair. Br. J. Plast. Surg. 45: 604, 1992.
references: Turvey, T. A., Vig, K. W. L., and Fonseca, R. J. (Eds.). Facial Clefts and Craniosynostosis: Principles and Management. Philadelphia: Saunders, 1996. P. 540.
references: Torkut, A., and Coskunfirat, O. K. Double reversing Z-plasty for correction of transverse facial cleft. Plast. Reconstr. Surg. 99: 885, 1997.
references: Talukder, B. C. Bilateral complete transverse facial cleft. J. Pediatr. Surg. 15: 690, 1980.
references: Ono, I., and Tateshita, T. New surgical technique for macrostomia repair with two triangular flaps. Plast. Reconstr. Surg. 105: 688, 2000.
references: Millard, D. R. British West Indies peregrinations. Br. J. Plast. Surg. 15: 325, 1962.
references: Mansfield, O. T., and Herbert, D. C. Unilateral transverse facial cleft: A method of surgical closure. Br. J. Plast. Surg. 25: 29, 1972.
references: Sugihara, H., Ohura, T., Ishikawa, T., et al. Commissuroplasty for congenital macrostomia. Jap. J. Plast. Reconstr. Surg. 28: 404, 1985.
references: May, H. Plastic and Reconstructive Surgery, 3rd Ed. Philadelphia: F. A. Davis, 1971. Pp. 357–358.
references: Itho, E., Murakami, T., and Osada, H. An operative technique for macrostomia. Jap. J. Plast. Reconstr. Surg. 14: 76, 1971.
references: Habal, M. B., and Scheuerle, J. Lateral facial clefts: Closure with W-plasty and implications on speech and language development. Ann. Plast. Surg. 11: 182, 1983.
references: Aygit, A. C., Ayhan, M. S., and Orak, F. A left transverse facial cleft with a median cleft of the lower jaw. Cleft Palate Craniofac. J. 36: 448, 1999.
references: Nagai, I., and Weinstein, I. Surgical repair of horizontal facial cleft: Report of a case. J. Oral Surg. 21: 251, 1963.
references: Weinstein, I. R. Surgical repair of transverse facial cleft. Oral Surg. 30: 309, 1970.
references: Kawai, T., Kurita, K., Echiverre, N. V., et al. Modified technique in surgical correction of macrostomia. Int. J. Oral Maxillofac. Surg. 27: 178, 1998.
references: Ballantyne, J. W. Preauricular appendages. Teratologia 2: 18, 1895.
references: Stricker, M., van der Meulen, J. C., Raphael, B., et al. Craniofacial Malformations. New York: Churchill Livingstone, 1990. Pp. 167–168.
references: Vento, A. R., LaBrie, R. A., and Mulliken, J. B. The O.M.E.N.S. classification in hemifacial microsomia. Cleft Palate Craniofac. J. 28: 68, 1991.
references: Anderson, R., and Kurtay, M. Reconstruction of the corner of the mouth. Plast. Reconstr. Surg. 47: 463, 1971.
references: Wall, N. R., Cameron, R. R., and Latham, C. W. Restoring the overhang of the upper lip in repairs of the oral commissure. Plast. Reconstr. Surg. 49: 626, 1972.
references: Kazanjian, V. H., and Roopenian, A. The treatment of lip deformities resulting from electric burns. Am. J. Surg. 88: 884, 1954.
references: Gillies, H. D., and Millard, D. R., Jr. Principles and Art of Plastic Surgery. Boston: Little, Brown, 1957. Pp. 507–511.