Long Term Outcome of Cleft Lip Repair Using Fisher's Technique with Modification of Nasal Dissection

Cleft lip is one of the most common birth defects affecting approximately 1:700 newborns each year.  A wide variety of surgical approaches are used to repair the lip deformity caused by this condition. Fisher's  technique has become widely used in recent years, but there have been few papers published showing long term follow up of patients treated with this technique. We are reporting long term follow up of a cohort of cleft lip patients operated on by the same surgeon over the last 12 years using Fisher's technique.  In the early years of the study the patients were treated with the technique as taught in Dr. Fisher's papers, but over time the technique was modified by the attending surgeon (DH).  It was noted that while the nose had a good cosmetic outcome, it felt unmoldable and unnatural  on palpation when extensive nasal dissection was completed. Therefore, the standard technique has been modified to exclude extensive nasal dissection and include aggressive sub-periosteal dissection of the nasal base.

A retrospective analysis was done of the cosmetic outcomes of the nasiolabial complex of ten non syndromic children with complete cleft lips that had undergone cleft lip repair using the Fisher technique by the same surgeon with at least one year follow-up post surgery.  The cosmetic outcome was analyzed using objective criteria: symmetry of lip at the cupid's bow and alignment of the skin at the vermillion border, symmetry of the lateral lip, symmetry of the free vermillion,

symmetry of nose, symmetry of dry/wet vermillion, hypertrophy/discoloration of scar, columellar deviation from midline (adapted from Operation Smile guidelines). Each criteria was judged 1-3, with 1 being unacceptable, 2 acceptable, and 3 excellent. All criteria were then summed and averaged to give an overall score. The criteria was judged by three  independent investigators. Scores were averaged and then graphed in respect to time, to show long-term results of the cleft repair.

Table 1: Average score of all three reviewers

Criteria			Average Score
Symmetry of lip at the cupid's bow and alignment of the skin at the vermillion border			2.400
Symmetry of the lateral lip			2.367
Symmetry of the free vermillion			2.433
Symmetry of nose			2.233
Symmetry of dry/wet vermillion			2.267
Hypertrophy/discoloration of scar			2.200
Columellar deviation from midline			2.367
Overall Score			2.324

Graph 1: Average overall score graphed versus time of surgery

            Our results show excellent long term outcomes of cleft lip repair using the Fisher's technique. Our cleft patients had an average score of 2.34/3, indicating a more than acceptable overall outcome of these patients after 1 year. Each individual criteria was also judged to be greater than acceptable.

            When graphed over time, we see a slight increase in average score, which would indicate that the modifications made to the standard technique do not change the overall cosmetic outcome. We feel that this modification allows for the same excellent cosmetic outcome as with the standard Fisher technique, while allowing for a more natural feeling of the nose.

References

Hoffman D. Comprehensive surgical treatment of cleft lip and palate patients: evidence-based discussion JOMS. 2005; 63:(8),131

Fisher DM. Unilateral cleft lip repair: an anatomic subunit approximation technique. PSR. 2005;116(1):61–71.