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 Table of Contents  
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 60-64

Kaplan's commissuroplasty and myoplasty technique in the reconstruction of isolated bilateral transverse facial clefts

Department of Surgery, Division of Plastic Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Date of Web Publication23-Feb-2018

Correspondence Address:
Dr. Abdulrasheed Ibrahim
Department of Surgery, Division of Plastic Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcls.jcls_72_17

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Bilateral transverse facial clefts are a rarity and are often isolated without other craniofacial deformities. The goals of surgery are to reestablish function and an esthetically pleasing outcome through the reconstruction of a functioning orbicularis oris muscle ring with minimal scars. We report our experience in the reconstruction of isolated bilateral transverse facial clefts in two patients using Kaplan's technique and a straight-line skin closure. There was a satisfactory preservation of the continuity of the vermillion at the commissure, as well as restoration of both the sphincteric function of the orbicularis oris muscle and size of the oral aperture in the patients.

Keywords: Bilateral, commissuroplasty, Kaplan's technique, macrostomia, myoplasty

How to cite this article:
Ibrahim A, Abubakar LM, Maina DJ, Adebayo WO, Kabir AM, Asuku ME. Kaplan's commissuroplasty and myoplasty technique in the reconstruction of isolated bilateral transverse facial clefts. J Clin Sci 2018;15:60-4

How to cite this URL:
Ibrahim A, Abubakar LM, Maina DJ, Adebayo WO, Kabir AM, Asuku ME. Kaplan's commissuroplasty and myoplasty technique in the reconstruction of isolated bilateral transverse facial clefts. J Clin Sci [serial online] 2018 [cited 2020 Jun 4];15:60-4. Available from: http://www.jcsjournal.org/text.asp?2018/15/1/60/226042

  Introduction Top

A transverse facial cleft (congenital macrostomia) is classified by Paul Tessier as a No. 7 cleft.[1] It is rare and constitutes <1% of all facial clefts.[2] Congenital macrostomia involves the commissures and is thus distinct from typical clefts of the lip and palate. It is a facial cleft between the maxillary and mandibular components of the first and second branchial arch.[3],[4],[5],[6] It may be unilateral or bilateral. Unilateral congenital macrostomia, comprising majority of reported macrostomia, appears to be associated in most cases with additional facial deformities.[7],[8] The spectrum of severity includes the presence of ear anomalies, preauricular tags, and mandibular dysplasia to extensive defects in craniofacial macrostomia involving the skin, muscle, and the underlying bone.[7],[8],[9] In contrast, bilateral macrostomia is a rarity and is more often isolated, without ear or skeletal deformities. The clinical presentation varies from a shallow groove continuous with the commissure to a wide cleft extending from the mouth to the ear.[3],[7],[8],[9] The width of the mouth is expanded, and the abnormal commissure is displaced inferolaterally. The bilateral form may thus be associated with disorders of function and gross distortion of facial appearance.[7],[8],[10]

The functional and esthetic dynamics of the lip and commissures are of the essence of speech, facial expression, and deglutition.[4] The delicate motion of the lips and commissures facilitates verbal communication and provides a panorama of facial expressions that facilitate nonverbal communication.[11] They also bestow competence to the oral cavity by acting as a sphincter to accept food and fluid, and closing to prevent spillage during mastication.[12],[13] These essential functional and esthetic requirements make reconstruction of the commissure in bilateral microstomia a challenging but rewarding undertaking. The functional goals are to reestablish oral competence and speech, through a reconstruction of the continuity of the orbicularis oris muscle ring. The esthetic goals include a restoration of the symmetry of both the commissure and lips with an adequate diameter of the oral aperture, as well as avoidance of conspicuous scars.[6],[14],[15],[16]

This article describes our experience in the reconstruction of isolated bilateral congenital macrostomia in two patients using the Kaplan's commissuroplasty and myoplasty technique and a straight-line skin closure.

  Case Reports Top

Case 1

A 24-year-old female apprentice seamstress presented to the plastic and reconstructive unit of our institution accompanied by her mother, with the complaint of macrostomia [Figure 1]a,[Figure 1]b,[Figure 1]c. The patient was worried about the cosmetic deformity and expressed heightened concerns about her unsatisfactory social relationships. Speech and hearing were normal. The parents had been aware of the deformity since birth but delayed evaluation because of lack of funds for treatment. Her mother reported a negative history of febrile illness or use of unprescribed medications during pregnancy. The patients had six other siblings and they all had normal facial function and form.
Figure 1: Preoperative clinical photos Case 1 – (a) frontal view; (b) right lateral view; (c) left lateral view (point C commissure)

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On examination, there was a bilateral extension of the angles of the commissures. The clefts were lined with skin externally and buccal mucosa internally. A demarcation was observed where the lips ended and the defect began [Figure 1]b and [Figure 1]c. There were no periauricular appendices. Physical examination of the eyes, ears, maxilla, and mandible did not reveal other abnormalities. A diagnosis of isolated bilateral macrostomia was made. She had reconstruction of the cleft using Kaplan's commissuroplasty and myoplasty technique with a straight-line skin closure. At 6-week follow-up, the commissures were esthetically positioned, with preservation of the continuity of the vermillion at the commissure. There was also a restoration of the sphincteric function of the orbicularis oris muscle and size of the oral aperture.

Case 2

A 17-month-old boy presented at the plastic and reconstructive outpatient clinic with an abnormally widened mouth noticed at birth. He leaked food and fluid from the commissures of the mouth. There was no family history of facial clefts or congenital birth defects and his parents were not blood related. His father is a 32-year-old farmer and his mother is a 27-year-old trader, and the level of antenatal care received at a peripheral hospital could not be ascertained. She however described an uneventful pregnancy and delivered the baby at term.

A general examination revealed an otherwise healthy boy. Examination of the face revealed a widened mouth with a cleft at the angles of the mouth bilaterally [Figure 2]a. Intraoral examination revealed good dentition with normal eruption time and sequence for age. There were no other anomalies noted. A diagnosis of an isolated bilateral transverse facial cleft was made. Preparation was done for surgery and the patient subsequently had a repair of the oral commissures with a straight-line closure [Figure 2]b,[Figure 2]c,[Figure 2]d. At 36-month follow-up, he had an acceptable appearance with restoration of the size of the oral aperture [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d,[Figure 3]e,[Figure 3]f. He also had a scar hypertrophy and this has resolved satisfactorily without intervention.
Figure 2: Reconstruction of macrostomia Case 2 – (a) preoperative clinical photo; (b) preoperative marking of point C on the upper and ower lips (left side); (c) immediate postoperative photo (left side); (d) mmediate postoperative photo (frontal view)

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Figure 3: Postoperative photos Case 2 – (a) lips in repose (right view); (b) lips in repose (front view); (c) lips in repose (left view); (d) smiling right view); (e) smiling (front view); (f) smiling (left view)

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Surgical technique

Reconstruction was performed under general anesthesia with nasotracheal intubation in all the patients. The preoperative clinical photos of the cleft in a 24-year-old woman [Figure 1]. The anatomic position of the new commissure was determined by a perpendicular line dropped from midpupil. This was outlined with a marking pen – point C, at the vermilion-cutaneous junction on the upper and lower lip [Figure 1]b and [Figure 1]c.

The schematic diagram [Figure 4]a and [Figure 4]b illustrates the technique of elevation of the vermilion and buccal mucosa flaps (V and BM flaps). Approximately 5 mm medial to the proposed new commissure-point C, another mark was made on the upper lip vermilion mucosa. This is the vermilion flap V. It is rectangular in shape with the base medially pedicled. The V flap will be transposed to the lower lip so that the suture line is not placed within the new commissure. The markings for a buccal mucosa flaps BM were made on the upper and lower lips. They are pedicled on the oral mucosa [Figure 4]b. The buccal mucosa flaps will reconstruct the intraoral lining of the transverse facial cleft. The buccal mucosa flap on the lower lip extends medially beyond the lower lip C point. This distance should be equal to the upper lip V flap 5 mm [Figure 4]b.
Figure 4: Schematic diagram – (a) preoperative markings of point C (commissure); (b) design of the V (vermillion) and BM (buccal mucosa) flaps

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A local anesthetic (0.5% lidocaine with 1:200,000 epinephrine) facilitates dissection in a bloodless surgical field. The procedure is begun by elevating the V flap off the underlying orbicularis oris muscle on the upper lip and basing it medially at the upper lip C point [Figure 5]a. This was performed with a size 15 blade. Next, the BM flaps were elevated off the upper and lower lip musculature by making an incision along the vermillion-cutaneous border. The BM flaps are pedicled on the intraoral mucosa. This dissection also exposes the underlying orbicularis oris muscle [Figure 5]b. The aberrant orbicularis oris muscle was dissected and freed 10 mm beyond the end of the cleft margin. The superior and inferior bundles of the orbicularis oris were identified, released, and transected [Figure 5]c and [Figure 5]d. To achieve a natural-looking commissure, the muscle bundles were reconstructed using Kaplan's method.[17] The muscle was transposed to overlap, with the upper bundle on top of the lower bundle to achieve a sphincter-like function. These upper and lower muscle bundles were sutured in a horizontal mattress fashion with 4-0 Vicryl sutures. The vermillion flap V is inset at point C on the lower lip to reconstruct the commissure [Figure 5]e. The BM flaps were sutured with 5-0 Monocryl sutures to reconstitute the intraoral buccal mucosa. The subcutaneous tissue was sutured using a 5-0 Vicryl suture, with care taken not to create any dead space. A linear closure was chosen for skin closure [Figure 5]f. Simple interrupted percutaneous 4-0 Nylon sutures were used and removed on the 4th postoperative day. The completed repair for Case 1 is shown in [Figure 6].
Figure 5: Surgical technique (Case 1) – (a) elevation of vermillion flap; (b) elevation of BM (buccal mucosa) flaps exposes the underlying orbicularis oris muscle (muscle indicated with arrow); (c) dissection and identification of orbicularis oris muscle; (d) superior and inferior bundles of the orbicularis oris muscle; (e) vermillion flap is inset at point C on the lower lip; (f) immediate postoperative photo (straight-line cutaneous closure)

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Figure 6: Immediate postoperative photo (Case 1)

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  Discussion Top

Reconstruction of bilateral transverse facial clefts is an integral component of the spectrum of craniomaxillofacial cleft care.[10] It remains a significant challenge because it is accompanied by functional and esthetic anomalies, and these have a negative impact on the psychosocial development of affected patients and their families.

Late presentation of patients with craniofacial clefts remains a common phenomenon in low-resource settings. This may be as a result of several factors including the relatively young age of craniofacial cleft care practice and a lack of specialists.[9] Furthermore, lack of awareness of treatment availability and funds contribute to late or nonpresentation for surgery. Many patients are thus not seen early, with a significant number presenting for the first time in late childhood and in some instances as adults.[9] Surgery should be performed in young age to restore normal function and form. This will reduce the anxiety and psychological stress on the child and family.[8],[9]

The complex anatomy of the oral commissure, with its extremely specialized function, deserves emphasis. The fibers of the orbicularis oris muscle from the upper and lower lips interdigitate at the oral commissure.[14] The modiolus is a focal anatomical landmark beneath the oral commissure. The surrounding muscles converge at the modiolus to facilitate the sphincteric function of the orbicularis oris muscle.[17] The lips and commissures are covered by a seamless segment of vermillion that folds inward when the mouth is in repose and stretches with mouth opening.[3] The vermilion is thus the most visible component of the lips and commissures and its reconstruction is elegantly delicate, as even minor defects may lead to a severe flaw.[14] Established principles of reconstruction were as follows: first, the creation and accurate placement of a symmetric and mobile commissure – this restores harmony to the lower third of the face;[9] second, a myoplasty to reestablish the labial function of the orbicularis oris muscle as a sphincter, and minimizing conspicuous scars and secondary contracture – this prevents the displacement of a correctly positioned commissure.[15],[16],[18],[19]

The position of the new commissure is crucial to attaining an esthetic symmetry of the lips.[19] Visual cues and preoperative measurements can be used to determine the position of the new commissure.[4],[9],[20] These may require a combination of methods – data from anthropometric tables for race, sex, and age, the position of the pupil and anatomic parameters of the lip (alteration of the vermillion characteristic) may all be used to establish the appropriate position of the commissure.[4],[5],[19] In patients with unilateral macrostomia, measurements are taken from the normal side and transposed to the abnormal side.[9] This is not feasible in bilateral macrostomia and the position of the new commissure is correlated with a vertical line centered through the ipsilateral pupil with the face in static forward repose.[4],[16],[19] In addition, there are distinct anatomic changes that exist at the cleft margin as a guide to positioning the new commissure.[19] An inspection of the cleft margin with identification of the point at which there is a change in contour, color, and quality of the vermillion from normal mucosa to cleft mucosa determines the site of the new commissure.[16],[18],[20]

Several reconstructive techniques have been described in the surgical literature over the last 5 decades.[5],[14],[16],[18],[19] The reconstructive options in commissuroplasty vary from excision of the vermilion at the margin of the cleft and direct closure, to the use of skin flaps, and full thickness vermilion flaps.[9],[19] A simple excision of the vermillion and closure is technically simple. However, its main disadvantages include the tendency to result in formation of fissures, recontracture, and an unnatural appearance.[3] Ono and Tateshita [6] used two triangular skin flaps for commissuroplasty. The flaps were raised above the upper lips. The larger inferior flap was used to elevate the lower lip, and the smaller superior flap was used to create a more normal looking commissure. The authors claimed that this resulted in a more natural-looking commissure.[6] Eguchi et al.[15] utilized the vermilion square flap method for commissuroplasty. This procedure involves elevation of the square vermilion flap from the lower lip. This flap, which is used to fill a similarly shaped defect created on the upper lip, also eliminates the scar that runs from the commissural vermilion to the lateral cheek. It has been claimed that this scar contracts and displaces the commissure laterally.[9],[15] The superiorly based vermillion transposition flap as described by Kaplan [17] solves two problems: first, it preserves the continuity of the vermillion at the commissure and provides normal color and thickness;[3],[17] second, it restores the size of the oral aperture and minimizes any esthetic defect caused by deformation of the commissure. The thickness of the vermillion flap, however, must be carefully considered, since too thick a flap may give the commissure an unsightly bulky appearance.[19]

Reconstruction of the disrupted orbicularis muscle is imperative to a good functional and esthetic outcome.[6],[20] We used the overlapping myoplasty technique described by Kaplan to further simulate the normal upper lip overlap. It involves a careful dissection of the superior and inferior bundles of the orbicularis oris. The upper larger bundle is overlapped on the inferior bundle and sutured together with multiple interrupted absorbable sutures.[3],[9],[17] It is important that they are sutured to each other under adequate tension as the surgeon decides the position of a new commissure.[3],[6],[19] An accurate approximation of the underlying musculature is required to prevent the “goldfish mouth” appearance. This is a mucosal skin web at the commissure devoid of underlying muscle.[20]

Controversy exists concerning the choice of skin closure technique. A linear cutaneous closure results in a minimal scar; however, some investigators have been concerned that the contracture of the straight-line scar might lead to lateral displacement of the commissure.[3] Various alphanumeric flaps including Z-plasty, W-plasty, and double Z-plasty techniques have been introduced to break the straight-line scar. However, these techniques may lead to a slightly longer scar, would be more noticeable if hypertrophic or keloid scar tissue forms.[10] This would exert an unpleasant effect on facial animation, especially in dark-skinned individuals and those of African descent.[3],[7],[9],[10] The authors prefer a straight-line scar, which gives an esthetically pleasing result with a symmetrical position of the commissure, both at repose and while smiling (Case 2) [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d,[Figure 3]e,[Figure 3]f.

  Conclusion Top

Reconstruction of the commissures in bilateral isolated congenital macrostomia remains an intriguing challenge. The Kaplan technique described restores the sphincteric function of the orbicularis oris muscle and size of the oral aperture. It preserves the continuity of the vermillion at the commissure and provides normal color and thickness with an esthetically pleasing symmetrical position of the commissure. It provides satisfactory results and alleviates the drawbacks of the numerous alternative techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Tessier P. Anatomical classification facial, cranio-facial and latero-facial clefts. J Maxillofac Surg 1976;4:69-92.  Back to cited text no. 1
Rogers GF, Mulliken JB. Repair of transverse facial cleft in hemifacial microsomia: Long-term anthropometric evaluation of commissural symmetry. Plast Reconstr Surg 2007;120:728-37.  Back to cited text no. 2
Li J, Liu K, Sbi J, Wang Y, Zbeng Q, Sbi B, Commissural symmetry in unilateral transverse facial cleft patients: An anthropometric study. J Oral Maxillofac Surg 2012;70:2184-90.  Back to cited text no. 3
Gleizal A, Wan DC, Kwan MD, Beziat JL. Myoplasty for congenital macrostomia. Cleft Palate Craniofac J 2008;45:179-86.  Back to cited text no. 4
Franco D, Franco T, da Silva Freitas R, Alonso N. Commissuroplasty for macrostomia. J Craniofac Surg 2007;18:691-4.  Back to cited text no. 5
Ono I, Tateshita T. New surgical technique for macrostomia repair with two triangular flaps. Plast Reconstr Surg 2000;105:688-94.  Back to cited text no. 6
Kawai T, Kurita K, Echiverre NV, Natsume N. Modified technique in surgical correction of macrostomia. Int J Oral Maxillofac Surg 1998;27:178-80.  Back to cited text no. 7
Buonocore S, Broer PN, Walker ME, da Silva Freitas R, Franco D, Alonso N, Macrostomia: A spectrum of deformity. Ann Plast Surg 2014;72:363-8.  Back to cited text no. 8
Fadeyibi IO, Ugburo AO, Ogunbanjo CV, Ilombu CA, Ademiluyi SA. The surgical repair of macrostomia. Cleft Palate Craniofac J 2009;46:642-7.  Back to cited text no. 9
Bütow KW, Botha A. A classification and construction of congenital lateral facial clefts. J Craniomaxillofac Surg 2010;38:477-84.  Back to cited text no. 10
Bailey BJ, Johnson JT, Newlands SD. Head & Neck Surgery: Otolaryngology Philadelphia, PA. Lippincott Williams & Wilkins; 2006.  Back to cited text no. 11
Clayton NA, Ledgard JP, Haertsch PA, Kennedy PJ, Maitz PK. Rehabilitation of speech and swallowing after burns reconstructive surgery of the lips and nose. J Burn Care Res 2009;30:1039-45.  Back to cited text no. 12
Vegter F, Hage JJ. Clinical anthropometry and canons of the face in historical perspective. Plast Reconstr Surg 2000;106:1090-6.  Back to cited text no. 13
Robotti E, Righi B, Carminati M, Ortelli L, Bonfirraro PP, Devalle L, Oral commissure reconstruction with orbicularis oris elastic musculomucosal flaps. J Plast Reconstr Aesthet Surg 2010;63:431-9.  Back to cited text no. 14
Eguchi T, Asato PH, Takushima A, Takato T, Harii PK. Surgical repair for congenital macrostomia: Vermilion square flap method. Ann Plast Surg 2001;47:629-35.  Back to cited text no. 15
Losee JE, Kirschner RE. Comprehensive Cleft Care. New York NY: McGraw-Hill Medical; 2009  Back to cited text no. 16
Kaplan EN. Commissuroplasty and myoplasty for macrostomia. Ann Plast Surg 1981;7:136-44.  Back to cited text no. 17
Schwarz R, Sharma D. Straight line closure of congenital macrostomia. Indian J Plast Surg 2004;37:121.  Back to cited text no. 18
Yu CC, Goh RC, Lo LJ, Chen PK, Chen YR. Surgical repair for macrostomia: Significance of Z-plasty limb directions. Ann Plast Surg 2010;64:751-4.  Back to cited text no. 19
Bauer BS, Margulis A. Invited discussion of surgical repair for congenital macrostomia: Vermilion square flap method. Ann Plast Surg 2002;48:328-9.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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