INTRODUCTION
This article aims to clarify and disseminate the history of cheiloplasty in the
treatment of unilateral lip fissures. It intends to demonstrate the fundamental
importance of eminent Brazilian plastic surgeons in their creation, execution
and teaching1.
About the origins of Z-plasty
The first reference we found of a Z-plasty is credited to Horner in
18372,3. As professor of anatomy at
the University of Pennsylvania, he reported the case of a left lower eyelid
ectropion caused by a burn scar four years ago (Figure 1).
Some authors attribute to Denonvilliers (1863)4 the first execution of a Z-plasty when he
operated on a young man with ectropion outside the lower right eyelid. The
case was presented on 20/09/1854 at the Société de Chirurgie
in Paris. This description was reported in Cazelles’ thesis in
18605 (Figure 2).
McCurdy was who first used the term Z-plasty at the University of Pittsburg
in 19136. There are doubts
that McCurdy has been aware of previous work on Z-plasty7.
In 1904, Berger8 described a
typical transposition of Z-plasty to treat armpit burn sequelae (Figure 3).
Small historical tour on the treatment of unilateral cleft lip
In 1836, Millard9 called for
the treatment of unilateral cleft lip fissures by curved incisions, but
which excised a lot of lip tissue, although stretching was effective. In
1891, Rose10 proposed a
design similar to Millard (1836)9, with concave incisions on both sides of the fissure and
preserving more labial tissue. The incisions went from the nostril to the
vermilion, and the technique became popular (Figure 4).
Later, in 191211, Thompson
described his technique with incisions angled at the edges of the fissure in
an attempt to outline the curves of a normal lip. It performs curved
incisions similar to rose’s (1891)10 at the fissure edges, making accurate
measurements with a calibrated compass. Today the straight excision and scar
technique is known as the Rose & Thompson technique (Figure 5).
Figure 1 - Scheme showing: incision in the lower eyelid. A second incision
part of the lower eyelid toward the angle of the mandible. Another
incision of the same extension is directed to the root of the nose.
Detachment and transposition of flaps. Almost immediate correction
of the defect. According to Borges and Gibson (1973)3.
Figure 1 - Scheme showing: incision in the lower eyelid. A second incision
part of the lower eyelid toward the angle of the mandible. Another
incision of the same extension is directed to the root of the nose.
Detachment and transposition of flaps. Almost immediate correction
of the defect. According to Borges and Gibson (1973)3.
Figure 2 - A. Zetaplasty performed by Denonvilliers (1863).
According to Borges and Gibson (1973). B. Zetaplasty
performed by Denonvilliers (1863). According to Borges and Gibson
(1973)3,4.
Figure 2 - A. Zetaplasty performed by Denonvilliers (1863).
According to Borges and Gibson (1973). B. Zetaplasty
performed by Denonvilliers (1863). According to Borges and Gibson
(1973)3,4.
Figure 3 - A. Typical double transposition of zetaplasty as it
is used today. According to Borges and Gibson (1973).
B. Typical double transposition of zetaplasty as it
is used today. According to Borges and Gibson (1973)3.
Figure 3 - A. Typical double transposition of zetaplasty as it
is used today. According to Borges and Gibson (1973).
B. Typical double transposition of zetaplasty as it
is used today. According to Borges and Gibson (1973)3.
Figure 4 - Rose’s Technique (1879)10.
Figure 4 - Rose’s Technique (1879)10.
Figure 5 - Thompson’s technique (1912)11 with his proposed
measures.
Figure 5 - Thompson’s technique (1912)11 with his proposed
measures.
Millard (1836)9 reports that
Veau,in19259,
published a unilateral cheiloplasty technique in which for the first time a
Z-plasty was used, but located on the vermilion, slightly surpassing this
and reaching the lip, which could impair the continuity of the
cutaneomucosal line. At the time, Z-plasty was accepted as a procedure to
solve straight line contractures, and according to Veau (1925) X could be
used to attenuate the straight line of cheiloplasty secondarily.
It is important to note that although Masters et al., in 195412, have advocated using
intermediate Z-plasties to repair incomplete labial fissures, it was Lemos
in 195613 who first
proposed a cheilo-Z-plasty for the repair of unilateral labial fissures. The
technique of Lemos (1956)13 was modified by Spina and Lodoviciin 196014 and came to bring
contributions to the technique of Lemos (1956)13. In 1961, Petit et al.15 proposed a technique with
two triangular flaps; they preached that a double Z produced a better
rotation of the nasal wings and a better release of the lip.
The technique of Perseu Lemos
We considered that Perseu Castro de Lemos (1956)13 was the first to recommend repairing
unilateral cleft through a Z-plasty of the entire lip thickness: skin,
musculature and mucosa. Its first publication was in the journal O Hospital
in Rio de Janeiro (1956)13
soon after the technique was presented at the International Congress of
Plastic Surgery in Rome (1967)16.
We also found in the literature reference of a previous note made by Lemos
(1956)13 recorded
at the 5th State Medical Congress of Pernambuco: “A new
technique for the correction of the leporine lip17”.
Interesting to know the fundamentals of the technique by the
author’s own description: “We then conceived our
operation which consisted essentially of the excision of the edges of
the fissure, respecting the beginning of the cupid’s bow, and
then performing a simple Z-plasty to lengthen the lip and break the
suture line. This Z-plasty, which was initially described in the middle
third of the lip, can be placed where it is most necessary, that is, in
the upper, middle or lower thirds. Equally, the branches’
angulation may vary in such a way as to obtain a more satisfactory
result, according to the case. The resulting triangular flaps, incised
throughout their lip thickness, are sutured between crossed, restraining
the resulting small excesses. As a final result, we have a preserved
cupid’s bow lip, with minimal tissue removed and a broken scar,
with no tendency to shrink.”18.
The author adds: “Surgery is above all of easy to do, no
longer requiring the surgeon than knowledge of the technical bases of
Z-plasty. However, the only resulting drawback is the interruption of
the common filter crest to all techniques with non-rectilinear
scars.”18.
Dr. Perseu13 (this is how
he was better known) refers to having applied the technique for the first
time in 1953, performing the technique for all types of unilateral lip
fissures: complete or incomplete, with or without cleft palate, in secondary
repairs, always obtaining satisfactory results. To do so, he said, it is
enough to have common sense in the positioning of the lateral branches of
the Z, in the most convenient length, height and direction. In a 26-year
retrospect, he assesses having operated around 1,000 cases19.
Still, in the words of the master himself: “Although we
initially described the Z in the middle third of the lip, we immediately
evolved into the concept that it can be positioned lower or higher or
preferably in the upper third with Z branches arranged so that the
external triangular flap created promotes the rotation alar up and in,
better reconstructing the nasal introitus. In fact, we think that the
wide variety of positions, angles, height and orientation of the
branches are the best thing of the technique.”18,19 (Figure 6).
Figure 6 - A. Technique of Perseu Lemos (1956)13. Zetaplasty used
in cases of high nasal wings or good position. All lip layers are
incised. B. Technique of Perseu Lemos (1956)13. Zetaplasty used
when the nasal wings are low. C. Perseu Lemos
technique. Zetaplasty used when hemilabium present with unequal
dimensions. According to Lemos (1981, 1996)18,19.
Figure 6 - A. Technique of Perseu Lemos (1956)13. Zetaplasty used
in cases of high nasal wings or good position. All lip layers are
incised. B. Technique of Perseu Lemos (1956)13. Zetaplasty used
when the nasal wings are low. C. Perseu Lemos
technique. Zetaplasty used when hemilabium present with unequal
dimensions. According to Lemos (1981, 1996)18,19.
The technique of Victor Spina and Orlando Lodovici
In 1959 and 1960, Victor Spina, together with Orlando Lodovici14,20, proposed the Z- plasty only to the cutaneous
plane, which seemed sufficient to determine the proper increase in lip
height.
In his Z-plasty, the upper arm is medial, and the lower arm is lateral. He
presents an ingenious repair of the vermilion without resections and the
entire mucosa’s use in part decorticated and buried in the
contralateral slope (Figure 7). Spina
and Lodovici (1960)20
recognize that their method corresponds to Lemos’s (1956)13 with its own modifications
to obtain better results. He spread the technique a lot throughout Brazil,
which became known to some as the Lemos & Spina technique. It is a
procedure widely used to this day21.
Figure 7 - Spina and Lodovici technique (1960)14.
Figure 7 - Spina and Lodovici technique (1960)14.
Other authors
Davies, in South Africa, published in 196522, cheiloplasty with two equal flaps of pure
Z-plasty. It also employs a Z-plasty of all planes and curiously does not
cite Lemos (1956)13. He
admits that the biggest snarl of his technique is that the final scar
crosses the filter crest.
In 1959, Clifford and Pool23 reviewed the principles of Z-plasty in cleft lip
surgery, an article that deserves to be consulted. In 1949, Huffman and
Lierle24 described
a cleft repair technique based only on the principle of Z-plasty, mainly
using accurate geometric measurements.
Today, it is known that in the use of Z-plasties in cheiloplasties, its
principles cannot be violated. When the design of Z-plasty is not well
planned, some valuable lip tissue can be redried, and the final scar may
violate the repair lines of the lip filter. So, therefore, the importance of
Lemos (1956)13 and Spina
and Lodovici (1959, 1960)14,20.
Repair of the musculature of the unilateral cleft
The mentioned cheilo-Z-plasties, at the time of their performance, did not
consider the adequate treatment of muscle deformities of the unilateral
cleft lip to be performed. This point seems important for us to update these
techniques.
Fara, in 196825, performed
dissections in stillborns with fissures. He described the anomalous
anatomical disposition of the muscular bundles of the fissure. He also
noticed that there was hypoplasia (poverty) of fibers on the medial side.
According to Randall et al., in 197426, “the functional treatment of cleft
lip clefts implies reorienting the lip muscles, regardless of the type
of skin incision to be used.” Another proposal for
surgical reorientation of orbicular fibers described by Skoogin
197427 emphasizes
the complete restoration of the lip’s muscular anatomy.
Nicholas, in 198328,
described the anatomy of the orbicularis of the lips with two layers: one
superficial whose fibers are related to facial mimicry and the other deep
whose fibers account for the sphincter function of the lip, having
importance in eating and retaining food in the mouth. The surface layer
presents an important alteration of its insertions in patients with cleft
lip29 (Figure 8).
Figure 8 - Diagram of Nicholas. According to Giglio (1996)29.
Figure 8 - Diagram of Nicholas. According to Giglio (1996)29.
Both Nicholas (1983)28, and
Randall et al. (1974)26
and Kernahan (1978, 1983)30,31,32 highlight that the modern
treatment of unilateral fissure undergoes an adequate orbicular muscle
reconstitution because the result of cheiloplasty should be evaluated not
only in the resting situation of the lip but also and, mainly, in activities
such as smiling and whistling.
Although they attach the same importance to the musculature’s
reconstitution, all these authors approach the musculature differently. We
have always been interested in the technique proposed by Kernahan (1978,
1983)30,31 with which we obtained
functionally and aesthetically very satisfactory results (Figure 9).
The proposal for a cheilo-Z-plasty
The use of Z-plasty in the treatment of unilateral fissures swelled with
great benefits. For its simplicity, ease of execution and learning will
always be a resource that can be used.
Figure 9 - Kernahan Technique (1978, 1983)30,31.
Figure 9 - Kernahan Technique (1978, 1983)30,31.
To keep alive the principles of Lemos (1956)13 and Spina and Lodovici (1959,
1960)14,20, with Z-plasties on the
skin and labial mucosa and conservative treatment of lip vermilion flaps,
appropriate treatment of the orbicular musculature should be added to them.
In our hands, what offered us better results was the Kernahan technique
(1978, 1983)30,31. We used this technique
for incomplete cracks, narrow and aligned complete fissures.
Here is the scheme of the technique that seems to us the most appropriate:
- Marking of Z-plasty;
- Z-plasty made on the skin and mucosa;
- The treatment of the musculature;
- The closure with the vermilion detail.
CONCLUSION
In 1996, Dr. Perseu19
considered that despite the new techniques that emerged over time that seek to
reconstruct the filter crest on the fissure side, some prefer Z-plasty for
producing less scar retraction, a preserved cupid’s bow, with minimal
tissue removed. The drawback is the interruption of the filter crest, common,
however, to all techniques with non-rectilinear scars. It also points out that
philosophically all its concepts that remain valid:
Preservation of the cupid’s bow;
Perfect alignment of the cutaneomucosal line;
Minimal resection of lip tissue;
Scar in alternating directions, without the tendency to
retraction;
(ease of teaching and implementation.
DEDICATION
Work dedicated to Perseu Castro de Lemos, master and friend of the senior author
and who, in 1994, expressed: “I consider all my contributions to
plastic surgery, cheilo-Z-plasty as the most
important”1.
Figure 10 - A. Proposed conduct: Lemos (1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: preoperative. B. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: preoperative. C. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: perioperative. D. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: perioperative. E. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: postoperative. F. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: postoperative. Source: Senior author.
Figure 10 - A. Proposed conduct: Lemos (1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: preoperative. B. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: preoperative. C. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: perioperative. D. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: perioperative. E. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: postoperative. F. Proposed conduct: Lemos
(1981, 1996)18,19, Spina and Lodovici
(1959-60)14,20 and Kernahan (1978,
1983)30,31. Incomplete right
unilateral cleft: postoperative. Source: Senior author.
REFERENCES
1. Lemos P. Pelos caminhos da cirurgia plástica. Recife:
Edições Bagaços; 1994.
2. Horner WE. Clinical report on the surgical department of the
Philadelphia Hospital, Blockley for months of May, June and July 1837. Am J Med
Sci. 1837;21:105-6.
3. Borges AF, Gibson T. The original Z-plasty. Br J Plast Surg. 1973
Jul;26(3):237-46.
4. Denonvilliers CP. De la méthode autoplastique par pivotempar
appliquée à la restauration des paupières. Bull Gén
Thér Méd Chirurg. 1863;65:110-22.
5. Cazelles EH. Du traitment de l’ectropion cicatriciel [tese].
Rognoux: Faculte de Médicine de Paris; 1860.
6. McCurdy SL. Z-plastic surgery: plastic operation to elongate
cicatricial contraction of the neck, lips and eyelids and across the joints.
Surg Gynecol Obst. 1913;16:209-11.
7. Borges AF. Historical review of Z-plastic techniques. Clin Plast
Surg. 1977 Abr;2(4):207-16.
8. Berger VP. Autoplastie par dédoublement de la palmure et
échange de lambeaux. In: Berger P, Banzet S, eds. Chirurgie
ortopédique. Paris: Steinfeil; 1904. p.180-5.
9. Millard Junior DR. Cleft craft: the evolution of its surgery. Volume
1 I. The Unilateral Deformity. Boston: Little, Brown and Company;
1976.
10. Rose W. On harelip and cleft palate. London: HK Lewis;
1891.
11. Thompson JE. An artistic and mathematically accurate method of
repairing the defect in cases of harelip. Surg Gynecol Obst.
1912;14:498-505.
12. Masters F, Georgiade N, Horton C, Pickrell K. Use of interlocking
Z’s in repair of incomplete clefts of the lip. Plast Reconstr Surg. 1954
Out;14(4):287-92.
13. Lemos PC. Nova operação para lábio leporino
simples. O Hospital. 1956;1(4):607-11.
14. Spina V, Lodovici O. Conservative technique for treatment of
unilateral cleft lip. Reconstruction of the midline tubercle of the vermilion.
Br J Plast Surg. 1960;13:110-7.
15. Petit P, Borde J, Malek R. Treatment of harelip by means of a
plastic procedure using a equilateral triangular flap. Ann Chir Infant. 1961
Dez;2:111-6.
16. Lemos PC. Cheilo-Z-plasty. Rev Lat Am Cir Plast.
1962;4(3):270-4.
17. Lemos PC. Novas técnicas para a correção do
lábio leporino simples, uni e bilateral (nota prévia). 5º
Congresso Médico Estadual de Pernambuco (Garanhuns), 1953
(Nov).
18. Lemos PC. Tratamento da fissura labial unilateral. In: Lessa S,
Carreirão S, eds. Tratamento das fissuras labiopalatinas. Rio de Janeiro:
Editora Interamericana; 1981. p. 37.
19. Lemos PC. Quilozetaplastia técnica pessoal para o tratamento
cirúrgico das fissuras labiais unilaterais. In: Tratamento das fissuras
labiopalatinas. In: Lessa S, Carreirão S, Zanini S, eds. Tratamento das
fissuras labiopalatinas. Rio de Janeiro: Revinter; 1996. p. 81.
20. Spina V, Lodovici O. Técnica conservadora para o tratamento
do lábio leporino unilateral: reconstituição do
tubérculo mediano. Rev Assoc Med Bras. 1959;5(5):325-30.
21. Anger J. Prof. Perseu Castro de Lemos e Prof. Spina: a
história da plástica em Z na queiloplastia para a
correção das fissuras lábio-palatinas unilaterais. Rev Soc
Bras Cir Plást. 2005;20(4):245-7.
22. Davies D. The repair of unilateral cleft lip. Br J Plast Surg. 1965
Jul;18:254-64.
23. Clifford RH, Pool Junior R. The analysis of the anatomy and geometry
of the unilateral cleft lip. Plast Reconstr Surg Transplant Bull. 1959
Out;24:311-20.
24. Huffman WC and Lierle DM. Studies on the patholic anatomy of the
unilateral harelip nose. Plast Reconstr Surg. 1949
Mai;4(3):225-34.
25. Fara M. Anatomy and arteriography of cleft lips in stillborn
children. Plast Reconstr Surg. 1968;42:29-36.
26. Randall P, Whitaker L, LaRossa D. The importance of muscle
reconstruction in primary and secondary cleft lip repair. Plast Reconstr Surg.
1974 Set;54(3):313-23.
27. Skoog T. Plastic surgery: new methods and refinements. Stockholm: WB
Saunders; 1974.
28. Nicolau PJ. The orbicularis oris muscle: a functional approach to
its repair in cleft lip. Br J Plast Surg. 1983
Abr;36(2):141-53.
29. Giglio AT. Tratamento funcional das fissuras labiais unilaterais.
In: Lessa S, Carreirão S, eds. Tratamento das fissuras labiopalatinas.
2ª ed. Rio de Janeiro: Revinter; 1996. p. 77.
30. Kernahan DA. Muscle repair in unilateral cleft lip, based on
findings on eletrical stimulation. Ann Plast Surg.
1978;1(1):48-53.
31. Kernahan D, Bauer BS. Functional cleft lip repair: a sequential
layred closure with orbicularis muscle realingment. Plast Reconstr Surg. 1983
Out;72(4):459-66.
32. Kernahan DA. The functional cleft lip repair with muscle alignment.
In: Kernahan DA, Rosenstein SW, eds. Cleft lip and palate-a system of
management. Baltimore: Williams & Wilkins Co.; 1990. p.
149.
1. Hospital da Plástica do Rio de Janeiro,
Rio de Janeiro, RJ, Brazil.
Corresponding author: Leila Lemos
Azem, Rua Julio de Castilhos, 83/301, Rio de Janeiro, RJ, Brazil., Zip
Code: 22081-025, E-mail: leilazem@globo.com
Article received: July 22, 2020.
Article accepted: January 10, 2021.
Conflicts of interest: none
Institution: Hospital da Plástica do Rio de Janeiro, Rio de Janeiro,
RJ, Brazil.