The British Association of Plastic Surgeons (2003) 56, 375 379 Surgical creation of a Cupid s bow using W-plasty in patients after cleft lip surgery Ayako Takeshita*, Tatsuo Nakajima, Tsuyoshi Kaneko, Masaki Yazawa, Ikkei Tamada Department of Plastic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan Received 17 April 2002; accepted 25 April 2003 KEYWORDS Cupid s bow; W-plasty; Vermilion; Cleft lip Summary The three-dimensional contour of the Cupid s bow is extremely important from a cosmetic standpoint, and many patients with bilateral or unilateral cleft lip require revision or reconstruction of the Cupid s bow. A number of surgical techniques have been reported for creating the Cupid s bow, among which the methods of Gillies and Onizuka are the most widely known. In the methods of Gillies and Onizuka, the dog-ear can result in excessive volume in the vermilion notch, raising the trough in the Cupid s bow and leading to regression during the post-surgical period. We have improved upon these techniques using the W-plasty and have obtained satisfactory results that preserve the white skin roll. In our method, the left and right prominence of the Cupid s bow is created through an incision of the white lip, while the central trough is created through a curvilinear incision of the vermilion mucosa. At the two sites of the white lip tissue and the curvilinear incision of the central vermilion tissue, the white skin roll is preserved as much as possible. In patients where the Gillies method had been used, the Cupid s bow tended to be flattened gradually after surgery. We report on the details of our method and the case reports using the technique. Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Asymmetry or loss of the Cupid s bow is not an uncommon occurrence after surgery to correct cleft lip. The three-dimensional contour of the Cupid s bow is extremely important from a cosmetic standpoint, and many patients with bilateral or unilateral cleft lip require revision or reconstruction of the Cupid s bow. A number of surgical techniques have been reported for creating the Cupid s bow, among *Corresponding author. Tel.: þ81-3-5363-3814; fax: þ81-3- 3352-1054. which the methods of Gillies and Onizuka are the most widely known. We have improved upon these techniques using the W-plasty and have obtained satisfactory results that preserve the white skin roll. We report on the details of our method and the case reports using the technique. Surgical technique The left and right prominence of the Cupid s bow is S0007-1226/03/$ - see front matter Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/s0007-1226(03)00128-0
376 A. Takeshita et al. Fig. 1 Our method. Fig. 2 Gillies method. Cupid s bow reconstruction by vermilion advancement. Full thickness skin excision is done. created through an incision of the white lip, while the central trough is created through a curvilinear incision of the vermilion mucosa. At the two sites of the white lip tissue and the curvilinear incision of the central vermilion tissue, the white skin roll is preserved as much as possible (Fig. 1). In the technique of Gillies, 1 the white lip tissue is incised to fit the image of a curve that forms the two regions of prominence of the Cupid s bow, and the vermilion mucosa is sutured along this curve to create a new vermilion border (Fig. 2). Onizuka, 2 inserted a back cut in the central region of the vermilion to create an emphasis in the curvature of the Cupid s bow (Fig. 3). In our technique, to emphasise the Cupid s bow contour, in addition to the white lip, the vermilion Fig. 4 The schema above is Gillies method. The schema below is our method. tissue is also incised in a curvilinear fashion. This creates a zigzag in the area of the excision, and the vermilion border is sutured by W-plasty, thus imparting the emphasis to the curve line created Fig. 3 Onizuka s method. Fig. 5 Appearance of the patient where the Gillies method had been used, the Cupid s bow tended to be flattened gradually after surgery.
Surgical creation of a Cupid s bow using W-plasty in patients after cleft lip surgery 377 Fig. 7 Appearance prior to surgery (A) and at 6 months after surgery (B). by the two prominences and the central trough of the Cupid s bow. By preserving the white skin roll at each part of the curvilinear incision, it is possible to create the two peaks and the trough of the Cupid s bow with a natural, three-dimensional vermilion border (Fig. 4). Fig. 6 Appearance prior to surgery (A) and at 18 months after surgery (B). The vermilion border can be seen quite clearly. Results Many methods have been reported for creating the
378 A. Takeshita et al. Fig. 8 Pre-operative design (A) and the appearance immediately after surgery (B). This indicates the appearance at 6 months after surgery (C). Cupid s bow after cleft lip surgery, of which the techniques of Gillies and Onizuka are the best known. Our technique is an improvement on these techniques using the principles of W-plasty. We created the Cupid s bow in eight patients. Of these, three had unilateral deformity of the Cupid s bow occurring after cleft lip surgery, while the remaining six had bilateral deformity of the Cupid s bow. The initial surgery for the first four cases had been performed at our institution. In the remaining four cases, the initial surgery had been performed at outside institutions.
Surgical creation of a Cupid s bow using W-plasty in patients after cleft lip surgery 379 Of the eight cases, three cases underwent Cupid construction using Gillies technique. Five cases underwent creation of the Cupid s bow using our technique, and more satisfactory results were obtained in the appearance of the Cupid s bow by our technique. In patients where the Gillies method had been used, the Cupid s bow tended to be flattened gradually after surgery (Fig. 5(A) and (B)). In patients in which our technique had been used, the contour of the Cupid s bow persisted for a long period. Cases using our technique are now presented. 1. Appearance prior to surgery and at 18 months after surgery. The vermilion border can be seen quite clearly (Fig. 6(A) and (B)). 2. Appearance prior to surgery and at six months after surgery (Fig. 7(A) and (B)). 3. Pre-operative design and the appearance immediately after surgery. This indicates the appearance at six months after surgery (Fig. 8(A) (C)). Discussion In Gillies technique, the white lip tissue is incised along the vermilion border. This creates a number of problems. Because the trough in the Cupid s bow is also created by the incision of the white lip tissue, increasing the amount of white lip tissue excised is unavoidable when creating an emphasis in contrast with the apex of the Cupid s bow, and as a result there is a risk of shortening of the white lip. Dogears may form at the time the white lip border is sutured to the vermilion border. The dog-ear thus formed can result in a bulky, excessive vermilion notch. Onizuka added to the Gillies technique by adding a back cut to the center of the vermilion to place emphasis on the trough in the Cupid s bow and impart a contrast to the curve line. Recently, Kikui et al. 3 have added to the white lip excision by dissecting and elevating the vermilion as a mucosal flap, to increase the degree of freedom of the vermilion border and create the Cupid s bow. We achieved good results by adding to the technique of Gillies excision of the vermilion mucosa in a curvilinear fashion to create the trough in the Cupid s bow, so as to place additional emphasis on the two peaks in the Cupid s bow. An additional advantage of this method is that by dividing the curvilinear incision into three regions, the left and right white lip tissues and the central vermilion tissue, it is possible to adjust the dog ear and control the volume of the vermilion notch created at the center of the vermilion. In the methods of Gillies and Onizuka, the dog-ear can result in excessive volume in the vermilion notch, raising the trough in the Cupid s bow and leading to regression during the post-surgical period. In our method, there is no post-surgical regression, and the curve of the Cupid s bow, with the two peaks, did not disappear during the long follow-up period. Creating the Cupid s bow is an important problem in lip reconstruction in cleft lip patients. For both unilateral and bilateral cleft lip, if a Cupid s bow with left right symmetry is not attained after the initial cleft lip surgery, we believe that a Cupid s bow touch-up operation is necessary. In such a case, the method reported here allows one to achieve an adequate curve line to the Cupid s bow, and post-operative flattering is avoided by this W-plasty technique. This may offer an extremely useful method for creating a Cupid s bow after cleft lip surgery. References 1. McCarthy Plastic Surgery, Cleft lip and palate reconstruction of philtrum and Cupid s bow. London: WB Saunders; 1990. pp. 2789 2790. 2. Onizuka T, Keyama A, Asada K, Shinomiya S, Aoyama R. Aesthetic considerations of the cleft lip operation. Aesthetic Plast Surg 1986;10(3):127 36. 3. Kikui T, Hashimoto H, Masada Y, Hosokawa K, Suzuki T. Secondary lip repair for Cupid s bow deformity in cleft lip. Sumitomoishi 1992;19:85 9.