A scar represents dermal fibrous replacement tissue and results from a wound that has healed by resolution rather than regeneration. Undesirable scars, such as hypertrophic or keloid scars, occur most frequently over the anterior chest, shoulders, scapular area, lower abdomen, and suprapubic region.6 The skin of the upper lip is also at risk of hypertrophic scars because of the repetitive movements of the underlying orbicularis oris muscle during speech, eating and drinking, and facial expression that transmit tension forces that distract and widen the healing wound. The incidence of hypertrophic upper lip scars ranges between 12 and 27 percent in the mixed population but increases when controlled for ethnicity to 32.2 percent in Hispanics and 36.3 percent in Asians.1,7,8 In addition, primary cheiloplasty scars are more conspicuous because they do not align with the relaxed skin tension lines of the face.
A patient’s cheiloplasty scar is a lifelong marker that he or she was born with a cleft lip. The position of a cheiloplasty scar makes it difficult to conceal, and its conspicuity can inflict significant psychological impact on its bearer. According to a structured semiquantitative survey of 97 elective/aesthetic surgical patients, 91 percent would value even a small improvement in the quality of their scar.9 Patients were dissatisfied with surgical scars irrespective of their sex, age, ethnicity, or geographic location, and wished their scars were less noticeable. With current cheiloplasty techniques, the anatomy of the lip can be restored adequately.10 As a result of charitable funding from the Noordhoff Craniofacial Foundation, almost all patients presenting to our center with cleft lip are able to undergo cheiloplasty at approximately 3 months of age. Our own survey of patients treated at our center revealed that more than 90 percent would regard even a small improvement in their cheiloplasty scar to be worthwhile (unpublished data). This is despite our use of several established strategies to attempt to optimize cheiloplasty scars in our center.
First, we repair the orbicularis oris muscle so that it bears the majority of the tension of the wound. This causes the overlying skin to become slightly redundant (and therefore tension-free), which allows enough skin for philtral column reconstruction on the cleft side. Second, we strictly use wound taping to minimize tension across the lip. These tapes span across the upper lip from cheek to cheek and are placed purposefully so that the nasolabial folds are deepened (and thus the skin is redundant) and the upper lip protrudes. Adhesive tape has been used by plastic surgeons for decades, with or without sutures, to reduce wound tension to prevent hypertrophic scar formation.11–13Third, we strictly use silicone gel sheeting over the scar when the baby is asleep. Topical silicone preparations have been recommended in the management of hypertrophic and keloid scars and are known to reduce the recurrence of hypertrophy following scar revision surgery in patients at higher risk of hypertrophic scarring.14,15 The benefit of topical silicone is less clear in patients who lack a history of abnormal scarring.15 Although there remains a lack of consensus as to whether topical silicone gel sheets should be applied routinely for upper lip cheiloplasty scars, this has remained routine practice at our center for many years.10 The compliance with lip taping and silicone sheets is very high in our population. The parents are well supported in this regard both by each other (many, if not most, of the parents of our children who have been operated on are routinely in contact on social media groups to encourage compliance) and by our Noordhoff Craniofacial Foundation social workers. The use of taping and topical silicone and the method of lip repair were all constant in this study; the only variable, which was blinded, was whether the vial for injection contained botulinum toxin or vehicle alone.
The contraction of the muscles of facial expression cause increased skin tension and the accentuation of dynamic rhytides that are often considered cosmetically undesirable. Carruthers et al. first realized that patients treated with botulinum toxin chemodenervation for blepharospasm experienced concurrent improvements in their dynamic glabella rhytides, sparking its widespread use in aesthetic practices ever since. Similarly, Gassner et al. injected botulinum toxin around frontal wounds to chemoimmobilize underlying musculature and therefore reduce wound tension during scar formation, with resultant improvements in cosmetic outcomes in an animal study.16Several human studies have since demonstrated that the injection of botulinum toxin can improve facial scars.17–20 Tollefson et al. first published the use of botulinum toxin to immobilize the upper lip for cheiloplasty in three cleft infants aged 3 to 6 months.2 However, it was unknown whether the botulinum toxin was responsible for the satisfactory aesthetic results that they reported. Galárraga injected the upper lips of five children undergoing cheiloplasty intraoperatively.3Electromyographic tracings proved that significant reductions in orbicularis oris muscular activity were resulting from the botulinum toxin treatment. Again, although the author hypothesized that this chemoimmobilization might benefit scarring, no direct evidence for the benefit of botulinum toxin was provided.
We investigated botulinum toxin injection as an additional potential intervention that might further improve our cheiloplasty scars over and above our established protocolized techniques. To our knowledge, this current study represents the first objective and subjective evaluation of scars following botulinum toxin injection into the upper lip during cheiloplasty. Although there was no significant difference in Vancouver Scar Scales between the experimental and control groups, photographic visual analogue scale and photographic measurements both revealed consistently better appearing and narrower scars as a result of botulinum toxin treatment compared with vehicle controls
No complications (i.e., infection, bleeding, wound dehiscence, oral incontinence, or feeding dysfunction) were found. Pascual-Pascual and Pascual-Castroviejo studied the safety of botulinum toxin type A in children younger than 2 years. The dosage used for obstetric brachial plexus palsy and cerebral palsy of 6.55 units/kg, which is much higher than the dosage required for chemodenervation of the orbicularis oris muscle, was considered safe.21 Moreover, neither of the previous studies that used botulinum toxin type A injection into the orbicularis oris muscle reported complications such as feeding difficulties.
CONCLUSIONSThese results indicate that our established method of upper lip repair and mechanical immobilization by taping is controlling well against wound tension in infants caused by orbicularis oris but that botulinum toxin has an additional beneficial effect on scar width that, although small, is subjectively noticeable. According to the Vancouver Scar Scale, however, botulinum toxin provided no additional benefits for scar pigmentation, vascularity, pliability, or height of cheiloplasty scars.
REFERENCE
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2. Tollefson TT, Senders CM, Sykes JM, et al. Botulinum toxin to improve results in cleft lip repair. Arch Facial Plast Surg. 2006;8:221–222
3. Galárraga IM. Use of botulinum toxin in cheiloplasty: A new method to decrease tension. Can J Plast Surg. 2009;17:e1–e2
4. Noordhoff MS, Chen Y, Chen K, et al. The surgical technique for the complete unilateral cleft lip nasal deformity. Oper Techn Plast Reconstr Surg. 1995;2:167–174
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7. Wilson AD, Mercer N. Dermabond tissue adhesive versus Steri-Strips in unilateral cleft lip repair: An audit of infection and hypertrophic scar rates. Cleft Palate Craniofac J. 2008;45:614–619
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10. Chen PKT, Noordhoff MS, Kane ANeligan PC. Repair of unilateral cleft lip. Plastic Surgery. 2013;Vol. 3 New York Elsevier Saunders:517–549 In:
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17. Gassner HG, Sherris DA, Friedman O. Botulinum toxin-induced immobilization of lower facial wounds. Arch Facial Plast Surg. 2009;11:140–142
18. Gassner HG, Brissett AE, Otley CC, et al. Botulinum toxin to improve facial wound healing: A prospective, blinded, placebo-controlled study. Mayo Clin Proc. 2006;81:1023–1028
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