OBJECTIVE: Outcomes from surgical repair of transverse facial cleft (macrostomia) may not be very satisfactory when conventional methods are used to position the oral commissure to be repaired. To improve patient outcomes, we developed a modified oral commissure positioning and reconstruction method for transverse facial cleft repair.
METHODS: In the modified positioning method, the oral commissure at the abnormal side was positioned precisely and reconstructed by a combination of two conventional methods, namely, the distance measurement method and the anatomical charateristics method. The function of the orbicularis oris muscle was preserved. Postoperative surgical scar score and oral commissure symmetry score were determined and compared between patients and healthy controls. The scores ranged from one to five, with one representing the best and five indicating the worst results.
RESULTS: Nine patients aged 4-31 months (7 girls) underwent the modified transverse facial cleft repair surgery. All the patients had unilateral transverse facial cleft with or without microsomia and/or complete cleft lip. The patients were followed up for one to five years. Although average surgical scar scores of patients (close-mouth: 1.8 ± 0.8, range: 1.0-2.8; open-mouth: 1.8 ± 0.9, range 1.0-3.6) remained significantly higher (P < 0.05) than those of the healthy controls (N = 8, close-mouth 1.1 ± 0.4, range: 1.0-1.4, open-mouth: 1.1 ± 0.3, range: 1.0-1.2) 6 months after the surgery, their average close-mouth oral commissure symmetry score (1.9 ± 0.7, range: 1.6-2.8) was similar (P = 0.381) to those of the healthy controls (1.8 ± 0.8, range: 1.0-2.6).
CONCLUSIONS: The modified procedure appears to lead to promising long-term benefit on restoring oral commissure symmetry.

Various techniques have been performed for repairing transverse facial clefts. This study aimed to investigate an optimal method for repairing transverse facial clefts. Twenty-seven patients from 2008 to 2017 were evaluated. Their mean age at repair was 6.7 months with a follow-up period of 6 months to 10 years. A method using an inferior lip-based triangular mucosa flap and a superior lip-based rectangular vermilion-mucosa flap was designed for transposition. The orbicularis oris was reconstructed by using everting mattress suture. The skin was sutured using linear cutaneous closure with a single superiorly rotated Z-plasty lateral to the commissure. A postoperative symmetrical commissure was obtained owing to complete contraction with the new commissure directed 2 or 3 mm medial to the symmetrical point on the lips individually for the 27 patients. Lateral displacement of the reconstructed commissure was not observed. The patients showed a plump and symmetrical cheek on the cleft side. Twenty-one patients with hemifacial microsomia achieved a prominent improvement compared with their preoperative appearance, although the postoperative cheeks still did not show fullness because of the lesser facial tissue on the cleft side. In the early follow-up period, most patients showed a minimal scar during movement. However, the scar became thinner and symmetrical oral movement was achieved over time. This method obtained a natural oral movement without a conspicuous scar and was reliable and remarkable for the postoperative appearance of commissural symmetry. We conclude that this is an optimal method to repair transverse facial clefts.