Second-generation surgical technique 1. Postoperative skin bulge In the subsequent follow-up observation, gradually some patients reflected that a skin bulge tends to form in the original depressed area after surgery, which looks like a bulge. After examination, it was found that this was due to an accumulation of excess skin, the reason being that the muscles on the deep side of the skin were sutured and reconstructed, the transverse space would be reduced, and the amount of transverse skin that had been adapted to the original space for a long time would appear to be excessive, and it was not difficult to understand the formation of this phenomenon when subcutaneous hematoma occurred at the same time. This problem will be solved naturally with partial excision of the skin, but if the skin is pursued intact, this problem is theoretically inevitable, but the degree is different. The good thing is that the human skin itself has the ability to “use in and out”, and this excess skin generally does not last long, and is absorbed to the point of being unnoticeable in about a year. In subsequent cases, after improving the muscle adjustment angle and focusing on braking to eliminate the dead space, the bulge was significantly reduced, but in the case of heavy preoperative nasal deformity, it is still unavoidable and can be left to absorb on its own. We believe that this short-term wait is worthwhile compared to the lifelong upper lip scar after surgery.
2. Postoperative hypertrophy of the affected upper lip The problem of postoperative hypertrophy of the affected upper lip compared to the healthy side is not only present in the endosseous procedure. We have observed similar strange results after a large number of other lip surgeries in the past, only that this problem did not attract the attention of patients and physicians after surgery due to its heavy deformity, while the lip occlusion deformity is mild and the slight postoperative hypertrophy is perceptually incongruous. In other words, the problem of hypertrophy can occur regardless of whether the cut is external or internal, as has been confirmed by a large number of routine postoperative cleft lip deformities and is considered one of the main manifestations of common secondary deformities.
Initially it was thought to be due to postoperative swelling, but the real situation is that a long passive wait for its swelling to go down is often meaningless, and I have had cases where the cleft lip was observed for ten years after the use of external incision and it was still swollen after ten years. For this reason, I organized my graduate students to do a large number of tissue sections for research, and the observation was that the lymphatic drainage was impaired combined with prolapse of the inner wall. After clarifying the cause of the hypertrophy, we again adjusted the technical procedure of the red lip operation, and with the new technical specifications, the problem of upper lip hypertrophy was reduced by about 80%. In the few cases where hypertrophy still occurs, regardless of whether the original surgery was performed internally or externally, I personally advocate not waiting for a long time and performing red lip adjustment before school age to give the child a more natural smile for psychological development.
I call it the second generation of the internal incision technique after the improved technique has been performed to avoid a lot of the problems of upper lip augmentation and red lip hypertrophy. Third generation surgical technique This technique originated from my research on the internal biomechanical configuration and stress distribution of the lip and nose in the last 3 years, which was a research project that I conducted myself with the support of the Capital Medical Development Fund, and is one of my several current research fund projects on cleft lip. In the study, through microanatomical studies and histological observations of the lip and nose, we proposed a theory of the composition of the two pairs of semi-cross structures and tension bands of the lip, and redefined the axial projection of the lip muscle fibers and their significance in the formation of the fine structure of the lip. Guided by the new theory, we repaired the internal muscle structure of the upper lip more finely through tiny incisions, and even achieved a directional reconstruction of the muscle fiber orientation. The new theory guided the new procedure, and the new procedure reached an unprecedented level of restoration. Preliminary clinical observation shows that the muscle reconstruction through small incisions with internal incisions not only restores the lip crest and red lip shape to all the requirements of external incisions, but even creates a long-lasting and realistic human middle ridge and human middle concavity, and even the lip bead contour. Not only were the patient’s family members delighted by this result, but many international colleagues in the cleft lip treatment field were also surprised when they saw this amazing result. This is because the result is the opposite of the conventional episiotomy: it is no longer “a cleft lip even if it was not a cleft lip”, but “a cleft lip even if it was a cleft lip”.
We call this endotomy, which pursues fine structural reconstruction, the third generation of endotomy.
However, although the results of the current clinical observations are encouraging, it must not be forgotten that this is a completely new theory that still needs a lot of practical refinement. We will continue to pursue it and strive to do more work for the children with labial occlusion so that he/she can have a bright future, which, I think, is a meritorious thing and worthy of our doctors’ redoubled efforts.
To conclude 1. The endotomy of labial occult cleft can technically achieve all the indicators of conventional endotomy, including lip and nose deformity. It is just more demanding and difficult to operate, requiring physicians to undergo more intensive training in surgical operation.
2. For cases where there are obvious pigmented dents on the skin itself, direct external incision can be considered instead of internal incision. Because the internal incision will leave pigmented indentations, which are no different from keloid scars, and it takes a lot of effort and increases the difficulty.
3, for the case of heavy lip and nose deformity, external incision is recommended. It is not because the internal incision cannot correct the deformity of the lip and nose, but because the internal incision will cause obvious skin elevation, which will take a long time to fade.
4. Although the effect of the current third generation of internal incision has significantly surpassed that of external incision in terms of fine structure, the essence of internal incision is still to complete the work to be done by external incision through a smaller skin incision. On the other hand, if the result is not satisfactory after the internal incision, it can be remedied by the external incision, whereas if the external incision is made first, there will never be a chance to avoid scarring, and the scar will stay with the child for the rest of his life. The physician is doing a good deed for the child by preserving more opportunities for the patient.
5, whether external or internal incision, the main purpose of the correction of nasal deformity is to restore the normal muscle biomechanical structure and correct the tendency of further development of nasal deformity, not to repair the nose in one go as most patients and some physicians imagine. The shape of the nasal base can be directly repaired due to muscle reconstruction, but the correction of nasal wing collapse and transverse nostril deformity should still be postponed in order to avoid excessive disturbance of the nasal cartilage causing nasal developmental disorders.
It is now recognized that around 12 years of age when the nasal development is completed is a good time. After an in-depth study of the relationship between the labial-nasal muscles and morphological composition, I proposed a new model for nasal deformity correction, namely the labial-nasal muscle tension band reconstruction model.
This procedure avoids excessive interference with the nasal cartilage and instead promotes more normal nasal development due to the repair of the biomechanical structure of the muscle. Even so, for safety reasons, I still advocate a compromise that nasal surgery should be performed around 6 years of age, i.e., preschool age. Doctors should be injury-friendly and must remember that the safety and health of the patient comes first and should not expose the patient to unnecessary medical risks.