Outcomes of Fisher Technique for Unilateral Incomplete Cleft Lip Repair

Background:- Cleft lip repair is imperative for a child's physical and mental well-being. Fisher's innovative technique adds versatility to conventional methods with optimal aesthetic results. An inconspicuous scar along the anatomical subunits is a hallmark of this procedure. Objective: This study aimed to evaluate the outcomes of Fisher technique for unilateral incomplete cleft lip. Methods: This Quasi experimental study was conducted at the Plastic Surgery Department, Mayo Hospital Lahore from 2017 to 2021. 50 consecutive patients with primary unilateral incomplete cleft lip were included in the study. Qualitative analysis was performed using Steffensen Grading Criteria 9. Improvement in pre-operative and post-operative anthropometric ratios was also analyzed. Symmetry of repaired cleft to normal cleft side was also assessed 9,12 . Results: Mean age of patients was 4.14±0.72 months. Parent's satisfaction score on the Likert scale was 4.84±0.37 (Mean ±SD). Significant improvement in anthropometric parameters (vertical lip height, vermilion height, nostril width and nostril height) except lip width was recorded. Significant symmetry was achieved for all parameters (p-value less than 0.05) except nasal height ratio (p-value=0.071). Good results were also achieved on all parameters according to Steffensen criteria. Conclusion: Fisher anatomical subunit repair is a reliable option for unilateral incomplete cleft lip repair producing aesthetically pleasing results.

He devised his repair to position the scar along the anatomical subunits. This technique is basically a type of a straight-line repair incorporating preceding principles; lengthening achieved by Rose-Thompson effect and a triangular flap to fill in the defect created by a back cut for downward rotation of the Cupid's bow. Although this hybrid approach has gained popularity, the outcomes of this technique have not been widely published and studies comparing Fisher's with the 9,19, 22 Millard technique are meagre and exiguous.
The rationale for this study was to analyze the quantitative and qualitative outcomes of Fisher's technique for unilateral cleft lip repair.

Methods
After institutional board review (290/RC/KEMU), this Quasi-experimental study was conducted at Burn Reconstructive & Plastic Surgery Department, Mayo Hospital Lahore from 2017 to 2021. Primary unilateral cleft lip patients; 3 months to 18 years of age were inclu-ded in this study. All the patients participating in this study were non-syndromic. Consecutive sampling technique was used. Sample size of 50 patients was calculated with 90% confidence level and 6.5% absolute precision. The procedure and postoperative follow up were explained to patients' parents and informed consent was taken. Demographic details, history and clinical examination were recorded. Preoperative and postoperative photographs were taken for comparison.
Under general anesthesia, marking for Fisher anatomical subunit repair was made as shown in figure 17. Dissection was carried out to release the abnormal attachments of orbicularis oris muscle from the alar base, collumellar base and maxilla in the extra periosteal plane. Lateral crus of lower lateral cartilage were released from pyriform aperture to allow antero-medial advancement of the alar base. The triangle base and length of the back cut was determined using Rose Thompson effect and varied from 1 mm to 2 mm. Orbicularis oris muscle was repaired by overlapping sutures to create a prominent philtral ridge. A Nordhoff triangular flap from the lateral lip was planned to prevent notching.

Figure 1. Figure illustrating the marking of Fisher technique for unilateral incomplete cleft lip
The muscle was approximated with vicryl 4/0, while vicryl 5/0 was used for dermal closure. Mucosa and vermilion were sutured with vicryl 5/0. Epidermal closure was achieved with prolene 6/0. Primary nasal by closed technique was done. Depending on the severity, the Tajima suspension suture, alar cinch suture and alar trans-fixation suture were used for nasal correction. Moreover, wedge resection of nasal sill as described in the original Fisher technique was also employed. However, tip plasty was not performed. Post operatively, surgical adhesives tapes (SteristripsTM) were applied. th Epidermal sutures were removed on 7 postoperative day under sedation. Surgical adhesive tapes (Steristrips TM) applied thereafter for 2 weeks. Massage and silicone sheet application were advised two weeks after the operation. The patients were advised a follow up and photographs taken. Assessments were done at 2 week and 6 month follow up. At each follow up, both qualitative and quantitative assessments were made using photographs to compare pre and post-operative variables. Given the age of the actual infant subjects, recording differences in millimeters was difficult. Photographic software (Adobe Photoshop CS6) was used for quantitative comparison of pre and post-operative pictures in millimeters. Objective assessment was done by anthropometric parameters as described by Rossell-Perry; vertical lip height, lip width, vermilion height, nostril width and nostril height 8 were noted. Improvement in pre-operative and postoperative parameters was statistically analyzed using SPSS (version 25). A ratio of cleft to non-cleft side was used as a quantitative measure for standardization of outcome in every patient. To analyze the symmetry, ratios of repaired cleft side to non-cleft side were calculated and compared with ideal standard ratio of 1.009,19. A ratio of 1.00 is considered to be perfect in an ideal symmetrical face as anthropometric parameters must be same for both sides of face. Qualitative analysis was 9,10 performed using Steffensen criteria. Scar placement within the anatomical subunits was also reviewed including cutaneous roll symmetry, vermilion symmetry scar appearance, Cupid's bow symmetry, lip length, nostril symmetry, alar dome and alar base symmetry. A consultant plastic surgeon who was not involved in the surgery was assigned to assess the outcome using photographs. The Likert scale was employed to gauge parent's satisfaction.

Results
Mean age of the patients in this study was 4.14±0.72 months. Among the patients 30(60%) were male and 20(40%) were female. Thirty one(62%) patients had left unilateral incomplete cleft and nineteen(38%) patients had right unilateral cleft. According to Likert score scale, parent's satisfaction for resultant scar was reported as 4.84±0.37 (Mean ±SD).
As depicted in Table 1, all anthropometric parameters showed significant improvements postoperatively except lip width. This leads to infer that anatomical subunit technique for cleft lip repair provides significant improvements in vertical lip height, vermilion height, nostril width and nostril height.   sutures after dissection of the nasal tip to improve nasal symmetry. Additionally, this technique results in a slightly longer lip (1.015 ±0.045). Table 2 and graph 1 illustrated this analysis. its results. These studies report the anatomical subunit approximation technique to be a reliable method for cleft lip repair with a natural scar along the philtral column. Our study provides both quantitative and qualitative evidence of good results with Fisher technique for incomplete cleft lip repair. Though incomplete cleft lip is considered to be of lesser severity than a complete cleft lip, it requires considerable skill to produce an aesthetic scar. Additionally, prior studies cite Fisher's method to have favorable outcomes irrespective of the severity of the cleft, compared to Millard  method and its variations. Repair with the resultant scar planned as a mirror image of the opposite philtral column. Fisher's mantra of "measure twice, cut once "provides a calculated imp-rovement in anthropometric parameters proven objec-tively in our study. "Delineating an ideal line of Repair" is an essential element of this novel technique allowing the 19 scar to lie within the anatomical subunits. Scar appearance is good in 96% of patients with excellent patient parent's satisfaction (4.86±0.36). White roll alignment, Cupid's bow symmetry and vermilion sym-20 metry were good in the majority of cases. Figure 2-5 shows the representative cases. Addition of a triangle above the white roll provides adequate white roll align-   Achievable goals of primary rhinoplasty in the originally described Fisher method are symmetrical nostril size, centralization of collumellar base, release of aberrant attachment of orbicularis oris from the lower lateral cartilages and the pyriform aperture, advancement of cleft side lateral crus and repositioning of alar bases without dissection in nasal tip area. However in our study, to achieve good nasal symmetry, excision of a nasal sill wedge combined with Tajima suspension 23 sutures was also employed. Consequently we achieved statistically significant improvement in nasal anthropo-   To summarize, eminent features of the Fisher's anatomical subunit repair include an acceptable scar within the anatomical sub units of nose and lip, better alignment of the vermilion cutaneous roll, adequate lengthening of the vertical and transverse lip height and a natural alar base contour curve. We found the Anatomical subunit Approximation to be a reliable alternative to the rotation advancement with an added benefit of a scar along the philtral column and dynamic symmetry.
Certain limitations of this study were a small sample size, being a single center study and included only unilateral cleft lip in our study. Standard aesthetic ratios using cleft and non-cleft side were used to minimize any bias. Future studies aim to compare anthropometrics with the Millard's repair.

Conclusion
Fisher's Anatomical subunit approximation technique has reliable and favorable results for cleft lip repair. Natural appearance of resultant scar makes this technique an acceptable alternative to conventional rotation advancement technique especially for incomplete cleft lip.
Ethical Approval: Given