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cpt the transverse vermilion mucosa and the superior part of the orbicularis oris
muscle from the lower lip. It was elevated, leaving a central cuff of muscle and
mucosa tissue for blood supply, and tapered down bilaterally. The flap was
transposed cephalically and inset to the deficient upper vermilion. Division of
the pedicle was performed 2 weeks later. The preoperative and postoperative
vermilion heights were measured, and the upper-to-lower vermilion ratios were
calculated.
Results: All consecutive patients tolerated the operations without perioperative
or flap complications. The vermilion discrepancy was corrected in all cases.
The vermilion height and projection were improved in the upper lip and the
prominent lower lip was reduced. The average vermilion ratio was 0.38 be-
fore and improved to 1.00 after surgery, as compared with the norm of 0.96.
Adequate lip function and mobility were maintained. All patients expressed
satisfaction after surgery.
Conclusion: The described technique of bi-winged myomucosa switch flap is
an effective method for reconstruction of upper lip vermilion deficiency with
excellent aesthetic outcome. (Plast. Reconstr. Surg. 140: 1251, 2017.)
A
fter primary bilateral cleft lip repair, there that the lower lip appears more protrusive and
may be a severe degree of tissue deficiency thicker (Fig. 1). In this clinical situation, we have
and structural distortion and asymmetry. It experienced inadequate or insufficient correction
is not uncommon that the secondary deformity of the discrepancy between the lips applying those
involves the upper lip with vermilion mucosa methods. The purpose of this study is to describe
deficiency, lack of median tubercle, irregular a new technique, the bi-winged myomucosa switch
scars, and disproportionate lip projection. Several flap, and its results.
methods have been described in the literature for
correction of the vermilion defect in the upper lip
Disclosure: Neither author has any sources of finan-
such as Abbe flaps,1–7 Z-plasty, V-Y advancement,
cial or other support or any financial or professional
transposition flaps, free dermal fat graft, fascial
relationships that might pose a competing interest.
graft, buccal musculomucosal, or cross-lip flaps.8–
17
The large vermilion mucosal tissue deficits of
the upper lip could cause a comparative effect
Supplemental digital content is available for
this article. Direct URL citations appear in the
From the Craniofacial Research Center, Chang Gung Memo- text; simply type the URL address into any Web
rial Hospital, Chang Gung University. browser to access this content. Clickable links
Received for publication November 22, 2016; accepted June to the material are provided in the HTML text
21, 2017. of this article on the Journal’s website (www.
Copyright © 2017 by the American Society of Plastic Surgeons PRSJournal.com).
DOI: 10.1097/PRS.0000000000003889
www.PRSJournal.com 1251
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Plastic and Reconstructive Surgery • December 2017
1252
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 140, Number 6 • Bi-Winged Myomucosa Switch Flap
1253
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • December 2017
CODING PERSPECTIVE
Coding perspective provided by Dr.
cpt Raymond Janevicius is intended to
provide coding guidance.
40761 Plastic repair of cleft lip/nasal defor-
mity; with cross-lip pedicle flap (Abbe-
Estlander type), including sectioning
and inserting of pedicle
• The bi-winged myomucosa switch flap is a
cross-lip flap. Tissue from the lower lip is
transferred to the upper lip via an inferior
labial artery pedicle.
• Code 40761 is reported for the bi-winged
myomucosa switch flap.
• This is an unusual code, as it includes a sub-
sequent operative procedure, the division
Fig. 3. The patient underwent simultaneous bi-winged myo- and inset of the flap. The descriptor for
mucosa switch flap and rhinoplasty. At 14 months after surgery, code 40761 indicates “including sectioning
the patient shows improvement of the lip profile and vermilion and inserting of pedicle.” One code describes
balance. two procedures performed at different op-
erative sessions.
with vermilion mucosa deficiency, lack of median
• It would not be appropriate to report code
tubercle, irregular scars, and disproportionate lip
15630 for the division and inset, as this is
projection. In this study group, the local flaps or
included in code 40761.
free graft was not adequate because of the severe
soft-tissue deficiency in the upper lip. The con- CODING PRINCIPLE: Although the bi-
ventional Abbe flap was ruled out because of the winged myomucosa switch flap contains muscle
acceptable prolabium with a good philtrum and and mucosa, it is not considered a myocutane-
Cupid’s bow definition. ous flap to be reported with code 15732. Code
The advantage of the bi-winged myomucosa 40761 is more specific and more accurate.
switch flap technique is its effectiveness in normal- Disclosure: Dr. Janevicius is the president of
izing vermilion defects and achieving better har- JCC, a firm specializing in coding consulting
mony between the lips. Sizable upper lip vermilion services for surgeons, government agencies,
defects associated with bilateral cleft lip repairs attorneys, and other entities.
can be managed well. Inclusion of a superficial
layer of the orbicularis oris muscle can provide
additional bulk. Therefore, this technique offers
an acceptable donor-site aesthetic result and aug- reconstruction for patients of different cultural
ments the tubercle by adding wet vermilion to the backgrounds. An important point is that many
upper lip. The characteristic lower lip fullness is patients tend to request treatment based on their
simultaneously reduced to provide better balance own racial norms.19 In Chinese female groups, a
between the lips. The aesthetic and functional tall upper vermilion height and a larger upper
morbidity of the donor site is insignificant. The lip volume have long been considered symbols
color mismatch is avoided by locating the incision of youth and beauty.20 However, the Caucasian
in the mucosa and posterior to the red line (i.e., female upper lip is found to be generally thin-
junction between the dry vermilion and mucosa in ner and to have a shorter upper lip height, and
the upper and lower lips). It should be mentioned for African American women, both upper and
that the bi-winged myomucosa switch flap is indi- lower lips are thicker and fuller based on Farkas’
cated only in selected patients with a significant analysis.18
cleft lip deformity as described in our patients. Possible surgical complications associated
The ethnic normative ratio of upper and with the bi-winged myomucosa switch flap include
lower lip heights should be considered, and extra bleeding, wound infection, dehiscence, flap fail-
effort should be made in planning secondary lip ure, and airway obstruction. The complications
1254
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Volume 140, Number 6 • Bi-Winged Myomucosa Switch Flap
were not seen in our series. Lastly, a disadvantage 6. Jackson IT, Soutar DS. The sandwich Abbe flap in secondary
of this technique is that it needs two-stage surgery. cleft lip deformity. Plast Reconstr Surg. 1980;66:38–45.
7. Holmström H. The Abbe flap converted to an island flap.
Of note, this technique is not indicated for recon- Scand J Plast Reconstr Surg. 1986;20:51–54.
struction of tight upper lip, short prolabium, or 8. Kawamoto HK Jr. Correction of major defects of the ver-
lack of philtral column of upper lip, for which the milion with a cross-lip vermilion flap. Plast Reconstr Surg.
full-thickness or conventional Abbe flap is more 1979;64:315–318.
appropriate. 9. Matsuo K, Fujiwara T, Hayashi R, Ishigaki Y, Hirose T.
Bilateral lateral vermilion border transposition flaps to
Lun-Jou Lo, M.D. correct the “whistling lip” deformity. Plast Reconstr Surg.
Plastic and Reconstructive Surgery 1993;91:930–935.
Chang Gung Memorial Hospital 10. Millard DR Jr, McLaughlin CA. Abbe flap on mucosal pedi-
5 Fu-Shin Street cle. Ann Plast Surg. 1979;3:544–548.
Kwei Shan, Taoyuan, Taiwan 333 11. Robinson DW, Ketchum LD, Masters FW. Double V-Y pro-
lunjoulo@cgmh.org.tw cedure for whistling deformity in repaired cleft lips. Plast
Reconstr Surg. 1970;46:241–244.
12. Cohen SR, Kawamoto HK Jr. The free tongue graft for cor-
ACKNOWLEDGMENT rection of secondary deformities of the vermilion in patients
with cleft lip. Plast Reconstr Surg. 1991;88:613–619.
The authors thank Brixton Anderson for the sche- 13. Chen PK, Noordhoff MS, Chen YR, Bendor-Samuel R.
matic illustration. Augmentation of the free border of the lip in cleft lip
patients using temporoparietal fascia. Plast Reconstr Surg.
1995;95:781–788; discussion 789.
PATIENT CONSENT 14. Ersek RA. Transplantation of purified autologous fat: A 3-year
The patient provided written consent for the use of follow-up is disappointing. Plast Reconstr Surg. 1991;87:219–
227; discussion 228.
her images. 15. Patel IA, Hall PN. Free dermis-fat graft to correct the whistle defor-
mity in patients with cleft lip. Br J Plast Surg. 2004;57:160–164.
16. Zhao Z, Li Y, Xiao S, et al. Innervated buccal musculomu-
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