Secondary Revision With Boot Flap in a Case of Tessier No. 0 Cleft

The use of de-epithelialized oral vestibular flap (boot flap) for treating free border deformity in unilateral cleft lip and for the correction of whistling lip deformity in bilateral cleft lip is reported. A 22-year-old patient with a Tessier no. 0 median cleft was referred after having undergone median lip repair, facial bipartition for correction of orbital hypertelorism, and nasal reconstruction using a scalping forehead flap at a different hospital. The patient presented with vermilion notching and a reverse V-shaped deformity of the upper lip. The standard bilateral cleft lip repair technique was modified, and satisfactory results were obtained. Specifically, a bilateral boot flap procedure was performed on the oral vestibule along the central suture line of the primary repair. The boot flap was designed to be shorter than that used in standard cases of bilateral cleft lip. The surface mucosa was de-epithelialized before flap elevation, and a subcutaneous pedicle was created beneath the flap, which was then connected to the orbicularis oris muscle. Bilateral subcutaneous pockets were dissected, into which the boot flap was inserted and fixed using absorbable sutures. The donor site was closed by advancing the bilateral mucosal flaps. Full-thickness skin from the nasal dorsum was grafted onto the pigmented forehead donor area of the scalping flap, and direct suturing was performed to narrow the nasal dorsum. The postoperative course was uneventful, and vermilion notching did not recur during a 7-year follow-up.