IDEAS AND INNOVATIONS

A New Method for Reconstruction of

Vermilion Deficiency in Cleft Lip Deformity:
The Bi-Winged Myomucosa Switch Flap
Kyung Hoon Chung, M.D.
Lun-Jou Lo, M.D.
Taoyuan, Taiwan
Background: This study reviewed the method of using the bi-winged myomu-
cosa switch flap for correction of secondary cleft lip deformity in patients with
vermilion mucosa deficiency, lack of the central tubercle, and disproportionate
lip projection, obviating the conventional Abbe flap when the prolabium has
acceptable philtrum and Cupid’s bow definition.
Methods: The technique was applied to adult patients with secondary vermil-
ion deficiency after primary bilateral cleft lip repair. The flap consisted of

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
may be a severe degree of tissue deficiency
and structural distortion and asymmetry. It
is not uncommon that the secondary deformity
involves the upper lip with vermilion mucosa
deficiency, lack of median tubercle, irregular
scars, and disproportionate lip projection. Several
methods have been described in the literature for
correction of the vermilion defect in the upper lip
such as Abbe flaps,1–7 Z-plasty, V-Y advancement,
transposition flaps, free dermal fat graft, fascial
graft, buccal musculomucosal, or cross-lip flaps.8–
17
The large vermilion mucosal tissue deficits of
the upper lip could cause a comparative effect
From the Craniofacial Research Center, Chang Gung Memo-
rial Hospital, Chang Gung University.
Received for publication November 22, 2016; accepted June
21, 2017.
Copyright © 2017 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000003889
that the lower lip appears more protrusive and
thicker (Fig. 1). In this clinical situation, we have
experienced inadequate or insufficient correction
of the discrepancy between the lips applying those
methods. The purpose of this study is to describe
a new technique, the bi-winged myomucosa switch
flap, and its results.
Disclosure: Neither author has any sources of finan-
cial or other support or any financial or professional
relationships that might pose a competing interest.
Supplemental digital content is available for
this article. Direct URL citations appear in the
text; simply type the URL address into any Web
browser to access this content. Clickable links
to the material are provided in the HTML text
of this article on the Journal’s website (www.
PRSJournal.com).

www.PRSJournal.com 1251
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 Plastic and Reconstructive Surgery • December 2017
Fig. 1. An 18-year-old female patient with bilateral cleft lip and
nasal deformity. She had a relatively short upper lip and lack of
lip projection. The vermilion was thin with no central tubercle
fullness. The lower lip was protruding.
PATIENTS AND METHODS
Patients undergoing the bi-winged myomu-
cosa switch flap procedure were reviewed. Data
were collected, including clinical information and
vermilion height ratio. Approval for this study was
given by the institutional review board.
To perform the procedure, the patients were
informed that 10 to 14 days of upper and lower
lip closure might be required. The procedure was
performed under general anesthesia. A schematic
illustration of the bi-winged myomucosa switch
flap is provided in Figure 2. Markings on the lower
lip started from the midline, and the shape and
size of the flap were outlined proportional to the
anatomical dimensions of the upper lip defect.
The marking on the vermilion was performed
2 mm below the wet and dry mucosal junction and
then extended bilaterally. After markings, local
anesthetics were infiltrated, not directly into the
lips but into the infraorbital and mental nerves
bilaterally to prevent lip swelling and distortion.
An incision was made over the mucosa approxi-
mately 3 mm in depth, including superficial parts
of the orbicularis oris muscle and approximately
10 to 15 mm in width on the mucosa portion.
Then, it was tapered down when it approached
laterally, making bilateral wings on the central
pedicle. The flap was elevated, leaving a 5 to 8-mm
cuff of pedicle tissue at the midline of the lower
lip that contained a small amount of superficial
muscle layer of the lower lip for blood supply. No
1252
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
attempt was made to dissect or isolate the labial
artery. The flap was easily rotated upward without
pedicle distortion or compromised vascular sup-
ply. The donor site was sutured to the edges of the
mucosa.
Next, a horizontal releasing incision was
made along the upper lip 2 to 3 mm below the
junction of wet and dry mucosa. The incision was
made through mucosa down to the superficial
parts of muscle layer to create a recipient site for
inset of the switch flap to be revascularized. The
bi-winged myomucosa switch flap was sutured to
the upper lip defect. The central pedicle spot
was not sutured in the posterior side. Adhesion
between the lower and upper lips was in the
midline vermilion, and both commissures of the
patient’s mouth were open. Division of the lips
was performed in 14 days under local anesthesia.
A schematic illustration of the final stage of the
bi-winged myomucosa switch flap is provided.
[See Figure, Supplemental Digital Content 1,
which shows (left) that the bi-winged myomu-
cosa switch flap pedicles were divided at a sec-
ond stage 14 days later. (Right) Complete inset
of the bi-winged myomucosa switch flap, http://
links.lww.com/PRS/C468.] Actual photographic
presentation of the bi-winged myomucosa switch
flap procedure is also provided. [See Figure,
Supplemental Digital Content 2, which shows
(above, left) a 17-year-old female patient with sec-
ondary deformity that involves the upper lip with
significant vermilion mucosa deficiency, lack of
median tubercle, and disproportionate lip pro-
jection. The patient decided to undergo the bi-
winged myomucosa switch flap procedure for
the first-stage reconstruction. (Left) Actual illus-
trative patient example of the bi-winged myomu-
cosa switch flap. (Below, right) Pedicle divided
and final result of flap inset, http://links.lww.com/
PRS/C469.]
RESULTS
Four patients with bilateral cleft lip nasal defor-
mity underwent the bi-winged myomucosa switch
flap procedure. The follow-up period was 4 months
to 13 years, with a mean of 5.6 years. The age of the
patients ranged from 17.6 to 19.4 years at the time
of surgery. All of them were female patients and
tolerated the procedure well, without complica-
tions. Three patients underwent orthognathic sur-
gery before the bi-winged myomucosa switch flap
procedure. The vertical height dimension on the
upper vermilion was increased. Preoperative ver-
milion ratios between the lips (ls-sto/sto-li) ranged
 Volume 140, Number 6 • Bi-Winged Myomucosa Switch Flap

Fig. 2. Schematic illustrations of the bi-winged myomucosa switch flap.

(Above, left) Upper and lower lip incision lines were marked (broken lines indi-
cate incisions). (Above, right) Lateral view of the flap dissection. (Below, left)
The upper lip recipient site was dissected after a releasing incision; the lower
lip elevation of the bi-winged myomucosa switch flap showing the wings and
central pedicle is shown. (Below, right) The donor site was closed primarily
and the flap was transferred and inserted to the upper lip and sutured. The
bi-winged myomucosa switch flap pedicles were divided at a second stage
14 days later.

from 0.33 to 0.48. The postoperative ratios (0.90 DISCUSSION

to 1.08) were close to the average Chinese female
subject (0.96) as set by Farkas.18 The patient’s fron-
tal view shows improvement of the lip profile and
vermilion balance (Fig. 3). Long-term follow-up
results were satisfactory. One of the patients under-
went a secondary rhinoplasty 6 months later, and
another patient underwent secondary rhinoplasty
and upper lip revision procedures and further
augmentation in the left vermilion 1 year later.
The mucosa scar at the donor site was not visible
in repose or in speaking situations.
Secondary reconstruction of a vermilion defect
is not uncommon after primary bilateral cleft lip
repair. Several methods have been described,
such as Z-plasty, V-Y advancement, transposition
flap, bilobed mucosal flap, Abbe flap, and sev-
eral other modifications.1–16 The techniques are
based on redistribution of the remaining ver-
milion mucosa from the upper lip or transfer of
tissue from the lower lip to match the color and
contour for normal appearance.7–16 These meth-
ods are, unfortunately, not suitable for patients

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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2017
Fig. 3. The patient underwent simultaneous bi-winged myo-
mucosa switch flap and rhinoplasty. At 14 months after surgery,
the patient shows improvement of the lip profile and vermilion
balance.
with vermilion mucosa deficiency, lack of median
tubercle, irregular scars, and disproportionate lip
projection. In this study group, the local flaps or
free graft was not adequate because of the severe
soft-tissue deficiency in the upper lip. The con-
ventional Abbe flap was ruled out because of the
acceptable prolabium with a good philtrum and
Cupid’s bow definition.
The advantage of the bi-winged myomucosa
switch flap technique is its effectiveness in normal-
izing vermilion defects and achieving better har-
mony between the lips. Sizable upper lip vermilion
defects associated with bilateral cleft lip repairs
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-
ments the tubercle by adding wet vermilion to the
upper lip. The characteristic lower lip fullness is
simultaneously reduced to provide better balance
between the lips. The aesthetic and functional
morbidity of the donor site is insignificant. The
color mismatch is avoided by locating the incision
in the mucosa and posterior to the red line (i.e.,
junction between the dry vermilion and mucosa in
the upper and lower lips). It should be mentioned
that the bi-winged myomucosa switch flap is indi-
cated only in selected patients with a significant
cleft lip deformity as described in our patients.
The ethnic normative ratio of upper and
lower lip heights should be considered, and extra
effort should be made in planning secondary lip
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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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
and inset of the flap. The descriptor for
code 40761 indicates “including sectioning
and inserting of pedicle.” One code describes
two procedures performed at different op-
erative sessions.
• It would not be appropriate to report code
15630 for the division and inset, as this is
included in code 40761.
CODING PRINCIPLE: Although the bi-
winged myomucosa switch flap contains muscle
and mucosa, it is not considered a myocutane-
ous flap to be reported with code 15732. Code
40761 is more specific and more accurate.
Disclosure: Dr. Janevicius is the president of
JCC, a firm specializing in coding consulting
services for surgeons, government agencies,
attorneys, and other entities.
reconstruction for patients of different cultural
backgrounds. An important point is that many
patients tend to request treatment based on their
own racial norms.19 In Chinese female groups, a
tall upper vermilion height and a larger upper
lip volume have long been considered symbols
of youth and beauty.20 However, the Caucasian
female upper lip is found to be generally thin-
ner and to have a shorter upper lip height, and
for African American women, both upper and
lower lips are thicker and fuller based on Farkas’
analysis.18
Possible surgical complications associated
with the bi-winged myomucosa switch flap include
bleeding, wound infection, dehiscence, flap fail-
ure, and airway obstruction. The complications
 Volume 140, Number 6 • Bi-Winged Myomucosa Switch Flap
were not seen in our series. Lastly, a disadvantage
of this technique is that it needs two-stage surgery.
Of note, this technique is not indicated for recon-
struction of tight upper lip, short prolabium, or
lack of philtral column of upper lip, for which the
full-thickness or conventional Abbe flap is more
appropriate.
Lun-Jou Lo, M.D.
Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
5 Fu-Shin Street
Kwei Shan, Taoyuan, Taiwan 333
lunjoulo@cgmh.org.tw
ACKNOWLEDGMENT
The authors thank Brixton Anderson for the sche-
matic illustration.
PATIENT CONSENT
The patient provided written consent for the use of
her images.
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