The authors compared the shape of the upper lip by means of preoperative and postoperative photographs [2-5]. The patient was seated in the chair placed 0.3 m in front of a background. The patient was asked to look forward at a comfortable angle. The patient's face was relaxed completely, and all of the patients were photographed by one plastic surgeon. The patients were also photographed while smiling and blowing a whistle postoperatively. The camera (Cannon EOS 450D, Canon Inc., Tokyo, Japan) with a Sigma DC 17-70 mm, 1:2.3 lens (Sigma, Kawasaki, Japan) was placed approximately 1 m in front of the patient. The authors measured the vertical height in three locations: from the white roll to the inferior free margin at the non-affected Cupid's bow point (a), the midline on the upper lip (b), and the affected Cupid's bow point (c) in unilateral cleft lip (Fig. 1). Because the author's study is retrospective, the absolute value of the vertical height could not be measured, so two height ratios (b/a, c/a) were calculated to compare the relative changes of vermilion volume before and after surgery through photogrammetry. Statistical analysis was performed using SPSS ver.16.0 (SPSS Inc., Chicago, IL, USA). The Wilcoxon signed rank test was used to evaluate the results. A P-value of <0.05 was considered statistically significant.

First, if the vermilion deficiency is mild, the upper lip itself can be used for reconstruction, such as Z-plasty, V-Y advancement, double pendulum flaps, bilateral lateral vermilion border transposition flaps, and bilobed mucosal flaps. Z-plasty and V-Y advancement are performed both the most frequently and easily. However, these methods are restricted to cases of small lesions. Kapetansky [9] reported double pendulum flaps for augmentation of the central defect. Juri et al. [10] developed the bilateral mucomuscular flaps to fill up the insufficient central tubercle in the Kapetansky technique. Matsuo et al. [11] developed bilateral lateral vermilion border transposition flapsn. This method can reduce the tension of the upper lips and deepen the labiogingival sulcus. However, the use of this method can impair the continuity of the orbicularis oris muscle because this flap contains only a thin layer of orbicularis oris muscle. In addition, a bilobed mucosal flap has some disadvantages in that there is a slight difference in the color between the dry and wet mucosa and the technique leaves additional scars in the vermilion [3].

Secondly, if a defect in the vermilion is moderate or severe, the adjacent tissue, including the tongue and lower lip, can be used. Guerrero-Santos [12] used two types of tongue flap for the reconstruction of the upper lip. However, these methods cause the discomfort to the patient of spending approximately three weeks with the tongue flap retained between the lips, and the patients must undergo secondary surgery. Furthermore, a postoperative mismatch in the texture and color remained. The Abbe flap is one of the good methods for treating the upper lip when the defect is severe [13,14]. This technique also needs two stage surgery and leaves a donor site deformity on the lower lip as well as a mismatch in the texture and color on the upper lip.

Finally, autograft or allograft material for reconstruction can be used. Patel and Hall [7] used dermal fat grafting to correct a whistle deformity although it has been conventionally used to correct a facial contour or nose deformity. Trussler et al. [2] reported upper lip augmentation using the palmaris longus tendon. Niechajev [15] also reported lip enhancement using various alternatives including implants, autologous fat graft, and dermofat graft. Dermofat and autologous fat graft methods are simple and easy techniques, but these were less reliable because it is difficult to predict the degree of absorption and patients are at increased risk of developing an infection [16,17]. Wakami et al. [17] used the mucosal flap concomitantly with artificial dermis. As described here, there are various surgical methods depending on the size of defects and the clinical characteristics of patients, each of which has its own benefits and drawbacks.

The authors have speculated that the mucosa or other tissues, except muscle, are less reliable and not firm enough for reconstructing a defect. In whistle deformity in secondary unilateral cleft lip, the method of using orbicularis oris muscle flaps on the lateral portion and medial tubercle portion was planned. The characteristics of the author's cases in secondary unilateral cleft lip are volume deficiency in half of the central vermilion notching, and lateral bulging. For solving these problems, we modified a crossed-denuded flap that Guerreo-Santos et al. used for the primary surgery of cleft lip in order to prevent the vermilion notching [1]. After excision of a previous scar on the vermilion notching area, we dissected half of the muscle on the medial and lateral vermilion. Dissected bulged orbicularis oris muscle on the affected side and medial orbicularis oris muscle were crossed and turned over for the reconstruction of the defective central tubercle. In cases that had vermilion notching with a lateral bulging segment on the affected side, we could lessen the lateral bulging segment on the affected side and augment the half area of the defective central tubercle and correct the lip notching deformity at the same time. After judging the direction of the vermilion notching, the orbicularis oris muscle flap was created according to the location of the notching. If the vermilion notching was situated at the antero-posterior portion, the authors produced both muscle flaps in the anteroposterior portion. This means that the position of the muscle flap was dependent on the location of the vermilion notching. This point is different from the method reported by Cho and Kim [18], in which vertical interdigitation of the orbicularis oris muscle flap was used to reconstruct a depressed philtralcolumn. Additionally, in cases of philtral reconstruction, the present authors have been using a buried deepithelized scar to add projection to the philtral column in a roll-over muscle flap from the central vermilion [19]. The surgical techniques of our cross-muscle flap can be easily performed and the correction can be achieved with a one-time procedure. The additional scars can be avoided by cutting through the previous vermilion scar incision. In addition, the orbicularis oris muscle plays a primary role in generating facial expressions [20]. Our methods can realign the orbicularis oris muscle and obtain an adequate volume of tissue and thereby restore the continuity of the orbicularis oris muscle. This method eventually contributed to achieving muscle rearrangement as well as symmetry on the upper lip. Thus, satisfactory outcomes from both functional and aesthetic perspectives could be obtained.