Wednesday, January 7, 2009

Tenisson-Randall Cutting

Tennison Triangular Flap (Randall Modification)
The triangular flap is but one of several methods of creating a flap in an otherwise straight line closure of the lip closure may be high or low and various surgeons promote their specific choice of location.
Although the rotation advancement technique of Millard has the greatest number of followers and is recognized as a simple method once experience is obtained, a number of surgeons prever a triangular technique, since it seems simpler to lay out and perform and is less of a “cut as you go” free hand performance. For some surgeons it seems simpler and easier to teach and possibly more reliable for those performing and teaching a small number of cases.
The Tennison triangular flap technique described by Randall demonstrates that the medial lip element contains the essential landmarks for Cupid’s bow. The triangular flap technique recognizes that Cupid’s bow is high on the cleft side. The technique plans for a diagonal incision directly above the raised lateral peak into the philtrum. When the lip element is lowered, a triangular defect is created by incision, which is filled upon closure with the triangular flap from the cleft side. Thus tissue is added to the noncleft side of the lip in the lower one third. This is in contrast to the Millard rotation advancement technique, which advance a triangle of tissue in the upper one third. A distinct difference is that the philtrum is not cut across by the Millard rotation incision. The triangular flap is in the lower one third of the lip and contains full thickness of the lip consisting of skin, muscle, and mucosa.
Advantages of the triangular flap are that it adds length to the medial lip element, rebuilds a good floor of the nostril, preserves Cupid’s bow, and adds tissue in the lower one third of the lip, where it is needed most. Furthermore, it gives dependable results.
The disadvantages are that the Z in the lip crosses the philtral line. It is a confusing technique to explain, especially the height adjustment and placement of the triangle in the lateral lip element. Furthermore, the vermilion countour is deficient in the midline and there is a tendency to get an increase in lip height on the repaired side. It is not clear how long to construct the lateral lip element, thus increasing the discrepancy in lip length.

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