Botulinum Toxin to Improve Results in Cleft Lip Repair
Botulinum Toxin to Improve Results in Cleft Lip Repair
Botulinum toxin type A (Botox; Allergan, Inc., Irvine, Calif) is widely used for facial
 rejuvenation and many other medical indications. It induces chemodenervation through its
 action on the presynaptic neuron, preventing release of acetylcholine, which leads to
 functional denervation of striated muscle for 2 to 6 months after injection. The use of
 botulinum toxin injection to reduce the facial scar is logical because this could reduce the
 tensile distracting force of the upper lip caused by the orbicularis oris muscle pull.
 Tollefson has demonstrate that botulinum toxin injection has decrease lip tension after
 primary lip repair in 3 children at 3-6 months of age The main aim of this randomized trial
 is to compare whether post-operative peri-surgical-injection of botulinum toxin into
 bilateral orbicularis oris muscles can improve scar formation for both primary and secondary
 cleft lip surgery.
This is a randomized controlled trial primarily designed to compare the scarring after
 primary and secondary cleft lip repair using post-operative botulinum toxin injection. There
 will be 4 main groups in this study:-

 1. Study group I: For primary lip surgery, immediately after primary lip repair will
 received botulinum toxin injection (1-2U/kg, at 25U/mL) into the bilateral aberrant
 oriented orbicularis ocuris muscle via 4 superficial injection site (Tollefson TT 2006).

 2. Study group II: For revision lip surgery, immediately after revision lip surgery 3
 injection of 2.5U of botulinum toxin with a distance of 0.5 cm from each injection and
 operative wound are injected over both sides of upper lip in a adult on the operation
 room.

 3. Control group I : Similar amount (in C.C.) of normal saline will be injected after
 primary lip surgery at 3 months of age.

 4. Control group II: Similar amount (in C.C.) of normal saline will be injected after
 revision lip surgery (secondary cleft lip repair).

 4. ELIGIBILITY 4.1 Inclusion criteria for the primary lip repair group (i) Baby born
 with cleft lip who will receive primary lip repair at 3 months of age (iii) Written
 informed consent given by parent/guardian.

 4.2 Inclusion criteria for the secondary lip repair group (i) Adult > 16 years old. (ii)
 Moderate to severe secondary cleft lip and/or nose deformity that warrants corrective
 surgery.

 (iii) Written informed consent given by parent/guardian/patient.

 4.3 Patient numbers: 60 for primary lip repair and 60 for secondary lip repair

 4.31 Sample size calculation: 10 consecutive patient selected from our OPD on march 2009.
 Vancouver Scar Scale means 4.6 with SD 1.264911 (rage 3-7). If the study group with
 improvement of 1 is clinical significant, giving power 0.8 with the same SD, the sample size
 calculated will be 26.

 Using Terason Ultrasound (capacity of measured 1/100 cm or 1/10 mm) the scar width mean is
 1.13 mm with SD .6201254. If the study group with improvement of 0.5 mm as clinical
 significant, giving the power of 0.8 with the same SD, the sample size calculated will be 25.

 We will use 30 patients for each group.

 4.41 Exclusion criteria for primary lip repair

 1. Combined other craniofacial anomalies

 2. Without permission of parent/guardian, without signed informed consent by
 parent/guardian.

 4.42 Exclusion criteria for the secondary lip repair

 1. Less than 15 years old

 2. Mild secondary cleft lip and / or nose deformity that does not warrant corrective
 surgery.

 3. Without written informed consent.

 4. Without permission of parent/guardian, the patient signed the consent himself.

 5. Botulinum Toxin injection 5.1 For Study group I: Injections are placed into the
 orbicularis oris muscle 5 mm adjacent to the scar and the vermilion border on each side
 of the operative wound (A total of 3 injections per side making a total of 6 injections
 per patient). 1-2U/kg (total dosage for baby) and 2.5 U (adult ) of botulinum toxin
 (Botox; allergen, Inc., Irvine, Calif) will be used for each injection. A total dosage
 of 15 U (for adult) will be injected into each patient.

 For control group a similar amount of Normal saline will be injected.

 6. STUDY VISITS AND ASSESSMENTS 6.1 Registration and Randomization (i) Confirmation of
 eligibility (ii) Information Sheet (iii) Written informed consent (iv) Registration of
 baby and adult into study and randomization (v) Scheduling of patient for botox
 injection immediately after surgery.

 6.2 Follow-up Assessments 6.2.1 Vancouver scar scale (Sullivan T 1990) measures
 pigmentation, vascularity, pliability and scar height on the postoperative 6 month F/U.

 Ultrasonography measurement of the scar (Fong SS 1997)

 For both primary and secondary lip surgery, the patient will receive postoperative
 follow up during 1wk, 1mo, 3mo, 6mo. On the 1st week postoperative follow up, the
 stitches will be removed, 3M taping will be placed over the wound to reduce surface
 tension and minimize the scar formation. On the 6th mo follow up, a lay person will
 assess the scar using the Vancouver scar and a plastic surgeon will use ultrasonography
 to measure the scar.

 The Independent T-Student test will be used to analyze the statistical significance
 between the two groups.

 Photographic measurement of scar The scar width of the patient's picture at 6 month
 after surgery will be measured using photoshop CS3 extended. One ruler will be placed on
 the patient's lip before taken the photo. Then the scar width could be measured.
Inclusion Criteria:

 Inclusion criteria for the primary lip repair group

 -  Baby born with cleft lip who will receive primary lip repair at 3 months of age

 -  Written informed consent given by parent/guardian.

 Inclusion criteria for the secondary lip repair group

 -  Adult > 16 years old.

 -  Moderate to severe secondary cleft lip and/or nose deformity that warrants corrective
 surgery.

 -  Written informed consent given by parent/guardian/patient.

 Exclusion Criteria:

 -  Those patient not fit inclusion criteria