10.5826/dpc.1302a83
Introduction:The early surgical treatment of the cleft lip led to a postoperative scar formation which may affect the physiological and psychological aspects of the patient.
Objectives: Evaluating the improvement rate of thescar flexibility and thickness of the cleft lip scar after treatment with the microneedling.
Methods: Sixteen patients (12 females and 4 males), aged 16-30 years who had a cleft lip scare were included in the current study.All patients suffered from a visible defective scar in the upper cleft lip.All patients were treated with a microneedling pen device combined with topical application of oil-based hyaluronic acid.The procedure was performed in 4 sessions with 3-week intervals between sessions.The scars were assessed by the patient and an external observer using the Patient and Observer Scar Assessment Scale.
Results:Thickness of the scar was improved according to the patient and observer opinions (67.28% and 61.55% respectively). Flexibility was improved according to the patient observer opinion (65.57% and 60.25% respectively).
Conclusions: Microneedling treatment can be considered as an effective method for the treatment of the defective scars resulting from the cleft lip plastic surgery.The microneedling technique is a simple,easy, safe, non-invasive, and low-cost procedure.
text/xml
2160-9381
2646
en
Yasser Almodalal
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
microneedling
Evaluation of Flexibility and Thickness of Cleft Lip Scars After Treatment with Microneedling Technique: a Cohort Trial
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-04-29
2022-06-10
2023-04-29
2023-05-31
e2023083
Dermatol Pract Concept
Introduction:The early surgical treatment of the cleft lip led to a postoperative scar formation which may affect the physiological and psychological aspects of the patient.
Objectives: Evaluating the improvement rate of thescar flexibility and thickness of the cleft lip scar after treatment with the microneedling.
Methods: Sixteen patients (12 females and 4 males), aged 16-30 years who had a cleft lip scare were included in the current study.All patients suffered from a visible defective scar in the upper cleft lip.All patients were treated with a microneedling pen device combined with topical application of oil-based hyaluronic acid.The procedure was performed in 4 sessions with 3-week intervals between sessions.The scars were assessed by the patient and an external observer using the Patient and Observer Scar Assessment Scale.
Results:Thickness of the scar was improved according to the patient and observer opinions (67.28% and 61.55% respectively). Flexibility was improved according to the patient observer opinion (65.57% and 60.25% respectively).
Conclusions: Microneedling treatment can be considered as an effective method for the treatment of the defective scars resulting from the cleft lip plastic surgery.The microneedling technique is a simple,easy, safe, non-invasive, and low-cost procedure.
Yasser Almodalal
2023/04/29
10.5826/dpc.1302a83
e2023083
Oral and maxillofacial surgery, University of Damascus Dental School, Damascus, Syria 
2160-9381
microneedling
en
e2023083
Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM: Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity. Plast Reconstr Surg. 2008, 121:1421-1429. 10.1097/01.prs.0000304612.72899.02
Evaluation of Flexibility and Thickness of Cleft Lip Scars After Treatment with Microneedling Technique: a Cohort Trial
https://dpcj.org/index.php/dpc/article/download/2646/2058
       Evaluation of Flexibility and Thickness of Cleft
       Lip Scars After Treatment with Microneedling
                  Technique: a Cohort Trial
                                      Mohamad Alghazzawi1, Yasser Almodalal2


1 Department of Oral and maxillofacial surgery, University of Damascus Dental School, Damascus, Syria
2 Oral and maxillofacial surgery, University of Damascus Dental School, Damascus, Syria



Key words: cleft lip, scar, scar management, scar treatment, microneedling
Citation: Alghazzawi M, Almodalal Y. Evaluation of Flexibility and Thickness of Cleft Lip Scars After Treatment with Microneedling
Technique: a Cohort Trial. Dermatol Pract Concept. 2023;13(2):e2023083. DOI: https://doi.org/10.5826/dpc.1302a83
Accepted: September 20, 2022; Published: April 2023
Copyright: ©2023 Alghazzawi et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Mohamad Alghazzawi, PhD student, Department of Oral and maxillofacial surgery, University of Damascus Dental
School, Damascus, Syria. E-mail: d.ghazawy86@gmail.com Mobile: +963988359129




  ABSTRACT             Introduction: The early surgical treatment of the cleft lip led to a postoperative scar formation which
                       may affect the physiological and psychological aspects of the patient.
                       Objectives: Evaluating the improvement rate of thescar flexibility and thickness of the cleft lip scar
                       after treatment with the microneedling.
                       Methods: Sixteen patients (12 females and 4 males), aged 16-30 years who had a cleft lip scare were
                       included in the current study. All patients suffered from a visible defective scar in the upper cleft lip. All
                       patients were treated with a microneedling pen device combined with topical application of oil-based
                       hyaluronic acid. The procedure was performed in 4 sessions with 3-week intervals between sessions.
                       The scars were assessed by the patient and an external observer using the Patient and Observer Scar
                       Assessment Scale.
                       Results: Thickness of the scar was improved according to the patient and observer opinions (67.28%
                       and 61.55% respectively). Flexibility was improved according to the patient observer opinion (65.57%
                       and 60.25% respectively).
                       Conclusions: Microneedling treatment can be considered as an effective method for the treatment of
                       the defective scars resulting from the cleft lip plastic surgery. The microneedling technique is a simple,
                       easy, safe, non-invasive, and low-cost procedure.




Original Article | Dermatol Pract Concept. 2023;13(2):e2023083                                                                          1
Introduction                                                       The mechanism of action is mainly based on the rupture and
                                                                   removal of the damaged subepidermal collagen followed by
The cleft lip is a congenital development defect caused by         substitution for new collagen and elastin fibers.
the lack of connection of the upper lip tissues during the            The microneedling treatment stimulates collagen produc-
embryonic period [1]. The cleft lip defect has an influence on     tion without removing the epidermis, and the tissue regener-
the normal facial appearance and functions such as feeding         ation time is commonly shorter than the ablative techniques,
and speech, which affect the child psychosocial development        which substantially reduces the risk of adverse effects when
negatively [2]. The surgical treatment of the cleft lip allows     benchmarked. As well, the skin becomes more resistant and
to secure continuity of the lip tissues. It is usually performed   thicker [15].
at the age of 2 to 6 months. There are many surgical tech-
niques for the primary repair of cleft lip. Unfortunately,
these techniques are associated with a postoperative scar
                                                                   Objectives
­formation [3].                                                    The current study aimed to evaluate the efficacy of micronee-
    The scar often undergoes contracture and hypertrophy,          dling in improving the flexibility and thickness of the cleft lip
due to the repeated movements related to facial expressions        scar as one of the conservative techniques in the manage-
and basic life activities, which adversely affect the postoper-    ment of postoperative scars.
ative wound healing process [4]. The scar tends to be raised
above the skin surface and is hyperpigmented more than the
normal skin [5]. The scar tissue leads to the creation of some     Methods
secondary deformities, such as deformed philtrum, Cupid’s
                                                                   Trial Design
bow asymmetry, tight upper lip, whistle deformity, and ir-
                                                                   This study was a cohort study. The current trial was achieved
regularities in the function of orbicularis oris muscle [6,7].
                                                                   at the Department of Maxillofacial Surgery at the Faculty
The scar of the upper lip may restrict the growth and devel-
                                                                   of Dentistry, Damascus university, Syria between August
opment of the maxilla, leading to a skeletal Class III maloc-
                                                                   2019 and September 2021. Ethical approval was obtained
clusion [8].
                                                                   from the Local Ethics Research Committee at the Uni-
    A mature cutaneous scar usually consists of a large
                                                                   versity of Damascus, Dental School (Reference Number:
amount of collagen fibers (80%-90% type I, the rest type III)
                                                                   25223102017-DEN).
[9]. The collagen fibers within the scar are arranged in bun-
dles parallel to the surface of the skin. On the other hand, the
collagen fibers in the normal skin are arranged in a nonpar-
                                                                   Participants and Eligibility Criteria
allel ‘‘basket-weave’’ orientation [10]. The basement mem-         The sample consisted of 18 scars in 16 patients (14 unilateral
brane of the epidermis that develops over the scar tissue is       clefts, 2 bilateral clefts). The distribution was as following:
flatter than the normal skin tissue because the scar does not      2 males (3 scars) and 14 females (15 scars) of cleft lip and
contain the rete pegs that penetrate the dermis [9]. In addi-      palate patients who completed their lip repair surgeries. The
tion, the cutaneous scar does not contain dermal appendages        age of patients ranged from 16-35 years. All patients had a
such as hair follicles, sebaceous glands, and stem cells [5,11].   visible defective scar and the desire to perform cosmetic pro-
The extracellular matrix (ECM) of the scar tissue contains         cedures in order to improve the general appearance of the lip.
less elastin than normal skin, resulting in decreased elasticity   All individuals were able to follow the stages of treatment.
in the scar [12].
    Clinically and cosmetically, a favorable scar has an im-       Microneedling Intervention
perceptible fine line and is parallel to skin creases and folds,   The automated microneedling tchnique was performed us-
similar in color and contour to the surrounding skin, and          ing an automated micro needling Dermapen (Beijing HYE
within the level of the skin [13].                                 Technology Co) which is considered an advanced technology
    Many methods were proposed for treating the scar of            for vertical pricking of the skin through several needles that
cleft lip including surgery, steroids injection, botulinum toxin   puncture the skin with an automatic percussion function.
Type A injection, silicone gel sheeting, fractional ablative la-   The device consists of a handpiece, equipped with an electric
sers, and microneedling [14,15].                                   motor and a head consisting of 12 needles, 33 gauges are
    The microneedling procedure is also called the Percuta-        attached to a disposable rod (Figure 1).
neous Needle Collagen Induction Technique (PCI). The PCI              The needles move up and down from 0.25 mm to 2.5
was firstly introduced by Orentreich and Orentreich [16]           mm entering depth. The speed of movements ranges from
who used the needles in order to stimulate the production          1 to 7 pricks per second. The entry depth and speed are ad-
of collagen in the treatment of depressed scars and wrinkles.      justed depending on the scare area via private keys.



2                                                                      Original Article | Dermatol Pract Concept. 2023;13(2):e2023083
    The treatment was divided into 4 sessions with an in-                for clinical cases were treated in the current study have been
terval of 3 weeks. The surface of scar was cleaned well                  included in Figures 4 and 5.
with 0.10 ml Hexamidine solution, then a local anesthetic                    All patients were informed that a redness can be seen af-
cream (EMLA) was applied for 20 minutes. After that an                   ter treatment and may last for 2-3 days after the procedure.
oil-based hyaluronic substance with a concentration of                   All of them were also asked to apply a cold compress to the
3.5% and formulated from a mixture of hyaluronic acid of                 workplace for the first couple of hours.
non-cross-linked biotechnological origin was applied to the
skin surface. The dermapen was applied to the scar with a                Outcome Assessment
prick depth of 2-2.5 mm and speed of 5 pricks per second,
                                                                         The thickness and flexibility of the cleft scar were assessed
depending on the device instructions for the treatment of
                                                                         before treatment and one month after the last treatment ses-
scars. Finally, the surface of the scar was cleaned with a piece
                                                                         sion by both the patient and three external observers from
of sterilized gauze soaked in saline solution and a steri-strip
                                                                         the Oral and Maxillofacial Surgery Residents using the Pa-
bandage was applied (Figures 2 and 3). Additional images
                                                                         tient and Observer Scar Assessment Scale (POSAS) [17].
                                                                         Comparisons have been made between the baseline data (be-
                                                                         fore treatment) and after one month of treatment.
                                                                         Thickness: the distance between the surface of the scar and
                                                                         the adjacent skin surface.
                                                                         Flexibility: It is measured by the flexibility of the scar be-
                                                                         tween the index finger and thumb.
                                                                             The evaluated items consist of a 10-point scale where 1
                                                                         indicates the best scar that matches the adjacent healthy skin
                                                                         and the number increases as the scar worsens as 10 indicates
Figure 1. The automated microneedling Dermapen.                          the worst scar.




Figure 2. (A) Topical anesthesia; (B) Application of hyaluronic acid; (C) The microneedling process; (D) Steri-strip dressing.



Original Article | Dermatol Pract Concept. 2023;13(2):e2023083                                                                       3
Figure 3. Clinical case 1. (A) Before treatment; (B) Immediately after microneedling; (C) After 1 month of the final microneedling process.




Figure 4. Clinical case 2. (A) Before treatment; (B) Immediately after microneedling; (C) After 1 month of the final microneedling process.




Figure 5. Clinical case 3. (A) Before treatment; (B) Immediately after microneedling; (C) After 1 month of the final microneedling process.



Statistical Analysis                                                    respectively). Flexibility was improved according to the
All statistical analyses were performed using SPSS software             patient’s and observer’s opinion (65.57% and 60.25%
(version 20; IBM)). The paired sample t-test was applied to             respectively).
assess the differences in the thickness and flexibility of the              The thickness and flexibility were improved signifi-
cleft lip scar before and after treatment with microneedling.           cantly after the PCI according to the patient and outer ob-
                                                                        server reports (P < 0.05) (Table 2). According to the patient
                                                                        opinion, the mean improvement rate was 4.899 and 5.791
Results                                                                 for thickness and flexibility of the scare respectively. Ac-
The percentage of improvement for both the thickness and                cording to the observer opinion the mean improvement rate
elasticity of the scar was assessed, according to the opinions          was 4.548 and 4.963 for thickness and flexibility of the
of both the patient and the observers with the POSAS, ac-               scar respectively.
cording to the following equation:
    The Improvement percentage = (the amount of the im-
                                                                        Conclusions
provement after treatment / pre-operative rate) * 100 (Table 1).
    The thickness of the scar was improved according to                 Aesthetics is a science, practice and experience. It is develop-
the patient’s and observer’s opinions (67.28% and 61.55%                ing rapidly due to the entry of new technologies and devices



4                                                                            Original Article | Dermatol Pract Concept. 2023;13(2):e2023083
                    Table 1. The descriptive values in both the thickness and elasticity of the scar.
    Studied Item       The Resident      Before      After     The amount of improvementa                   improvement percentage
                          Patient        7.281       2.382                      -4.899                                 67.28%
    Thickness
                         Observer        7.389       2.841                      -4.548                                 61.55%
                          Patient        8.831       3.040                      -5.791                                 65.57%
    Flexibility
                         Observer        8.237       3.274                      -4.963                                 60.25%
a
    The amount of improvement = post-operative rate value – pre-operative rate value.


                  Table 2. Comparison of the thickness and flexibility of the lip scar before and after
                                           the microneedling operation.
       Variable            Assessor              Time                  N              Mean ± SD           T-test value          P valueb
                                                Before                 18              7.28±1.36
                        Patient                                                                               15.149            <0.001a
                                                 After                 18              2.38±1.17
    Thickness
                                                Before                 18              7.38±0.99
                        Observer                                                                              23.795            <0.001a
                                                 After                 18              2.84±0.79
                                                Before                 18              8.83±1.58
                        Patient                                                                                5.57             <0.001a
                                                 After                 18              3.04±1.14
    Flexibility
                                                Before                 18              8.23±0.74
                        Observer                                                                              30.233            <0.001a
                                                 After                 18              3.27±0.67
a
 P <0.05 significant difference; b paired t test was applied
SD = standard deviation.


in this field. On the other hand, aesthetics has a principal                scare. In the current trial, the microneedling treatment and
role in people social and professional life.                                hyaluronic acid application were combined together. Lee
      This study was conducted to evaluate the efficacy of mi-              et al combined the microneedling treatment with a human
croneedling with hyaluronic acid therapy in the management                  stem cell conditioned medium [20]. The same findings were
of postoperative cleft lip scars resulting from primary and                 observed by Aust et al who conducted a study to evaluate the
secondary repair surgeries in cleft lip patients. The elastic-              effectiveness of microneedling in improving the appearance
ity and thickness of the scar were assessed according to the                of post-burn scars [21].
opinion of the patient and external observers.                                 Finally, the lack of number of the patients in the current
      In the current study, the flexibility of the scar was improved        study and the short duration of the follow-up period are the
to reach as close as the surrounding natural skin with an av-               main limitations of this trial.
erage improvement percentage of 65.57% and 60.25% for                          In conclusion, the cleft lip scar management should be
the patient and observer respectively. The same findings were               considered as a principal element of the treatment plan in
observed in the thickness of scar. The level of scare (thickness)           cleft patients. In the case of patients with secondary cleft lip
also improved to become very similar to the surrounding nat-                deformities, surgical correcting methods should be consid-
ural skin with an average improvement percentage of 67.28%                  ered taking into account that any surgical intervention leads
and 61.55% for patient and observer respectively.                           to new scars formation. Therefore, it is necessary to imple-
      These results were similar to what was reported by                    ment nonsurgical methods to prevent the scar hypertrophy.
Lakshmi et al who evaluated the PCI efficacy in treating the                Microneedling therapy can be considered an effective mo-
scars resulting from trauma, surgery, or cleft lip. Lakshmi                 dality for the treatment of surgical cleft lip scars in patients.
et al reported that the scar improvement rate after micronee-               Microneedling treatment is a simple and cost-effective tech-
dling was 100% [18]. This percentage was higher than the                    nique in the treatment of the facial scars. Damascus Dental
current results. This dissimilarity may be due to the involve-              School (Reference Number: 25223102017-DEN).
ment of many types of scares not only the scars resulting
from postoperative clef lip scars.
      El-Domyati et al demonstrated that the treatment with                 References
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6                                                                                Original Article | Dermatol Pract Concept. 2023;13(2):e2023083
