The British Association of Plastic Surgeons (2003) 56, 375–379

Surgical creation of a Cupid’s bow using W-plasty in

patients after cleft lip surgery
Ayako Takeshita*, Tatsuo Nakajima, Tsuyoshi Kaneko, Masaki Yazawa,
Ikkei Tamada

Department of Plastic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo
160-8582, Japan

Received 17 April 2002; accepted 25 April 2003

KEYWORDS
Cupid’s bow; W-plasty;
Vermilion; Cleft lip
Summary The three-dimensional contour of the Cupid’s bow is extremely important
from a cosmetic standpoint, and many patients with bilateral or unilateral cleft lip
require revision or reconstruction of the Cupid’s bow.
A number of surgical techniques have been reported for creating the Cupid’s bow,
among which the methods of Gillies and Onizuka are the most widely known. In the
methods of Gillies and Onizuka, the dog-ear can result in excessive volume in the
vermilion notch, raising the trough in the Cupid’s bow and leading to regression during
the post-surgical period. We have improved upon these techniques using the W-plasty
and have obtained satisfactory results that preserve the white skin roll.
In our method, the left and right prominence of the Cupid’s bow is created through
an incision of the white lip, while the central trough is created through a curvilinear
incision of the vermilion mucosa. At the two sites of the white lip tissue and the
curvilinear incision of the central vermilion tissue, the white skin roll is preserved as
much as possible.
In patients where the Gillies method had been used, the Cupid’s bow tended to be
flattened gradually after surgery.
We report on the details of our method and the case reports using the technique.
Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights
reserved.

Asymmetry or loss of the Cupid’s bow is not an
uncommon occurrence after surgery to correct
cleft lip. The three-dimensional contour of the
Cupid’s bow is extremely important from a cos-
metic standpoint, and many patients with bilateral
or unilateral cleft lip require revision or reconstruc-
tion of the Cupid’s bow.
A number of surgical techniques have been
reported for creating the Cupid’s bow, among
*Corresponding author. Tel.: þ 81-3-5363-3814; fax: þ81-3-
3352-1054.
which the methods of Gillies and Onizuka are the
most widely known. We have improved upon these
techniques using the W-plasty and have obtained
satisfactory results that preserve the white skin
roll. We report on the details of our method and the
case reports using the technique.
Surgical technique
The left and right prominence of the Cupid’s bow is

S0007-1226/03/$ - see front matter Q 2003 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/S0007-1226(03)00128-0
376 A. Takeshita et al.

Fig. 1 Our method.

Fig. 4 The schema above is Gillies’ method. The schema

below is our method.

tissue is also incised in a curvilinear fashion. This

creates a zigzag in the area of the excision, and the
vermilion border is sutured by W-plasty, thus
imparting the emphasis to the curve line created
Fig. 2 Gillies’ method. Cupid’s bow reconstruction by
vermilion advancement. Full thickness skin excision is
done.

created through an incision of the white lip, while

the central trough is created through a curvilinear
incision of the vermilion mucosa. At the two sites of
the white lip tissue and the curvilinear incision of
the central vermilion tissue, the white skin roll is
preserved as much as possible (Fig. 1).
In the technique of Gillies,1 the white lip tissue is
incised to fit the image of a curve that forms the
two regions of prominence of the Cupid’s bow, and
the vermilion mucosa is sutured along this curve to
create a new vermilion border (Fig. 2). Onizuka,2
inserted a back cut in the central region of the
vermilion to create an emphasis in the curvature of
the Cupid’s bow (Fig. 3).
In our technique, to emphasise the Cupid’s bow
contour, in addition to the white lip, the vermilion

Fig. 5 Appearance of the patient where the Gillies

method had been used, the Cupid’s bow tended to be
Fig. 3 Onizuka’s method. flattened gradually after surgery.
Surgical creation of a Cupid’s bow using W-plasty in patients after cleft lip surgery 377

Fig. 7 Appearance prior to surgery (A) and at 6 months

after surgery (B).

by the two prominences and the central trough of

the Cupid’s bow. By preserving the white skin roll at
each part of the curvilinear incision, it is possible to
create the two peaks and the trough of the Cupid’s
bow with a natural, three-dimensional vermilion
border (Fig. 4).

Fig. 6 Appearance prior to surgery (A) and at 18 months Results

after surgery (B). The vermilion border can be seen quite
clearly. Many methods have been reported for creating the
378 A. Takeshita et al.

Fig. 8 Pre-operative design (A) and the appearance immediately after surgery (B). This indicates the appearance at 6
months after surgery (C).

Cupid’s bow after cleft lip surgery, of which the
techniques of Gillies and Onizuka are the best
known. Our technique is an improvement on these
techniques using the principles of W-plasty.
We created the Cupid’s bow in eight patients. Of
these, three had unilateral deformity of the Cupid’s
bow occurring after cleft lip surgery, while the
remaining six had bilateral deformity of the Cupid’s
bow. The initial surgery for the first four cases had
been performed at our institution. In the remaining
four cases, the initial surgery had been performed
at outside institutions.
Surgical creation of a Cupid’s bow using W-plasty in patients after cleft lip surgery
Of the eight cases, three cases underwent Cupid
construction using Gillies technique. Five cases
underwent creation of the Cupid’s bow using our
technique, and more satisfactory results were
obtained in the appearance of the Cupid’s bow by
our technique. In patients where the Gillies
method had been used, the Cupid’s bow tended
to be flattened gradually after surgery (Fig. 5(A)
and (B)).
In patients in which our technique had been
used, the contour of the Cupid’s bow persisted for a
long period.
Cases using our technique are now presented.
1. Appearance prior to surgery and at 18 months
after surgery. The vermilion border can be seen
quite clearly (Fig. 6(A) and (B)).
2. Appearance prior to surgery and at six months
after surgery (Fig. 7(A) and (B)).
3. Pre-operative design and the appearance
immediately after surgery. This indicates the
appearance at six months after surgery (Fig.
8(A) – (C)).
Discussion
In Gillies technique, the white lip tissue is incised
along the vermilion border. This creates a number
of problems. Because the trough in the Cupid’s bow
is also created by the incision of the white lip tissue,
increasing the amount of white lip tissue excised is
unavoidable when creating an emphasis in contrast
with the apex of the Cupid’s bow, and as a result
there is a risk of shortening of the white lip. Dog-
ears may form at the time the white lip border is
sutured to the vermilion border. The dog-ear thus
formed can result in a bulky, excessive vermilion
notch.
Onizuka added to the Gillies technique by adding
a back cut to the center of the vermilion to place
emphasis on the trough in the Cupid’s bow and
impart a contrast to the curve line.
Recently, Kikui et al.3 have added to the white
lip excision by dissecting and elevating the vermi-
lion as a mucosal flap, to increase the degree of
379
freedom of the vermilion border and create the
Cupid’s bow.
We achieved good results by adding to the
technique of Gillies excision of the vermilion
mucosa in a curvilinear fashion to create the trough
in the Cupid’s bow, so as to place additional
emphasis on the two peaks in the Cupid’s bow. An
additional advantage of this method is that by
dividing the curvilinear incision into three regions,
the left and right white lip tissues and the central
vermilion tissue, it is possible to adjust the dog ear
and control the volume of the vermilion notch
created at the center of the vermilion. In the
methods of Gillies and Onizuka, the dog-ear can
result in excessive volume in the vermilion notch,
raising the trough in the Cupid’s bow and leading to
regression during the post-surgical period. In our
method, there is no post-surgical regression, and
the curve of the Cupid’s bow, with the two peaks,
did not disappear during the long follow-up period.
Creating the Cupid’s bow is an important
problem in lip reconstruction in cleft lip patients.
For both unilateral and bilateral cleft lip, if a
Cupid’s bow with left – right symmetry is not
attained after the initial cleft lip surgery, we
believe that a Cupid’s bow touch-up operation is
necessary.
In such a case, the method reported here allows
one to achieve an adequate curve line to the
Cupid’s bow, and post-operative flattering is
avoided by this W-plasty technique. This may offer
an extremely useful method for creating a Cupid’s
bow after cleft lip surgery.
References
1. McCarthy Plastic Surgery, Cleft lip and palate reconstruction
of philtrum and Cupid’s bow. London: WB Saunders; 1990.
pp. 2789—2790.
2. Onizuka T, Keyama A, Asada K, Shinomiya S, Aoyama R.
Aesthetic considerations of the cleft lip operation. Aesthetic
Plast Surg 1986;10(3):127—36.
3. Kikui T, Hashimoto H, Masada Y, Hosokawa K, Suzuki T.
Secondary lip repair for Cupid’s bow deformity in cleft lip.
Sumitomoishi 1992;19:85—9.