Operative Technique in Plastic Surgery – Kevin C.Chung

FIG 1 • Diagram of different pedicle dissections in
propeller flap harvest; A. subcutaneous propeller flap,
muscle-based propeller flap (B), and “true” skeletonized
propeller flap (C). Note the relative bulkiness of the
subcutaneous and muscular pedicles, placing them at
higher risk for pedicle kinking with greater than 90

degrees of rotation.
SURGICAL MANAGEMENT
Preoperative Planning
■ Unless contraindicated, general anesthesia with endotracheal intubation is
preferred for these cases as the meticulous perforator dissection benefits from
muscular paralysis intraoperatively. We routinely utilize preoperative Doppler
detection of perforators for flap planning; however, it is not always necessary.
■ Although we find the use of a Doppler to be helpful, perforator detection may
be confounded by superficial feeding blood vessels. In the setting of normal
lower extremity arterial anatomy, intermuscular perforators are reliably found
during intraoperative dissection, making preoperative Doppler identification a
useful adjunct rather than a requirement.
■ If a Doppler is used, the length and width of the flap can be designed as
follows:
■ The distance between the marked perforator and most distal aspect of the
planned defect is measured; this distance is then transposed proximally, and 1
to 2 cm is added to determine the total length of the flap.
■ Half a centimeter is added to the anticipated defect width (to allow for
contraction of the flap) to determine flap width (FIG 3).

FIG 2 • Schematic of lower extremity vascular territories
and their feeding vessels. ATA: anterior tibial artery,
PTA: posterior tibial artery, PA: peroneal artery. Small
dots represent location of reliably found septocutaneous
perforators within each angiosome.
Positioning
■ Location of the anticipated defect and dominant perforator dictate operative
positioning as propeller flaps are useful in head-to-toe reconstruction.
■ For propeller flaps supplied by the posterior tibial artery system, supine
positioning is used with the hip in abduction and leg externally rotated.
Propeller flaps based off the peroneal system also require supine positioning,
but a “bump” is placed under the ipsilateral hip. The hip and knee are then
flexed and internally rotated.
■ For all flaps below the hip, a circumferential prep of the entire extremity is

used routinely to ensure full visualization and allow intraoperative
repositioning as needed. This also facilitates split-thickness skin graft harvest if
required for donor site coverage.
■ For gluteal, sacral, or lumbar flaps, the patient is placed in prone position. The
patient is sterilely prepped and draped widely—typically from the midthoracic
region to the upper thighs.
FIG 3 • The distance between the marked perforator
(red star) and most distal aspect of the planned defect
is measured (distance a). This distance is then
transposed proximally, and 1 to 2 cm is added to
determine the total length of the flap (length = 2a + 1–2
cm). Half a centimeter is added to the anticipated defect
width (to allow for contraction of the flap) to determine
flap width (b + 0.5 cm).

Approach
■ When designing a propeller flap, it must be kept in mind that a skeletonized
perforator can be rotated maximally 180 degrees around itself, whereas
subcutaneous and muscle pedicled propeller flaps only allow for 90 degree
rotation without kinking (see FIG 1).
■ As mentioned above, though preoperative Doppler use may help identify
perforator locations, for skeletonized perforator flaps, the target perforator is
only chosen after a suprafascial or subfascial dissection allows for visual
inspection and confirms palpable pulsatility. An exploratory incision must be
planned for adequate perforator exposure and examination which should not
violate bail-out local flaps or an adjacent propeller flap supplied by a different
perforator.
■ Predicted preoperative flap outlines (based off on-table Doppler examinations)
often change after intraoperative dissection locates the dominant perforator.
■ Maximum size has yet to be described, but there are case reports of a 22 × 8
cm peroneal artery perforator propeller flap1,2 and a 19 × 13 cm posterior tibial
artery propeller flap1 based off one perforator. Perforators off the anterior tibial
artery are generally the smallest caliber in the lower extremity and require
smaller flap designs accordingly.
■ Skin grafting may be required for donor site coverage; however, in our
experience, primary closure is often achievable when defects are lesser than 6
cm in greatest width.
■ Although primary donor site closure is ideal, it should not be done under
excessive tension that could potentially compromise the flap or lead to wound
breakdown. A small skin graft is preferable to either of those potential
consequences.
T E C H N I Q U E S
■ Islandized Propeller Flap
■ The defect with its appropriate margins is first defined (TECH FIG 1A).
■ A Doppler is then used to locate dominant perforators (most often
originating from the intermuscular septa).
■ The length between the perforator and most distal aspect of this defect is

transposed proximally (1 cm is usually added) to determine total length of the
flap whereas 0.5 cm is added to the defect width to calculate flap width
(TECH FIG 1B).
■ If the defect is below the hip, a thigh tourniquet may be applied. The leg is
elevated for 1 minute prior to tourniquet inflation, but not completely
exsanguinated in order to assist with visual identification of perforators.
■ After completion of the flap design, a no. 15 blade is used to incise only one
edge of the planned flap.
■ Using loupe magnification and microsurgical dissection technique,
exploration of perforators is then carried out in either the supra- or subfascial
plane.
■ We recommend using 3.5× loupe magnification for optimal perforator
visualization in addition to a subfascial approach as we find this dissection
plane is often faster and safer.
■ In either the supra- or subfascial plane, perforators are identified. The ideal
perforator is large, associated with two venae comitantes, and has a strong
palpable pulse (TECH FIG 1C).
■ The tourniquet is released, allowing assessment of the vessel’s pulsatility.
■ Spasm may prevent a pulse from being palpable; it can take up to 10 to 20
minutes after tourniquet deflation for pulse appearance.
■ To protect against vasospasm, papaverine or 4% lidocaine is used liberally
on preserved perforators.
■ If two or more perforators have characteristics capable of flap sustainability,
they can be alternatively clamped after the tourniquet is released to determine
the optimal source vessel.
■ Once the ideal perforator is located, the perforator foramen is then enlarged
to allow for 2 cm clearance of fascial strands and muscular side branches (to
prevent pedicle kinking during rotation) (TECH FIG 1D).
■ After complete skeletonization, the flap design is adjusted to optimize the
perforator location for rotation into the defect. The remaining edges of the
flap are then incised, and dissection is carried out in the same plane until the
flap is fully elevated and isolated on the single perforator.
■ The flap can be rotated up to 180 degrees (see TECH FIG 1D) clockwise or
counter clockwise (whichever direction provides greatest coverage with the
least amount of pedicle kinking).
■ After rotation around the pedicle is complete, the edges of the flap are

evaluated for healthy bleeding, and the distal flap is inspected for any signs
of venous congestion.
TECH FIG 1 • A. Defect with exposed tibia. B. The
flap is marked adjacent to the defect. C. Subfascial
dissection reveals a dominant perforator. D. The
pedicle is appropriately skeletonized around the
dominant perforator and rotated 180 degrees. E. Flap
inset and closure can often be achieved without skin
grafts and closed suction drains unless the donor site
is too large to be closed primarily as seen above.
■ Satisfied with flap viability, inset occurs in the following sequence:
■ Secure the flap in place with two to four deep (fascial) sutures (often 3-0
PDS), equally spaced along the perimeter of the flap.
■ If a closed suction drain is necessary, it is positioned away from the
vascular pedicle.
■ Superficial, interrupted, skin sutures (3-0 nylon) complete the flap’s inset.
■ Loose inset is preferable as postoperative swelling may cause venous
congestion and/or ischemia.
■ If the donor is not amenable to tension-free primary closure, a skin graft is
harvested for coverage (TECH FIG 1E).

■ Nonskeletonized Propeller Flaps
■ The design and execution of a nonskeletonized propeller flap is similar to its
islandized counterpart, and the initial steps are similar, but the dissection is
significantly faster; the differences in planning and techniques will be
outlined here.
■ The defect is first defined (either by tumor ablation or adequate wound
debridement) and converted into a circular shape (TECH FIG 2A).
■ A Doppler is then used to locate dominant perforators within 360 degrees of
the defect.
■ Note that when planning these nonskeletonized flaps, tissue can only be
rotated a maximum of 90 degrees to avoid pedicle kinking (see TECH FIG
2C).
■ Once the ideal perforator is located, the flap can then be designed.
Depending upon the degree of rotation, flap length must be greater than
defect width as the effective length of a flap becomes shorter with increasing
rotation (TECH FIG 2B,C).
■ A subfascial plane is again preferred for dissection. After rotation around the
pedicle is complete, the edges of the flap are evaluated for healthy bleeding,
and the distal flap is inspected for any signs of venous congestion.
■ Satisfied with flap viability, inset occurs in the following sequence:
■ Secure the flap in place with two to four deep (fascial) sutures (often 3-0
PDS), equally spaced along the perimeter of the flap.
■ If a closed suction drain is necessary, it is positioned away from the
vascular pedicle.
■ Superficial, interrupted, skin sutures (3-0 nylon) complete the flap’s inset.
■ Loose inset is preferable as postoperative swelling may cause venous
congestion and/or ischemia.
■ If the donor is not amenable to tension-free primary closure, a skin graft is
harvested for coverage (TECH FIG 2D).

TECH FIG 2 • A. Defect and surrounding indurated
tissue around the medial malleolus. B. The defect is
created and the anterior flap is raised; the perforators
perfusing the flap are left in the subcutaneous tissue
and not skeletonized, making a relatively easy and
fast dissection. C. When the dominant perforator is not
skeletonized, maximum rotation is 90 degrees. D. If
the defect is too large for primary closure, a skin graft
may be used.
PEARLS AND PITFALLS
Incision
placement
■ Incisions should not violate adjacent bail-out options or
alternative flaps.
■ Initial exploratory incision should be as wide as possible so
multiple perforators can be evaluated.
Perforator choice
■ Visual and manual inspection is key to determining the
optimal perforator.
■ When possible, the chosen perforator should be at least 2 cm
away from the most proximal aspect of the defect.
■ Venae comitantes are at high risk of kinking during rotation

and fascial attachments must be cleared liberally.
■ Perforators from the anterior tibial artery are usually the
smallest in the leg and allow for the smallest flap dimensions.
Flap inset
■ After dissection of the flap is complete and only attached by
the skeletonized perforator, the tourniquet should be released
to assess viability and perfusion.
■ Vasodilators (lidocaine, papaverine) should be used liberally.
■ Before inset, the flap should be rotated clockwise and
counterclockwise to determine which way causes less kinking.
■ Excessively tight closure can result in vascular compromise
with subsequent partial or complete flap loss.
Contraindications
■ Poorly controlled diabetes
■ Peripheral vascular disease
■ Peroneal artery and its perforators are most likely to be
resistant to atherosclerotic disease and can still be used in
diabetic and peripheral vascular disease patients.
POSTOPERATIVE CARE
■ Patients should rest with the reconstructed extremity or body part elevated
above heart level where possible.
■ A gentle ACE wrap can be applied to lessen postoperative edema but should
not be too tight to cause ischemia; a small window should be cut in the
dressing (especially over the most distal aspect of the flap) to monitor
perfusion and congestion.
■ An orthotic boot or plaster posterior slab can be applied to maintain optimal
positioning for pressure offloading.
■ Skin sutures can be removed 10 to 14 days after surgery.
■ If a skin graft is placed over the donor site, a VAC dressing bolster should be
applied over the skin graft and removed 5 to 7 days postoperatively.
OUTCOMES
■ Complication rates of propeller perforator flap are close that of free flaps.3–5
■ Most flap loss is related to venous congestion from pedicle kinking.4,5
■ In the case of flap loss, outcomes are usually better than free flap loss as most
often only the superficial portion of the propeller flap becomes necrotic,
leaving vital structures covered by deep portions of the flap.2,4
■ If congestion or ischemia is suspected, flap can be deinset and derotated, or a

venous microsurgical anastomosis can be performed if feasible.
COMPLICATIONS
■ Distal tip necrosis
■ Pedicle kinking
■ Venous congestion
■ Flap loss
■ Contour deformities, scarring
■ Hematoma
■ Infection
REFERENCES
1. Ayestaray B, Ogawa R, Ono S, Hyakusoku H. Propeller flaps: classification
and clinical applications. Ann Chir Plast Esthet. 2011;56:90-98.
2. Georgescu AV. Propeller perforator flaps in distal lower leg: evolution and
clinical applications. Arch Plast Surg. 2012;39:94-105.
3. Hallock GG. The propeller flap version of the adductor muscle perforator flap
for coverage of ischial or trochanteric pressure sores. Ann Plast Surg.
2006;56(5):540-542.
4. Hyakusoku H, Yamamoto Y, Fumiiri M. The propeller flap method. Br J Plast
Surg. 1991;44:53-54.
5. Teo TC. Perforator local flaps in lower limb reconstruction. Cir Plast
Iberolatinoam. 2006;4:15-16.

PART 8
Pediatrics

(Trang không có chữ)

1
CHAPTER
Section I: Cleft Lip
Anatomical Subunit Repair
of Unilateral Cleft Lip
David K. Chong and Kathryn V. Isaac
DEFINITION
■ Cleft lip is a congenital malformation in embryonic development leading to
discontinuity of the upper lip. The cleft may be:
■ Complete or incomplete
■ Bilateral or unilateral
■ Cleft lip may occur in isolation or in combination with a cleft palate. It may
occur as part of a syndrome or in the absence of associated anomalies.
■ A cleft lip has an associated cleft nasal deformity with characteristic features
varying in severity depending on the type of cleft lip, width of the cleft, and
presence of associated cleft palate.
■ The cleft lip nasal deformity affects the skeletal, cartilaginous, and muscular
framework.
ANATOMY
■ During the 5th to 7th weeks of gestation, cleft lip occurs as a failure of
complete union of the medial nasal process and the maxillary prominence.
■ Clefting occurs through the skin, muscle, and mucosa of the labial and nasal
structures.
■ The cleft of the lip distorts and/or disrupts several important anatomic
structures.
■ Muscles
• Orbicularis oris (pars marginalis and pars peripheralis)

• Pars alaris, depressor alae nasi
■ Upper lip
• Cutaneous lip: philtral columns, central dimple, cutaneous roll
• Red lip: Cupid’s bow, vermillion, mucosa
■ Nose
• Nasal floor, alar base, nasal cartilages, septum, columella
PATHOGENESIS
■ The etiology of cleft lip is genetically complex and is due to multiple genetic
and environmental risk factors.
■ Most cases are sporadic, but some are familial, X-linked, or autosomal
dominant. Familial history of clefting is an important risk factor.
■ Cleft lip and cleft lip with cleft palate are considered variants of an entity that
differ in severity.
■ The environmental risk factors associated with clefting include maternal
smoking, infection, poor nutrition, teratogen exposure (alcohol, phenytoin,
valproic acid, retinoic acid), and advanced paternal age.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Diagnosis of a cleft lip is made by prenatal ultrasonography, by MRI, or by
physical examination at birth. Detailed assessment is made of the child’s
breathing, feeding, growth, and development.
■ Assessment of growth and weight is key to identify and monitor feeding
difficulty and use of feeding aids (Haberman/Pigeon teat).
■ The plastic surgeon should define the cleft lip type according to the anatomic
structures involved, laterality, width of the cleft, and presence/absence of a
cleft palate.
■ Also, the child should be assessed for associated anomalies suggestive of a
syndrome—craniofacial dysmorphism, airway compromise, cardiac defects,
ocular and auricular abnormalities, and musculoskeletal anomalies. A genetics
referral is suggested if suspicious of a syndromic etiology.
DIFFERENTIAL DIAGNOSIS
■ Syndromic cleft lip with or without cleft palate
■ Van der Woude syndrome
■ Gorlin syndrome
■ CHARGE syndrome

■ Ectrodactyly-ectodermal dysplasia-clefting
■ Brachio-oculofacial syndrome
■ Kabuki syndrome
■ Kallmann syndrome
SURGICAL MANAGEMENT
■ Cleft lip repair is ideally performed at age 6 months because the landmarks are
larger and easier to identify.
■ The principles of the anatomical subunit repair enable the surgeon to formulate
a plan for the predictable and successful closure of any type of cleft lip.1
■ The labial cleft closure is designed, measured, and determined prior to skin
incision. The operation is the execution of a formulated plan. This eliminates
the potential of compromising landmarks and removes the fear of under-
rotation, as well as lip height or length discrepancies.
■ With this repair, the most visible part of the scar lies along the anatomical
subunits, and the labial elements are perfectly matched in length to create an
optimal continuity of vermilion, cutaneous lip, and alar-labial junction.
■ Rotation of the labial elements is achieved by:
■ Skin triangle above the cutaneous roll
■ Muscle repair
■ Mucosal release
■ Risks of the procedure are scar deformity, nasolabial asymmetry and/or
deformity, wound dehiscence, and infection.
■ The main objectives of the cleft lip repair are to (1) separate the nasal and oral
cavities; (2) restore lip continuity and continence; (3) reconstruct a functional
labial sphincter for facial expression, speech, and feeding; (4) and restore
aesthetics of the labial and nasal subunits.
■ The main steps of the procedures are as follows:
■ Marking key landmarks and designing closure of labial elements based on
pre-incision measurements
■ Medial lip element release of skin, muscle, and mucosa to adequately balance
the Cupid’s bow, then composite elevation of lateral lip elements to insert into
the created “jigsaw”
■ Restoration of muscle continuity
■ Closure of the mucosa
■ Closure of the nasal floor
■ Skin and vermilion closure

■ Nasal correction with suture techniques
■ In discussing this repair, the language used in Millard’s description of the
rotation-advancement cleft lip repair will be used.2 The application of this
language will help to clarify and describe this technique for surgeons who have
adopted the Millard technique or modifications of it.
Preoperative Planning
■ If the child has a cleft lip and cleft palate, dentofacial orthopedics are utilized
for aligning the cleft maxillary arches and improving the nasal deformity
(lower lateral cartilage shape and position and septal cartilage alignment). The
device is discontinued prior to the cleft lip repair.
Positioning
■ The patient is positioned supine with the neck neutral and head stabilized in a
head ring.
■ The surgeon must have the ability to freely examine the face from all angles
throughout the procedure to ensure that three-dimensional balance is achieved.
Corneas are protected with transparent tape to use the plane and position of the
eyes in the surgical field as an aid to assessing labial and nasal symmetry. The
transparent tape should still allow the cheek to move freely.
■ Loupe magnification is helpful for accurate identification of anatomical
landmarks, for precise tissue dissection, and for perfect approximation.
Approach
■ Successful application of this cleft lip repair is facilitated by highlighting
conceptual differences between the rotation-advancement repair and anatomic
subunit repair.
■ Important landmarks are marked out, never compromised, and incisions are
made for closure that follows anatomical subunits.
■ Paradigm shift: Spend more time marking before any incisions are made and
the surgeon is committed to the plan.
■ Calipers are used to measure incisions for perfect length match.
■ Paradigm shift: The artistic “eye” is supplemented by precise measurements.
■ Foundation of repair is in the muscle.
■ Paradigm shift: Extension of skin incision outside of the proposed philtrum to
achieve rotation is not required.

■ Inferior triangle is placed above the cutaneous roll. This location restores the
cutaneous roll without interruption and achieves any additional lip lengthening
required for the skin.
■ Paradigm shift: Triangle is premeasured. Most measure 1 to 2 mm because
the muscle repair and mucosal M flap both contribute to lip lengthening.
T E C H N I Q U E S
■ Planning the Repair: Medial Nasolabial Element
■ Markings are made with methylene blue dye after the patient is prepped and
draped.
■ Markings of landmarks and anatomic contours are made with dots at the
landmarks listed below and along the line of interest for measurement,
incision, or alignment of elements.
■ Tattoo all points to prevent loss of landmarks.
Vermilion, Cupid’s Bow, and Nose
■ Mark the junction of the vermilion and mucosa along both medial and lateral
lip elements (TECH FIG 1A).
■ This helps determine the vermilion height discrepancy and points of
closure and ensures a continuous natural curve is achieved.
■ The following marks are placed on the medial lip element (TECH FIG 1B):
■ Mark the peak of Cupid’s bow on the noncleft side with one point above
and below the cutaneous roll.
■ Mark the trough of Cupid’s bow.
■ Mark the peak of Cupid’s bow on the cleft side with one point above and
below the cutaneous roll. The point above the cutaneous roll guides the
placement of the opening incision for insertion of the triangular cutaneous
flap, if required. Choose this point just medial to the actual peak of the
Cupid’s bow because it is difficult to surgically create a curve. It is
preferable to use the existing curve on the lateral lip element.
■ Mark the columellar points: one central and two adjacent that are
symmetrically distanced from the center and lie at the superior end of the
philtrum.
• The noncleft side of the medial lip element will guide you to pick the

superior extent of the philtrum, and you can mirror this onto the
anticipated created philtrum on the cleft side of the medial lip element
(TECH FIG 1C).
TECH FIG 1 • Medial lip markings. A. Vermilion. The
border between the vermilion and the mucosa is
marked. B. Cupid’s bow. C. Nose. (Copyright © David
Chong.)
• Remember that the apparent curve of the noncleft side philtral column is
due to the unopposed action of the unrepaired orbicularis oris and is
almost always a straight line in the Caucasian population once repaired.
■ In the noncleft nasal sill, mark the point where the medial footplate of the
medial crus meets the nasal floor (Nx). This point is used to guide the nasal
sill closure on the cleft side.
Measurements and Interpositional Triangle
■ Measure the distance on the noncleft side from the superior extent of the
philtrum to the peak of Cupid’s bow above the cutaneous roll (TECH FIG
2A).
■ This is the total height of the philtrum (a) on the noncleft side that you
need to recreate on the cleft side philtrum.
■ Measure the distance on the cleft side from the superior extent of the
philtrum to the peak of Cupid’s bow above the cutaneous roll with tissue

unfurled to mimic repair (TECH FIG 2B). This is the height of the cleft
philtrum (b). It is key to unfurl the convex surface of the medial lip during
this measurement; this maneuver aims to mimic the lengthening achieved
with muscle dissection and repositioning with mucosal release.
■ Perform a simple calculation to decide the need for an opening triangle:
subtract the distances between the philtrum of the noncleft side and the cleft
side (a − b − 1) (TECH FIG 2C).
■ Note that 1 mm of length will be achieved by the Rose-Thompson effect
(TECH FIG 2D,E). If greater than 1 mm of difference remains between
the philtral lengths, a cutaneous triangle from the lateral lip element will be
required, with its base equal to the distance deficit remaining.
■ Most cutaneous triangles have a base width of 1 mm (70% of cases), 1.5
mm (20% of cases), or no triangle (10%) depending on whether the cleft is
complete or incomplete.
■ Place a reference point in the nasal sill at the junction of the skin and mucosa
on the cleft side of the medial lip. This point (Nm) will guide you to place the
alar base at the correct vertical position. Ideally, this point is placed in mirror
image to the contralateral side, where the medial footplate of the medial crura
meets the nasal floor (Nx). Practically, you would like to maximize the
amount of skin available for nasal closure when learning to perform this lip
repair. Therefore, this reference point should be placed at the vermilion
cutaneous junction. In the initial learning phase of this repair, there is a
certain amount of “cut as you go” during closure of the nasal sill, as
permitted by the laxity of the skin in this region.
■ Tattoo all points listed above to prevent loss of landmarks.

TECH FIG 2 • Medial lip measurements. A. Noncleft
philtral column length is measured (a). B. Length of
the cleft philtrum is measured while placing gentle
downward traction (b). C. To determine whether an
interpositional triangle is needed, the difference
between the philtral heights of the cleft and noncleft
sides is calculated by subtraction (a – b – 1=c [height
of equilateral triangle]). D. Rose-Thompson effect.
Original description of lip lengthening with biconcave
excision closure by Rose in 1879. E. Rose-Thompson
effect applied to the anatomic subunit repair.
■ Elevate the Lateral Lip Element

■ Before placing the lateral lip markings, release the gingivobuccal sulcus and
lateral nose at the level of piriform aperture to facilitate marking the nasal
closure in complete clefts. Incise along the gingivobuccal sulcus beginning at
the junction point in the nasal floor between the vestibular mucosa, oral
mucosa, and nasal skin.
■ Continue the incision laterally and superiorly into the nasal cavity (TECH
FIG 3A).
■ Dissect the lateral lip element and alar base off of the maxilla in a
supraperiosteal plane (TECH FIG 3B).
■ Place one digit along the inferior orbital rim to help control the extent of
dissection needed and to prevent inadvertent entry into the orbit, as the
maxilla is vertically short in this age group.
■ Blunt dissection will prevent infraorbital nerve injury.
■ Dissect all attachments off the lateral and inferior portions of the piriform
aperture to ensure that the aberrant connection between the lower lateral
cartilage and the maxilla is released.
■ Release is complete once the lateral lip element and alar base are sufficiently
mobile to allow tension-free repositioning of the alar base, permitting
visualization of the repair and symmetrical nasal closure.
TECH FIG 3 • A. Lateral labial element release. B.
Supraperiosteal dissection of lateral lip element. The
shaded area is undermined in the supraperiosteal
plane to allow mobilization and medial advancement

of the muscle.
■ Planning the Repair: Lateral Nasolabial Element
Nordhoff's Point
■ With the lateral lip element and alar base mobilized, you may now
predictably mark the lateral lip:
■ Mark the point of lip closure “Nordhoff's point” with a point above and
below the cutaneous roll3 (TECH FIG 4). Parameters used to select this
point include the following:
■ Quality and shape of the cutaneous roll
■ The thickest portion of the red lip (vermilion)
■ The most anterior projecting point (need to assess from head of table)
■ The authors do not use the distance from commissure to the peak of
Cupid’s bow for determining the point of lip closure. It is unreliable due to
the variable extent of contraction that may be present from the orbicularis
oris muscle.
Nasal Sill
■ Mark the point for the nasal sill closure (Nl).
■ It is helpful to have an assistant to simultaneously assess the symmetric
positioning of the alar base in all planes.
■ Looking from the head of the bed, mimic nasal closure by moving the
lateral lip element to the medial lip element and position the alar base on
the cleft side at the same vertical height as the noncleft side.
■ From the submental view, the assistant should use forceps to elevate the
slump of the alar rim and recreate an oval nostril shape with a symmetric
diameter.
■ When the correct diameter of the nostril and the correct alar base position
are determined compared to the noncleft side, place a point (Nl) on the
lateral lip skin to mark closure to the equivalent point on the medial lip
(Nm) (TECH FIG 5).
■ When these two points meet (Nm and Nl), the nostril should be of equal
diameter, and the vertical position of the alar bases should be the same.
■ The alar base vertical position (in the cephalad-caudal dimension) is most
difficult to correct postoperatively if it is placed too low or too high relative
to the noncleft side.

■ In practice, you will find that minor adjustments in the width of the nasal
floor are achievable so err on the side of placing Nl more medial during the
initial application of this repair. This can then be adjusted by excising excess
tissue during nasal closure. As you begin to use this repair with increasing
confidence, you will trust the point you mark, minimizing the need to cut as
you go.
Matching Nasolabial Lengths
■ Now, you have two points of closure: one on each side of the lip to match the
vermilion and white lip and one on each side of the nasal sill to match and
achieve the right vertical height for the alar base and symmetrical diameter of
the nostril opening (TECH FIG 6A).
■ Finally, you must mark the following on the lateral lip:
■ The dimensions of the inferior triangular skin flap
■ The labial and nasal sill incisions within the confines of the two fixed
points of Nordhoff and nostril sill closure (TECH FIG 6B)
■ Set the caliper equal to the distance of the noncleft philtral height (b). Orient
the caliper to determine the inclination of the line b on the lateral lip.
■ Select the ideal orientation to account for the caliper distance (b), the
inferior triangle size (t), and nasal floor distance (d) to tailor the
“advancement flap” for precise lip and nasal closure (TECH FIG 6C).
■ Mark the advancement triangle in the vermillion as required by the
discrepancy in the vermilion height and volume between the cleft and
noncleft sides. The red lip advancement flap includes mucosa.

TECH FIG 4 • Selection of Nordhoff's point. A. This
point is selected along the vermilion border where the
cutaneous roll is thick, just starting to flatten, and
beginning to converge with the red line (arrowhead).
The distances marked by x should be equal at the end
of surgery but are not measured when marking as
they are hard to determine prior to repair. B. When
marking Nordhoff's point, it is important to always
mark at 90 degrees to the cutaneous roll. With
appropriate positioning of Nordhoff's point, closure of
the labial elements should result in mirror-image
symmetry of the cutaneous roll and red line of Cupid’s

bow. C. The most anterior projecting point on the
lateral lip.
TECH FIG 5 • Selection of nasal sill points of closure.
A. The lateral point of the nasal sill is determined by
lifting the cleft ala medially. Use the noncleft side
nasal sill point (Nx) to help select the cleft side nasal
sill points of closure (Nm and Nl). B. Alar bases are
leveled.
TECH FIG 6 • Lateral lip markings. Lip (A) and nasal
(B) points of closure are marked, and then limbs are

drawn between those points (C). Like an articulated
ruler, with the two end points fixed, the two
intermediate points are selected by establishing best
fit with known measurements. (Copyright © David
Chong.)
■ By planning the repair, one recognizes the variability of unilateral cleft lip
presentations and individualizes the repair to the presenting deformity, much
like a tailor would measure a suit for an individual. With this approach, you
will achieve a balanced lip with:
■ The correct thickness of vermilion and mucosa of the red lip
■ A continuous cutaneous roll
■ A symmetric Cupid’s bow
■ A length-matched closure of the lip incision that reflects the philtral
column position
■ A nasal sill closure with the appropriate orientation, position, and diameter
to match the contralateral naris
■ Dissection
Medial Labial Element
■ Incise the medial lip element first (TECH FIG 7). This allows you to verify
that prior to cutting the lateral lip element, you are able to achieve the
necessary rotation to create a vertically balanced lip and ensure no
adjustments are required to the size of the triangle.
■ Use a no. 11 blade to incise along the medial lip markings. It is critical to
precisely cut perpendicular to the cutaneous roll. If a triangle is planned,
make the opening incision above the cutaneous roll as your final cut to level
Cupid’s bow and ensure its size is appropriate.
■ Incise along the markings of the vermilion and continue the incision onto the
mucosa and release the maxillary frenulum.
■ Release the aberrant muscular insertions to the anterior nasal spine. Perform
minimal dissection of the muscle from the skin and mucosa.
■ Elevate the skin along the vermilion-cutaneous junction (analogous to C-
Flap elevation) to facilitate nasal sill closure and allow access to the nasal

septum.
■ Elevate the mucosa (analogous to M-flap elevation) off the medial cleft edge
to inset at the site of the maxillary frenulum release and elongate the medial
lip mucosa.
Nasal Structures
■ Expose the caudal septum on the noncleft side with elevation of the
mucoperiosteal flaps for direct visualization of the cartilage. Reposition the
caudal septum with gentle traction toward the cleft side.
■ The amount of lower lateral cartilage dissection varies according to surgical
preference.4-7
■ If nasal degloving is to be performed, place scissors carefully in the plane
between the skin and medial crura. Gently dissect in this plane between the
skin and the cartilage from the medial crus toward the lateral crus.
TECH FIG 7 • Medial labial incisions and dissection of
the skin, muscle, and mucosa.
■ Opponents of nasal cartilage degloving consider the risk of cartilage injury,
tissue destruction, subsequent scarring, and impaired growth to far

outweigh the minimal benefit achieved with this degloving. In primary
nasal correction without cartilage degloving, the correction is achieved
with release of abnormal ligamentous attachments at the piriform and
suture techniques, avoiding the risks listed above.
■ The muscle release, repositioning, and approximation are the foundation of
the lip repair.
■ Verify the muscle is sufficiently released by measuring the lip length. Once
committed to the opening incision, make the cut perpendicular to the philtral
incision and above the cutaneous roll with a beaver blade.
■ By incising and committing to the medial lip plan first, you can then adjust
the lateral lip markings if the planned triangle size was incorrect. This is
particularly helpful in the learning stages of this technique (the planned
triangle may not be necessary or the wrong size).
Lateral Nasolabial Element
■ Use a no. 11 blade to incise the lateral lip and a beaver blade to make the
fine incisions around the triangle.
■ Release the muscle from the alar base. Continue dissection laterally for a 2-
cm distance dividing the muscle to allow for its advancement and to create a
muscle of symmetric height for repair.
■ Perform dissection between skin and muscle, especially along the superior
portion of the lateral lip to allow for advancement. Perform minimal release
of the muscle from the underlying mucosa.
■ Elevate the nasal floor off the nasal vestibule to allow for repositioning in a
horizontal plane for nasal floor closure.
■ If cartilage degloving is being performed for primary nasal correction,
complete the degloving in the plane between the skin and cartilage joining
the previously dissected pocket.
■ Closure of the Lip
Muscle Repair
■ The muscle repair sets the foundation for the lip repair. To correctly position
the muscle elements for repair, have an assistant use a skin hook to lengthen
the medial lip element to balance the Cupid’s bow (taking care not to
excessively elongate) and another skin hook to hold the lateral lip element at

the ideal position for a lip closure (TECH FIG 8A).
TECH FIG 8 • A. Level Cupid’s bow to position the
muscle elements for repair. B. A. In repair of a cleft lip,
it is essential to release the aberrant orbicularis oris
muscle insertions and reposition the muscle fibers to
restore continuity. After release, repositioning, and
repair of the orbicularis oris muscle, a superior
gathering suture is placed (C, right) to improve the
shape of the lip on profile view (D).
■ With the setup outlined above, repair the muscle beginning superiorly. Place
the initial stitch superiorly to set the lip length and set the alar base in a
symmetrical vertical position. To ensure the cutaneous roll points of closure

are perfectly matched, check the alignment of the points of closure after each
successive muscle stitch.
■ After repairing the length of the muscle, consider placing a plication suture
at the superior end of the muscle repair at the base of the columella. This
accentuates the pout of the repaired lip (TECH FIG 8B–D).
■ Repair the mucosal incision with eversion of the mucosal edges. Ensure
correct approximation of the mucosal lengths and excise excess length at the
cephalad margin as required.
Cutaneous Approximation
■ Suture the labial skin and the vermilion without any cutaneous excision or
alteration of the labial incisions. A perfectly approximated closure of the
labial elements should be achieved based on the planned markings.
■ The only “cut as you go” occurs at the nasal sill where some adaptation is
often required to ensure the right diameter and shape of the nostril opening.
■ Primary Nasal Correction: Suture Techniques
■ Suture techniques detailed below necessitate that the alar base and aberrant
nasal attachments to the piriform and underling maxilla are completely
released.
■ The alar bases must be symmetrically repositioned and the caudal septum
must be centralized.
■ If cartilage degloving was performed:
■ Place an alar shaping suture as an interdomal suture between the genua of
the lower lateral cartilages (LLC).
■ Place a lower lateral hitching suture with an absorbable suture to secure the
dome of the LLC to the contralateral nasal bone periosteum. This elevates
the slumped LLC. Beginning from inside the nasal vestibule on the cleft
side, pierce the suture through the nasal mucosa, capture the dome of the
slumped LLC, exit the nasal skin with grasped nasal bone periosteum, and
back through the same cutaneous needle puncture to return to the nasal
vestibule through the same tissues.
■ If cartilage degloving was not performed:
■ Place an internal nasal valve plication suture in the vestibule between the
upper and LLC to recreate the scroll area.
■ Place an alar transfixion suture to lateralize the vestibular web. Beginning

from inside the vestibule, pierce through the nasal mucosa just below the
caudal LLC and exit the skin at the alar-facial junction. Re-enter the same
cutaneous puncture hole but exit more posteriorly in the nasal mucosa.
Tying the knot will lateralize the nasal mucosa.
PEARLS AND PITFALLS
Planning
■ Important landmarks are marked and never compromised.
■ There should be no “cut as you go” on the lip. The labial closure
should be precisely measured and tailored fitted because
compromise in the lip closure point is unforgiving.
■ Spend more time marking before any incisions are made and
commit to a plan.
■ It may be disconcerting initially as a lot more tissue seems to be
discarded than when “hedging your bets” by unnecessary
preservation of tissue.
Markings
■ Choose the cleft side of Cupid’s bow point just medial to the
actual peak of the Cupids bow as it is difficult to surgically create
a curve. Pick a slightly more lateral point on the lateral lip
element (which has the curve).
■ The triangular cutaneous flap is smaller than anticipated for two
main reasons:
■ The skin is elastic and rests in a concave contour due to the
aberrant insertion of the muscle. It will lengthen with release of
the muscle and dissection between these layers.
■ Rotation of the medial lip is also achieved by the muscle repair
and the mucosal release.
Measurements
■ Use calipers for measurements. This results in length-matched
incisions and precise alignment.
Muscle repair
■ The muscle is detached from its abnormal insertion, and the
lateral lip muscle is advanced into the gap superiorly as the
muscle released medially is drawn caudally to achieve lip length.
This allows planning the skin incision to mimic the philtral
column position rather than the misguided intention that it
achieves rotation.
Inferior
triangle above
the cutaneous
■ Creates a continuous cutaneous roll without interruption. Insert
any required triangle in the shadow of the roll, that is, just above

roll
the roll.
■ Achieves any additional lip lengthening required.
■ Work out the precise size of triangle and confirm measurement by
cutting medial lip element first.
FIG 1 • Preoperative and postoperative images of an
infant with cleft lip and palate following repair with
anatomical subunit technique. (Copyright © David
Chong.)
POSTOPERATIVE CARE
■ Prevent crusting along the suture line with incision care.
■ Apply saline as required to prevent scab and then emollient.
■ Sutures are removed after 5 days.
■ Nasal stents are kept for up to 6 weeks.
OUTCOMES
■ Since 2008, Dr. Chong has performed 200 consecutive cleft lip repairs using
the technique described (FIG 1).
■ Nasolabial revisions were required in three cases (1.5%), one for alar
repositioning and two for retained permanent suture.
■ There have been no revisions required for a shortened lip.
COMPLICATIONS
■ Infection
■ Hemorrhage

■ Lip or nasal revision required for asymmetry
■ Poor scarring
■ Nasal airway obstruction
REFERENCES
1. Fisher DM. Unilateral cleft lip repair: An anatomical subunit approximation
technique. Plast Reconstr Surg. 2005;116:61-71.
2. Millard DR. Complete unilateral clefts of the lip. Plast Reconstr Surg.
1960;25:595-605.
3. Nordhoff MS, Chen Y, Chen K, Hong K, Lo L. The surgical technique for the
complete unilateral cleft-lip nasal deformity. Oper Tech Plast Reconstr Surg.
1995;2:167-174.
4. McComb H. Primary correction of unilateral cleft lip nasal deformity: A 10-
year review. Plast Reconstr Surg. 1985;75:791-799.
5. Salyer KE. Primary correction of the unilateral cleft lip nose: A 15-year
experience. Plast Reconstr Surg. 1986;77:558-568.
6. Salyer KE. Early and late treatment of unilateral cleft nasal deformity. Cleft
Palate Craniofac J. 1992;29:556-569.
7. Fisher MD, Fisher DM, Marcus JR. Correction of the cleft nasal deformity:
from infancy to maturity. Clin Plast Surg. 2014;41:283-299.

2
CHAPTER
Unilateral Cleft Lip Repair:
Millard/Mohler Modifications
Roberto L. Flores and Gerald J. Cho
DEFINITION
■ A unilateral cleft lip is a congenital separation of the upper lip. The degree of
clefting can be microform, minor form, incomplete, or complete.
■ Microform
• Discontinuity of the vermilion-cutaneous junction
• Cupid’s bow symmetrical
• Slight notching of mucosal free border
• Variable nostril deformity and alveolar defect
■ Minor form
• Vermilion notch greater than 3 mm above the level of Cupid’s bow on the
noncleft side
• Discontinuity of orbicularis oris
• Nasal deformity
• Alveolar cleft present
■ Incomplete
• Complete full-thickness separation of upper lip with intact nasal sill or a
Simonart band along the nasal floor
■ Complete
• Complete full-thickness separation of upper lip
ANATOMY
■ Both the soft (upper lip and nose) and hard tissues (maxilla, septum, lower
lateral cartilages of nose) are affected (FIG 1).
■ Upper lip—The deformities in this area can be categorized into those affecting

the medial and lateral lip elements.
■ In the medial lip element, Cupid’s bow is preserved but with vertical
deficiency of the vermilion. The columella and philtral column are shortened
on the cleft side. The orbicularis oris has an abnormal and unilateral insertion
at the nasal base, and its disruption results in vertical shortening of the medial
upper lip, superior rotation of the Cupids bow, and vertical shortening of the
vermilion.
■ In the lateral lip element, the height and transverse length are shortened.
Medially, there is a distinct point where the white cutaneous roll and junction
of the wet and dry vermilion start to converge medially (Nordhoff point). The
pars superficialis on the lateral lip alters the direction of this muscle to run
almost vertically in the area below the ala, leading to aberrant attachments to
the nostril and periosteum of the piriform aperture. This leads to a vertically
foreshortened lateral lip, sometimes producing a bulge in this area.
■ Nose—The alar base on the cleft side sits on the piriform margin of the
maxilla, which is laterally and posteriorly displaced. The malposition of the
bony foundation combined with separation of the orbicularis oris causes
unopposed action of the ipsilateral zygomaticous major. This results in
widening of the nostril, depression of the alar dome, and canting of the
columella toward the cleft side (see FIG 1). Unilateral attachment of the
orbicularis oris to the medial crura footplates, anterior nasal spine, and caudal
septum on the noncleft side exacerbates the columellar tilt and contributes to
deviation of the caudal septum toward the noncleft side. Internally, the caudal
portion of the ala has a vestibular web. The underlying cartilaginous structures
are also malformed. On the cleft side, the medial crus of the lower lateral
cartilages is shortened, and the lateral crus is elongated and inferiorly
displaced. The septum is dislocated out of the vomer and bows toward the cleft
side.
■ Maxilla—The underlying skeleton forms the platform upon which the soft
tissues rest. Thus, the skeletal abnormalities of the maxilla can explain many
of the soft tissue abnormalities seen, particularly in the nose. The greater
segment of the alveolus is anteriorly rotated due to the fetal protrusion of the
tongue. The lesser segment of the alveolus rotates posteriorly. The medial
buttress of the maxilla can be hypoplastic and posteriorly displaced.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The preoperative assessment of a patient with a unilateral cleft lip includes

complete physical exam with assessment for other comorbidities. Facial exam
includes the side (left vs right vs midline), the degree of clefting (microform,
minor form, incomplete, or complete), and the extent of nasal deformity.
IMAGING
■ Typically not needed unless within the context of a midline or facial cleft
SURGICAL MANAGEMENT
■ This surgery is often the first step in the larger multidisciplinary treatment plan
for cleft care.
■ The quality of the primary repair establishes the initial function and
appearance for the patient and has great bearing on their future quality of life.
■ Nasoalveolar molding (NAM) is strongly recommended for patients with a
complete cleft or a significant nasal deformity.
■ Microform clefts can be repaired with less extensive methods than a full
rotation advancement.
■ Minor forms can be repaired with a modified rotation-advancement–type
repair with complete primary nasal reconstruction.
■ Incomplete and complete clefts can be repaired with a full rotation-
advancement–type repair.
■ Initial lip and nose repairs are performed at approximately 3 months of age.

FIG 1 • The soft (upper lip and nose) and hard tissue
(maxilla, septum, lower lateral cartilages of nose)
anatomy of a left complete unilateral cleft lip.
Preoperative Planning
■ The authors use NAM in patients with a complete cleft or a significant nasal
deformity. As mentioned above, a cleft through the maxilla not only disrupts
the platform upon which the soft tissues sit but also interrupts the dental arch.
NAM can help correct the outwardly rotated greater segment and
posterolaterally displaced lesser segment. The correction of the skeletal
platform into an anatomic position helps place the lip and nose into a more
favorable alignment. Furthermore, when the alveolar segments are aligned
within 1 mm, a gingivoperiosteoplasty can be performed, which can avoid a
secondary bone grafting procedure in 60% to 73% of patients without
detriment to midface growth by midterm follow-up. For these reasons, we feel
that NAM provides a more predictable lip and nose repair and potentially
decreases the overall number of surgical procedures for the child.
■ NAM typically commences 2 weeks after birth and is completed after 10
weeks of therapy in patients with a unilateral cleft.
Positioning
■ Supine with gentle neck extension from a shoulder roll
Approach
■ There are many techniques to repair a unilateral cleft lip, each with its own
advantages and disadvantages. In this chapter, we will present Cutting’s
modification of the extended Mohler repair.
■ In this approach, there are eight main steps to the operation: markings,
incisions, medial lip dissection, lateral lip dissection, mucosa closure, nasal
dissection, lip closure, and nasal refinement.
T E C H N I Q U E S
■ Millard/Mohler Modifications for Unilateral Cleft

Lip Repair
Markings (TECH FIG 1A–D)
■ Medial and lateral lip elements (TECH FIG 1A)
■ Medial lip element: The depth (point 1) and height of the noncleft side
(point 2) are identified and marked. The distance between these two points
is used to mark the height of the Cupid’s bow on the cleft side (point 3).
The white roll usually starts to disappear at this point. If Cupid’s bow is
wide or indistinct, the marks can be placed more narrowly so that less
downward rotation is required.
■ Lateral lip element:
• The height of the lip from the alar base to the height of the Cupid’s bow
on the noncleft side is measured with a caliper, and the vertical distance is
used to locate the corresponding white roll point on the lateral lip element
(point 4). Some surgeons use the widest point of the vermilion (Nordhoff
point) to determine point 4. However, in patients with a wide cleft,
Nordhoff point will commonly result in a vertically foreshortened lip.
Using the vertical height of the contralateral upper lip can sacrifice
horizontal lip length for preservation of vertical lip height. The horizontal
lip discrepancy will correct over time; however, a vertically shortened
upper lip will remain.
■ Mohler Back Cut (TECH FIG 1B)
■ The apex of the back cut is critical to the success of the design (see Pearls
below). This point (point 5) is placed approximately 1.5 mm superior to the
base of the columella and just over halfway (four-sevenths) across the
noncleft side.
■ A line is drawn connecting point 5 to a point just lateral to point 3. This
line should be bowed out to the same degree as the philtral column of the
unaffected side to recreate the subtle curve.
■ A straight line is drawn from the apex of the Mohler backcut (point 5) to
the height of the philtrum on the noncleft side but no farther (point 6). The
angle formed by these two lines and length of the backcut will affect the
degree of downward rotation of the Cupid’s bow.
■ C flap and M flap on the medial lip element (TECH FIG 1C)
■ C flap: A line is drawn along the skin/mucosa junction lateral to point 3.
Care is taken to incorporate as much white lip into the C flap as possible
while avoiding the mucosa (see Pearls below).

■ M flap: The medial/inferior border of the M flap is drawn as a straight line
starting from point 3 and perpendicular to the white roll. A second line is
drawn on the vermilion of the medial lip element as an oblique line starting
at a point 1 mm inferior to the white roll, traveling laterally and inferiorly
to the red line. This is the receiving incision for the Nordhoff triangular
flap.
■ Alar base and L flap on the lateral lip element (TECH FIG 1D)

5 3 4 ? ! 3/ A C

TECH FIG 1 • Markings. A. Key tattoo points. B.
Mohler back cut. C. C flap and M flap. Dashed blue
line represents the receiving incision for a vermilion
triangular flap if used. The dashed red line represents
the intranasal incisions on the septum and vomer
made during nasal floor closure. D. Alar base and L
flap (L) outlined in blue. The dashed blue line is the
triangular flap as described by Nordhoff. Dashed
green line is the intranasal incision at the piriform
aperture, and the dashed red line is the gingivobuccal
sulcus incision, which will be made at the time of the
lateral lip dissection.
■ Alar base: A small incision is marked along the alar crease on the cleft side
with care not to extend this incision around the alar base.
■ L flap: The border of the L flap is then marked by first marking an incision
1.0 mm inferior to the white roll on the lateral lip element. This mark then
transects the white roll perpendicularly and then curves swiftly and softly
to meet the medial edge of the previously made mark on the alar crease.
The remainder of the L flap can then be made with or without the addition
of a vermilion triangular flap, as described by Nordhoff. When marking the
L flap, care is taken to extend the mark just superior to the alveolus. This

will base the L flap off of the lateral nasal wall and not the alveolus, as
originally described by Millard.
■ Points 1 to 6 are tattooed. The lip and nose are infiltrated with 0.5%
lidocaine with 1:200 000 epinephrine.
Incisions
■ All premarked incisions are made through skin and mucosa.
Medial Lip Dissection (TECH FIG 2A,B)
■ M flap is elevated in a submucosal plane (TECH FIG 2A).
■ C flap is elevated in the subcutaneous plane with care to preserve the
underlying orbicularis oris (see TECH FIG 2A).
■ Mohler back cut (TECH FIG 2B).
■ A transverse incision is made across the full-thickness orbicularis oris
muscle where it abnormally inserts at the nasal base. This incision is made
at the base, not the apex, of the Mohler back cut. If this incision is made at
the apex of the back cut, the medial crura will be transected. Care should
also be taken to avoid going through the underlying mucosa during this
incision.
■ Complete full-thickness transection of the muscle should be confirmed by
placing a small single hook into the medial lip element and pulling the lip
down. The lip should rotate downward with no tension.
• If additional downward rotation is still required, the labial frenulum is
horizontally transected. This defect may be filled by the mucosa of the
lateral lip element.
■ Medial lip element preparation: The philtral skin is dissected free from the
muscle in a subcutaneous plane up to but not past the philtral dimple.
Lateral Lip Dissection (TECH FIG 3)
■ L flap elevation:
■ The L flap is carefully elevated from the orbicularis oris in the
subcutaneous and submucosal plane. As one approaches the area of the
piriform aperture, the dissection plane changes from a submucosal to a
subperiosteal plane.
■ A Woodson elevator is then used to create a subperiosteal pocket in the
interior/lateral aspect of the piriform aperture. A horizontal incision is made
at the exact border of the lateral nasal wall with the nasal floor. An incision

is made at the base of the vomer, and a vomer flap is elevated with the
periosteal elevator. The lateral nasal wall flap and vomer flap will be used
to close the anterior nasal floor later in the surgery.
■ Piriform aperture incision:
■ A vertical intranasal incision is made at the border of the nasal mucosa and
squamous skin to meet the superior border of the L-Flap. Sharp dissection
is performed to reach the bone of the piriform aperture.
■ Subperiosteal dissection will complete the elevation of the L flap
posteriorly until it is based off the lateral nasal wall.
TECH FIG 2 • Medial lip dissection. A. M flap (m)
elevated in a submucosal plane and turned down. C
flap elevated in the subcutaneous plane. B. Mohler
back cut. Dashed yellow line represents a transverse
incision made across the full-thickness orbicularis oris
muscle where it abnormally inserts at the nasal base.
Complete full-thickness transection of the muscle
should be checked by placing a small single hook into
the medial lip element and pulling the lip down. The lip
should rotate downward with no tension. The philtral
skin is dissected free from the muscle in a
subcutaneous plane up to but not past the philtral
dimple.

TECH FIG 3 • Lateral lip dissection. L flap (L) elevated
in a submucosal plane and shown retracted medially.
The stippled area represents the L flap that will be
trimmed before inset into the lateral nasal wall. As one
approaches the area of the piriform aperture (dashed
green line), the dissection plane changes from a
submucosal to a subperiosteal plane. A gingivobuccal
sulcus incision (dashed red line) is made in continuity
with the piriform aperture incision, with care to
preserve the L flap. A supraperiosteal dissection is
made across the maxilla to fully mobilize the alar base
and lateral lip element. The alar base skin (a) should

be elevated as a thick split-thickness skin graft so that
a layer of dermis is present on the underlying dermal-
muscular pennant flap.
■ Gingivobuccal sulcus incision:
■ A gingivobuccal sulcus incision is made in continuity with the piriform
aperture incision, with care to preserve the L flap. A supraperiosteal
dissection is made across the maxilla to fully mobilize the alar base and
lateral lip element. In cases where presurgical orthopedics is not used, this
dissection may continue widely across the face in the maxilla.
■ Tension-free translation of the alar base flap to the anterior nasal spine will
demonstrate adequate dissection.
■ Alar base flap:
■ The alar base skin should be elevated in a thick split-thickness skin graft
plane so that a layer of dermis is present on the underlying muscular flap.
The dermal-muscular pennant will be used to relocate the alar base.
■ Lateral lip element preparation:
■ The lateral lip skin is mobilized from the orbicular oris as far lateral as the
alar base incision.
Mucosa closure: If gingivoperiosteoplasty is to be performed,
it should be completed before the mucosa is closed.
■ L flap inset (TECH FIG 4A)
■ The L flap is sutured under tension to the base of the piriform aperture
incision. Excess L flap is trimmed, and the remainder of the L flap is
sutured into the defect created by the piriform aperture incision.
■ Nasal floor closure (TECH FIG 4B)
■ The lateral nasal wall flap/L flap is sutured to the vomer flap using several
absorbable sutures. The sutures are placed first in a simple fashion and then
in a horizontal mattress fashion to create a watertight closure of the nasal
floor. Closing the anterior nasal floor will facilitate successful
gingivoperiosteoplasty and/or alveolar bone graft.
■ Oral mucosa (TECH FIG 4C):
■ The gingivobuccal sulcus incision is closed using several oblique oriented
sutures. This will relieve tension from the midline of the mucosal
reconstruction. The mucosa of the upper lip is then closed with simple

sutures, with care not to incorporate muscle in the mucosal reconstruction.
Nasal Dissection (TECH FIG 5)
■ The rhinoplasty portion of this procedure will elongate the columella and
elevate the depressed lower lateral cartilage.
■ A hemimembranous septum incision is first made on the cleft side.
■ Through the apex of the Mohler backcut, blunt dissection is performed to
create a dissection pocket between the medial crura. This dissection pocket is
then connected with the hemimembranous incision in the septum, and this
dissection is continued superiorly toward the septal angle.
■ Dissection scissors are then inserted through this pocket and over the upper
and lower lateral cartilages on the cleft and noncleft side.
■ Careful blunt dissection will create a subcutaneous pocket over the upper
and lower lateral cartilages in preparation for rhinoplasty. Care is taken not to
close the dissection scissors in the dissection pocket, as it can lead to damage
to the lower lateral cartilages.

R

TECH FIG 4 • Closure. A. Excess L flap (L) is
trimmed, and the remainder of the L flap is sutured
into the defect created by the piriform aperture incision
(A to A’, B to B’, C to C’). B. The L flap is then sutured
to the vomer flap (V) to close the nasal floor. C. The
gingivobuccal sulcus incision is closed using several
oblique oriented sutures (blue arrows); this will relieve
tension from the midline of the mucosal reconstruction
(green arrow). The mucosa of the upper lip is then
closed with simple sutures, with care not to
incorporate the musculature in the mucosal
reconstruction.
■ If no NAM is performed, an additional nostril rim incision is made and a
dissection pocket created to connect the rim incision to the subcutaneous
pocket underneath the nasal tip.
■ A retractor is used to elevate the depressed lower lateral cartilage in a
supercorrected position.