Operative Technique in Plastic Surgery – Kevin C.Chung

lateral cartilage to the upper lateral cartilage to further reinforce the elevated
position of the lower lateral cartilage.
Lip Closure (TECH FIG 6A,B)
■ Repositioning of alar base (TECH FIG 6A)
■ A long-lasting absorbable suture is first placed through the dermomuscular
pennant underneath the alar base. Using this suture as a leash, the location
of the caudal septum is sighted and then placed through this area and the
medial crus on the noncleft side. Tying the suture down will set the alar
base in an anatomic position, medialize the columella, and straighten the
anterior septum.
■ A second such suture is placed to reinforce the first.
■ Muscle (see TECH FIG 6A)
■ The orbicularis oris is then reconstructed from superior to inferior using
several buried sutures. Prior to reconstruction, excess orbicularis oris is
carefully trimmed so that the skin edges are perfectly opposing at the
completion of the muscular reconstruction. The superior suture may be
attached to the anterior and nasal spine to prevent elongation at the upper
lip.

TECH FIG 6 • Closure. A. The dermal-muscular flap at
the alar base is sutured to the area of the anterior
nasal spine and the medial crus on the noncleft side
(dashed light blue arrow). The orbicularis oris is then
reconstructed from superior to inferior. B. The white
roll point is first reconstructed, and the remainder of
the upper lip is meticulously closed using several fine
permanent sutures. The vermilion is also inset at this
time. If a triangular flap is used, this is trimmed and

inset.
■ Upper lip skin (TECH FIG 6B)
■ The white roll point is first reconstructed, and the remainder of the upper
lip is meticulously closed using several fine permanent sutures. The
vermilion is also inset at this time. If a triangular flap is used, this is
trimmed and inset.
■ C-Flap inset (see TECH FIG 6B)
■ In the extended Mohler repair, the C flap is used to fill the defect created
by the downward rotation of the Cupid’s bow. The C flap is carefully
scored and cut. The C flap is then inset into this defect, and the columellar
incision is also closed with several simple sutures. The alar base incision is
also closed at this time. Excess C flap and alar skin are also trimmed, and
the nostril floor is closed.
■ Nostril floor (see TECH FIG 6B)
■ Care is taken to close the nostril floor and the philtral incision in a stair-
step fashion to avoid a confluence of four corners at the nostril floor
incision.
Nasal Refinement
■ Nostril apex elevation (TECH FIG 7)
■ If NAM was used, the nostril apex overhang is addressed using a long-
lasting absorbable suture that is placed just behind the nostril rim, through
the depressed lower lateral cartilage on the cleft side, underneath the skin
of the nasal tip, and out the nostril on the opposite side. The trajectory of
this suture is oblique, directed laterally and posteriorly. The suture is then
returned 2 mm behind the exit suture hole in the noncleft side, parallel to
the first suture, and returning to the cleft side nostril. Tying down this
suture corrects nostril apex overhang and adds to tip definition.

TECH FIG 7 • Nostril apex elevation (red) and
vestibular web obliterating sutures (blue).
■ In patients who did not undergo NAM, the depressed lower lateral cartilage
is elevated by the previously placed suture from the lower lateral to upper
lateral cartilage. A small rim of overhanging skin at the nostril apex is
carefully trimmed and the rim incision is closed.
■ Regardless of technique, there should be an overcorrection of the depressed
lower lateral cartilage such that the cleft side is higher than the noncleft
side.
■ Vestibular web obliterating suture (TECH FIG 7)
■ The vestibular web can be addressed by placing a long-lasting absorbable
suture behind the web out of the nasal facial groove; the suture can then be
returned through the same cutaneous hole and back into the nostril anterior
to the vestibular web. Tying this suture down will obliterate the vestibular
web and accentuate the nasal facial groove. Multiple sutures may be
required to achieve the full effect.
PEARLS AND PITFALLS

Anatomy
■ It is critical that the surgeon has a thorough understanding and
ability to identify the pathologic soft and hard tissue
deformities and individualize the surgery as needed.
The apex of the
extended
Mohler back cut
■ It should be high enough onto the columella to allow for full
downward rotation of the Cupid’s bow. If point 5 is too low, it
will result in inadequate downward rotation.
■ If point 5 is too close to the cleft side, the C flap will be too
narrow and inadequately fill the defect created by the
downward rotation of the Cupid’s bow.
■ Placing point 5 too far toward, the noncleft side will result in a
narrow philtral column at the superior aspect of the upper lip.
C flap
■ In wide clefts where presurgical orthopedics (NAM) was not
used, it is important to incorporate as much white lip into the C
flap as possible because the C flap may be used in its entirety to
fill the defect created by the downward rotation of the Cupid’s
bow.
■ Care must be taken to avoid incorporating mucosa, which will
result in the transposition of mucosal tissue onto the nose and
upper lip.
Tension-free
closure
essential for
optimal wound
healing
■ Medial lip element: Adequate release of the orbicularis oris
muscle where it abnormally inserts at the nasal base to allow
for full rotation downward
■ Lateral lip element: Supraperiosteal dissection is made across
the maxilla to fully mobilize the alar base and lateral lip
element.
■ Adequate release of abnormal attachment of cleft-side lower
lateral cartilage from piriform rim
Multidisciplinary
care
■ Essential for optimal outcomes
POSTOPERATIVE CARE
■ Children are placed in elbow restraints for 5 to 7 days.
■ A syringe feeder or cleft feeding nipple (ie, Haberman nipple) is used for
feeding.
■ Sutures are removed after 5 days and the lip taped in compression for 5 weeks.
OUTCOMES
■ In experienced hands, primary cleft lip and nasal repair can achieve lasting
symmetry to the lip and nose while camouflaging scars within the subunit

borders of the face.
COMPLICATIONS
■ Relapse of the nasal deformity
■ Scar contracture/widening
■ Inadequate multidisciplinary care and follow-up during growth
■ Maxillary growth inhibition
SUGGESTED READINGS
1. Cutting CB, Dayan JH. Lip height and lip width after extended Mohler
unilateral cleft lip repair. Plast Reconstr Surg. 2003;111(1):17-23.
2. Grayson BH, Garfinkle JS. Early cleft management: the case for nasoalveolar
molding. Am J Orthod Dentofacial Orthop. 2014;145(2):134-142.
3. McComb H. Primary correction of unilateral cleft lip nasal deformity: a 10-
year review. Plast Reconstr Surg. 1985;75(6):791-799.
4. Millard DR, Jr. Discussion: unilateral cleft lip repair. Plast Reconstr Surg.
1987;80(4):517.
5. Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg. 1987;80(4):
511-516.
6. Mulliken JB, LaBrie RA. Fourth-dimensional changes in nasolabial
dimensions following rotation-advancement repair of unilateral cleft lip. Plast
Reconstr Surg. 2012;129(2):491-498.
7. Noordhoff MS. Reconstruction of vermilion in unilateral and bilateral cleft
lips. Plast Reconstr Surg. 1984;73(1):52-61.
8. Salyer KE. Primary correction of the unilateral cleft lip nose: a 15-year
experience. Plast Reconstr Surg. 1986;77(4):558–568.
9. Yuzuriha S, Mulliken JB. Minor-form, microform, and mini-microform cleft
lip: anatomical features, operative techniques, and revisions. Plast Reconstr
Surg. 2008;122(5):1485-1493.

3
CHAPTER
Salyer Unilateral Cleft
Lip/Nose Repair
Kenneth E. Salyer
DEFINITION
■ Cleft lip/nose deformity occurs during embryonic development when there is
lack of normal migration and proliferation of neural crest cells leading to
failure of the facial prominences to fuse.
ANATOMY
Normal Upper Lip Anatomy
■ The foundation of the face is the facial skeleton. The upper lip is supported by
the underlying maxillary and mandibular framework, with its teeth and alveolar
bone. Alveolar bone develops and matures with primary and secondary tooth
eruption.
■ The orbicularis oris muscle consists of two well-defined and functional
components: the pars superficialis and the deep pars marginalis.
■ The pars superficialis is located under the skin of the lip and is related to
other facial muscles of expression (levator labii superioris, alaeque nasi, and
zygomaticus minor), and these retract the upper lip as a group. The pars
superficialis consists of an upper and lower bundle.
• The upper bundle represents the common insertion of the muscles of facial
expression and itself inserts onto the anterior nasal spine, septopremaxillary
ligament, and the nostril sill, passing deep to the alar base.
• The lower bundle derives its fibers from the depressor anguli oris muscle on
each side and decussates in the midline, inserting in the skin and forming
the philtral ridges of the contralateral side.
■ The deep portion of the pars marginalis muscle is responsible for sphincteric

action of the mouth and runs under the vermilion from one modiolus to the
other.
■ The two portions of the orbicularis oris muscle thus correspond to the double
function of the upper lip. The deep pars marginalis, extending from one
modiolus to the other, seals the extrinsic facial muscles to open the mouth as a
retractor.
■ Contraction of the deep pars marginalis, when the mouth is pursed, thickens
the vermilion and lengthens the upper lip height. Simultaneous relaxation of
the pars superficialis produces perioral fine wrinkles and accentuates the
philtral columns while flattening the nasolabial folds.
■ In contrast, when the mouth is opened, the contraction of the pars superficialis
leads to flattening of the perioral wrinkles and philtral columns and accentuates
the nasolabial fold. In addition, the upper lip height shortens. Simultaneous
relaxation of the deep pars marginalis decreases the thickness of the vermilion.
Abnormal Cleft Lip/Nose Anatomy (FIG 1)
■ Varying degrees of cleft dysmorphogenesis of the lip, alveolus, and palate
result in skin, soft tissue, muscle, and skeletal deficiencies with functional and
aesthetic imbalance.

FIG 1 • Three-month-old with left unilateral complete
cleft lip/nose and palate.
■ This affects nasal symmetry in both complete and incomplete unilateral cleft
lip/nose deformity by distorting the position of the ala base and shape of the
nostril.
■ With an interruption of the orbicularis oris muscle in the unilateral cleft
lip/nose, the other attached facial muscles pull the ala base more laterally
compared to the noncleft side. The existing muscle imbalance also changes the
position of the alar cartilage, as well as the orientation of the nostril from an
oblique to a horizontal orientation.
■ When the muscle inserted on the base of the septum and columella is
contracted on the noncleft side, the septum and columella is pulled toward that
side. Thus, the severity of the cleft nasal deformity depends on the degree of
separation of the orbicularis.
■ Hypoplasia of the lesser segment, or base, of the cleft nose results in the
displacement of the lower lateral cartilage laterally and inferiorly on the cleft
side. The nasal dome is flattened and slumped in a downward position.

■ The alar cartilage on the cleft side is flat, giving it the false appearance of
having greater length when compared to the contralateral alar cartilage, which
also is abnormally displaced to the noncleft side.
■ The relationship of the lower lateral cartilage to the septum is normal;
however, the septum itself is deformed, thereby tilting the base of the nose
toward the noncleft side and the tip of the nose toward the cleft side.
■ The following summarizes a list of characteristics typical of a unilateral cleft
lip/nose deformity. The degree and severity of the deformities vary, and not all
of them are present in each patient.
■ The columella is shorter on the cleft side with its footplate displaced and
tethered inferiorly.
■ The base of columella is deviated to the noncleft side.
■ The medial crus of the alar cartilage is shorter on the cleft side.
■ The lateral crus of the alar cartilage on the cleft side is longer and, together
with the adherent skin, is drawn to an S-shaped fold.
■ The alar cartilage on the cleft side is displaced in the backward and
downward planes.
■ The nasal tip is displaced and asymmetric, with loss of the defining point on
the cleft side.
■ The dome on the cleft side is obtuse.
■ The flattened ala results in horizontal orientation of the nostril on the cleft
side, and it is usually larger than the opposite side.
■ The entire nostril is retropositioned.
■ The base of the ala is displaced posterior and inferiorly where it is tethered to
the displaced underlying bone on the cleft side.
■ The nasal floor is lower or absent on the cleft side.
■ The caudal septum and anterior nasal spine are deflected to the noncleft
vestibule (FIG 2).
■ Septal deviation of varying degrees leads to posterior nasal obstruction on the
cleft side due to the deviation of the septum and, often, the narrowing of the
internal nasal valve.
■ The lower turbinate on the cleft side is hypertrophic.
■ Nasolabial fistula may be present.
■ The lesser maxillary segment is hypoplastic and displaced on the cleft side.
■ The nasal pyramid is asymmetric.
PATHOGENESIS

■ Three major factors influence the nasal deformity in both complete and
incomplete unilateral clefts:
■ Muscle imbalance
■ Tissue hypoplasia
■ Asymmetry of the skeletal base
NATURAL HISTORY
■ Orofacial clefting is the most common craniofacial birth defect, occurring in
1:500 to 1:750 live births worldwide.
■ The incidence of cleft lip in combination with cleft palate is estimated at
1:1000 with a gender ratio of 2:1 (male to female) with reverse gender ratio for
cleft palate only.
■ In the population of children with cleft lip and/or cleft palate (CL +/− P),
approximately 50% have CLP, 30% to 35% CP, and 15% to 20% CL.
■ Approximately 15% of CLP patients will have a syndrome, whereas 40% of
CP patients are part of a syndrome.
FIG 2 • Anterior nasal spine deviated to the right and
noncleft side.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ The diagnosis of a cleft lip and/or palate is made by prenatal ultrasonography
or by physical examination at birth and in early infancy. A detailed assessment
is made of the child’s breathing, feeding, growth, and development.
■ Airway assessment must exclude the presence of sleep apnea and micro-
/retrognathia.
■ Assessment of growth and weight is key to identify and monitor feeding
difficulty, gastroesophageal reflux, and use of feeding aids (Haberman/Pigeon
teat).
■ Hearing and middle ear function must be assessed and treated early by an
otolaryngologist when associated with cleft palate.
■ The plastic surgeon should define in detail the cleft lip type according to the
anatomic structures involved, ie, complete or incomplete, unilateral with or
without a Simonart band or bilateral, and presence or absence of a cleft palate.
■ The child should also be assessed for associated anomalies suggestive of a
syndrome, including craniofacial dysmorphia, airway compromise, cardiac
defects, ocular and auricular abnormalities, and musculoskeletal anomalies. A
genetics referral is suggested if syndromic cleft palate is suspected.
IMAGING
■ At 16 weeks gestational age or older, 3D, 4D, and HD in utero ultrasound
provide early diagnosis readily available in the developed and, in certain
places, in the developing world. Parents may seek consultation with
experienced surgeons, genetics experts, and other team members for education
and decision-making about treatment.
DIFFERENTIAL DIAGNOSIS
■ One of the main questions to determine in the presence of a cleft lip or cleft lip
and palate is, “Does the patient have an isolated, or syndromic, cleft, which
plays a major role in prognosis of treatment and genetic inheritance?” Van der
Woude syndrome is a prime example, diagnosed with the presence of lip pits
and means 50% subsequent inheritance.
■ If cleft lip and palate are present, then 15% will be syndromic.
Syndromic Cleft Lip and Palate
■ Stickler syndrome
■ Robin sequence

■ 22q11.2 deletion syndrome
■ Treacher Collins syndrome
■ Nager syndrome
■ Ectrodactyly-ectodermal dysplasia
■ Klippel-Feil syndrome
■ Others
NONOPERATIVE MANAGEMENT
■ All cleft lip patients should be treated surgically unless in extreme cases where
anesthetic risk for surgery is high.
SURGICAL MANAGEMENT
■ Cleft lip repair is ideally performed at 3 months of age, with the infant
weighing greater than 5 kg.
■ Risks of the procedure are based on the risk of the anesthetic, which is
minimal.
■ Main objectives of the procedure:
■ Separate the oral and nasal communication
■ Completely release and restore orbicularis oris function
■ Reconstruct the lip and nose to restore normal oral and nasal function
■ Provide an aesthetic result, which is accepted by the society and the patient
■ Main steps of the procedure:
■ Mark the lip.
■ Dissect, release, and mobilize all abnormally displaced structures of the lip
and nose simultaneously: muscles of the lip and base of the nose with other
abnormal soft tissue attachments including alar and septal cartilage of the
nose.
■ A complete tension-free closure must be achieved, or further dissection is
necessary.
■ Focus on creating 3D aesthetic balance and functional harmony of the lip and
nose.
■ Muscle repair:
■ The muscle alignment is more important than the design of skin incision in
achieving an excellent result.
■ Repositioning the muscle is one of the keys to achieving a good and stable
result whether sub- or supraperiosteal, as this provides the foundation and
support of the repair, maintaining alar base and nasal tip projection and

symmetry.
■ To achieve complete mobilization and reconstruction, the complete release of
the abnormal attachments of the muscle, and proper alignment, is key. The
muscle should be vigilantly aligned.
• Any under- or over-rotation of a carefully planned repair is usually due to a
malaligned muscle repair.
■ Nose repair: Correction of the nasal cleft deformity is a necessary and integral
part of the primary surgery.
Preoperative Planning
■ Perioperative orthopedics
■ Preoperative passive appliance: Hotz of Zurich introduced the use of an
appliance placed preoperatively to control the greater and lesser segments,
providing guidance for positioning the segments after lip/nose closure. This is
left in place to prevent arch collapse until palatoplasty is performed.
• Definitive scientific proof that this improves the end result is lacking. Thirty
years of experience in Dallas improves the dental skeletal result, maxillary
deformity, septal deviation, and other related deformities.
■ Preoperative active appliance: Nasoalveolar molding (NAM) with active
preoperative segmental positioning has become internationally popular and
used by many centers and teams. It provides better positioning of the
maxillary segments while expanding and positioning the nasal soft tissues. It
makes the surgery easier, particularly for the inexperienced surgeon.
■ Latham’s earlier techniques using active forces were proven to be detrimental
to maxillary growth and alignment. Adverse effects on growth need further
scientific investigation before the final outcome of all active techniques is
known.
■ In my experience, excellent results can consistently be obtained without
adding nasoalveolar molding in the unilateral cleft lip and palate patient. The
technique can be labor intensive requiring family compliance and frequent
visits to the orthodontist.
■ With NAM, the molding of the nose must be done carefully to prevent
creating a mega nostril through the potential tissue expansion effect, rather
than just the desired reshaping of the nostril.
■ Skin incision.
■ After three decades of cleft surgery, we believe that the skin incision is not
very important in and of itself. The final aesthetic and functional outcome is

determined by the extended dissection that allows the surgeon to free all the
anatomic elements of the lip and nose that were displaced by the cleft in order
to achieve complete repositioning of these elements.
■ The concept of the Salyer lip/nose repair is one of totally freeing all elements
of the lip and nose in a plane above the periosteum, so they are floating free
above the abnormal skeletal base.1
■ The lip and nose elements are then placed in the proper position, visualizing
the 3D reconstruction and attempting to make form and function as normal as
possible. The aesthetic result always remains foremost.
■ Repositioning the muscle is one of the keys to achieving a good and stable
result, as this provides the foundation and support of the repair, maintaining
alar base and nasal tip projection and symmetry. Lining up the muscle is the
single most important maneuver in the repair, and it should be vigilantly
aligned.
■ Various techniques today put emphasis on exact preoperative markings,
which commits the surgeon. The repair should be fluid, allowing for
improvisation and artistry by the surgeon, especially with respect to the nose.
■ For the first 20 years, I believed that an incision around the alar base was
necessary to reshape the ala; however, today, this incision has been entirely
eliminated, and we feel it only adds an unnecessary scar.2
Positioning
■ The infant’s head is stabilized on a small donut-shaped gel headrest placed at
the edge of the head of the table.
■ The surgeon sits at the head of the table operating upside down with the
infant’s head almost in the surgeon’s sterile lap slightly hyperextended to
provide complete visualization of the infant’s face.
■ The patient is orally intubated by the anesthesiologist with a prebent tube fixed
in the midline providing no distortion to the face or lip with minimal protrusion
so as not to interfere with the procedure but provide safe control of the airway.
Approach
■ Delaire described a subperiosteal approach with a wide dissection and
incisional release of the periosteum with anatomic muscle closure.
■ Supraperiosteal dissection is preferred by most plastic surgeons. We believe
that the dissection above the periosteum is less detrimental to growth. Whether
this philosophy is totally valid needs to be established.

■ Preperiosteal dissection offers the advantage of allowing the tissue to move
more easily, which is especially important in wider clefts. The analogy can be
drawn to a scalp flap, which mobilizes with greater freedom when raised in a
preperiosteal (ie, subgaleal) plane vs a subperiosteal plane.
T E C H N I Q U E S
■ Salyer Unilateral Lip/Nose Repair
■ Key identifiable points are marked on the lip and nose (TECH FIG 1A).
■ The base of each ala is identified and marked using methylene blue or
appropriate marking pen. The alar base on the cleft side is usually elongated
and distorted compared to the normal side.
■ The peak of the Cupid’s bow is identified and marked on the normal side.
The height of the lip, from the alar base to the peak of the Cupid’s bow at rest
and without tension on the noncleft side, is measured using a caliper or is just
estimated.
■ The height to be achieved on the cleft side is usually 6 to 11 mm and
averages 7 mm in the 3-month-old.
■ The midline nadir, or lowest point, of the Cupid’s bow is identified and
marked. An equal distance, from the height of Cupid’s bow on the noncleft
side to the midline of Cupid’s bow, is used to identify the peak of the new
Cupid’s bow on the cleft side and is marked on the vermilion-cutaneous
junction.
■ The exact point may have to be altered a millimeter in order to have a lip
that is long enough. The lip height needs to be equal to the normal side when
completely dissected and placed on tension with a skin hook.
■ The wet line is marked with dots along its course on the vermilion on both
sides of the cleft. Identification of this line provides symmetry and improved
color match of the vermilion.
■ The peak of the Cupid’s bow and height of the lip on the lateral lip segment
are determined by the height of the lip on the normal side, based on the initial
measurement. The distance along the vermilion and down the lateral lip
segment may be altered according to the height of the lip desired.
■ It may be necessary to go along the vermilion-cutaneous border, down the

lateral lip segment, a few millimeters more in order to create a lip, which is
equal to the normal side. This may result in a shorter distance from the new
peak of the Cupid’s bow on the medial cleft side to the commissure of the
lateral lip segment, as compared to the peak of the Cupid’s bow to the
commissure on the normal side.
■ The proposed operation is marked with methylene blue, shown in the
illustration as dots forming broken lines (TECH FIG 1B). The incision is
marked from the peak of the Cupid’s bow on the cleft side on the medial lip
element and extends up and below the columella, across the base of the
columella, toward the opposite normal philtrum edge, but stops just short of
this landmark.

(Trang không có chữ)

TECH FIG 1 • A. Key landmarks identified on the
unilateral cleft lip/nose. B. Cleft lip incisions marked
with dotted lines. An alternative technique does not
extend the incision into the nose above the inferior
turbinate. C. Initial performance of the medial and
lateral lip element incisions for Salyer lip/nose
procedure. D. Skin of lateral lip element is undermined
over the orbicularis oris muscle for a maximum of 4 to
5 mm, thereby holding and freeing the orbicularis oris
muscle. E. Preperiosteal dissection of the lateral lip
element up to the infraorbital nerve using a Colorado
needle. F. Alar base approach for dissection and
release of the lateral crus of the alar cartilage and
muscles of the lip from their abnormal attachment to
the alar base along with freeing the nasal skin
envelope to shift the cartilage, reshaping and
projecting the nasal tip. G. Intraoperative view
showing the dissection demonstrating the technique.
H. Medial incision approach for the subcutaneous
dissection of the nasal tip skin and releasing the
abnormal attachment of the medial crus of the alar
cartilage so the entire alar lcartilage can be shifted
without exposure to create nasal tip projection. I.
Intraoperative view demonstrating the dissection and
technique of the medial approach. J. Intraoperative
view of a Keith needle with Prolene with Dacron

pledget to shape and reposition the alar cartilage and
secure it while it heals. Sutures can alternately be
used. K. Alar base cinch and alar cartilage tip sutures.
L. Suturing of the muscle and trimming excess
vermillion. M. Immediate postoperative view showing
use of Dacron pledges (other materials may be used)
for nasal reshaping with lip sutures.
■ The surgeon should pull the lip down with a single skin hook and hold the
lip in its new position while marking. If the incision is carried past the
philtral ridge on the normal side, there is a risk that over-rotation of the lip
may occur and a long lip may be created.
■ The lateral lip element is marked along the cleft margin down to the newly
marked peak of the new Cupid’s bow (TECH FIG 1C). The design of the lip
repair is the Salyer modification of the rotation-advancement procedure and
is noted by the dotted lines. The classic incision around the alar base is not
necessary and only adds scar to the final result.
■ The incision on the lateral lip element continues from the vermilion-
cutaneous border, and enters the nasal cavity, onto the lateral nasal wall
above the inferior turbinate at the level of the piriform aperture extending to
the nasal bones as necessary.
■ Through this incision, the displaced and abnormally attached soft tissues of
the alar base are freed from the underlying abnormal skeletal base. The
incision made on the medial lip element attempts to simulate the normal
philtrum, creating a normal symmetric shield-shaped Cupid’s bow. The
incision can be made with a no. 15 or no. 11 standard type blade, or a no. 65
or no. 67 beaver blade, which is our preference.
■ The medial incision is cut through and through, including the skin and
muscle; while along the vestibule of the lip, the mucosa is released and
partially separated from the muscle. The medial lip element is dissected and
mobilized so that it can be gently pulled down, with a skin hook, to rest at the
same height as the normal side, leveling the Cupid’s bow.
■ The excess vermilion, containing a small amount of muscle, is left attached
to the medial lip element. The lateral lip element is likewise incised, leaving
an excess vermilion-muscle flap attached to it.
■ These two vermilion-muscle flaps are tailored as the lip is closed and used to

produce a full pouting vermilion of the lip. This helps eliminate vermilion
notching of the lip at the suture line.
■ The incision of the lateral lip element is carried along the free border of the
lip.
■ The muscle of the lateral lip element, overlying the lesser segment, is
completely freed and released above the periosteum, so the muscle can be
mobilized and sutured, creating a normal anatomic muscle with nice pout to
the lip (TECH FIG 1D). In the incomplete cleft lip, there is usually more
muscle available than in the complete cleft lip.
■ The orbicularis oris muscle is pulled with pickups, and the dermis is
undermined 4 to 5 mm, releasing it from the underlying muscle on the lateral
lip element. The operation is estimated by an experienced surgeon.
■ Laterally, the point corresponding to the new peak of the Cupid’s bow is
marked on the border of the vermilion-cutaneous junction, along the cleft
margin, at a distance equal to the future height of the lip.
■ This measurement should begin superiorly on the lip, however, not in the
nose, so that the skin designated for the floor of the nose is not compromised.
This is an important step in achieving an adequately reconstructed nose.
■ The incision on the medial lip element begins at the newly marked peak of
the Cupid’s bow and continues up to, but not through, the philtral column on
the noncleft side.
■ If the incision is continued past the philtral column on the normal side, it has
the potential to create an overly rotated philtrum and abnormally lengthen the
cleft side, creating disproportion to the lip as well as an obviously abnormally
placed scar that no longer mimics the philtral column.
■ The vermilion and muscle on each side of the lip are cut and maintained
until closure of the vermilion. Excess vermilion is tailored to create fullness
of the vermilion, preventing notching.
■ The incision on the medial lip element is made with a no. 15 standard blade
but may be performed with a no. 67 beaver blade or a no. 11 standard blade,
as shown on the lateral lip element in the image.
■ This incision should be made perpendicular to the skin and include the
muscle, creating the C-flap, or columellar flap. This flap is used as dictated
by each case when all the elements are totally freed.
■ The incision on the lateral lip segment is carried through and through along
the vermilion-cutaneous border, dissecting a vermilion flap for orbicularis

marginalis reconstruction. How the surgeon holds and cuts the lip determines
the amount of muscle left in the vermilion.
■ This lateral lip incision extends inferiorly, at least to where an adequate
white roll begins, but may be continued down the lateral lip element as lip
length is needed.
■ The freshly cut orbicularis marginalis muscle is pulled with pickups, and the
skin of the lateral lip segment is undermined from the underlying muscle for
a distance of 4 to 5 mm from the edge of the incision.
■ The medial lip segment is rotated downward and pulled with a skin hook
until its height matches that of the noncleft side.
■ The medial lip is freed from the underlying skeleton in a preperiosteal plane,
using scissors. Additional dissection may be necessary to achieve adequate
rotation of the philtrum and lengthening of the lip.
■ Again, an opening incision above the white roll is used if additional rotation
is required, and then a triangle is incorporated into the lateral lip markings.
This is why the medial skin incision is always cut first.
■ A Colorado needle (Stryker-Leibinger) is used to create the incision through
the nasal lining just above the inferior turbinate (TECH FIG 1E). This
provides a bloodless field for the dissection.
■ Through this intranasal incision, as well as a vestibular buccal sulcus
incision beneath the lateral lip element, the Colorado needle is used to dissect
above the periosteum to the level of the infraorbital nerve.
■ This maneuver provides for a bloodless dissection and the appropriate
release of the abnormally displaced orbicularis oris muscle to provide
symmetric closure. Complete preperiosteal release of the muscles facilitates
complete reconstruction of the muscle of the lip.
■ The beginning surgeon should be aware that the vertical height of an infant
maxilla is short, and a guiding finger at skin level will ensure that inadvertent
entry into the orbit is avoided as well as transection of the infraorbital nerve.
■ Small curved tenotomy scissors with a round tip are inserted through the
incision of the cleft-side alar base to dissect the skin from the lateral crus of
the lower lateral cartilage (TECH FIG 1F).
■ The nasal lining, if distorted, is dissected as well from the lower lateral
cartilage as necessary. The nasal lining is left attached and never dissected at
the region of the genu.
■ The scissors are carried over the alar dome and into the subcutaneous pocket

to be created from the medial nasal approach over the tip of the nose (TECH
FIG 1G). The intraoperative view shows the placement of the surgeon’s
finger as the tenotomy scissors dissect above the alar cartilage freeing the
entire skin of the nasal tip on the cleft side.
■ Attention is now turned to the nasal tip from the medial approach. Tenotomy
scissors are placed through the medial lip incision and used to
subcutaneously dissect the nasal dome (TECH FIG 1H).
■ The scissors are inserted subcutaneously and between the medial crura,
separating the skin of the nasal tip from the alar cartilage, and carried over to
the nasal dome.
■ The skin over the noncleft side alar cartilage is likewise freed in order to
shift the nose and gain equal projection of the ala cartilages at the tip (TECH
FIG 1I). The intraoperative photographic view shows this maneuver.
■ Once all the elements of the lip and nose are totally freed, a Keith needle
with Prolene suture and a Dacron pledget is used to shift the alar cartilage
within the skin envelope without exposure of the cartilage to project and
create a new symmetric nasal tip (TECH FIG 1J).
■ The alar cartilage is shifted into its new position held by a surgical assistant
as the surgeon places a key suture shifting the lateral orbicularis muscle.
■ This may have to be repeated until the desired symmetry is achieved. It is a
very important step.
■ Simultaneously, a 4-0 Monocryl suture (Ethicon Inc., Somerville, NJ) is
placed from below into each alar base to achieve symmetry shown by the
dotted line (TECH FIG 1K).
■ At the completion of the muscle repair with 3-0 and 4-0 chromic sutures, the
orbicularis oris and pars marginalis have been positioned to provide
symmetry of the lip as well as maintain projection of the nasal tip (TECH
FIG 1L).
■ The vermilion excess is trimmed until the proper volume to obtain a full lip
remains, preventing notching of the free margin of the lip.
■ An additional suture of nylon over Dacron pledgets is placed through the
lateral ala, correcting intranasal webbing and providing additional contouring
and projection of the nasal tip. Initiation of skin closure is begun with the
nasal sill.
■ The subdermis is closed with interrupted 6-0 PDS (Ethicon, Inc., Somerville,
New Jersey).

■ Mucosal closure is performed with a 4-0 chromic suture, and 6-0 nylon is
used for the skin closure. Intraoperative view at completion of the Salyer
lip/nose repair (TECH FIG 1M).
■ To diminish scarring, we utilize lip taping over the scar for 3 months
postoperatively, and we educate parents on how to massage the upper lip in
hopes of preventing hypertrophic scarring and diminishing postoperative
redness.
■ Preoperative frontal view of a left unilateral complete cleft lip/nose and
palate patient (TECH FIG 2A). Postoperative frontal view 1 year
postoperative following Salyer lip/nose repair (TECH FIG 2B).
■ Preoperative submental vertex view of the same patient (TECH FIG 2C).
Postoperative submental vertex view 1 year postoperative of the patient
(TECH FIG 2D).
TECH FIG 2 • A. Preoperative frontal view of a 3-
month-old patient. B. Postoperative view of the same
patient 1 year following Salyer lip/nose repair. C.
Preoperative submental vertex view. D. Postoperative
1-year submental vertex view.

■ Triangular Skin Flap for Lengthening the Lip
■ At the time of closure, when the peak of Cupid’s bow on the cleft side is too
high (or short), an additional technique that provides lengthening of the lip
can be performed.
■ This can be executed at the time of lip closure when the peak of the Cupid’s
bow on the cleft side is not balanced and is short by 1 or 2 mm. The dotted
lines demonstrate the design of the incisions (TECH FIG 3A). By placing an
incision 2 to 3 mm in length in the lateral lip element at a 45-degree angle 3
to 4 mm above the vermillion, a flap is created that can be advanced into an
incision in the medial lip. This opens to receive the flap, which becomes
triangular in shape when sutured in place. This provides 1 to 2 mm lowering
of the peak of the Cupid’s bow on the cleft side. This is only needed in about
30% of the time in my experience. Fisher’s repair designs a triangular flap as
part of the lip repair.
■ The medial lip incision opens to receive the insertion of the lateral lip
triangular flap, and this lengthens the lip on the cleft side (TECH FIG 3B).
The triangular flap should be designed 3 to 4 mm above the white roll, and
should not be confused with the white roll flap, which I have found to be
inadequate compared to the technique described.

TECH FIG 3 • A. The design of the triangular flap is
shown by dotted straight lines as marked when
determined at the time of closure that the peak of the
Cupid’s bow on the cleft side is too high (30%). B. The
incisions create a lateral triangular flap that is
advanced into the medial lip incision lengthening the
peak of the Cupid’s bow on the cleft side to match the
height of the normal side.
■ We use this technique on innumerable occasions finding it to be quite
helpful. Variations of this, first described by Bardach and now Fisher, are
planned at the time of the initial marking and utilize a larger triangular flap.

This is needed in my estimation in 35% of cases and is unnecessary the rest
of the time.
■ The triangular flap is almost always used by Fisher and Chong and
incorporated into the original planning. This provides a nicer lip with better
anatomic proportions in their experience. (See Chapter 1: Anatomical
Subunit Repair of Unilateral Cleft Lip.)
Noordhoff’s Vermilion Flap Technique
■ Another useful technique for matching the wet and dry vermilion at the time
of lip closure is Noordhoff’s vermilion flap.3
■ This is designed along the line where the color change in the vermilion
occurs between the wet and dry vermilion. Frequently, the vermilion on the
medial lip element cannot be adequately matched to maintain the width of
both the wet and dry vermilion at the level of the peak of the Cupid’s bow,
because the height of the dry vermilion on the medial lip element is
inadequate.
■ To correct this mismatch, a triangular flap of dry vermilion is designed from
the lateral lip element and sutured into an opening created in the medial
vermilion along the wet line (TECH FIG 4A, upper).
■ This eliminates the vermilion color mismatch that occurs in the vermilion
border that acts as an obvious visual indicator of an abnormal lip (TECH FIG
4B, lower).

TECH FIG 4 • A. An incision along the red line in the
medial lip vermillion receives a triangular flap created
from the lateral lip wet vermillion when the excess
vermillion is trimmed. This provides a uniform red line
and vermillion. B. Suture closure of the lip using
vermillion flap of Noordhoff to increase the height of
the vermillion matching the red line.
■ Abyholm Closure of the Anterior Palate

■ Abyholm in Oslo used an anterior vomer flap closure at the time of primary
lip closure. The results regarding growth produced the best results in the
Eurocleft studies conducted by Semb and Shaw.4,5
■ This provides a simple and much less invasive approach that I highly
recommend every surgeon to consider using. I use this in mission surgery
where this is a good and simple technique to add to the Salyer lip/nose or
whatever your preference for the lip closure.
■ The technique is shown in combination with the lip closure in TECH FIGS
5 TO 7.
TECH FIG 5 • Dotted line shows lip closure with
anterior vomer flap in combination with closure of floor
of nose, alveolus, and anterior palate. Performing this
while the lip is open facilitates closure of the anterior
palate in one simple procedure, which is minimally
detrimental to growth.

TECH FIG 6 • Incisions are made in the lip showing
elevation of the vomer flap in the subperiosteal plane
and opening of the palatal subperiosteal mucosa flap
to receive it.

TECH FIG 7 • The lip is closed with sutures and the
palate closed showing single layer closure of the
anterior palate by fixing the mucosal or raw surface of
the vomer flap below the elevated oral mucoperiosteal
edge of the lesser segment creating a pocket to insert
the vomer flap.
PEARLS AND PITFALLS
Age at
operation
■ Development of structures occurs by 3 mo or older, which is the best
time to perform the operation.
Overview
■ Surgeon must view the deformity as a lip/nose complex and repair
both at the time of the primary repair. Technical skill and 3D

visualization are important.
Dissection
■ All displaced and abnormally tethered structures must be completely
released including the skin, cartilage, muscle, and mucosa.
3D puzzle
■ Float all structures freely in space 3D so they can be reconstructed.
The biggest mistake seen repeatedly is inadequate release of the
abnormal attachments of the alar base and alar cartilage medially and
laterally resulting in relapse, which is really inadequate release of all
the structures.
Nasal
lining
■ Inadequate closure of the floor of the nose. Develop septal mucosa
flap and lateral mucosa closing floor of nose as far back as possible.
Cleft nose
■ If technically capable, perform submucosal dissection of the septal
cartilage, to straighten the caudal septum.
■ Create adequate skin pocket and totally free the alar cartilage so it can
be translocated, shaped, and fixed.
Closure
■ Completely tension-free. The muscle is the key to the lip and nose and
must be dissected, mobilized, and sutured into position setting up the
lip and nose three-dimensionally.
Muscle
alignment
■ Any under- or over-rotation of a carefully planned repair is usually
due to a misaligned muscle repair.
POSTOPERATIVE CARE
■ Routine suture line care is important. Keep the suture line clean from blood
and other fluids.
■ A liquid diet is recommended without the use of a nipple. Keep patient’s hands
and all objects away from the repair.
OUTCOMES
■ Unless a simple lip repair, all cases require multiple procedures to achieve
excellence, as illustrated by the patient in FIGS 3 to 10.6
■ The patient underwent left unilateral cleft lip repair and primary cleft nasal
repair at age 3 months, followed by palatoplasty at age 9 months. Very minor
secondary lip/nose revision was required before 5 years of age. Orthodontic
treatment with palate expansion was performed following eruption of the
permanent first molars. This was followed by alveolar bone graft with
cancellous bone at the time of eruption of the lateral canine tooth into the
cleft.

FIG 3 • A. Preoperative frontal view of a 3-month-old girl
with a left unilateral complete cleft lip and palate. B.
Postoperative view after primary stage 1 Salyer lip/nose
repair demonstrates a slightly larger nostril on the cleft
side performed so as not to constrict the nostril,
anticipating a minor secondary procedure when the
patient is older. The primary lip/nose repair at age 3
months corrected the major deformity at the time of the
primary operation.
■ In addition to good surgical technique, a coordinated team approach is critical
to achieving excellence.7
COMPLICATIONS
■ There should be no dehiscence of any closure. Tension-free closure is
important.

FIG 4 • A. Orthodontic treatment during mixed dentation
stage. B. Demonstrates occlusion with mixed dentation
before bone grafting.

FIG 5 • A. Frontal view after secondary cleft lip/nose
repair. Stage 2. Cleft lip/nose. Stage 3. Palatoplasty.
Stage 4. Cancellous bone graft. B. Smiling view after
completion of treatment.
FIG 6 • A. Right lateral view. B. Left lateral view.

FIG 7 • Popular photographic view (nonclinical).

FIG 8 • A. Panoview before bone graph mixed dentition.
B. Cephalometric view, age 6. C. Panoview after bone
graft and completion of treatment. D. Cephalometric
view, age 12, after completion of treatment.
FIG 9 • Frontal view of occlusion of teeth showing also
small anterior lower gingival graft below central incisors.

FIG 10 • A. Right lateral occlusion. B. Left lateral
occlusion.
REFERENCES
1. Salyer KE. Primary correction of unilateral cleft lip-nose: a 15-year
experience. Plast Reconstr Surg. 1986;77:558-568.
2. Salyer KE. Excellence in cleft lip and palate treatment. J Craniofac Surg.
2001;12(1):2-5.
3. Noordhoff M.S. Reconstruction of vermillion in unilateral and bilateral cleft
lip. Plast Reconstr Surg. 1984;73:52-61.
4. William SC, Erik D, Asher-McDade C, et al. A six-center international study
of treatment outcome in patients with clefts of the lip and palate. Part 5.
General discussion and conclusions. Cleft Palate Craniofac J. 1992;29(5).
5. Nollet PJPM, Katsaros C, van’t Hof MA, et al. Treatment outcome after two-
stage palatal closure in unilateral cleft lip and palate: a comparison with
Eurocleft. Cleft Palate Craniofac J. 2005;42(5):512-516.
6. Salyer KE. A passion for excellence. J Craniofac Surg. 2009;20(Suppl
2):1632-1634.
7. Salyer KE, Genecov E, Genecov DG. Unilateral cleft lip-nose repair long-
term outcome. Clin Plast Surg. 2004;31(2):191-208.

4
CHAPTER
Section II: Cleft Palate
Repair
Lip Adhesion
Catharine B. Garland, Jesse A. Goldstein, and Joseph E.
Losee
DEFINITION
■ For infants with complete unilateral or bilateral cleft lip, lip adhesion is an
alternative to presurgical infant orthopedics (PSIO).
■ Any child with a wide complete cleft lip may be a good candidate for some
form of presurgical intervention to reduce tension and optimize symmetry prior
to repair.
■ Presurgical interventions include the following:
■ Lip adhesion surgery, which converts a complete cleft lip into an incomplete
cleft lip
■ Presurgical orthopedics such as nasoalveolar molding (passive)1 or use of a
Latham device (active)2
■ Lip adhesion decreases the tension on the final repair, improves symmetry of
the nasal alar bases, and restores compressive forces on the alveolar segments
to assist with alignment.3 In the wide unilateral or bilateral cleft lip, this may
ultimately improve the final surgical outcome.4
ANATOMY
■ A complete cleft lip distorts both the lip and nose anatomy.
■ In the unilateral complete cleft lip (FIG 1):
■ The orbicularis oris muscle is not in continuity. In the lateral lip element, the
orbicularis oris muscle inserts vertically into the alar base and piriform.
■ The alar base on the cleft side is typically positioned laterally, inferiorly, and

posteriorly on the collapsed minor alveolar arch.
■ The caudal septum and columella are deviated to the noncleft side. The
medial component of the orbicularis oris muscle inserts on these structures.
FIG 1 • Unilateral complete cleft lip and nose. Note
inferior, lateral, and posterior positioning of cleft side
alar base and deviation of columella. (Reprinted from
Kirschner RE, Adetayo OA, Losee JE. Lip adhesion. In:
Comprehensive Cleft Care. 2nd ed. Vol 2, Chapter 41.
Boca Raton, FL: CRC Press; 2016:781-791,
with permission.)
■ In the bilateral complete cleft lip (FIG 2):
■ The premaxilla is often displaced anteriorly and may be twisted or locked out
of the transversely collapsed lateral maxillary segments.
■ The lateral maxillary segments are relatively retropositioned and often
collapsed.
■ The orbicularis oris muscle is widely separated, inserting into the alar bases
at the piriform bilaterally.
■ The alar bases are laterally displaced and often asymmetric.
■ The columella is shortened.
■ Normalizing some of this anatomy prior to definitive lip repair may improve
the outcomes of surgery with regards to lip and nose symmetry.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The sequence of surgical intervention for a complete cleft lip depends on

individual patient and family characteristics and the surgeon and cleft center
experience. This determines whether a patient undergoes a single-stage lip
repair, lip adhesion prior to formal lip repair, or PSIO prior to lip repair.
■ On physical examination, the width of the cleft, the presence of nostril sill
tissue (a Simonart band), the relationship of the major and minor alveolar
segments in the unilateral cleft lip, or the size and position of the premaxilla in
the bilateral cleft lip are all evaluated carefully.
■ Patient history must include an assessment of the infant’s feeding and growth
and identification of any medical comorbidities that may alter treatment.
■ Family characteristics that factor into decision-making include financial,
geographic, or other constraints. These may influence the parents’ ability to
frequently travel for PSIO or to be compliant with the daily care required.
FIG 2 • Bilateral complete cleft lip and nose. Note wide
alar bases, short columella, and the anterior
displacement of the premaxilla relative to the lateral
maxillary arches.
■ Determining whether an infant is a good candidate for a lip adhesion includes
weighing the advantages and disadvantages with the family:
■ Lip adhesion will convert the complete cleft lip to an incomplete cleft lip and
reduce the alveolar gap as well as tension on the final repair.5
■ Compared with nonoperative PSIO, which requires frequent office visits, lip
adhesion can reduce the burden of care on the family.6
■ In the bilateral complete cleft lip, labial adhesion may retract the prominent
premaxilla and help to lengthen the columella.7

■ Lip adhesion incurs the additional costs of a second operation6 and risks of
an additional general anesthetic for the infant.
IMAGING
■ None needed
NONOPERATIVE MANAGEMENT
■ PSIO
■ Nasoalveolar molding (NAM)1: NAM is a passive technique that aligns the
maxillary arches, narrows the alveolar gap, and molds the nasal cartilage. It is
typically initiated within the first several weeks after birth. The infant must
wear the device daily, and the orthodontist adjusts it weekly.
■ Latham device2,5: For the protruding premaxilla, the Latham device employs
active lateral movement of the maxillary alveolar segments and retraction of
the premaxilla posteriorly to realign the arch form.7 This is a more rapid
repositioning than nasoalveolar molding but does require a general anesthetic
for placement of the Latham device.
■ Single-stage cleft lip repair: Some authors argue that lip adhesion is an
unnecessary procedure, despite the width of the cleft, and that equivalent
results can be obtained in a single-stage repair.
SURGICAL MANAGEMENT
■ Indications for lip adhesion include patients with wide complete clefts who are
unable to undergo nonsurgical PSIO.
■ Risks of surgery include infection, dehiscence, and scarring.
■ In the bilateral cleft lip and palate patient with a protuberant premaxilla, lip
adhesion may be combined with a premaxillary setback to optimize alignment
of the premaxilla. This is typically reserved for older patients whose tissues
(ie, premaxilla) are unlikely to mold under the compression of the lip adhesion
alone.
Preoperative Planning
■ All infants with a cleft must undergo full physical examination to rule out any
concomitant cardiopulmonary disease or airway abnormalities. If additional
medical problems are identified, genetic evaluation may be warranted.
■ After birth, feeding evaluation is performed by instructing parents in the use of
specialized bottles as needed. Weight gain is monitored weekly to ensure that

nutrition is adequate.
■ A complete blood count can be performed before surgery to evaluate for
anemia of infancy. After birth, hemoglobin typically reaches a nadir between 8
and 12 weeks of life in healthy term infants. In premature infants, the nadir is
more profound and occurs earlier.
Positioning
■ General anesthesia is induced, and the patient is intubated with an oral Rae
tube, which is taped in the midline of the chin to prevent any distortion of the
upper lip.
■ The patient is positioned supine with the head on a small gel donut.
■ Lubrication ointment is placed in the eyes.
■ The face is prepared with Betadine, and sterile drapes are applied.
Approach
■ Loupe magnification is used to optimize precision of the procedure.
■ The markings for a formal cleft lip repair are performed, as they would be at
the time of definitive repair. Key points are tattooed with methylene blue.
■ Importantly, the alar bases and alar-facial grooves are marked, so that the
adhesion will lead to both vertical and horizontal symmetry of these features.
■ The markings for the lip adhesion are then made within the tissues that would
be discarded at the time of the formal repair or within the “L” and “M” flaps.
■ Some surgeons perform primary nasal repair at the time of lip adhesion, while
others defer this until the time of the formal lip repair.
T E C H N I Q U E S
■ Unilateral Cleft Lip Adhesion
Markings
■ The unilateral cleft lip repair is marked and key points are tattooed. The alar
bases and alar-facial grooves are marked (TECH FIG 1A).
■ Incisions for the labial adhesion are marked within the area of the vermillion
that is normally discarded on both the medial and lateral lip element. The
incisions are around 10 to 15 mm in length and symmetric (TECH FIG

1B,C). The inferior half of the incision is performed on the upper lip, and,
the superior half is performed on the nasal floor—truly making this a “lip-
nose adhesion.” On the medial lip element, the midpoint of the incision is
centered at the columellar-lip junction. On the lateral lip element, the alar
base denotes the midpoint of the incision. The position of these incisions is
critical for alignment of the alar base. The alar base must be symmetric with
the contralateral side in both the horizontal and vertical plane, or an
asymmetric adhesion and repair will be performed and will make the
subsequent definitive cleft lip and nose repair more challenging.
■ The lateral buccal sulcus incision is marked to mobilize medially of the
lateral lip element and ultimately a tension-free adhesion. This incision is
carried up around the piriform aperture to just above the inferior turbinate
(TECH FIG 1D).
Incision and Dissection
■ Epinephrine is infiltrated into the incisions.
■ Incisions are made using a number 15 blade or ophthalmic knife.
■ The buccal sulcus incision is dissected in a supraperiosteal plane. The alar
base is released from the piriform rim and the lateral lip element is widely
mobilized to reduce tension on the adhesion.
■ During this mobilization, some surgeons may continue their lateral
dissection up and over the lower lateral cartilage if they plan to perform
primary nasal repair at the time of adhesion.
■ The adhesion incisions on the medial and lateral lip elements are then made.
The skin and mucosa are dissected to expose the orbicularis oris muscle.
■ In the medial lip element, the dissection is carried toward the anterior nasal
spine. Here the quadrangular cartilage is found displaced away from the cleft
(TECH FIG 2A). The caudal septum may be repositioned now, rather than at
the time of definitive lip repair. The quadrangular cartilage is released from
the anterior vomer at the anterior nasal spine (for about 1 cm). This allows
the caudal septum to be repositioned to the cleft side of the anterior nasal
spine (TECH FIG 2B).
Suturing
■ The septum is brought back to the midline, and it is sutured into place using
a 4-0 Monocryl suture.

■ A 2-0 Prolene horizontal mattress retention suture (single armed on a large
needle) is placed in the orbicularis oris muscle. This stitch begins at the
inferior end of the lateral lip incision (TECH FIG 3A). It is passed in a
subcutaneous plane laterally into the cheek, then deep through muscle, and
exits in the buccal sulcus laterally (TECH FIG 3B). The Prolene suture is
then passed back through the same exit site and is passed in the submucosal
plane out through the superior end of the lateral lip incision (TECH FIG 3C).
Care is taken to ensure that the skin does not dimple with this stitch. The
process is repeated on the medial lip element, from superior to inferior
(TECH FIG 3D,E). The stitches exit on the inferior aspect of the lip
adhesion incisions on both sides (TECH FIG 3F). As much of the orbicularis
oris muscle is captured in the loops of the sutures as possible (TECH FIG
3G). This allows the medial and lateral lip elements to be approximated
through the orbicularis muscle (TECH FIG 3H). The ends of the suture are
clamped and tied later.
TECH FIG 1 • A. Preparation for a unilateral lip
adhesion. An oral Rae endotracheal tube is positioned
in the midline and taped into place. The markings for a

unilateral cleft lip and nose repair are marked and
tattooed, including the alar bases. The lip adhesion
incisions are made within the tissue that would
normally be discarded. Design of the lip adhesion
incisions on the (B) medial and (C) lateral lip
elements. D. An upper buccal sulcus incision is
carried up around the piriform aperture over the
inferior turbinate. (Reprinted from Kirschner RE,
Adetayo OA, Losee JE. Lip adhesion. In:
Comprehensive Cleft Care. 2nd ed. Vol 2, Chapter 41.
Boca Raton, FL: CRC Press; 2016:781-791,
with permission.)
TECH FIG 2 • Repositioning the caudal septum. A.
The anterior nasal spine and caudal septum are
deviated away from the cleft in the native position. B.
After the caudal septum is separated from the anterior
nasal spine, it may be repositioned (forceps are
mobilizing the septal cartilage).
■ As the lateral lip element is advanced, the buccal sulcus incision back cut is
closed with interrupted 4-0 chromic sutures.

TECH FIG 3 • Placement of the internal retention
suture. A. The suture is passed through the inferior
aspect of the adhesion incision. B. After capturing the
muscle, it exits laterally through the oral mucosa. C.
The needle is placed back through the same exit site
to exit through the superior part of the adhesion
incision. D,E. The process is repeated on the medial
lip element. F,G. The orbicularis oris muscle is
captured in the loop of suture on both sides of the
cleft. H. The ends of the suture are pulled together.
The tension placed on a wide swath of orbicularis oris
muscle reapproximates the lip and nose. (Reprinted
from Kirschner RE, Adetayo OA, Losee JE. Lip

adhesion. In: Comprehensive Cleft Care. 2nd ed. Vol
2, Chapter 41. Boca Raton, FL: CRC Press;
2016:781-791, with permission.)
■ The deep/posterior edge of the mucosal incision is then closed using
interrupted 5-0 Vicryl sutures. Half of this suture line makes up the floor of
the nose, and half makes up the superior lip.
■ The Prolene suture is tied down, and care is taken to bury it into the muscle.
■ The edges of the orbicularis oris muscle are approximated with three 4-0
Monocryl sutures.
Completion
■ The anterior edge of the adhesion incision is closed last with interrupted 5-0
fast-absorbing plain gut sutures (TECH FIG 4A)
■ If nasal repair is planned with the lip adhesion, this is performed now. The
senior author, however, uses postadhesion nasal stents to mold the nose
during the healing process and defers the rhinoplasty to the time of definitive
cleft lip-nose repair. At that time, our preferred technique is open primary
rhinoplasty through rim incisions to expose and reposition the lower lateral
cartilage.8,9 A Tajima, inverted-U rim incision is utilized on the cleft side of
the nose.
■ Duoderm is placed on the cheeks bilaterally. While bringing the cheeks
together, a Steri-Strip is placed across the lip to additionally take tension off
the repair.
■ Our practice is to use nasal conformers postoperatively to optimize nasal
symmetry. These conformers are sized in the operating room (TECH FIG
4B) and subsequently taped into place (never sewn) and used daily by the
parents at home in the months between lip adhesion and definitive lip repair
(TECH FIG 4C).

TECH FIG 4 • A. Completion of unilateral cleft lip
adhesion and (B) sizing of nostril conformers. C. The
nostril conformers are taped into place and worn daily
in the postoperative period after both the lip adhesion
surgery and after definitive lip and nose repair, as
shown here. (Reprinted from Kirschner RE, Adetayo
OA, Losee JE. Lip adhesion. In: Comprehensive Cleft
Care. 2nd ed. Vol 2, Chapter 41. Boca Raton, FL:
CRC Press; 2016:781-791, with
permission.)
■ Bilateral Cleft Lip Adhesion
■ The bilateral cleft lip repair is marked and key points are tattooed (TECH
FIG 5A).
■ The incision for the adhesion is marked on both sides of the prolabium at the
junction of the skin and mucosa, approximately 10 to 15 mm in length
(TECH FIG 5B). The incision is centered at the junction of the columella
and prolabium, such that half of the incision is on the prolabial lip element
and half is intranasal.
■ The lateral lip incisions are marked in the part of the vermilion that would
normally be discarded or used as a “C” flap. These are also centered at the
alar base, such that half of the incision is on the lip vermilion and the superior
half is within the nose. The incisions are drawn so that the alar bases will be
positioned symmetrically when the lip-nose adhesion is completed (TECH
FIG 5C).
■ Epinephrine is infiltrated into the incisions and these are made with a
number 15 blade or ophthalmic knife. The orbicularis oris muscle is exposed