Operative Technique in Plastic Surgery – Kevin C.Chung

■ The posterior edge of the mucosa is closed with 5-0 Vicryl suture from the
superior/nasal end of the incision down toward the inferior/labial end on both
sides.
■ The 2-0 Prolene suture is tied down and the knot is buried in the lateral
muscle.
■ Additional 4-0 Monocryl sutures are placed to secure the orbicularis oris
muscle to the prolabium on each side.
■ The anterior skin incisions are then closed using interrupted 5-0 fast-
absorbing plain gut sutures.
■ At the completion of the closure, the markings for the C flap and nasal sill
on both sides should be perfectly lined up such that the alar bases are
symmetric in both the vertical and horizontal planes (TECH FIG 6).
■ Duoderm is placed on each cheek. While bringing the cheeks together, a
long Steri-Strip is placed across the labial adhesion to reduce tension on the
repair.
TECH FIG 6 • Bilateral complete cleft lip after
premaxillary setback and lip adhesion (A)
anteroposterior and (B) worm’s-eye views.
■ Premaxillary Setback
■ In the infant who is older than 6 months, the vomer is likely to be ossified. In
these cases, a protuberant premaxilla will be unlikely to move when
subjected to the forces of lip adhesion alone. In these cases, we will typically
perform a premaxillary setback at the time of lip adhesion.

■ A 10 mm vertical incision is marked along the anterior vomer, just posterior
to the premaxillary segment (TECH FIG 7A).
■ The periosteum is elevated off the vomer bilaterally to the level of the
quadrangular cartilage.
■ A closing wedge osteotomy is designed behind the premaxilla, and a small
rongeur is used to remove this bone (TECH FIG 7B). No cartilage is
removed. The closing wedge osteotomy is noted to be sufficient when the
premaxilla can be repositioned posteriorly and in good alignment with the
lateral alveolar segments (TECH FIG 7C).
TECH FIG 7 • Premaxillary setback. A. The incision is
marked on the vomer just behind the premaxilla. B.
After dissecting in a subperiosteal plane, rongeurs are
used to create a closing wedge osteotomy. C. The
premaxilla is repositioned in alignment with the lateral
maxillary arches and affixed with 4-0 PDS sutures.
■ A 4-0 PDS is sufficient to fixate the premaxilla into its new position,
promoting bone-to-bone contact. This is secured from the premaxilla to the
posterior vomer. Additionally, on each side, a 4-0 PDS suture can be passed
directly through the mucosa of the lateral premaxillary alveolus and through
the medial edge of the lateral arch alveolus (as an external stitch). When tied,
this will secure the repositioned premaxilla to the lateral segments during
healing.
■ The vomer incision is closed using a running 5-0 Chromic gut suture.
■ Combining a premaxillary setback and bilateral lip adhesion, as described
herein, will not compromise the perfusion of the premaxillae. The authors do
not perform a premaxillary setback and complete bilateral cleft lip and nose

repair, rather stage the late presenting patient with: stage 1: premaxillary
setback and lip adhesion. Stage 2: complete cleft palate repair. Stage 3:
complete cleft lip and nose repair.
PEARLS AND PITFALLS
Timing
■ Optimal timing is at 2 months of age.
Incisions
■ Incisions must be placed in tissue that will be discarded at the time of
definitive lip repair.
■ Therefore, the markings for a definitive lip repair are performed first.
Permanent
retention
suture
■ A permanent suture is placed through the orbicularis oris muscle on
both sides of the cleft.
■ It must capture a large swath of orbicularis oris muscle on both sides
in order to reduce tension on the lip adhesion and decrease the risk of
dehiscence.
Alar base
positioning
■ Symmetrical placement of the alar bases during the lip adhesion is
critical.
■ Alar bases must be symmetric in both the horizontal and vertical
planes.
■ If the alar bases are asymmetric at the completion of lip adhesion,
this deformity will be more difficult to correct at the time of
definitive cleft lip repair.
Nasal
stents and
conformers
■ The use of nasal conformers after lip adhesion helps to lengthen the
columella and mold the lower lateral cartilages to optimize nasal
form prior to definitive lip repair.
POSTOPERATIVE CARE
■ The patient is admitted postoperatively for monitoring and typically
discharged home the following day if oral intake is adequate to maintain
hydration.
■ Patients may return to their usual bottle-feeding.
■ Elbow splints are typically used to prevent inadvertent injury to the repair.
■ Steri-Strips are utilized and can be replaced for 2 weeks following surgery to
take tension off of the repair.

■ Nasal conformers are used postoperatively. The parents are taught how to
clean and replace the stents daily. If the adhesion was performed under more
tension than desired, or if there is a tenuous soft tissue closure, nasal stenting
can be started in 1 to 2 weeks after adequate healing has occurred.
■ The nasal conformers are increased in size as the infant grows over the next 3
to 4 months.
■ Definitive cleft lip and nose repair is then performed in 3 to 4 months, at
approximately 6 months of age. At the time of the repair, the adhesion scar is
excised and the permanent retention suture is removed.
OUTCOMES
■ Labial adhesion has been shown to increase the vertical height of the medial
and lateral lip elements in unilateral cleft lip10 and increase the bulk of
orbicularis oris muscle tissue for closure and reconstruction of the philtral
ridge.11
■ The adhesion of the orbicularis oris muscle molds the alveolar segments and
reduces a wide alveolar gap by approximately 60% in both unilateral and
bilateral cleft lips.3,12 If gingivoperiosteoplasty is planned, however, passive
alveolar molding may still be required to align the maxillary segments.
COMPLICATIONS
■ Dehiscence: Either partial or total dehiscence occurs between 4% and 17% of
the time.6,10,12 Dehiscence is more common in the bilateral than the unilateral
complete cleft lip, because the bilateral lip (without premaxillary setback) is
often under more tension. Partial dehiscence may not require operative
intervention if some of the alignment is maintained.
■ Scarring: Scarring of the lip can occur, and some authors report that it can
interfere with the final repair. When the incisions are planned carefully,
however, the scarring will only occur in tissues that would normally be
discarded at the time of definitive lip repair.
REFERENCES
1. Grayson BH, Santiago PE, Brecht LE, et al. Presurgical nasoalveolar molding
in infants with cleft lip and palate. J Craniomaxillofac Surg. 1992;20:99-110.
2. Latham RA. Orthopedic advancement of the cleft maxillary segment: a
preliminary report. Cleft Palate J. 1980;17:227-233.
3. Meijer R. Lip adhesion and its effect on the maxillofacial complex in

complete unilateral clefts of the lip and palate. Cleft Palate J. 1978;15:39-43.
4. Randall P. A lip adhesion operation in cleft lip surgery. Plast Reconstr Surg.
1965;35:371-376.
5. Millard DR, Latham R, Huifen X, et al. Cleft lip and palate treated by
presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (POPLA)
compared with previous lip adhesion method: a preliminary study of serial
dental casts. Plast Reconstr Surg. 1999;102:1630-1644.
6. Shay PL, Goldstein JA, Paliga JT, et al. Comparative cost analysis of cleft lip
adhesion and nasoalveolar molding before formal cleft lip repair. Plast
Reconstr Surg. 2015;136:1264-1271.
7. Bitter K. Repair of bilateral clefts of lip, alveolus and palate. Part 1: A refined
method for the lip-adhesion in bilateral cleft lip and palate patients. J
Craniomaxillofac Surg. 2001;29:39-43.
8. Lu TC, Lam WL, Chang CS, Chen PK. Primary correction of nasal deformity
in unilateral incomplete cleft lip: a comparative study of three techniques. J
Plast Reconstr Aesthet Surg. 2012;65:456-463.
9. Monson LA, Kirschner RE, Losee JE. Primary repair of cleft lip and nasal
deformity. Plast Reconstr Surg. 2013;132:1040e-1053e.
10. Van der Woude DL, Mulliken JB. Effect of lip adhesion on labial height in
two-stage repair of unilateral complete cleft lip. Plast Reconstr Surg.
1997;100:552-557.
11. Ridgway EB, Estroff JA, Mulliken JB. Thickness of orbicularis oris muscle in
unilateral cleft lip: before and after labial adhesion. J Craniofac Surg.
2011;22:1822-1826.
12. Gatti GL, Lazzeri D, Romeo G, et al. Effect of lip adhesion on maxillary arch
alignment and reduction of a cleft’s width before definitive cheilognathoplasty
in unilateral and bilateral complete cleft lip. Scand J Plast Reconstr Surg Hand
Surg. 2010;44:88-95.

5
CHAPTERBilateral Cleft Lip Repair
John A. van Aalst
DEFINITION
■ A cleft of the lip occurs when the maxillary prominence fails to fuse, first with
the lateral nasal prominence and then the medial nasal prominence; when this
failure of fusion occurs bilaterally, a bilateral cleft deformity is the result.1
■ Cleft lip occurs most commonly in patients from Southeast Asia and the
southwestern United States (1/250 to 1/400 live births), is less common in
Caucasians (1/1000), and is least common among African Americans
(1/2000).1
ANATOMY
■ Bilateral clefts of the lip involve the tissues of the primary palate. This
includes the skin, muscle, and mucosa of the lip and the alveolus, extending
posteriorly to the incisive foramen.
■ The premaxillary segment contains the central alveolus (maxilla) with the
tooth buds of the central incisors; this bone is attached to the vomer, the bony
underside of the septum.
■ The premaxillary segment presents with variable anterior flaring, which may
have variable presentation: it may be very anteriorly positioned or may be
correctly positioned within the maxillary arch.
■ A complete bilateral cleft is likely to have significant anterior flaring,
whereas the premaxillary segment of an incomplete cleft is likely to be
positioned correctly between the lateral segments of the maxilla.
■ Gingiva and mucosa cover the bone of the premaxillary segment and then
transition to skin; this segment does not contain true lip vermilion. The skin is
generally circular in shape and is without a true white roll. No muscle is

present in this region (except in incomplete clefts, where the muscle is in
continuity with the lateral lip elements).
■ Lateral segments of a bilateral cleft lip have all of the elements of the lip
present lateral to the nasal ala (wet vermilion, dry vermilion, white roll, skin,
and muscle); moving medially, the fullness of each of these components
diminishes as the lip structures narrow and ascends toward the cleft of the
nose.
PATHOGENESIS
■ Lip fusion occurs on day 42 of gestation.
■ Fusion may be interrupted secondary to genetic causes (MSX1 gene anomaly),
environmental causes (including medications—steroid, anticonvulsants,
retinoic acid—alcohol, tobacco use), or a combination of the two (alcohol
consumption and cigarette use in the face of an MSX1 genetic anomaly).1
■ The medial migration of the maxillary prominence is arrested, leading to
failure of fusion with the medial and lateral nasal prominences; failure of
fusion of these latter two leads to clefting of the nostril floor.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Many children with bilateral cleft lip will be diagnosed in utero, prompting a
prenatal visit with cleft team members, including the surgeon. The cleft team
member describes the concept of team care to the family, the needs of the child
immediately following birth, and the surgical preparation for cleft lip repair at
approximately 3 months of age.
■ Patient history should include the presence of family members with clefting;
maternal exposure risks: cigarette and alcohol use; medications, including
anticonvulsants and steroids; and folic acid supplementation during early
pregnancy.1
■ Following delivery, the first visit to the surgeon is generally within the 1st
week of life.
■ In addition to a full physical examination, the tailored examination of the face
detects whether the cleft is complete or incomplete, whether there is
asymmetry between the two sides, and whether the premaxilla is proclined
(FIG 1). In addition, the presence of clefts of the alveolus and of the palate
must be documented.

FIG 1 • Infant with bilateral cleft lip. Figure A
demonstrates a frontal view of an infant with a bilateral
complete cleft lip and palate; the premaxilla is anteriorly
positioned (proclined). Figure B is a worm’s eye view of
the same infant, demonstrating the asymmetry of the
cleft, with the premaxilla positioned more to the
patient’s left. As can be noted more clearly in this figure,
the patient also has a cleft of the alveolus and palate.
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ No routine imaging studies are required for children with bilateral cleft lip
prior to surgical repair.
■ Because these children may have other congenital anomalies, additional
findings on physical examination will dictate the need for additional diagnostic
studies.
■ If the child has evidence of breathing difficulties, or sleep apnea, a sleep study
may be warranted. If there is any evidence of feeding/swallowing difficulties
with concerns about aspiration, a swallow study may be warranted; if other
cranial abnormalities are present, a craniomaxillofacial computed tomography
scan may be warranted.
NONOPERATIVE MANAGEMENT
■ Although nonsurgical management of the bilateral cleft lip is not appropriate,
presurgical management for control of the proclined maxilla is recommended.
■ The proclined maxilla can be treated with a simple taping regimen (FIG 2),
with nasoalveolar molding2,3 or actively with a Latham device4,5 to direct
position of the alveolar segments prior to surgical repair.
SURGICAL MANAGEMENT

■ Children are judged ready for surgery using the rule of 10s: approximately 10
lb (4.5 Kg), 10 week of age, and a hemoglobin count of 10.6–8
■ If there are any other symptomatic comorbidities or concerns about
appropriate weight gain, delay in surgery is warranted.
Positioning
■ At the time of surgery, the child is positioned in the supine position and
intubated with an oral Ring-Adair-Elwyn (RAE) tube (FIG 3A).
■ A shoulder roll is placed to obtain gentle extension of the neck.
■ The entire face is prepped and draped, and a throat pack is placed.
■ Markings are made for lip repair with tattooing of key landmarks (TECH FIG
1).
■ Local anesthetic with epinephrine is injected following the markings.

FIG 2 • Preoperative preparation of the patient in FIG 1
with a taping regimen. This taping regimen needs to
start shortly after birth to maximize the effect on
premaxillary segment retroclining (an early start is also
true for other forms of presurgical orthopedics, including
nasoalveolar molding). A. During the taping regimen. B.
At completion of the taping regimen. C,D. Immediate
preoperative photographs demonstrate an improved
position of the premaxilla in a more symmetrical
position after taping regimen.

FIG 3 • A. The patient is positioned supine and
intubated with an oral RAE tube, with taping on the chin
so that the upper lip is not distorted. B. Landmarks. The
central philtral column with skin (a) is 2 mm wide at the
waist and 2 mm from low to high point of Cupid’s bow.
The lateral flanking de-epithelialized regions (b) are
also 2 mm wide. The remnant skin and mucosa of the
premaxillary segment have been incised into three
parts. These areas are labeled (e) bilaterally and (f)
centrally and inferiorly. At the superior philtral column
(b-a-b) are extensions of skin (c) that will be eventually
be used to close the floor of the nose. The central flap
(f) is used to reconstruct the central upper buccal
sulcus; the two lateral flaps (e) are turned out laterally
and used to reconstruct the anterior surface of both
alveolar clefts. Bilateral upper buccal sulcus incisions
(d) allow medialization of cheek tissue to minimize
tension at final closure. The vertical component of the
incision is made medial to Stensen duct (the greater the
height of this incision, the greater the capacity to
medialize cheek tissue). The horizontal incision is made
at the junction of the gingiva and oral mucosa to the
base of the L flap (without injuring the L flap). A Freer

elevator is used to lift the periosteum from the maxillary
surface, exposing the infraorbital nerve. The region of
the nerve is the most significant area of tethering, which
prevents medial movement of cheek tissue. The
periosteum medial and lateral to the nerve is cut
vertically, avoiding injury to the nerve and releasing the
tethering effect of the periosteum.
T E C H N I Q U E S
■ Markings
■ The two most commonly used techniques to repair the bilateral cleft lip are
the Millard technique6 and the Mulliken technique.7–10
■ Based on modifications of the Mulliken technique, markings for the
neophiltrum include the following:
■ 2 mm at the waist (at the junction of the columella with the premaxillary
skin; TECH FIG 1)
■ 2 mm between the low and high points of Cupid bow
■ Flanking de-epithelialized regions, each 2 mm wide and the same height as
the philtral column
■ The three-part division of the premaxillary mucosa is marked.
■ The bilateral advancement flaps are marked, with 2 mm of intact white roll
retained with the vermilion component on both sides, with as much as
possible skin conserved, but avoiding vermilion (see TECH FIG 1).
■ Bilateral upper sulcus-releasing incisions are marked:
■ The vertical component is medial to Stensen duct.
■ The horizontal component is marked at the junction of the gingiva and
upper buccal sulcus mucosa, extending medially to the edge of the L flap.

TECH FIG 1 • Attention to detail in the markings is key
to an aesthetic outcome. Before making the marks,
take note of the asymmetries present. Markings are
made before injection of local anesthetic, and the
points are tattooed into tissue with a 30-gauge insulin
needle using either Bonnie blue or methylene blue.
The high and low points of Cupid’s bow are 2 mm
wide; the waist of the philtral column is also 2 mm
wide. The flanking regions that will be de-epithelialized
on either side of the philtral column skin are also 2
mm in width. At the superior lateral position of the two
areas marked for de-epithelialization, there should be
a horizontal extension along the skin, which will be
used for eventual closure of the nostril floor. The
lateral lip markings begin with the medial marking for
the white roll. This point should be marked at the
medial-most position of full (complete) white roll
(moving further medial from this position, the white roll
tapers); a second point is marked 2 mm lateral to the
first point. The medially curved line on the vermilion
has its furthest medial extension at the junction of dry
and wet vermilion; the 2 mm of white roll will remain
with the vermilion and be used to reconstruct the white
roll under the philtral column (also 2 mm in width). The

upper buccal sulcus–releasing incisions are also
tattooed so the marks continue to be visible despite
oral secretions or bleeding (shown in FIG 3B).
■ Incisions
■ The neophiltrum is incised with de-epithelialization of the two flanking
regions. These three regions are lifted as a single unit (TECH FIG 2A),
improving blood supply to the philtral skin.
■ The three parts of the premaxillary mucosa are incised (see TECH FIG
2A). The central portion is used to reconstruct the upper buccal sulcus
(TECH FIG 2B).
■ The lateral two flaps are used to provide coverage over each of the alveolar
clefts (TECH FIG 2C,D).
■ The advancement flap is incised, starting laterally, at the white roll, leaving 2
mm of intact white roll with the dry vermilion (see TECH FIG 2B–D),
extending along the junction of skin and vermilion (carefully avoiding
inclusion of vermilion with the skin flap).
■ The incision is then extended inferior to the nose, then laterally, along the
crease between the nose and lip, but not extending beyond the alar margin
(see TECH FIG 2C,D).
■ The lateral vermilion flap (L flap) is incised, leaving excess dry and wet
vermilion for lip reconstruction (this helps to create a pout of the central lip).
■ The inferior part of the incision is continued on the mucosal side toward
the alveolus in a line parallel to the advancement flap incision.
■ At the superior-medial incision of the advancement flap, the L flap incision
is extended into the nose at the junction of skin and mucosa, extending
toward the inferior turbinate.
■ The skin margin of the advancement flap is then separated for 3 to 4 mm
from the orbicularis oris muscle (during reconstruction, this separation will
allow approximation of the muscle as a separate layer; see TECH FIG 2D).
■ Next, the lateral releasing incision is made in the upper buccal sulcus: the
vertical component is made 1 cm medial to the Stensen duct, extending down
to the junction of the oral mucosa and gingiva; the horizontal component is
then incised along the junction of the oral mucosa and gingiva, to the base of
the L flap (see FIG 3B).

■ Using the lateral releasing incision, maxillary tissue is dissected from the
maxilla in a subperiosteal plane with a Freer elevator. The infraorbital nerve
is identified.
■ The periosteum is incised medial and lateral to the nerve, allowing
medialization of cheek tissue.
■ The right angle of the releasing incision can now be extended medially to
decrease tissue tension during closure.
TECH FIG 2 • A. Incisions for bilateral cleft lip. A
beaver blade is used to make all incisions. At the skin
markings, part of the tattooed mark is maintained on
the retained flap in order to clarify positioning of the
flaps at final closure. B. Lifting of the philtral flap with
flanking de-epithelialized regions. Note the inset of the
central premaxillary mucosal flap to the periosteum of
the premaxillary segment with a central stitch; this

reconstructs the central upper buccal sulcus. Closure
of the right nostril floor with the L flap and the right
turnover flap from the premaxilla. These two flaps are
sutured to each other, simultaneously closing the
nostril floor and the anterior surface of the alveolar
cleft ((C) on the left, (D) on the right). Note that the
nostril orifice is maintained despite approximation of
these flaps.
■ Reconstruction
■ The L flap is inset into the floor of the nose using 5-0 chromic with the intact
mucosa facing down toward the oral cavity and raw surface up toward the lip
(see TECH FIG 2B–D).
■ The lateral premaxillary flaps are turned over (intact surface down) and
sutured with 5-0 chromic to the periosteum of the maxilla at the lateral base
of the L flap.
■ The two flaps are then sutured to each other, to close the floor of the nose.
■ A 4-0 PDS is used as an alar cinch suture (TECH FIG 3A), setting the alar
margins at the medial canthi bilaterally (TECH FIG 3B).
■ Oral mucosa is reapproximated at the medial-most extension of the releasing
incision (medializing tissue that was at a right angle into a straight line) using
4-0 and 5-0 chromic interrupted sutures.
■ Muscle is approximated using 4-0 PDS interrupted sutures with buried knots
(TECH FIG 3C).
■ The dry vermilion and white roll are approximated with 5-0 plain interrupted
sutures (TECH FIG 3D).
■ The neophiltrum is inset with 6-0 Monocryl deep dermal suture at the lateral
margins of the flap, which correspond to the high points of Cupid’s bow,
followed by 6-0 plain suture at the skin.
■ 6-0 plain sutures are placed from philtrum to vermilion between the high and
low points of Cupid’s bow. 6-0 Monocryl is used for deep dermal closure
along the philtral column.
■ 7-0 PDS subcuticular stitch is used to close the skin. The nostril floor is
closed using 5-0 chromic suture (TECH FIG 3E).

■ Dermabond or Steri-Strips are applied to the lip incisions.
TECH FIG 3 • The alar cinch suture (which sets the
lateral ala at the medial canthus bilaterally) is placed
on the underside of the alae of the nose (A) and is
used to set the lateral alae at the medial canthi
bilaterally (B). Importantly for the lip repair, positioning
the base of the nose begins the process of medializing
tissue to close the lip. C. Muscle closure is performed
using 4-0 PDS interrupted buried sutures.
Reapproximation of muscle must be accomplished
throughout the full extent of the lip. The philtral tissue
is visualized from the underside ((a) with skin and
bilateral (b) regions that are de-epithelialized). The de-
epithelialized regions will be placed under the skin
advancement flaps (c) and will provide fullness in the
lateral philtral column bilaterally. The philtral flap will

be inset at (d) bilaterally for final closure. Note the
white roll (e) at the medial superior area of vermilion.
The areas of white roll (e) will be approximated to
each other. D. Reapproximation of the white roll with
dry vermilion prepares for inset of the philtral column.
E. Final closure of the lip.
■ Variations in the Technique
■ The same technique can be used in older patients requiring correction of a
wide philtrum (TECH FIG 4).
■ Though the author’s preferred sutures are delineated in this chapter, multiple
sutures can be substituted during various junctures of the repair. For example,
4-0 Vicryl can be substituted for 4-0 PDS for reapproximation of the muscle.
■ Although the width of philtral column skin flap in a 3-month old patient is
recommended as 2 mm from low to high point of Cupid’s bow, and 2 mm at
the philtral waist (abutting the nasolabial junction), surgeons may choose to
incorporate the flanking de-epithelialized regions (also approximately 2 mm
wide) into the actual skin-based philtral flap, thereby increasing the width of
the skin.

TECH FIG 4 • A 9-year-old with previous bilateral cleft
lip repair. A,B. The high points of Cupid’s bow are
elevated bilaterally because the entire skin paddle of
the premaxillary segment was used for lip repair.
Retained mucosa of the premaxillary segment is
present; the patient has a wide philtrum due to use of
the central maxillary skin and mucosa as a vermilion
substitute. The white roll remains laterally displaced.
C. Markings have been made for repair of the cleft lip
with central philtral column, flanking de-epithelialized
regions, scar excision, and premaxillary segment
mucosa excision. D. Final closure at revision surgery.
PEARLS AND PITFALLS

Physical
findings
■ Be cognizant of asymmetries on initial examination; they may be
correctable by presurgical molding techniques; if not, they must be
accounted for during initial lip markings.
■ Retroclining the premaxilla is key to improving lip repair
outcomes.
■ Failure to retrocline the prominent premaxilla often results in
lateral maxillary arch collapse, thereby “locking out” the
premaxillary segment in its abnormal anterior position. If this
occurs, the premaxilla cannot be positioned properly until
maxillary expansion is initiated, which is usually done during the
phase of mixed dentition.
Markings
■ Make the philtral column as long as possible on the premaxillary
skin.
■ An appropriately narrow philtral column avoids a too-wide
philtrum with continued facial growth.
■ Borrowing white roll from the lateral lip segments is crucial
because true white roll does not exist at the skin margin of the
premaxillary segment.
■ Provide extra fullness in the central vermilion to avoid a whistler’s
deformity.
Incisions
■ Avoid the mistake of making the incisions on the lateral lip
elements too medial. This will make the height of the lip
incongruent with the philtral column height.
Closure
■ Closure with tension is the primary cause of muscle dehiscence
and scar widening.
■ Releasing incisions in the upper buccal sulcus provide tension-free
closure.
■ If tension persists, re-examine the releasing incisions for further
release in areas of periosteal banding.
■ Muscle closure should be performed along the full height of the
lip.
Postoperative
care
■ No change in feeding regimen is needed after surgery.
■ Scar massage at 1 mo
POSTOPERATIVE CARE
■ Postoperative in-hospital stay is optional.
■ Arm restraints should be considered.
■ Gentle narcotic use for pain is recommended.

■ Undertreatment of pain may hinder the child’s ability to feed.
■ Overtreatment can lead to constipation.
■ Breast or bottle feeding is initiated in the recovery room following completion
of surgery.
OUTCOMES
■ Ideally, primary repair of the bilateral cleft lip should result in a symmetrical,
aesthetically pleasing repair that does not require revision (FIG 4).
FIG 4 • The child in FIGS 1 and 2 is shown at 1 month
(A) and 4 months (B) after surgery.
■ However, the reality is that revisions are often needed (TECH FIG 4 and
FIG 5).
■ Timing for revision is controversial. Times for possible lip revision:
■ 5 years of age, on entry into kindergarten
■ Life changes, including transfer to a new school

■ Timed with other surgeries, such as speech surgery or bone grafting
■ After skeletal maturity following orthognathic surgery
COMPLICATIONS
■ Early
■ Bleeding
■ Dehiscence of the repair, either partially or totally
■ Loss of the neophiltral column
■ Stitch spitting/abscess
■ Rarely, infection
■ Late
■ Scar widening, including the philtrum becoming too wide in proportion to the
overall size of the lip
■ Asymmetry: the most noticeable asymmetries are of the Cupid’s bow, with
one high point being higher than the other
■ Poor animation because of muscle dehiscence or heavy scar burden

FIG 5 • Postoperative results of the lip revision shown in
TECH FIG 4. The patient is seen in a frontal view (A) and
a worm’s eye view (B). Note that the patient has
improved philtral width, Cupid’s bow, and wet with dry
vermilion balance.
REFERENCES
1. Watkins SE, Meyer RE, Strauss RP, Aylsworth AS. Classification,
epidemiology, and genetics of orofacial clefts. Clin Plast Surg.
2014;41(2):149-163.
2. Dec W, Shetye PR, Davidson EH, et al. Presurgical nasoalveolar molding and
primary gingivoperiosteoplasty reduce the need for bone grafting in patients
with bilateral clefts. J Craniofac Surg. 2013;24(1):186-190.
3. Grayson BH, Santiago PE, Brecht LE, Cutting CB. Presurgical nasoalveolar
molding in infants with cleft lip and palate. Cleft Palate Craniofac J.
1999;36(6):486-498.
4. Millard DR, Latham R, Huifen X, et al. Cleft lip and palate treated by
presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion (POPLA)
compared with previous lip adhesion method: a preliminary study of serial
dental casts. Plast Reconstr Surg. 1999;103(6):1630-1644.
5. Cruz C. Presurgical orthopedics appliance: the Latham technique. Oral
Maxillofac Surg Clin North Am. 2016;28(2):161-168.
6. Millard DR. Bilateral cleft lip and a primary forked flap: a preliminary report.
Plast Reconstr Surg. 1967;39(1):59-65.
7. Mulliken JB. Principles and techniques of bilateral complete cleft lip repair.
Plast Reconstr Surg. 1985;75(4):477-487.
8. Mulliken JB. Primary repair of bilateral cleft lip and nasal deformity. Plast
Reconstr Surg. 2001;108(1):181-194.
9. Mulliken JB, Wu JK, Padwa BL. Repair of bilateral cleft lip: review,
revisions, and reflections. J Craniofac Surg. 2003;14(5):609-620.
10. Yuzuriha S, Oh AK, Mulliken JB. Asymmetrical bilateral cleft lip: complete
or incomplete and contralateral lesser defect (minor-form, microform, or mini-
microform). Plast Reconstr Surg. 2008;122(5):1494-1504.

6
CHAPTER
Secondary Deformities
Catharine B. Garland, Jesse A. Goldstein, and Joseph E.
Losee
DEFINITION
■ After cleft lip and nose reconstruction, secondary deformities of the lip and
nose are common. The actual incidence of deformity is difficult to quantify
because of individual variability in assessing what constitutes a deformity. For
example, the incidence of revisionary surgery ranges from 0% to 100%.1
■ Asymmetries leading to deformity can be encountered anywhere along the lip-
nose complex. These are caused by inadequate tissue in some cases and
excessive tissue in others.
■ This chapter focuses on addressing secondary cleft lip deformities rather than
secondary cleft rhinoplasty. Correcting asymmetries of the alar bases, however,
is often an important component of secondary lip revision surgery.
ANATOMY
■ The ideal lip and nose complex is composed of the following features:
■ A symmetric nostril shape, with symmetric nostril sills and alar base position
■ A balanced Cupid’s bow with a smooth curve to the vermilion border
■ Symmetric philtral columns with a well-defined philtral dimple2
■ Smooth contour and balance of the mucosa
■ A central pouting tubercle in the vermilion
■ A functional orbicularis oris muscle sling that leads to symmetry with
animation
■ Appropriate tooth show at rest
PATHOGENESIS
■ Some secondary deformities are intrinsic, such as the nasal deformity

characterized by a hypoplastic and flattened lower lateral cartilage.
■ Other deformities are iatrogenic from the primary cleft repair. These include
deformities caused by scarring, inadequate correction, an unbalanced
reconstruction, or altered growth and development.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The most important part of the history is to ascertain what bothers the patient
and the family. This may not always be congruent with what the surgeon sees
as the most significant deformity. Realistic expectations of operative
intervention must be discussed preoperatively.
■ The physical examination must include a careful analysis of the deformity. The
reconstruction is then tailored to address the specific anatomic abnormality.
■ Are the alar bases symmetric in shape and position? They must be symmetric
in the vertical, transverse, and sagittal plane.
■ What is the nature of the cutaneous scar? Assess whether the scar is
hypertrophic, atrophic, or pigmented. This helps to inform the surgeon about
the patient’s innate healing response.
■ Is the philtrum well defined and symmetric?
■ Is Cupid’s bow balanced or is there a discrepancy in height on the cleft side?
Are the vermilion border and white roll congruous structures?
■ Is the red line, wet-dry junction, in alignment? An excess of wet mucosa in a
region that should be composed of dry vermilion often causes persistent
chapping of the lip in that area.
■ Is there adequate lip length and appropriate tooth show? Is the buccal mucosa
scarred and tethered?
■ Is the mucosa symmetric? Is there excess mucosa on the cleft side or
deficient mucosa at the central tubercle? Is there a notch in the mucosa at the
site of repair?
■ Is the lip symmetric in animation? Bunching of the lip may suggest
dehiscence of the orbicularis oris muscle.
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative workup is per hospital routine.
■ Under anesthesia, a careful analysis of the lip and nose is again performed to
characterize the asymmetries.

■ For more severe deformities, consideration must be given to a complete
revision of the primary cleft lip and nose repair.3,4
Positioning
■ Supine
■ We typically use an oral RAE endotracheal tube. This minimizes any
asymmetry caused by taping a standard endotracheal tube in the corner of the
mouth.
■ The table is turned according to surgeon preference.
■ The face is prepped with Betadine, and sterile drapes are applied. A head wrap
or four towels may be used for draping according to surgeon preference.
Approach
■ Markings: Mark all the key anatomical landmarks of the lip and nose (eg, alar
bases, columella, peak and nadir of Cupid’s bow, white roll, and wet-dry
junction). Tattoo the key points with methylene blue.
■ Measure: Measure both the normal and cleft sides with calipers to determine
the exact discrepancy of height and/or width in the lip and nose that requires
correction.
■ Epinephrine: Consider whether epinephrine is needed for your surgery. The
hemostatic benefit is helpful in many cases. However, for subtle contour
abnormalities, epinephrine infiltration may obscure your ability to assess the
result on the table. In these cases, pinch the lip between the thumb and index
finger to occlude the labial artery while you are incising the tissues and use
Bovie electrocautery sparingly.
■ Skin repair: Although hypertrophic scarring may be inherent to the patient, all
precautions are taken to minimize this risk. Care is taken to ensure a tension-
free closure. The skin is approximated with 5-0 or 6-0 Monocryl buried dermal
sutures. When these are placed precisely, additional cutaneous sutures may not
be required. When cutaneous sutures are needed, we use strategically placed 6-
0 fast-absorbing plain gut or 6-0 nylon sutures in the epidermis to align the
skin edge. These are removed 4 to 5 days after surgery.
■ Muscle repair: Muscular dehiscence may be suspected in patients who have a
muscle bulge laterally with facial animation. In addition, muscular dehiscence
can contribute to a shortened lip, notching of the mucosa, or widening of the
cutaneous scar. When these are noted, reconstruction of the orbicularis oris
musculature must also be performed with the repair. The orbicularis oris

muscle is dissected free from the skin and mucosa. When the muscle is found
dehisced, it is reapproximated or overlapped. Some surgeons describe a benefit
to tightening the orbicularis oris muscle with horizontal mattress sutures to
evert the muscle and accentuate the philtral column.
■ Mucosa repair: After the planned local tissue rearrangement or excision, the
mucosa is typically repaired with 5-0 chromic gut sutures. These can be placed
as everting horizontal mattress sutures to prevent a notch in the vermilion and
mucosa.
T E C H N I Q U E S
■ Deformities of Cupid’s Bow
Small Vermilion Mismatch (Less Than 1 mm) or a Widened
Scar at the Cutaneous-Vermilion Border
■ This can be managed by a diamond or curved excision of the scar, similar to
the classically described Rose-Thompson straight line repair (TECH FIG
1A).
■ The Cupid’s bow nadir and high points are marked (TECH FIG 1B). An
equal distance from high point to nadir is transposed to the cleft side, and this
is typically positioned on the medial side of the scar. The vermilion border is
marked medially and laterally to the scar that is to be excised. These points
will come together to create the new high point of Cupid’s bow on the cleft
side.
■ The white roll is marked, as is the red line wet-dry junction. The diamond
excision is marked to excise the scar or mismatch and allow realignment of
the vermilion border and white roll.
■ The critical points are tattooed with methylene blue.
■ Epinephrine-containing solution is infiltrated into the tissues for hemostasis.
■ Using an ophthalmic knife, the diamond is excised through the skin down to
muscle. If the muscle repair is adequate, superficial scar is excised, but the
muscle is left intact.

TECH FIG 1 • A. Hypertrophic scar at the vermilion
border with slight shortening of Cupid’s bow on the
cleft side preoperatively. The remainder of the
cutaneous scar is well healed. B. The peak and nadir
of Cupid’s bow are marked on the noncleft side and
transposed to the cleft side. The white roll is marked
and these points are tattooed. A diamond excision of
the scar is marked at the vermilion border. C. The
diamond excision realigns the vermilion border and
white roll and provides adequate additional length to
balance Cupid’s bow.
■ 5-0 Monocryl is used to realign the vermilion border with a deep dermal
suture (TECH FIG 1C). Additional deep dermal sutures are used to realign
the wound margins precisely.
■ 5-0 Chromic is used to reapproximate the mucosa with everting sutures. To
prevent a standing cone or “dog ear,” excess mucosa is excised as needed in
this process.
Cupid’s Bow Mismatch of 1 to 2 mm
■ For a Cupid’s bow mismatch of 1 to 2 mm (TECH FIG 2A), a small
triangular flap is inserted at the cutaneous border.
■ This excision and reconstruction are often similar to the microform cleft
repair described by Mulliken.4
■ The cutaneous-vermilion border, white roll, Cupid’s bow peak on the normal
side, low point, and peak on the cleft side are marked and tattooed (TECH
FIG 2B).
■ Using calipers, the distance from subnasale to the normal Cupid’s bow peak
is measured, and the equal distance from subnasale is marked on the cleft
side.
■ A laterally based cutaneous equilateral triangular flap is marked on the lip
above the white roll, with the base of this triangle being the difference in the
distance between subnasale and height of Cupid’s bow peak on each side.
■ An incision of equal length is marked on the medial lip element above the
white roll.

■ The length of vertical excision is long enough to excise any abnormal scar
tissue or to prevent formation of a “dog ear.”
■ If there is a deficiency of central tubercle vermilion, a laterally based triangle
of vermilion may be designed as well.3 If there is an excess of lateral mucosa,
a mucosal excision may be included (TECH FIG 2C).
■ The tissue is infiltrated with epinephrine. It is excised with an ophthalmic
knife or no. 15 blade.
■ The scar tissue is excised and the skin flaps are separated from the
underlying orbicularis oris muscle.
■ The muscle is reconstructed if needed, and skin and mucosa repair proceeds
as previously described (TECH FIG 2D,E).

TECH FIG 2 • A. Lip deformity characterized by both
shortening of Cupid’s bow on the cleft side and lateral
mucosal fullness. B. The peak and nadir of Cupid’s
bow are marked on the noncleft side, and the peak of
Cupid’s bow is marked symmetrically on the cleft side.
The excision is designed with a laterally based
triangular flap at the white roll. In addition, the lateral
mucosal fullness is addressed with an excision
planned along the red line or junction of wet and dry
mucosa. C. After excision of the tissues, prior to
repair. Mucosa is being excised in both the transverse
and vertical planes. D. Closure includes the inset of a

laterally based triangular flap above the white roll to
increase the length of the lip on the cleft side. This
realigns and balances Cupid’s bow. E. After excision
of excess mucosa, the mucosa is more symmetric.
The scar is hidden along the red line and closed with
5-0 chromic sutures.
Cupid’s Bow Asymmetry More Than 2 mm High
■ For a larger asymmetry, a complete revision of the cutaneous scar is
performed (TECH FIG 3).
■ Many primary lip repair techniques may be adapted to achieve the necessary
goals in these more complex deformities.
■ The vermilion discrepancy may be addressed by rerotation of the medial lip
element as in a classic Millard repair (TECH FIG 3C).
■ Use of a triangular flap above the white roll in the manner first described by
Tennison and Randall and subsequently modified by Fisher5 is also an option
for a complete revision of the lip repair to address a major deformity.
■ The orbicularis oris muscle may need to be reconstructed fully or in part to
achieve adequate repair.
■ In the bilateral cleft lip, complete revision is used for patients with a wide
philtrum, significant philtral scarring, or a severe deficiency of vermilion in
the midline (TECH FIG 4).

TECH FIG 3 • A. Shortening of the unilateral lip with
mild widening of the cutaneous scar. B. A complete
excision of the cutaneous scar is planned. A backcut
is designed to allow secondary rotation of the medial
lip element. C. After rotation of the medial lip element,
Cupid’s bow is now more symmetric. D. The
improvement in the symmetry of Cupid’s bow is
maintained at 18 months postoperatively.

TECH FIG 4 • A,B. A 12-year-old boy with significant
residual cleft lip and nasal deformity after bilateral lip
repair. Cupid’s bow is unbalanced, and there is a
paucity of mucosa in the central tubercle. He has had
no correction of his cleft nasal deformity with lateral
displacement of the alar bases. C. With this degree of
deformity, a complete bilateral lip and nose repair is
planned and marked as if this were a primary
incomplete bilateral lip repair. The peak of Cupid’s
bow is marked at Noordhoff point on the lateral lip
element. The skin and mucosa between this and his
existing scar are planned for excision. D,E. The
bilateral lip and nose are completely reconstructed to
restore balance to Cupid’s bow and the vermilion.
Note the improved positioning and symmetry of the
lower lateral cartilages and alar bases after open
reconstruction with inverted-U rim incisions to address
the lower lateral cartilages.

■ Abnormalities of the Vermilion and Mucosa
■ Minor notches in the vermilion, asymmetries of the mucosa, incongruity of
the red line, or asymmetry of the dry vermilion may all be managed with
small elliptical excisions or local tissue rearrangement.
■ Incisions are confined to the mucosa and vermilion unless a cutaneous
deformity must also be addressed.
■ Each problem discussed here has a slightly different solution, but our typical
step-by-step approach is as follows:
■ Assess the deformity and design the excision or flap for reconstruction.
■ Mark the red line for accurate realignment later. Tattoo this with methylene
blue if needed.
■ We typically do not infiltrate the tissues with epinephrine-containing
solution when addressing a mucosal defect. The infiltration will distort the
tissues and prevent accurate intraoperative assessment. We find it is easier
to determine if adequate tissue has been excised or rearranged without
infiltration.
■ Rather than using epinephrine, the labial artery is pinched between two
fingers while making an incision in the tissues with a no. 15 blade.
■ Electrocautery is used for hemostasis as needed.
■ Mucosal flaps are elevated from the underlying orbicularis oris muscle.
■ The orbicularis oris muscle is reconstructed as needed with 4-0 Monocryl
mattress sutures.
■ The mucosa is redraped to assess contour of the lip. Additional excision,
augmentation, or dissection is performed as needed to optimize the contour.
■ Closure of the mucosa is performed with interrupted 5-0 chromic sutures.
Malalignment of the Red Line
■ This may lead to a notch in the border or an area of chapped mucosa
interposed between dry vermilion.
■ A notch caused by inadequate dry vermilion at the central tubercle can be
addressed by advancing lateral vermilion excess. A small laterally based
triangular flap of vermilion is raised above the muscle. An incision is made
along the red line medially. After any necessary muscle repair, the lateral
triangular flap is inset into the medial incision.
■ Alternatively, when wet mucosa is interposed in the vermilion, this may be
excised with a vertical ellipse of this tissue. The mucosa is elevated on both
sides to reduce tension. After muscle reconstruction or reinforcement, the

mucosa is closed with the red line now in precise alignment.
Lateral Mucosa Fullness
■ This is common after unilateral cleft lip repair. It can often be corrected by
excising an ellipse of tissue from the mucosa.
■ A transversely oriented ellipse addresses excess in the anteroposterior
direction. This may be placed along the red line if there is an excess of both
dry vermilion and mucosa (TECH FIG 5), or it may be hidden in the labial
buccal sulcus if the excess is composed only of wet mucosa.
■ Festooning of the lip suggests excess mucosa in the transverse direction.
This should be addressed with a vertical ellipse of mucosa along the cleft
scar.
■ We find that often both ellipses are needed (TECH FIG 6). In these cases,
both are marked and the closure is usually in the shape of a “T.”
TECH FIG 5 • A. Lateral mucosal fullness is noted
after unilateral cleft lip repair. B. The excess was
primarily in the anteroposterior dimension. A
transverse ellipse, centered on the red line, is marked
for excision to address the region of excess. C. After

excision and closure, the contour of the lip margin is
improved.
TECH FIG 6 • A. This child has lateral mucosa excess
at rest and (B) with animation after unilateral cleft lip
repair. C. On closer evaluation, the mucosal excess
was felt to be in both the transverse direction and
anteroposterior direction. For this reason, both a
transverse ellipse and vertical ellipse were marked.
The final closure will be in a “T” configuration along
the cleft lip scar and in the buccal sulcus.

TECH FIG 7 • After fat is harvested from the lower
abdomen, it is placed in 1-mL syringes for injection.
This is typically injected via a fine fat grafting cannula
or 18-gauge needle under the vermilion border.
Hypoplastic Medial or Lateral Lip Element
■ In this case, soft tissue augmentation is required. Autograft, allograft, and
synthetic tissue fillers have all been described. When possible, our preference
is to use autograft either as a structural fat graft or dermal fat graft.
■ Structural fat grafting may be used for secondary lip augmentation.
■ Autologous fat is harvested in the standard fashion from the lower
abdomen and prepared according to the Coleman technique.
■ This can then be injected under the vermilion border using a very small
cannula (TECH FIG 7).
■ Structural fat grafting is versatile. In addition to augmenting the vermilion,
it may also be used to augment a deficient philtral column or nostril base.6
Limitations with fat grafting include unpredictable resorption and survival,
as well as the risk of asymmetric hypertrophy with added weight gain over
time.
■ Autologous dermal fat graft is used when a larger augmentation is needed
(TECH FIG 8).
■ The requisite size graft is typically harvested from the groin and de-
epithelialized.

■ The graft is ideally positioned between the mucosa and muscle under the
vermilion border and dry vermilion.
■ Two small counterincisions in the mucosa can be made to create a tunnel
for the graft, which is passed with a tendon passer (TECH FIG 8D).
Chromic sutures are placed on both ends of the graft prior to passing it
through the tunnel. These are then used to anchor the graft into the
appropriate location.
■ If a Z-plasty or V-Y advancement of the buccal sulcus tissue is planned in
addition to augmentation, this flap is raised and the dermal fat graft may be
placed directly and sutured into place (TECH FIG 9). We commonly use
this strategy to augment the central tubercle in the bilateral cleft lip.

TECH FIG 8 • A. After unilateral cleft lip repair, this
patient has an asymmetric free margin of the lip. She
has mucosal excess on the left, with a relatively
hypoplastic lip on the right side. Given the thin lip on
the right side, augmentation with an autologous
dermal fat graft was planned. B. Harvest from the right
hip was planned, with the incision in a favorable
location. C. The graft is de-epithelialized and thinned
to the necessary size. D. In this case, a tunnel was
made from the lateral commissure to the central lip. A
tendon passer is used to introduce the graft into the
planned location along the right lip. E. After graft inset,
the lip thickness is more uniform across the upper lip.
■ Dermal allograft is an alternative to autologous tissue and may be used in a
similar manner to a dermal fat graft.7
Notch in the Free Edge of the Lip or Whistle Deformity
■ This may be caused by inadequate tissue, dehiscence of the orbicularis oris
muscle, or scarring of the mucosa that leads to tethering or shortening of the
lip.
■ When scarring is present, the buccal mucosa may be lengthened by local
tissue rearrangements or grafts, such as:
■ Mucosa Z-plasty
■ V-to-Y advancement of the buccal sulcus tissue

■ Transposition of a buccal mucosa flap8
■ Interposition of a buccal mucosal graft harvested from inside the lateral
cheek
■ When the cause is a deficiency of tissue rather than scarring, augmentation
with autologous fat may be adequate.
■ For a mild deficiency, structural fat grafting may be used.
■ Elevation of a buccal flap and augmentation with dermal fat graft are used
for a moderate-size defect (see TECH FIG 9).
TECH FIG 9 • A. Persistent central vermilion
deficiency after bilateral cleft lip repair. B. In the area
of notching, an anteriorly based mucosa flap is
designed. The flap and surrounding mucosa are
elevated from the orbicularis muscle, and a dermal fat
graft is positioned in the region of deficiency. C,D.
After augmentation with a dermal fat graft, the fullness
of the central tubercle fullness is improved.
■ In more significant cases, or when vermilion deficiency is associated with a
widened philtrum and nasal base, complete revision of the repair may be

performed to recruit additional lateral mucosa into the defect (see TECH FIG
4).
■ In severe cases, usually after bilateral cleft lip repair, the whistle deformity
may require reconstruction with an Abbe flap (see below).
■ The orbicularis oris muscle must be reconstructed in all cases.
■ Abbe Flap
■ The bilateral cleft lip often is accompanied by a deficiency of mucosa as
well as a shortened philtrum. Furthermore, horizontal lip deficiency may
limit the ability to reconstruct the central tubercle by borrowing tissue from
the lateral lip elements.
■ For these severe whistle deformities (TECH FIG 10A), an Abbe flap may
provide the best option for reconstruction of the entire philtral unit.9,10
■ The patient is nasally intubated in preparation for surgery (TECH FIG
10B).
■ If the patient is in braces, tight elastics are placed to prevent full mouth
opening after surgery. Alternatively, intermaxillary fixation screws may be
placed with tight elastics or wires.
■ The flap is designed in the midline of the lower lip (TECH FIG 10C). The
length and width of the new philtrum are designed and drawn onto the lower
lip. The flap tapers slightly toward midline as it approaches the labiomental
crease. Darts are made at the labiomental crease to address the donor site
“dog ear” at closure.
■ The vermilion border and white roll are marked and tattooed on the lower
lip.
■ The flap is incised full-thickness through the skin, muscle, and mucosa on
one side (TECH FIG 10D). During this dissection, the location of the labial
artery is noted, so that this area is well preserved on the contralateral side. A
Doppler may be used to confirm the pedicle location if there is prior scarring
in the area.
■ The remainder of the flap is dissected with preservation of the labial artery.
A small muscular cuff is preserved around the artery. The composite flap is
then able to be rotated a full 180 degrees.
■ The lower lip incision is closed in layers. The mucosa is repaired with 4-0
chromic gut, the lower lip orbicularis oris muscle is repaired with 3-0

Monocryl sutures, and the skin is closed with 5-0 Monocryl sutures in the
dermis and 6-0 nylon in the skin.
■ The critical points of the upper lip are marked. The columella, vermilion
border, and white roll are marked and tattooed. The scarred prolabium is
marked for excision.

TECH FIG 10 • A. Bilateral cleft lip with significant
whistle deformity composed of deficiency of mucosa,
vermilion, and philtrum. On worm’s-eye view, the
patient also has a severely shortened columella. B.
Preparation for Abbe flap includes nasal intubation.
This patient’s braces were used for intermaxillary
fixation with heavy elastics. C. The Abbe flap is
planned and marked in the midline of the lower lip.
The flap is measured to the desired length and width
of the new philtrum. The length is limited by the

location of the labiomental crease, but this crease is
used to accommodate any dog ear at closure. The
columella, scarred philtrum, and new high points of
Cupid’s bow are marked. The high points of Cupids
bow are marked to match the length and fullness of
the lower lip flap. D. The central upper lip defect is
created and the orbicularis oris muscle is dissected
out for repair. The lower lip Abbe flap is cut full
thickness through skin, muscle, and mucosa. One
side remains pedicled on the labial artery. E,F. The
Abbe flap is able to be rotated a full 180 degrees into
the upper lip defect. G. The Abbe flap is inset with
care taken to align Cupid’s bow and the lower lip
vermilion border. H. After 10 to 14 days, the flap is
well healed and ready for division. The lip pedicle may
be compressed to ensure there has been adequate
vascular ingrowth. I. The mucosal bridge is divided,
and the mucosa is repaired. Silicone tape is applied to
the cutaneous portions of the scars to optimize
healing. J. Several months after surgery, the patient
has improved lip contour and increased philtral length.
■ The new high point of Cupid’s bow is selected. This is ideally at a height
that matches the new philtral column created by the Abbe flap. Furthermore,
this point is selected such that the thickness of the upper lip mucosa matches
the lower lip tissue bulk to achieve a smooth mucosal contour.
■ Prior to incising the upper lip, 0.25% bupivacaine is infiltrated as bilateral
infraorbital nerve blocks. Epinephrine may be infiltrated into the upper lip
tissues.
■ The cutaneous incisions are made with a no. 15 blade, and the prolabial
scarring is excised. The upper lip is divided at 90 degrees to the white roll
and vermilion. The orbicularis oris muscle is dissected and preserved.
■ Buccal mucosal incisions are made bilaterally to advance the lateral lip
medially toward the new philtrum. The lateral lip is advanced and the buccal

mucosa backcut is closed with 4-0 chromic gut suture.
■ After the defect has been created, the Abbe flap is rotated to fill the defect
(TECH FIG 10E,F). The mucosa is inset with 4-0 chromic gut to the lateral
lip elements.
■ The orbicularis oris muscle of the upper lip is then repaired to the muscle of
the Abbe flap.
■ The vermilion and white roll are aligned at the previously tattooed points,
and the remainder of the skin and mucosa is inset (TECH FIG 10G).
■ During the inset, the color of the Abbe flap is monitored to ensure the flap
remains adequately perfused. If perfusion is compromised, routine maneuvers
for flap ischemia are taken, such as release of tension, replacement of flap to
donor site, hyperbaric oxygen, etc.
■ Flap division is performed 10 to 14 days later (TECH FIG 10H–J). After
division, the mucosa of the upper and lower lip is closed with 5-0 chromic
gut sutures.
■ The vermilion Abbe flap may be modified from this pattern to address a
severe defect of the mucosa only (TECH FIG 11). This eliminates the need
for cutaneous scarring while augmenting a severe deficiency of tissue at the
central tubercle.

TECH FIG 11 • A. In some cases, the philtral length is
adequate, but the deficiency of vermilion is so severe
that Abbe flap is considered. B. In this case, however,
the Abbe flap is designed to stay within the mucosa
and does not cross the vermilion on either the upper
or lower lip. C. Two weeks later, the flap is ready for
division. D. After several months, the mucosa is well
healed with a significant improvement in upper lip
contour.
■ Lip Pits
■ Lip pits are commonly associated with cleft lip and palate in van der Woude
syndrome. Most lip pits occur on the lower lip as paired structures lateral to
midline; however, midline pits on the upper or lower lip are also possible.
They can range from slight depressions to deep tracts lined with epithelium.11
■ The tracts are associated with serous or mucous glands along their course
and track toward the labiogingival sulcus.
■ Excision must include management of the mucosal deformity as well as
removal of the entirety of the tract.
■ The orbicularis oris muscle may need to be reconstructed after excision of
the tract.
■ A lacrimal probe is used to assess the course and depth of the tract.
Methylene blue is then injected into the tract with an angiocatheter to mark
the tract.
■ The mucosal excision is planned to optimize contour. Authors have
described multiple different approaches to address the concerns with mucosal
contour.
Simple Transverse Elliptical Excision of the Pit and Tract
■ In this technique, a transverse ellipse is designed around each pit (TECH
FIG 12A,B).
■ Dissection is carried down around the tract until it is completely excised,
using the lacrimal probe to guide the excision.
■ The orbicularis oris muscle is reconstructed with 4-0 Vicryl sutures.

■ The mucosa is closed using interrupted 5-0 chromic gut sutures (TECH FIG
12C).
■ Simple excision may be adequate when a single lip pit is present or when lip
pits are small and shallow.
■ Multiple deep pits may result in contour abnormalities of the lower lip.
Vertical Elliptical Wedge Excision
■ A full-thickness vertical elliptical wedge of the lower lip is designed. This
wedge extends to the mucosa internally and crosses the vermilion border onto
the skin externally (TECH FIG 13).
■ The lacrimal probe is used to verify that the sinus tract is contained within
the wedge. The wedge is excised full thickness.
■ The orbicularis oris muscle is repaired.
■ The mucosa, vermilion border, and skin are closed.
■ Though this technique may lead to a smoother contour of the lower lip, the
scarring on the skin of the lower lip is a major drawback.

TECH FIG 12 • A. Central lower lip pit in a child with
van der Woude syndrome. B. Simple transverse
elliptical excision. C. After simple transverse elliptical
excision of the lip pit.
Split Lip Advancement Technique (SLAT)12
■ In SLAT, the pits and tracts are excised in a central wedge of tissue from the
vermilion border to the gingivobuccal sulcus.
■ The lip is then split from the central incision to a point near the commissure.
■ An incision is made along the vermilion border through the pars marginalis.
This incision is then carried vertically and inferiorly in a plane between the
orbicularis oris muscle and the submucosa (TECH FIG 14).
■ The labial artery is preserved within this posterior mucosa flap with the
pars marginalis, whereas the skin and majority of the orbicularis oris
muscle are maintained in the anterior flap.
■ The posterior mucosa flap is advanced toward the midline, and the
orbicularis oris muscle is reconstructed.
■ Skin and mucosa closure is in a T from the midline along the vermilion
border anteriorly.
Inverted-T Excision13
■ The lip pits are both included in a large transverse ellipse. The outer edge of
this ellipse is parallel to the white roll, which helps to maintain a constant
thickness of vermilion.
TECH FIG 13 • Vertical wedge excision of lower lip
pits.

TECH FIG 14 • SLAT technique for lower lip pits.