Operative Technique in Plastic Surgery – Kevin C.Chung

TECH FIG 2 • A. Markings demonstrating the extent of
the surgical incisions. B. The incision is extended to
the apex of the labial cleft. C. Exposure of the maxilla
on the lateral cleft up to the level of the defect in the
piriform rim. D. Scoring the periosteum of the lateral
flap to facilitate medial transposition of the flap and
fistula closure.
TECH FIG 3 • A. Elevation of the mucosa within the
cleft on the medial side of the cleft. B. Division of the
mucosal flaps within the cleft for creation of the nasal
floor of the alveolus.
Closure
■ Closure of the nasal lining should be performed prior to closure of the
palatal defect as the nasal closure is often the most technically demanding
portion of the procedure and is facilitated by optimal exposure.
■ The senior author prefers use of a 5-0 Vicryl suture on a P-2 needle for
closure of the nasal lining.
■ Regardless of the needle selected, a small radius of curvature will facilitate
manipulation of the needle within the confined space of the alveolar cleft.
■ Closure of the palatal fistula is then performed. Use of horizontal mattress
sutures optimizes healing through eversion of the edges of the stiff palatal
mucosa.
■ If palatal flaps have been elevated, the palatal mucosa can be resuspended
and circumdental sutures secured above the cingulum.

■ The space created for the bone graft can now be visualized in three
dimensions (TECH FIG 4A; see FIG 1).
■ The cancellous bone graft is packed into the alveolar cleft from the piriform
rim to the alveolar margin (TECH FIG 4B).
■ The gingival flaps are then sutured to cover the labial fistula.
■ The lateral and medial flaps are sutured to one another with resorbable
everting horizontal mattress sutures.
■ The inferior margins of the gingival flaps are sutured to the palatal flaps
with simple, interdental sutures (TECH FIG 4C).
■ If a splint is to be used, it should be secured prior to awakening the patient.
TECH FIG 4 • A. The alveolar cleft can be visualized
with nasal and palatal closure. B. Demonstrating
placement of the bone graft within the cleft. C. Final
closure of the cleft after placement of the bone graft.
■ Iliac Crest Bone Graft Harvest

■ The incision should be marked prior to the surgical prep.
■ The anterior superior iliac spine (ASIS) is identified and marked.
■ The distal aspect of the incision is placed 2 cm proximal to the ASIS to
protect the lateral femoral cutaneous nerve (TECH FIG 5).
■ The incision should be designed by rolling the lateral skin medially over
the iliac crest. This maneuver allows the surgeon to identify a point lateral
to the iliac crest that can be easily positioned over the iliac crest for surgical
dissection while keeping the incision off of the bony prominence.
■ Designing the incision lateral to the iliac crest will avoid a painful scar
over the iliac crest that may be irritated by clothing.
■ The incision should measure approximately 3 cm in length.
TECH FIG 5 • Design of the incision for harvest of the
iliac crest bone graft.
■ The skin is infiltrated with 1% lidocaine with epinephrine prior to surgical
preparation in order to facilitate hemostasis.
■ After allowing adequate time for vasoconstriction, the incision is extended
sharply to the iliac crest.
■ A self-retaining retractor may be used to assist with exposure.
■ The iliac crest should be identified at the junction of the insertion of the
external oblique musculature and the origin of the tensor fasciae latae.
■ Entering the iliac crest through the junction will eliminate an incision

through deep fascia and minimize postoperative pain.
■ The lateral and medial surfaces of the iliac wing are palpated to identify the
angle of the iliac wing.
■ An osteotome is then used to open the cartilaginous cap in line with that
angle.
■ The senior author prefers to make a single linear opening in the middle of
the cartilage cap that parallels the lateral and medial surfaces of the iliac
wing.
■ This linear opening in the cartilage cap may be widened with a small
curette to allow access to the cancellous bone, without elevating the
cartilage cap.
■ A small curette is then used to harvest the cancellous bone graft; avoid
perforating the lateral or medial cortices of the ileum.
■ When sufficient cancellous bone has been harvested, the wound should be
irrigated and 0.25% Marcaine infiltrated along the periosteum and instilled
into the medullary cavity for analgesia.
■ A resorbable suture may be used to close the cartilaginous cap of the ileum.
■ The incision is then closed in layers, and a sterile dressing applied.
PEARLS AND PITFALLS
Physical findings
■ Closure of residual oronasal fistulae must be performed prior
to or at the time of alveolar bone grafting.
■ Evaluation and optimization of oral hygiene prior to alveolar
grafting is essential to successful bone graft surgery.
Dental/orthodontic
preparation
■ Orthodontic evaluation and preparation with appropriate
restorations, extractions, and palatal expansion is essential.
Technique
■ Watertight closure of the nasal floor is essential for bone
graft take.
■ Wide exposure of the cleft allows adequate visualization of
the nasal floor and access to the cleft for grafting.
■ Sufficient bone graft should be harvested to allow the
alveolar cleft to be filled from the piriform rim to the
alveolar margin.

■ Tension on flap closure should be minimal and may be
assisted by scoring the periosteum at the base of the lateral
buccogingival flap.
Postoperative
care
■ A splint should be utilized in patients with uncorrected
traumatic occlusion and in those who have undergone
transverse maxillary expansion.
■ A soft diet should be maintained for 3 wk postoperatively to
minimize the risk of traumatic injury to the surgical site.
■ Contact sports should be avoided for 4 wk following surgery
if the iliac crest is used as the donor site.
POSTOPERATIVE CARE
■ An intraoral splint is used to maintain palatal expansion if orthodontic
appliances are removed prior to surgery. The splint will also relieve traumatic
occlusion, potential injury to the surgical site, and impaction of food.
■ A liquid diet is advocated for the first 24 hours, and a soft diet is appropriate
for 3 weeks postoperatively.
■ The patient maintains the splint in position while eating and only removes the
splint to perform an oral rinse after each meal.
■ At 3 weeks, the patient may remove the splint and begin brushing gently.
■ The patient may bear weight as tolerated on the donor hip immediately but
should refrain from contact sports for 4 weeks.
OUTCOMES
■ Outcomes assessment includes clinical evaluation and radiographic imaging of
the alveolar bone graft.
■ Clinically, the presence of an alveolar or palatal fistula is a primary outcome
determining surgical efficacy of closure of the fistulae.
■ It may be necessary to use a fine dental probe to assess for small fistulae.
■ In the absence of an overt fistula, clinical symptoms of liquid regurgitation
into the nose should alert the physician to the presence of a persistent or
recurrent fistula.
■ Dehiscence of the oral and/or nasal suture lines jeopardizes the viability of the
alveolar bone graft.
■ Radiographic evaluation of the alveolar bone graft is usually deferred until 6
months following bone grafting, so as to allow for bony regeneration across the
alveolar cleft.

■ The Bergland Scale Score serves as a radiographic gold standard for assessing
alveolar bone graft take. The scale is a four-point scale that serves to assess the
height of interdental bone as viewed on occlusal radiographs.13
■ This scale may fail to adequately evaluate the presence of interdental bone as
it is a two-dimensional analysis of the alveolar cleft. Occlusal radiographs fail
to clearly demonstrate the overall quality of bone retention in the coronal
plane.
■ Recently, the Americleft Project has introduced a new assessment standard, the
Standardized Way to Assess Grafts (SWAG).14 This is a six-point scale with
scores of 0 to 1 indicating graft failure, 2 or 3 indicating a poor graft requiring
regrafting, 4 or 5 indicating a successful graft that may require augmentation,
and 6 a successful graft.
■ Cone-beam computed tomography has emerged as a safe, rapid, and effective
means of obtaining a three-dimensional evaluation of the graft site. While a
scale using cone-beam CT has not been validated, studies have shown that
scales using standard radiographs do not identify bone resorption in the
buccopalatal dimension.15
■ Resorption of approximately 50% in this transverse dimension has been
reported within the first year following bone grafting.16
COMPLICATIONS
■ Infection
■ Bleeding
■ Partial or complete graft loss
■ Recurrence of the oronasal fistula
■ Tooth damage or loss
■ Hip pain
■ Fracture of the iliac wing
■ Injury to intra-abdominal contents
■ Paresthesia of the lateral femoral cutaneous nerve
■ Hypertrophic scar
■ Scar irritation with clothing if the incision is placed directly over the iliac crest
■ Anesthetic complications
REFERENCES
1. Boyne PJ, Sands NR. Secondary bone grafting of residual alveolar and palatal

clefts. J Oral Surg. 1972;30(2):87.
2. Sadove AM, Nelson CL, Eppley BL, et al. An evaluation of calvarial and iliac
donor sites in alveolar cleft grafting. Cleft Palate J. 1990;27:225.
3. Sindet-Pedersen S, Enemark H. Reconstruction of alveolar clefts with
mandibular or iliac crest bone graft: a comparative study. J Oral Maxillofac
Surg. 1990;48:554.
4. Kalaaji A, Lilja J, Elander A, et al. Tibia as donor site for alveolar bone
grafting in patients with cleft lip and palate: long-term experience. Scand J
Plast Reconstr Surg Hand Surg. 2001;35:35.
5. Maxson BB, Baxter SD, Vig KW, et al. Allogenic bone for secondary alveolar
cleft osteoplasty. J Oral Maxillofac Surg. 1990;48:933.
6. Boyne PJ. Application of bone morphogenetic proteins in the treatment of
clinical oral and maxillofacial osseous defects. J Bone Joint Surg Am.
2001;83(suppl 1):S146.
7. Dahlloef G, Ussisoo-Joandi R, Ideberg M, et al. Caries, gingivitis, and dental
abnormalities in preschool children with cleft lip and/or palate. Cleft Palate J.
1989;26:233.
8. Pruzansky S. Presurgical orthopaedics and bone grafting for infants with cleft
lip and palate: a dissent. Cleft Palate J. 1964;1:164.
9. Robertson NR, Jolleys A. Effects of early bone grafting in complete clefts of
the lip and palate. Plast Reconstr Surg. 1968;42:414.
10. Wegscheider W, Bratschko R, Pilschka G, et al. The system of prosthetic
treatment for CLAP patients. J Craniomaxillofac Surg. 1989;17(S1):49.
11. Reisberg DJ. Dental and Prosthodontic care for patients with cleft or
craniofacial conditions. Cleft Palate J. 2000;37(6):534.
12. McKee DE, Lalonde DH, Thoma A, et al. Optimal time delay between
epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg.
2013;131(4):811.
13. Bergland O, Semb G, Abyholm FE. Elimination of the residual alveolar cleft
by secondary bone grafting and subsequent orthodontic treatment. Cleft Palate
J. 1986;23:175.
14. Russell KA, Long RE Jr, Daskalogiannakis J, et al. A multicenter study using
the SWAG scale to compare secondary alveolar bone graft outcomes for
patients with cleft lip and palate. Cleft Palate J. 2016;53:180.
15. Liu L, Ma L, Lin J, et al. Assessing the interdental septal thickness in alveolar
bone grafting using cone beam computed tomography. Cleft Palate J.
2016;53:683.

16. Feichtinger M, Mossboeck R, Kaercher H. Assessment of bone resorption
after secondary alveolar bone grafting using three-dimensional computed
tomography: a three-year study. Cleft Palate J. 2007;44:142.

30
CHAPTER
Surgical Management of
Facial Clefts
David C. Matthews, Samer Abouzeid, and Edward W. Kubek
DEFINITION
■ Craniofacial clefts are rare congenital anomalies of facial development
involving the facial bones, overlying soft tissue, and temporomandibular joint.
■ Facial clefts are classified by their involvement of the orbitomaxillary anatomy
according to the Tessier classification.1
■ Each craniofacial cleft is associated with characteristic, yet highly variable,
bony and soft tissue changes ranging from mild hypoplasia to total agenesis.
■ Facial clefts and labiopalatine clefts are separate entities with key differences
in surgical management and incidence.
■ The extreme variation of facial cleft anatomy mandates a unique surgical
approach for every patient.2
ANATOMY
■ Dr. Paul Tessier published his 0 to 14 organizational system in 1976 (FIG 1).1
■ Because of its clinical utility and relative simplicity, Tessier’s nominal system
continues to be used widely.
■ For purposes of nomenclature, the palpebral fissure/orbit separates lower facial
clefts from their cranial extensions.
■ When they occur together, the numerology of the lower facial cleft plus its
cranial extension always equals 14.
■ Tessier’s 0 to 14 system is based on clinical experience, not embryologic study
(Table 1).
PATHOGENESIS
■ The etiology of facial clefting is incompletely understood but likely involves

both genetic and epigenetic factors.2
■ Abnormalities or premature resolution of the stapedial artery during fetal
development is known to cause facial clefting.
■ The severity of the deformity relates to the timing of stapedial artery
regression in utero.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ In facial clefts, the bone and soft tissue are rarely affected to the same degree.
FIG 1 • Tessier classification of clefts. A. Paths of
various clefts on the face. B. Location of the clefts on
the facial skeleton. (From Tessier P. Anatomical
Classification of facial, craniofacial and lateral-facial
clefts. J Maxillofac Surg. 1976;4:69-92.)
Table 1 Tessier System of Cleft Identification
Tessier
Cleft
No.
Description
Cranial
Extension
Equivalent
Cleft No.
Bony
Abnormalities
Effects on Soft
Tissue and
Appearance

0
Median craniofacial
dysraphia
14
• Similar to
labiopalatine
cleft but
located at the
midline (teeth
fall into cleft)2
• Wide nasal
bones with
enlargement of
the sphenoid
and ethmoid
sinuses
• Duplication of
the crista galli
• Cleft of the
primary and
secondary
palate
• Maxilla lacking
vertical height
• Hypertelorism
• Broad philtral
columns
• Duplication of
midline nasal
structures,
including the
nasal spine
and septum
• Bifid nose and
labial frenulum
1
Paramedian
craniofacial cleft
13
• Traverses
nasal bone
and maxilla
into the
pyriform
• Results in an
anterior open
bite
• Effect on the
ethmoids
results in
orbital
hypertelorism
• Traverses the
dome of the
alar cartilage,
giving a
notched
appearance
• Widening of
the columella
and nasal tip
2
Paramedian
craniofacial cleft
12
• Traverses the
• Traverses

lateral mass of
the ethmoid
with
malformation
of ethmoidal
labyrinth
• Localization
on the frontal
bone
(corresponding
with no. 12
cleft) is
anatomically
imprecise
• Flat glabella
with enlarged
frontal sinus
between the
nasal tip and
the base of th
alar cartilage
• Associated
with cleft lip
• Ipsilateral
absence of th
lacrimal
apparatus
• Hypertelorism
3
Medial
orbitomaxillary cleft
or paranasal cleft
11
• The oblique
course of the
cleft traverses
the lacrimal
groove
• Frontal
process of
maxilla is often
absent
• Medial wall of
maxillary sinus
is often absent
• Traverses the
alar base,
nasolabial fold
and alveolus,
causing a clef
lip

4
Median
orbitomaxillary cleft
10
• Traverses
infraorbital rim
and floor
medial to
infraorbital
nerve
• Traverses the
maxillary sinus
leading to
sinus
exstrophy
• Associated
• Vertically
traverses the
lacrimal
segment of th
lower lid
• Cleft lip is
located
between
philtral crest
and
commissure

alveolar cleft
appears
similar to the
typical alveolar
cleft
5
Lateral
orbitomaxillary cleft
9
• Traverses the
infraorbital rim
lateral to
infraorbital
foramen
• Results in an
alveolar cleft
of the
premolar
region
• Traverses the
medial third o
the lower lid
• Soft tissue
groove is
visible on the
cheek from
lower lid to
lateral lip nea
the
commissure
6
Intermaxillozygomatic
cleft
8
• Located
between the
maxilla and
zygoma;
opens into the
inferior orbital
fissure
• Laterally
located
coloboma of
the lower lid
7
Temporozygomatic
cleft
7
• Absent or
atrophic
zygomatic
arch
• Shortening of
the ascending
ramus and
• Absence of
the coronoid i
accompanied
by ipsilateral
absence of th
temporalis
muscle

reduced height
of the maxilla
• Absence of
the coronoid
and
mandibular
condyle is
common
• Microtia and
pretragal
enchondroma
• Macrostomia
8
Frontozygomatic cleft
6
• When the
malar portion
of zygoma is
absent, the
greater wing of
sphenoid
becomes the
lateral-most
border of the
orbit
• A true cleft of
the lateral
canthus is
associated
with Goldenha
syndrome
9
Superolateral orbital
cleft
5
• Traverses the
superolateral
orbit
• Traverses the
lateral third of
the upper lid
10
Central superior
orbital cleft
4
• Traverses
medial third of
supraorbital
rim and orbital
roof
• Lateral to the
supraorbital
nerve
• Coloboma of
the upper lid
can be severe
(clinical
ablepharia)
11
Superomedial orbital
3
• Traverses the
• Coloboma of

cleft
ethmoid or
supraorbital
rim lateral to
the ethmoid
the medial
third of the
upper lid
• Cleft traverse
the medial
brow
12
Paramedian
craniofacial cleft
2
• Traverses
frontal bone
and lateral
mass of the
ethmoid
• Enlargement
of the frontal
sinus
• Coloboma at
the root of the
eyebrow
13
Paramedian
craniofacial cleft
1
• Traverses the
frontal bone
and olfactory
groove of the
cribriform plate
• Absence of
the ipsilateral
nasal bone
• Cleft is media
to the eyebrow
• Associated
with
encephalocele
and
hypertelorism
14
Median craniofacial
dysraphia
0
• As with cleft
no. 0, often
see duplication
or widening of
midline
structures
• Bifid crista
galli and
ethmoid plate
may be
present
• Rotation of the
sphenoid
wings causes
• Widening or
duplication of
midline
anatomy,
including
frontonasal
encephalocele
hypertelorism
and
telecanthus

attenuation of
the middle
cranial fossa
FIG 2 • Patient with a Tessier no. 5 cleft on the right side
of the face and no. 3 cleft on the left.
■ From midline to the infraorbital foramen, the physical deformity and
morbidity of the soft tissue defects are more evident compared to the bony
defects (FIG 2).

■ From the infraorbital foramen to the temporal bone, bony defects are more
clinically severe with the exception of changes to the external ear.
■ The spectrum of soft tissue deficiency of facial clefts varies more widely than
standard labiopalatine clefts.
IMAGING
■ A maxillofacial CT scan helps define the anatomy of the orbit and maxilla.
■ The orbital floor defect and position of the zygoma are key features to
examine.
■ Evaluate for comorbid conditions (eg, cardiopulmonary anomalies).
DIFFERENTIAL DIAGNOSIS
■ Hypertelorism
■ Microphthalmias
■ Orbital dystopias
■ Treacher Collins syndrome
■ Goldenhar syndrome
■ Hemifacial microsomia are all associated with facial clefting
NONOPERATIVE MANAGEMENT
■ Management is tailored to each individual patient and guided by principles
over protocols.
■ The older the patient at the time of bone grafting, the better.
■ The one exception is if the cornea is compromised. Earlier surgery is
mandatory in this case.
■ The eye should always be hydrated if exposure is suspected due to facial
clefting.
SURGICAL MANAGEMENT
■ This chapter focuses on the management of Tessier no. 3, 4, and 5 clefts.
■ Tessier clefts other than 0/14, 0/13, and 2/13 require a large amount of bone.
■ Otherwise, the bone resorbs and has to be regrafted several times because it
does not grow with the patient.
■ There can be major soft tissue defects with minor bone defects and vice versa.
■ Marked individuality is the rule.
■ Careful attention to eyelid colobomas is mandatory.
■ There may be a future for cadaver grafts for initial surgeries because the bone

graft sources are limited in children.
■ The ideal time for grafting is after facial growth is nearing completion. At this
time, grafts do not resorb to the same extent.
Preoperative Planning
■ Ophthalmologic exam is documented preoperatively.
■ Goals of surgical management of Tessier clefts no. 3, 4, and 52,3:
■ Protect the cornea from exposure keratopathy and blindness with early repair
of colobomas (upper greater than lower lid).
■ Early repair of soft tissue deformities with rotation advancement and
avoidance of Z-plasty incisions that violate subunit principles.4
■ Address anatomic structures for optimal symmetry (lip, nasal ala, alveolus,
inferior orbit/globe, and medial canthus).
■ Plan incisions along subunit lines whenever possible.
■ Dissection and anatomic repositioning of facial musculature improves future
animation and midface growth.4
■ Liberal use of secondary tissue expansion for wider clefts where medial
subunit incision lines were not feasible initially.2
■ As a general rule, 2 to 3 mm of overcorrection is required when suspending
the medial canthus, adding bone to the inferior orbital rim, and dropping the
cleft-side alar base are essential to durable results.4
■ Split calvarial bone grafts can be obtained after 5 years of age.
■ Orthodontic management of occlusion follows a timeline similar to
labiopalatine clefts.
Positioning
■ Supine with shoulder role to extend the neck
■ The endotracheal tube is positioned at midline.
■ The face and neck receive a sterile prep (Betadine); eyes are irrigated with
balanced salt solution (BSS) and closed with ophthalmic ointment.
■ The head is draped with the entire face in the field.
Approach
■ The designs for skin incision must be tailored to the severity of soft tissue
deficiency between the nasal ala and medial canthus. A simple Z-plasty
approach is shown.

T E C H N I Q U E S
■ Management of Tessier Cleft No. 3, 4, or 5
■ The skin is incised along subunit lines medially (TECH FIG 1A).
■ Incise the medial side of the cleft and then the lateral side. The subunits are
the lip, nose, and then the cheek-nose junction.
■ For soft tissue–only operations, facial muscles are reapproximated (nasalis,
orbicularis oculi, and oris).
■ For bony clefts, dissection is extended to the bony cleft margin (TECH FIG
1B).
■ The bony margins are exposed with subperiosteal dissection.
■ Unlike labiopalatine clefts, our practice is to refresh the bone edges with a
bur similar to the technique described by Tessier.
■ The dimensions of autologous bone needed for harvest are measured and
confirmed.
■ Autologous bone (calvarial, iliac, tibial) is preferred over nonautologous
bone, but in our experience, demineralized cadaveric bone substitutes are also
useful.
■ Bone grafts are placed to bridge the cleft and approximate normal anatomic
contours while anticipating a significant degree of graft resorption.
■ Overcorrecting natural anatomic contour is recommended to the maximal
extent that soft tissue coverage allows.
■ To that end, wide periosteal elevation of soft tissue, as advocated by Tessier
(lateral to the molars on each side), is allowed.
■ To gain additional soft tissue mobility for wide or bilateral facial clefts,
Tessier advised a back-cut in the periosteum along the lateral maxillary
buttress.
■ The bone grafts are fixed as necessary using lag screws, 2-0 Vicryl, or are
simply held in place by the soft tissue envelope and globe (TECH FIG 1C).

TECH FIG 1 • A. To access the underlying bony
defect, incisions are made along the border of the
cleft, at the junction of skin and mucosa. B. Once
incisions are made, the body margins of the cleft are
exposed, and cancellous bone is used to fill the entire
defect. C. In addition to cancellous bone filling, cortical
bone should be used along the alveolar edge and the
orbital edge and then fixed into position with screws.
■ Medullary (cancellous) bone is used like plaster to fill gaps between cortical
bone grafts and should lay over the interface of graft and maxilla.
■ Lower eyelid support is achieved with bone grafts to the orbital rim and
inferiorly based frontonasal flaps.
■ Bone grafts to the orbital rim should exceed the normal height by 2 to 3 mm

anticipating partial resorption.
■ Medial canthopexy is best done using a transnasal wire technique.
■ The lateral canthus is suspended vertically with anchoring sutures to the
orbital periosteum superiorly. Lateral traction places the medial canthopexy
at risk.
■ Proper bone graft volume necessitates moderate tension of the soft tissue at
the time of closure.
■ Meticulous layered closure of periosteum, mucosa, muscle, and skin is
performed top-down to align lower lids, malar soft tissue, alar bases, and
involved lip segments. Approximating the orbital to malar periosteum is
essential for malar suspension.
■ A tarsorrhaphy is recommended.
■ If parietal bone is harvested, a 7-French closed suction drain is placed and
removed at 24 to 48 hours.
■ The goals of revision at the time of secondary surgery are to conceal
incisions along medial subunit lines.
■ A combination of planning far into the future at the time of initial surgery,
nasalis muscle dissection and reinsertion, and tissue expansion to allow
medialization of scars is essential to achieve optimal surgical and
psychosocial outcomes.2,4
PEARLS AND PITFALLS
Physical
findings
■ Soft tissue and bone deformities often do not correspond to each
other.
■ Medial to the infraorbital nerve, the soft tissue deformities
predominate.
■ Lateral to the infraorbital nerve, bony deformities predominate.
Technique
■ Z-plasty incisions that violate subunit principles will not improve
with time.2
■ For wide clefts where Z-plasties are used for initial closure, future
use of tissue expansion to reposition scars along medial subunit
lines markedly improves appearance.2
■ The orbital rim bone graft is essential for lower eyelid support and
correction of dystopia.

■ Raising the rim and globe 2–3 mm (on-table) compared to the
noncleft side is advised.
■ We recommend periosteal coverage of bone grafts whenever
possible.
■ Calvarial bone is preferred over rib grafts.
■ Overcorrecting the alignment of key structures by 2–3 mm is
advised.2–4
■ Upper eyelid colobomas pose a greater risk to vision loss and
should be corrected early.2
Postoperative
■ Eye ointment should always be used to protect the eye.
■ Repeat bone grafting may be required.
■ For more severe deficiencies, an inferiorly based paramedian frontonasal flap
can be designed to rotate 90 degrees toward the facial cleft to provide exposure
and additional soft tissue between nasal ala and medial canthus (this maneuver
helps to lengthen the nose and support the lower lid).
■ Anatomic structures along the facial cleft margins are often hypoplastic or
absent.
■ A Doppler probe can be used to assess and preserve the ipsilateral angular
artery. If the angular artery is absent, collateral flow from the contralateral
system will perfuse an inferiorly based frontonasal flap.
■ The lacrimal system is absent or nonfunctional in most Tessier cleft number 3
cases. If present, the anatomy is defined using probes and a lacrimal duct stent
is placed.
■ The insertion and function of muscles located between the cleft and nasal
midline (nasalis, levator labii superioris, orbicularis oris, and orbicularis oculi)
are often abnormal.
POSTOPERATIVE CARE
■ Eye ointment should be used to keep the eye lubricated.
■ Chlorhexidine mouth wash should be used if patient is old enough to
cooperate; if not, water gargle after each meal is advised.
■ After healing, a light massage to the eyelid to soften scar tissue should be
applied.
OUTCOMES
■ Secondary bone grafts may be required due to lack of growth in the area of the
graft.

■ Bone resorption and/or loss should be anticipated.
COMPLICATIONS
■ Bone infection, especially involving areas of the bony reconstruction where it
will take the longest for the avascular bone graft to be replaced with new
vascular bone
■ Wound dehiscence
■ Bone resorption
■ Skin retraction (especially involving the lower eyelid)
REFERENCES
1. Tessier P. Anatomical Classification of facial, craniofacial and lateral-facial
clefts. J Maxillofac Surg. 1976;4:69-92.
2. Monasterio FO. Taylor JA. Major craniofacial clefts: case series and treatment
philosophy. Plast Reconstr Surg. 2008;122(2):534-543.
3. Alonso N, Freitas Rda S, de Oliveira e Cruz GA, et al. Tessier no. 4 facial
cleft: evolution of surgical treatment in a large series of patients. Plast
Reconstr Surg. 2008;122(5):1505-1513.
4. Chen PK, Chang FC, Chan FC, et al. Repair of Tessier no. 3 and no. 4
craniofacial clefts with facial unit and muscle repositioning by midface
rotation advancement without Z-plasties. Plast Reconstr Surg.
2012;129(6):1337-1344.

31
CHAPTERGingivoperiosteoplasty
Mark C. Martin
DEFINITION
■ Involvement of the alveolus in an oral cleft requires treatment to establish
bony continuity of the divided maxilla.
■ Closure of the alveolar cleft has many positive effects including preventing
nasal regurgitation of liquids, preservation of crestal bone height necessary for
periodontal health, allowing safe orthodontic movement of teeth, and
improving stability of the maxillary arch against relapse after occlusal
correction.
■ The ideal age for alveolar cleft closure is controversial.1–4
■ Gingivoperiosteoplasty (GPOP) refers to repair of the alveolar cleft without
bone grafting with the intention of promoting osteogenic bridging of the cleft
by surgically creating a closed space across the alveolar cleft lined by
mucoperiosteal flaps.
ANATOMY
■ The alveolar cleft ranges from a minor notch to a complete cleft of the primary
and secondary palate.
■ The cleft presents as a variable gap that involves displacement, deformity, and
hypoplasia.
■ The cleft margin on the major segment flares anteriorly and deviates toward
the noncleft side, and the alveolar stump curves cranially as the growth force of
the vomerine septum lacks a restraining connection to the lesser maxillary
segment (FIG 1A).
■ The cleft margin of the minor segment is positioned posteriorly, and its
alveolar stump curves in a cranial direction from the frontal view as it

approaches the cleft (FIG 1).
■ The maxillary primary central incisors erupt at a variable age (usually between
6 and 12 months) and depending on the age of presentation and the surgeon’s
preferred timing for GPOP, these teeth may or may not be present at the time of
surgery.
■ The primary lateral incisor erupts between 12 and 18 months and on the cleft
side is commonly hypoplastic or may be absent or accompanied by
supernumerary teeth.
■ Natal teeth may go unnoticed early in life in the setting of the cleft and be
present high in the nose, which can affect the design of mucoperiosteal flaps.
■ The abnormal anatomy of the lateral cleft must be recognized as failure to
develop different tissue types with heterotopic placement of existing tissues;
choosing nonosteogenic membranes to line the alveolus repair may diminish
the chance of adequate bone formation (FIG 1B–D).
■ Synergistic with correct lining of the GPOP, the use of a medial nasal lining
flap to resurface a lateral vestibular releasing incision between vestibular skin
(vibrissae) and vestibular mucosa (hairless) allows correction of alar base
position without using nonanatomic flaps.
■ The anatomy of the medial cleft is difficult to visualize due to the three-
dimensional deformity (FIG 1E–G).
■ Dislocation of the caudal septum into the noncleft nasal floor and the cranial
inclination of the medial stump of the alveolus creates an acute angle between
the septal mucoperichondrium and nasal floor mucoperiosteum, which can be
challenging to dissect and mobilize.
■ By lifting the medial nasal lining flap in continuity with the septal
mucoperichondrium and subsequently correcting the caudal septum in the
midline, the medial nasal lining flap can be used for tension-free
reconstruction of the nasal floor, as well as to line the vestibular release with
thin supple tissue (FIG 2).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Age of patient at presentation is important.
■ Early institution of nasoalveolar molding (NAM) is thought to have more
lasting effects on nasal cartilages due to the presence of maternal hormones.5
■ Older children are more likely to disturb the appliance creating compliance
difficulties.

■ An alveolar cleft with alveolar segments in apposition may not benefit from
NAM but should be monitored for unfavorable changes in position (increased
gap) of the maxillary segments that can occur with oral-digital habits or
feeding behaviors.
■ An isolated cleft of the lip (primary palate) may benefit from the nasal
molding effects of NAM, but the change at the alveolus will be limited by the
rigidity imparted by bony continuity of the secondary palate.
■ Infants with medical comorbidities will often tolerate NAM therapy, but
individualized attention to the appliance’s effect on feeding and weight gain is
indicated.
IMAGING
■ Imaging in the setting of isolated cleft lip and palate is not normally obtained
before GPOP, but may be indicated to evaluate more extensive craniofacial
clefts.
■ Imaging to assess results of GPOP is not standardized and may involve a
variety of modalities.
■ Plain occlusal radiographs are commonly used to assess alveolar bone
formation in young patients (primary and early mixed dentition) and periapical
and/or panoramic radiographs in older patients (late mixed and permanent
dentition).
■ Cone-beam computed tomography (CBCT) is increasingly used and provides
more detailed information than plain films regarding the adequacy of alveolar
bone; the clinical utility of CBCT use is still under evaluation.

FIG 1 • A. The cleft alveolus deformity. The columellar
base is displaced toward the noncleft side (yellow
arrow). The greater segment alveolus stump is flared
anteriorly (red arrow). The alar base on the cleft side is
displaced posteriorly through its relationship to the
pyriform rim (blue arrow). B. Lateral cleft anatomy. C.
Gingival mucoperiosteum shaded green, labial mucosa
shaded orange, vestibular skin with vibrissae shaded
blue, vestibular mucosa pink, and hairless shaded
yellow. D. Yellow incision plan including vestibular
release between vestibular skin and vestibular mucosa
to achieve medial nasal lining flap during closure. E.
Medial cleft anatomy. F. Gingival mucoperiosteum

shaded green, labial mucosa shaded orange, vestibular
skin with vibrissae fixed to medial crus shaded blue,
mobile vestibular mucosa of membranous septum and
nasal floor mucoperiosteum shaded pink, and hairless
shaded yellow. G. Incision plan including medial nasal
floor mucoperiosteal lining flap for nasal floor repair and
lining of lateral vestibular back cut.
NONOPERATIVE MANAGEMENT
■ There is no dispute that alveolar clefts benefit from repair; however, the timing
and techniques for repair remain controversial.1–4
■ If GPOP is not done in infancy by design, or if it has been done
unsuccessfully, secondary alveolar cleft repair with autologous bone grafting
(most commonly with cancellous iliac crest bone) is a well-established
procedure with a high success rate.6
SURGICAL MANAGEMENT
■ GPOP in infancy is technically challenging and reported outcomes vary widely
among authors.1–3,6–8
■ Some authors have reported an increase in midface growth deficiency, whereas
others have not.2,4
■ A surgeon’s technique has been shown to be an important determinant of facial
growth after repair of oral clefts in general.
■ Modern authors have demonstrated useful bone filling of the alveolar cleft
from 73% to 100% depending on the specific technique and protocol.1,6
■ Even in patients who do not form adequate bone after GPOP, it has been
reported that subsequent successful standard mixed dentition bone grafting is
technically easier than in those not having undergone GPOP.6
■ Successful GPOP eliminates one operation at school age and the need to use a
painful distant donor site (most commonly the iliac crest in North America).
■ GPOP is often preceded by NAM, which requires a skilled dental professional,
significant time commitment from caregivers, may be costly, and can be
ineffective in the setting of noncompliance.9

FIG 2 • A. Infant skull schematic showing caudal septal
dislocation into noncleft nasal floor with dark pink nasal
lining and light pink palate mucoperiosteum. B. Midline
correction of the caudal septum allows lateral
movement of the in-continuity medial nasal floor lining
flap in concert with palatal mucoperiosteal repair.
■ GPOP is most often performed at the time of cleft lip and nasal repair in North
America either after NAM or in the setting of a pre-existing narrow cleft gap.
■ Alternatively, mucoperiosteal repair of the alveolus can also be highly
successful when performed at the time of palate repair, after muscle forces of
the repaired lip mold the palatal segments into proximity.1,10
Preoperative Planning
■ Children with cleft lip and palate should be evaluated before surgery by a
multidisciplinary team including the cleft surgeon, pediatrician, medical
geneticist, otolaryngologist, pediatric dentist, speech and language pathologist,
and social worker.
■ Children with complete cleft lip and palate with an alveolar gap and/or
significant nasal deformity benefit from NAM by a pediatric dentist or
orthodontist with training and experience in the technique.
■ The purpose of NAM is to gradually approximate the alveolar segments and to
mold the nasal deformity in order to allow GPOP with minimal dissection and
to facilitate cleft lip and nasal repair (FIG 3).
■ Patients should be evaluated and treated by a trained pediatric anesthesiologist.

Positioning
■ An oral Ring-Adair-Elwyn (RAE) tube is used and is secured in the midline.
■ A short “mesentery” of tape allows use of a Dingman retractor without
pinching the lower lip (FIG 3B).
■ The infant is treated in the supine position using a soft headrest with mild neck
extension and routine warming measures.
■ The eyes are irrigated with balanced salt solution and protected with skin tape.
Approach
■ Skoog reported a technique using wide undermining of the maxilla and
periosteal flaps with Surgicel implantation in an attempt to promote bone
formation at the alveolar cleft without bone graft.
■ Skoog’s technique utilizing periosteal flaps has been generally abandoned due
to reports of midface growth inhibition and poor bone formation.11
FIG 3 • A. A wide cleft alveolus gap at initial
presentation. B. After nasoalveolar molding with
abutted alveolar segments.
■ Millard reported a protocol involving a pin-retained appliance for maxillary
segment positioning followed by GPOP with small flaps.3
■ Concerns about midface growth inhibition, possibly related to strong forces
generated by the screw-activated facial orthopedic appliances, limit the current
use of protocols relying on active pin-retained appliances.

■ Smith et al. suggested an anatomic repair of the primary palate with
mucoperiosteal flaps after physiologic alveolus molding occurred following
initial nasolabial and soft palate repair, but reported no long-term outcomes.10
■ Meazzini et al. used a similar protocol to that suggested by Smith et al. and
reported a 100% success in avoiding secondary bone grafting.1
■ Wood et al. reported that a Millard-type GPOP after NAM did not result in
early midface growth inhibition.4
T E C H N I Q U E S
■ Markings and Incisions
■ The plan for the cleft lip repair is marked per the surgeons’ preferred
technique.
■ The alveolar cleft is inspected, and local anesthetic with epinephrine is
injected along the gingival margins, palatal mucoperiosteum, nasal septum,
and nasal floor (TECH FIG 1A).
■ Incisions are made on the crest of the alveolus, mesial and distal to the cleft
at the junction of gingival mucoperiosteum and palatal mucoperiosteum
(TECH FIG 1B,C).
■ Incisions are then made on the palatal surface along the margins of the cleft
at the junction where the deep red nasal floor lining meets the light pink
palatal mucoperiosteum.
■ As part of the concurrent lip repair, the mobile labial mucosa is incised from
the nasal vestibular mucosa on the lateral segment and the mobile mucosa of
the membranous septum on the medial segment (TECH FIG 1B).
■ The alveolar ridge incision between gingival and palatal mucoperiosteum
converges with the incision between labial mucosa and vestibular mucosa at
the entrance to the floor of the nose (TECH FIG 1C).

TECH FIG 1 • A. Frontal view of an infant with
complete cleft lip and palate. B. Greater segment
incisions between gingival and palatal
mucoperiosteum on the crest of the alveolus and
diverging at the nasal floor to define the medial nasal
floor lining flap. C. Lesser segment incision between
gingival and palatal mucoperiosteum along with
vestibular release incision between vestibular skin and
vestibular mucosa.
■ Flap Elevation
■ The lateral segment gingivoperiosteal flap is elevated gently with a fine
periosteal elevator.
■ Dissection should proceed mesial to distal and caudal to cranial starting at
the crest of the alveolus and proceeding up the maxilla.
■ The teeth in the lateral segment are typically unerupted at the usual time
for GPOP, and it is important to be gentle with dissection here as forceful
dissection directed from cranial to caudal has the potential to avulse
unerupted teeth.
■ Dissection at the crest of the alveolar ridge should be completed sharply with
scissors or scalpel to leave the tooth bud intact and not expose the crown.
■ A lateral segment palatal mucoperiosteal flap is gently elevated with a Freer
elevator with similar precautions to avoid traction on teeth at the crest of the
alveolus.
■ The mucoperiosteum of the lateral nasal floor is carefully elevated with a
periosteal elevator.

■ Elevation of the gingival, palatal, and nasal floor mucoperiosteal flaps on the
lateral segment is performed progressively, only up to the point where
tension-free closure becomes possible.
■ On the medial segment, the gingivoperiosteal flap is elevated distal to mesial
with a periosteal elevator in a subperiosteal plane, except at the crest of the
alveolus where sharp dissection with scissors or scalpel frees the flap from
the soft tissue of the tooth bud; the crown is not exposed if it has not yet
erupted.
■ A medial segment primary palatal mucoperiosteal flap is elevated with a
Freer elevator.
■ A medial segment nasal lining flap is elevated from the bone of the nasal
floor, over the nasal surface of the primary palate up to the junction with the
septum.
■ The septal-nasal floor angle may be very acute, and gentle dissection is
important to avoid flap perforation or injury to the caudal septum.
■ Repositioning of Elements
■ At this point, contralateral subperichondrial dissection on the cartilaginous
septum may proceed to allow midline relocation of the caudal septal
cartilage.
■ The caudal septal cartilage is thin. Avoid damaging the septum during this
step.
■ Septal relocation to the midline has beneficial effects.
■ Subsequent primary rhinoplasty is easier when the septum is straight.
■ Bringing the septum to the midline lateralizes the medial nasal lining flap
to allow tension-free nasal floor reconstruction (see TECH FIG 1B).
■ The cleft deformity results in a posterior positioning of the bony nasal
pyriform rim on the cleft side.
■ The alar base and lateral crus of the lower lateral cartilage are tethered
posteriorly and benefit from a vestibular releasing incision to allow
repositioning of the alar base and lateral crus (see TECH FIG 1C).
■ The medial nasal floor lining flap based on the cleft-side septal
mucoperichondrium is used to span the nasal floor cleft and can also be used
to line the defect resulting from a vestibular releasing incision (obviating the
need for nonanatomic labial or inferior turbinate mucosal flaps; TECH FIG

2).
■ At this point, the cleft-side alar dome can be easily repositioned without
vestibular tightness or vestibular web formation.
TECH FIG 2 • Repaired palatal and gingival
mucoperiosteal flaps with view of medial nasal floor
lining flap inset into apex of vestibular releasing
incision.
■ Suturing and Completion
■ Nasal floor mucosal repair is performed with 6-0 Vicryl or equivalent
sutures.
■ Nostril sill skin repair is completed with 6-0 chromic or equivalent simple
sutures up to the junction of the sill and cutaneous lip.
■ A short, locking Castroviejo needle holder is useful for intranasal suturing,
where access is limited.
■ If the ipsilateral septal mucoperichondrial undermining has been avoided up
to this point, the septum will typically be held in passive midline correction
by the effect of the nasal floor repair.
■ If the ipsilateral septal mucoperichondrium was inadvertently undermined,

the caudal septum may be sutured superficially to bone with an absorbable
suture to maintain it in midline position.
■ Palatal mucoperiosteal flaps are repaired with 5-0 Vicryl or equivalent
sutures.
■ Gingivoperiosteal flaps are repaired with 5-0 Vicryl or equivalent sutures
(TECH FIG 3).
■ Lip and nose repair proceed per the surgeon’s preferred technique (TECH
FIG 4).
■ Vestibular tightness will normally have been eliminated by this point with
nasal floor and vestibular repair allowing untethered lower lateral cartilage
repositioning.
■ Using medial nasal floor mucosa to line the resulting lateral vestibular defect
allows anterior positioning of the cleft-side alar base so that cartilage
repositioning can be achieved without posterior restraint.
TECH FIG 3 • Repaired cleft of the alveolus and lip.

TECH FIG 4 • Unilateral cleft lip and palate before
(A,B) and after (C,D) gingivoperiosteoplasty along
with lip and nasal repair showing the beneficial effect
of formal nasal floor and vestibular reconstruction on
the anteroposterior position of the cleft alar base.
PEARLS AND PITFALLS
Hemostasis
■ GPOP is technically demanding and cannot be safely completed in
the setting of active bleeding.
■ Careful use of epinephrine-containing local anesthetic is essential.
Technique
■ The anatomy of the unerupted dentition is unfamiliar to many
surgeons and should be studied before attempting GPOP.
■ Rough, blunt dissection of gingival flaps can easily luxate
unerupted or recently erupted teeth.
■ Perform gentle subperiosteal dissection over bone and sharp
dissection over unerupted teeth.
■ A short, locking Castroviejo needle driver is useful for suturing in
tight spaces such as the nasal floor.

■ Short radius needles such as the P2 are useful for suturing in areas
with limited access.
Nasoalveolar
molding
■ Close approximation of maxillary segments is critical for
minimizing the growth inhibiting effects of surgery.
■ Prolonged NAM has diminishing returns because older infants are
more adept at removing the device.
■ Significant skin irritation from taping the device may occur and
impede identification of lip landmarks. Discontinuation of the
appliance several days before surgery may be indicated for
significant skin irritation.
■ The alveolar cleft gap must be diminished through alveolar
molding and not through transverse collapse of the segments, as this
will lead to loss of arch length and “locking in” of improper arch
form.
Cleft lip and
nose
■ Midline relocation of the cartilaginous septum simultaneously
facilitates primary rhinoplasty and GPOP.
■ By using the primary palatal nasal lining flap to fill the lateral
vestibular releasing incision, the use of nonanatomic labial or
turbinate mucosal flaps is avoided.
POSTOPERATIVE CARE
■ Arm restraints are used only until the effects of general anesthesia have worn
off.
■ A well-repaired alveolus is not at risk from the infant’s fingers.
■ Feeding is resumed using the patient’s preoperative routine with the exception
of limiting the use of any hard feeding implements (eg, plastic spoons and
cups) or toys until primary healing is observed in the outpatient setting
(typically between 10 and 14 days).
■ Patients remain in hospital until normal feeding and adequate pain control are
achieved (1–2 nights in most cases).
■ Patients are seen in the outpatient clinic at weekly intervals until primary
healing is confirmed and then at intervals otherwise dictated by early aftercare
requirements of associated lip and secondary palate repairs.
■ The child is subsequently seen at least yearly in the Cleft and Craniofacial
Team Clinic until the end of growth and treatment.
OUTCOMES
■ The NYU group studied patients treated with NAM and GPOP using Millard’s

technique at the time of primary lip repair.6,8
■ The alveolar cleft sites treated with GPOP did not require secondary alveolar
bone grafting in 73% of cases.6
■ Using cephalometric analysis of unilateral cleft lip and palate patients
evaluated before puberty, they found no significant difference in vertical or
sagittal midface growth between those receiving GPOP and those who did
not.8
■ Brusati and colleagues performed a technique of gingivoalveoloplasty in
concert with palatal repair with more extensive mobilization of mucoperiosteal
flaps analogous to those used in secondary bone grafting procedures.
■ In a study of 87 unilateral and 29 bilateral cleft lip and palate patients, none
required secondary alveolar bone grafting.1
■ In a retrospective study, 15 gingivoalveoloplasty patients were compared
with 10 receiving only secondary bone grafts. An increased need for
orthognathic surgery was projected for gingivoalveoloplasty patients (26.6%)
vs secondary bone grafted patients (10%).2
■ Interpreting studies attempting to measure the effect of GPOP on facial growth
must account for the wide variability in the rate of orthognathic surgery
reported at different centers.
■ Daskalogiannakis and Mehta reported a 48% rate of orthognathic surgery for
unilateral cleft lip and palate patients.12
■ Such intercenter variability can relate to many factors:
■ Differing rates of syndromic diagnoses
■ Anthropometric differences between population groups under study
■ Lack of standardized orthognathic surgery indications
■ Variability in acceptance of orthodontic camouflage
■ Cultural variations in concepts of attractiveness
■ Variation in access to interceptive dental treatment
■ Changes in technique over time
■ Errors relating to incomplete records and follow-up
■ Preclinical studies have demonstrated risks of neurotoxicity from exposure to
common anesthetic agents.13
■ There has been increased interest in limiting anesthesia exposure in the
pediatric population while ongoing clinical studies attempt to quantify the
actual risk.
■ The possible detrimental effect of early anesthesia may be a consideration

when choosing between surgical lip adhesion and NAM therapy for the
purpose of alveolar cleft approximation.
■ The burden of multiple surgeries is significant for cleft patients. McIntyre et
al. found in their single center retrospective study that unilateral cleft lip and
palate patients averaged 9.4 surgeries between birth and age 21.14 Limiting
numbers of surgeries may have significant benefit to patients.
■ NAM therapy may be a useful means of reducing secondary operations.
■ Dec et al. found that out of 178 patients undergoing NAM and subsequent
staged lip and palate repair, only four palatal fistulas occurred with only one
requiring repair.7
■ Patel et al. found that only 3% of NAM-treated unilateral cleft lip and palate
patients required early nasal revision vs 21% of non-NAM patients.5
COMPLICATIONS
■ Fistula
■ Tooth injury
■ Suture granuloma
■ Growth restriction
■ Inadequate bone formation requiring secondary bone grafting
■ Infection
REFERENCES
1. Meazzini MC, Tortora C, Morabito A, et al. Alveolar bone formation in
patients with unilateral and bilateral cleft lip and palate after early secondary
gingivoalveoloplasty: long-term results. Plast Reconstr Surg.
2007;119(5):1527-1537.
2. Meazzini MC, Capasso E, Morabito A, et al. Comparison of growth results in
patients with unilateral cleft lip and palate after early secondary
gingivoalveoloplasty and secondary bone grafting: 20 years follow up. Scand J
Plast Reconstr Surg Hand Surg. 2008;42(6):290-295.
3. 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.
4. Wood RJ, Grayson BH, Cutting CB. Gingivoperiosteoplasty and midfacial
growth. Cleft Palate Craniofac J. 1997;34(1):17-20.
5. Patel PA, Rubin MS, Clouston S, et al. Comparative study of early secondary

nasal revisions and costs in patients with clefts treated with and without
nasoalveolar molding. J Craniofac Surg. 2015;26(4):1229-1233.
6. Sato Y, Grayson BH, Garfinkle JS, et al. Success rate of
gingivoperiosteoplasty with and without secondary bone grafts compared with
secondary alveolar bone grafts alone. Plast Reconstr Surg. 2008;121(4):1356-
1367.
7. Dec W, Shetye PR, Grayson BH, et al. Incidence of oronasal fistula formation
after nasoalveolar molding and primary cleft repair. J Craniofac Surg.
2013;24(1):57-61.
8. Lee CT, Grayson BH, Cutting CB, et al. Prepubertal midface growth in
unilateral cleft lip and palate following alveolar molding and
gingivoperiosteoplasty. Cleft Palate Craniofac J. 2004;41(4):375-380.
9. Shay PL, Goldstein JA, Paliga JT, et al. A comparative cost analysis of cleft
lip adhesion and nasoalveolar molding before formal cleft lip repair. Plast
Reconstr Surg. 2015;136(6):1264-1271.
10. Smith WP, Markus AF, Delaire J. Primary closure of the cleft alveolus: a
functional approach. Br J Oral Maxillofac Surg. 1995;33(3):156-165.
11. Skoog T. The use of periosteum and surgicel for bone restoration in
congenital clefts of the maxilla: a clinical report and experimental
investigation. Scand J Plast Reconstr Surg. 1967;1(2):113-130.
12. Daskalogiannakis J, Mehta M. The need for orthognathic surgery in patients
with repaired complete unilateral and complete bilateral cleft lip and palate.
Cleft Palate Craniofac J. 2009;46(5):498-502.
13. Miller TL, Park R, Sun LS. Report of the fourth PANDA Symposium on
anesthesia and neurodevelopment in children. J Neurosurg Anesthesiol.
2014;26(4):344-348.
14. McIntyre JK, Sethi H, Schönbrunner A, et al. Number of surgical procedures
for patients with cleft lip and palate from birth to 21 years old at a single
children’s hospital. Ann Plast Surg. 2016;76(suppl 3):S205-S208.

32
CHAPTER
BMP Use in the Craniofacial
Skeleton
James P. Bradley and Kristen S. Yee
DEFINITION
■ Synthesized recombinant human bone morphogenetic proteins (BMPs) have
osteoinductive activity (ability to induce new bone formation) for use in the
craniofacial skeleton and may replace bone grafts, which have a high
morbidity, and alloplastic grafts, which are incompatible with the growing
skeleton.
■ Craniofacial operative procedures that utilize BMP-2 and a resorbable matrix
include (a) alveolar cleft repair (both primary and secondary), (b) cranial vault
defect reconstruction, and, less commonly, skeletal reconstruction, like (c)
mandibular defect repair with supportive crib or (d) rare Tessier cleft repair.
ANATOMY
■ Alveolar cleft defects may be unilateral or bilateral and are thought of as three
dimensional (3D) trapezoid shapes that span from the floor of the nose
(superiorly), to the alveolar ridge (anteriorly), to the bottom of the gingiva or
adjacent tooth root with attached gingiva (inferiorly), and to the incisor
foramen (posteriorly) (FIG 1A,B).
■ Cranial vault defects vary in size and location and may be complete or
incomplete; these defects have varying degrees of intervening scar from the
deep dura to the more superficial periosteum, galea, or skin. Reconstructions of
skull defects near the frontal sinuses or other areas lined with mucosal
membranes are fraught with infectious problems.1
■ Mandibular defects also vary in size and location and present after tumor
resection or as a result of complications of trauma (including nonunion and
osteomyelitis).2 They may be separated into anterior (symphyseal,

parasymphyseal), lateral (body, ramus), or posterior (condylar).
■ Rare Tessier clefts are associated with bony defects in the facial skeleton based
on defined embryologic zones numbered from 0 to 14 (FIG 2). Skeletal
defects correlate with overlying soft tissue deficits and may extend from the
maxilla, through the maxillary sinus, into the orbit and/or into the cranium.
These skeletal defects benefit from bony reconstruction.
PATHOGENESIS
■ Congenital: Facial clefts (common, cleft lip and palate, and rare, Tessier-
numbered clefts) occur due to failure of fusion of facial embryologic elements.
FIG 1 • Intraoperative image of right cleft lip and palate
patient during primary lip, nose, and GPP with BMP-2
repair. A. The alveolar defect is represented
anatomically as a 3D trapezoid that extends from the
floor of the nose (superiorly), to the alveolar ridge
(anteriorly), to the bottom of the gingiva or adjacent
tooth root with attached gingiva (inferiorly) and to the
incisor foramen (posteriorly). B. The BMP-2–
impregnated collagen gel fills the alveolar defect after
deep mucosal flaps are closed. Careful soft tissue
closure over the implant is then performed.

FIG 2 • Tessier classification of craniofacial clefts.
Skeletal locations of numeric clefts are depicted on the
right side of the face, and soft tissue landmarks are
outlined on the left side of the face. Facial clefts are
numbered 0 through 7, and cranial clefts are numbered
8 through 14. A mandibular midline facial cleft is
number 30.
■ Oncologic: Tumors in the craniofacial skeleton may arise from a variety of
pathologies involving bone or adjacent soft tissue.

■ Traumatic: Defects typically arise as sequelae of initial bony repair, such as
nonunion, osteomyelitis, or absorption of a bone flap or graft.3,4
NATURAL HISTORY
■ Alveolar clefts that are not repaired (or poorly repaired) can have several
consequences.
■ A persistent oronasal fistula may result in poor speech and difficult hygiene.
■ Insufficient or absent bone may prevent eruption of teeth in the cleft area and
also result in malocclusion due to maxillary arch collapse.
■ Discontinuity of the maxillary arch increases difficulty of a future Le Fort I
advancement.
■ Lack of bone under the nasal base results in nasal asymmetry.
■ Large cranial defects necessitate the use of helmets to protect the brain and
may result in the “syndrome of the trephine”—neurologic cognitive deficits
related to disruption of equilibrium of intracranial pressure secondary to
exposure of the brain to atmospheric pressure.5
■ Unrepaired mandibular defects can result in difficulties with mastication and
speech and an “Andy Gump” deformity, characterized by severe retrognathia
and the appearance of an absent chin from contraction of the soft tissues over
the area with missing bone.
■ Rare Tessier craniofacial clefts repairs that do not receive adequate skeletal
support will result in soft tissue collapse and progressive worsening of the
deformity over time.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Alveolar cleft: An alveolar defect can be associated with nasal regurgitation
and poor feeding when associated with a cleft palate or oronasal fistula; a gap
or notch in the alveolar ridge is seen on examination.
■ Cranial defect: The history may include head trauma or prior intracranial
hemorrhage necessitating decompressive craniotomy; the edges of the bony
defect are palpable, and with long-standing, large defects, the skin may be
contracted into the depression (sunken skull deformity).
■ Mandibular defect: The patient’s history includes prior mandibular surgical
resection. The patient may report problems with mastication, oral competence,
or pain. Malocclusion and soft tissue collapse can be seen on exam.
■ Rare craniofacial cleft: Larger clefts can be noted on prenatal ultrasound and
consultation may be planned before delivery; findings vary depending on the

site and severity of the cleft. Careful examination of the eye and lid structures,
and nasal and oral cavities should be performed, particularly when the cleft is
adjacent to these structures.
IMAGING
■ Alveolar cleft: Although imaging should be used sparingly in infants and
children due to risks of radiation exposure, a CT scan can be useful to assess
the volume of the defect and the graft “take” after surgery (FIG 3). Routine
records for secondary alveolar grafting include a panorex and periapical films.
■ Cranial defect: A CT scan (1-mm cuts from the apex to the hyoid) with 3D
reconstruction gives an accurate assessment of the defect size and location, as
well as record of brain pathology, including ventricular size. In addition, a 3D
CT scan model may be helpful for intraoperative resorbable plate shaping.
■ Mandibular defect: A CT scan with 3D reconstruction, with or without model
reconstruction, acts as a road map for reconstruction and guide for creation of
custom-made supportive cribs (FIG 4).
■ Rare Tessier clefts: A CT scan with 3D reconstruction is of paramount
importance with these cases because of the unique skeletal abnormalities that
occur within Tessier-numbered regions that the outward soft tissue findings
only partially suggest.
SURGICAL MANAGEMENT
■ Alveolar cleft: Primary alveolar cleft closure at the time of cleft lip or palate
repair with gingivoperiosteoplasty (GPP) and BMP-2 is possible after
presurgical molding approximates alveolar segments within 2 mm (FIG 5A,B).
Secondary alveolar closure may be performed after orthodontic palatal
expansion at approximately age 6 to 10 years of age.

FIG 3 • CT scan with axillary cuts of a patient with right
cleft lip and palate. A. Preoperative image shows the
alveolar defect. B. Postoperative image 6 months after
gingivoperiosteoplasty (GPP) and BMP-2 grafting
shows bony healing and closure of the alveolar defect.
3D CT scan of a patient with right cleft lip and palate. C.
Preoperative image shows the alveolar defect. D.
Postoperative image 6 months after GPP and BMP-2
grafting shows bony healing and closure of alveolar
defect.
■ Cranial defect: Bilaminar resorbable matrix with BMP-2 reconstruction is an

alternative to titanium, alloplastic, or autologous bone reconstruction (FIG
6A,B). Each of these techniques provides structural support to protect the
underlying brain. The bilaminar resorbable matrix with BMP-2 reconstruction
has the added benefit of decreased donor-site morbidity and eventual resorption
of all foreign material.6
FIG 4 • 3D model created for mandibular reconstruction
with BMP-2 and titanium plate crib.
■ Mandibular defect: The indication for BMP-2 crib reconstruction is similar to
an iliac crest bone graft in that there is a defect size limit of 5 to 8 cm after
which vascularized fibular bone is preferred. Importantly, this technique is not
performed after oncologic resection because of concern that BMP-2 can cause
unrestricted bone growth.
■ Rare Tessier clefts: During the initial procedure, when soft tissue flaps are
raised for repair of the cleft, there is excellent access to the osseous defect.
Autologous bone donor sites may be limited at the time of this initial repair
due to the patient’s age, so the use of BMP-2 becomes a good option.7

FIG 5 • 3D Illustration of alveolar segments in a patient
with left cleft lip and palate. A. Prenasoalveolar molding
(NAM) shows collapse of the lesser segment. B. Post-
NAM image shows approximation of the alveolar
segments and creation of a normal alveolar “U shape.”
FIG 6 • Illustration of customized bilaminar construct. A.
The bottom (endocranial) resorbable plate has
supportive struts (pins); the BMP-2–impregnated
resorbable sponge (blue) is placed between the plates.
B. Ectocranial plate (top plate) is placed on top of the
pins (supportive columns) which were previously placed
through the endocranial plate and sonic welded.