Geoffrey 3 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery-Craniofacial, Head and Neck Surgery-Pediatric Plastic Surgery. 3-Elsevier (2018)

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SECTION I
CHAPTER 21.2 • Rotation advancement cheiloplasty
Adequate rotation
Adequate muscle dissection should reach the nasal floor of
the non-cleft side as this releases the abnormal muscle inser-
tion to the columellar base (Fig. 21.2.15A). Downward traction
on the free border of the lip will determine if the rotation is
A
Fig. 21.2.14  (A) Markings for the Mohler technique are designed with the incision extending into the columella and followed with a black cut. The height on the cleft
margin is similar to the height of philtral column on the non-cleft side. The angle of the back cut is around 90°. (B) The lip is stabilized with hook and finger while incised
with #67 blade to ensure an accurate cut.
B
Mohler14 and Onizuka13 analyzed the shape of philtrum
and concluded that the majority have philtral columns in an
outward curvilinear configuration. Therefore, the authors
strongly feel the curvilinear incision of Mohler gives a better
philtral morphology compared to a straight line incision.
A
B
Fig. 21.2.15  (A) Adequate muscle dissection should reach the nasal floor of the non-cleft side as this releases the abnormal muscle insertion to the columellar base.
(B) Downward traction on the free border of the lip will determine if the rotation is adequate, that is, both points CPHR and CPHL are at the same level. (C) Muscle layer is
dissected along the skin edge initially with blade. (D) The muscle dissection is then continued with a pair of tenotomy scissors. The abnormal muscle insertion beneath the
columellar base and nasal floor is released, followed by muscle attachment to the skin in the subdermal plane for a distance of 2–3 mm. The dissection plane is deeper,
initially leaving a cuff of muscle on the incision edge and gradually to the subdermal level for better philtral ridge morphology.
C
D

509
Operative techniques
alveolar margin, extending along the free border of the lip to
the point where the red line and WSR converge. The width of
the L-flap is around 5 mm. The upper margin of the L-flap
corresponds to the skin incision from the WSR flap distally to
point CPHSL’. The upper L-flap incision line is extended
inwardly to the “split point” of nasolabial groove, or the skin-
mucosal junction on the piriform rim. This incision meets the
inferior edge of the turbinate (Fig. 21.2.18A,B).
Inferior turbinate (T) flap
An inferior turbinate (T) flap, pedicled anteriorly, is created
by making incisions on the lower and upper edges of the
turbinate for 1.5 cm. A transverse incision is made posteriorly,
connecting the upper and lower incisions and pedicling the
flap anteriorly. This flap is helpful to fill the mucosal defect
created by releasing the alar base from the retro-positioned
lesser maxillary segment (Fig. 21.2.18A).
Incision and dissection
The lateral lip is stabilized with a hook and finger. The WSR
flap incision is made with #11 blade, followed by #67 blade
for the vermilion and skin incision along the cleft margin. The
adequate, that is, both points CPHR and CPHL are at the same
level (Fig. 21.2.15B). If the rotation is inadequate, extending
the back cut beyond the non-cleft side philtral column should
never be attempted. This will result in a vertically long lip. At
this point, if the Cupid’s bow is not leveled, no further action
is to be taken until the muscle dissection and repositioning
has been completed. The back cut down the non-cleft side
philtral column, advocated by Millard, leaves a wider and
lower defect at the apex of the rotation, compared to the
Mohler incision. This defect is then filled with a square-shaped
advancement flap, always closed with much tension. This
results in a conspicuous oblique scar across the upper phil-
trum. Therefore, this back cut on the non-cleft side philtrum
should be avoided.
As mentioned, the authors routinely insert a WSR flap for
lip subunit repair. This WSR flap provides an additional
1–2 mm of lip length, lowering and balancing Cupid’s bow.
This decreases the necessity of a back-cut.
Muscle dissection on the rotation flap
The muscle layer is dissected along the skin edge initially with
a blade, then continued with a pair of tenotomy scissors. The
abnormal muscle insertion beneath the columellar base and
nasal floor is released. Following this, the muscle attachment
to the skin, in the subdermal plane, is released for a distance
of 2–3 mm. Initially, along the free edge of the lip, the dissec-
tion plane is deeper, leaving a small cuff of muscle on the
incision edge. The dissection then moves gradually to the
subdermal level. This provides for better philtral ridge
morph­ology (Fig. 21.2.15C,D).
C-flap and footplate of medial crura
The C-flap incision is made on the line extending from point
CPHL along the skin and mucosa junction to the deepest point
of the skin on the premaxilla. At this point, the incision turns
superiorly, for 5 mm or more, along the columellar skin and
septal mucosa junction. The intercrural space beneath the
columella is separated by tenotomy scissors (Fig. 21.2.16A,B).
This allows mobilization of the C-flap and for repositioning
the downward displaced medial crural foot plate on the cleft
side LLC. The medial tip of the C-flap (at point CPHL) will
be used to fill in the defect at the columellar base created by
the Mohler incision. For patients with a simple rotation inci-
sion, it will be trimmed accordingly.
Septal dissection
The authors favor anterior palate repair during primary lip
repair. The septal incision behind the C-flap is extended
downward behind the premaxilla along the junction of the
vomer and hard palate (Fig. 21.2.17A). Instead of a caudal
septal dislocation, advocated by other surgeons, a septal
mucosal flap is raised subperichondrially in continuity with
the vomer flap used for the anterior palate repair (Fig.
21.2.17B,C).
Incisions on the cleft side lateral lip element
White skin roll flap and L-flap
A triangular WSR flap above point CPHL’ is marked accord-
ing to the width of the WSR at point CPHR (Figs. 21.2.9A,B
& 21.2.12B). Usually the width and length are around 2 mm
in a 3–6-month-old baby. An L-flap is marked based on the
A
Fig. 21.2.16  (A) The C-flap extends from point CPHL along the skin and mucosa
junction to the deepest point of the skin overlying the premaxilla. At the premaxilla,
the incision turns superiorly for 5 mm or even longer along the columellar skin and
septal mucosa junction. The CM flap is separated from the C-flap. (B) Use a
tenotomy scissors to separate the foot plate of the medial crura in the C-flap.
B

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CHAPTER 21.2 • Rotation advancement cheiloplasty
A
B
Fig. 21.2.17  (A) The septal flap is extended backward connecting the vomer flap
if the anterior palate is repaired together with lip repair. (B) Intraoral view shows the
design of the vomer flap. Its anterior part is connecting with the septal flap.  
(C) Repairing the anterior palate with vomer flap. The vomer flap is imbricated
under the mucoperiosteum of the lesser segment.
C
L-flap is raised with a tenotomy scissor, and including a thin
layer of muscle to ensure adequate blood supply. The T-flap
is elevated in a retrograde fashion, and is pedicled on the
lateral nasal vestibular skin (Fig. 21.2.18A, inset). After eleva-
tion of the L- and T-flaps, the attachments of the LLC to the
maxilla and ULC are released, allowing easy mobilization of
the LLC and the lateral lip. The lateral lip is released from
maxilla in a pre-periosteal plane (Fig. 21.2.18C). The extent of
maxillary dissection is usually close to the infraorbital
foramen. Even in wide clefts, adequate mobilization of the lip
and alar base can be accomplished with a more extensive
dissection over the maxilla.
The lateral lip mucosa is incised and dissected 2 mm from
the muscle edge. Excessive mucosal dissection will result in
thick scarring and should be avoided. The orbicularis periphe-
ralis muscle is bunched up as a disorganized mass of fibers
with numerous dermal insertions. Using a tenotomy scissors,
the orbicularis peripheralis muscle is dissected along the edge
of the dermis to a line extending from the base of the
ala (SBAL) to the base of the philtral column (CPHL′). The
dissection is continued in a subdermal plane superiorly
around the alar base. This releases the abnormal insertions of
the paranasal muscles, including the transverse portion of the
nasalis muscle, depressor septi, and levator muscles of the
upper lip and ala. The extent of muscle dissection should be
lateral to the angular artery; ensuring most of the abnormal
muscle insertions to the alar base are completely released (Fig.
21.2.18D–G). Adequate muscle release allows the tethered and
bunched-up muscle to be stretched out, thus lengthening the
lateral lip effectively to gain a substantial increment of vertical
height and horizontal length. Similar to the non-cleft side, the
dissection plane is deeper initially and gradually becomes
subdermal, thus leaving a cuff of muscle on the edge of the
incision, for better philtral ridge morphology.
Removal of fat pad under the vestibulum
Upon adequate muscle dissection beneath the alar base, a cuff
of fat pad will usually bulge out from the nasal vestibule.
Removal of this bulging fat pad will decrease some tissue
thickness at the alar base, thus improving the vestibular
webbing which is a common deformity seen after primary lip
repair (Fig. 21.2.18H).
Mulliken uses a lenticular excision at primary repair to
effectively eliminate the vestibular web.16,17 However, this
results in a linear scar on the lateral nasal vestibule, which
might tether the LLC from medial advancement in secondary
rhinoplasty.
Creation of the orbicularis marginalis flap
The orbicularis marginalis (OM) flap is incised along the free
border of the lip and includes the orbicularis marginalis
muscle, the vermilion medial to point CPHL′, and the corre-
sponding mucosa posteriorly.9 The incision line of the OM
flap is perpendicular to the skin. The muscle volume at CPHL′
is preserved similar to the volume at point CPHR on the
non-cleft side (Fig. 21.2.18I). Gentle downward traction of the
OM flap can determine the tissue adequacy along the free
margin, and the lip contour should be in a smooth line (Fig.
21.2.18J).
Nasal floor reconstruction and alar
base repositioning
When the anterior palate repair is done simultaneously with
primary lip repair, the vomer flap is imbricated beneath
the mucoperiosteal edge of the lesser segment. The nasal
floor is reconstructed by the septal and L-flaps. The septal
flap is sutured to the lower margin of the L-flap, while the

511
Operative techniques
L
CPHL’
CPHSL’
Split point of nasolabial groove
L
T
OP
T
A1
A2
B
C
D
E
Fig. 21.2.18  (A) An inferior turbinate flap is designed to provide enough soft tissue coverage on the lateral nasal wall if there is lip repair alone without anterior palate
repair. The L-flap will be brought across the nasal floor suturing to the septal incision. (B) The design of the L-flap. The width is around 5 mm and the length is depending
on the width of the cleft. Its upper margin incision goes from the WSR flap above the CPHL’ through CPHSL’ to the split point of nasolabial junction, then turns 90° along the
skin-mucosal junction on the piriform area. (C) The lateral lip is released from maxilla above the periosteum plane. The extent of the maxillary dissection is usually close to
the infraorbital foramen. (D) The orbicularis peripheralis muscle is released from skin. The dissection is started with a blade. (E) Dissection is then continued with tenotomy
scissors, which is initially deep and then becomes more superficial leaving a cuff of muscle on the wounds edge.
Continued

512
SECTION I
CHAPTER 21.2 • Rotation advancement cheiloplasty
F
G
H
I
J
(F) The abnormal muscle insertions around the alar base are
adequately released. The bulging lateral to the alar base created by the tip of
scissors showing the extent of the dissection. (G) The angular artery is used as a
landmark for muscle dissection. (H) Removal of this bulging fat pad under the nasal
vestibulum will decrease some tissue thickness at the alar base, thus improving the
vestibular webbing which is a common deformity seen after primary lip repair.  
(I) The incision line of the OM flap is perpendicular to the skin. Similar muscle
volume is preserved at CPHL′ and point CPHR on the non-cleft side. (J) Gentle
downward traction of the OM flap can determine the tissue adequacy along the free
margin and the lip contour should be in a smooth line.
Fig. 21.2.18, cont’d
upper margin of the L-flap is sutured to the lower margin
of the piriform incision (Fig. 21.2.19A,B). As the anterior
part of the vomer flap is in continuity with the septal flap,
a complete nasal floor closure is obtained. The vestibular
skin with attached ala is advanced medially and superiorly.
The upper margin of the piriform incision is sutured to the
septal/L-flaps, while the split point of nasolabial groove is
sutured to the uppermost point of the septal incision (Fig.
21.2.19C). This provides a two-layer closure of the nasal
floor. The alar base is advanced medially to achieve a 2 mm
over-correction on nostril width.6 The vertical position of the
alar base should be at the same level as the non-cleft side.
Final positioning of the alar base can be adjusted after nasal
reconstruction.
When the lip repair is separated from anterior palate repair,
the T-flap, based on vestibular skin, is rotated 90° to fill in
the defect on piriform rim. Its superior edge is sutured to the
inferior edge of the piriform incision. The T-flap corrects the

513
Operative techniques
A
B
C
Fig. 21.2.19  (A) Suturing the septal flap (S) with the lower margin of L-flap (L) for
nasal floor reconstruction. As the septal flap is continuous with the vomer, a
complete nasal floor closure can be achieved. (B) Suturing the upper margin of
L-flap (L) to the lower margin of piriform incision (P). (C) The upper margin of the
piriform incision is sutured to the septal/L-flaps while the split point of nasolabial
groove is sutured to the uppermost point of the septal incision to complete the
nasal floor reconstruction. (D) The turbinate flap (T) is rotated into the piriform
area. The nostril floor is reconstructed with the L-flap behind the columella, and  
the CM flap mucosa is sutured lateral to the maxilla. Completion of nostril floor
reconstruction with advancement of the vestibular skin rotating the alar base inward.
There is good mucosal closure without raw surfaces for secondary healing and scar
contracture. OP, orbicularis peripheralis muscle.
L
T
CM
CM
OP
OP
L
T
D
mucosal deficiency and allows repositioning of the LLC and
ala base without restriction. The L-flap is brought medially
behind the columella and sutured to the mucoperichondrial
flap of the posterior septal incision. The inferior edge of the
T-flap is sutured to the superior edge of the L-flap. The C-flap
mucosa is turned laterally and placed anterior to the L-flap.
Its tip is sutured to the base of L-flap and its upper margin is
sutured to the inferior edge of the L-flap. This gives good
mucosal coverage of the nostril floor and lateral nostril wall
without exposing any raw surface or tension. The vestibular
skin with attached ala is advanced as described previously
(Fig. 21.2.19D).
Muscle reconstruction
The muscle is approximated with 5–0 polydioxanone. A key
suture is placed in the muscle approximating points CPHL to
CPHL′. Downward traction is placed on this suture to level
the Cupid’s bow, and assures correct placement of subsequent
muscle sutures (Fig. 21.2.20A). The superior-most stitch is
placed through the tip of the advancement flap muscle (which
was released from the superolateral attachment to the alar
base) and is anchored to the caudal edge of the nasal septum,
in a vertical mattress fashion (Fig. 21.2.20B). This anchoring
suture helps to pull the lateral lip medially, centralizing
Cupid’s bow and correcting the possible lateral deviation of

514
SECTION I
CHAPTER 21.2 • Rotation advancement cheiloplasty
curvature is more natural looking compared to the straight
line technique. The final position of a Mohler incision mimics
the natural curve of the non-cleft philtral column, and this
holds to the subunit concept. (2) Muscle reconstruction: The
overlapping muscle approximation, with vertical mattress
sutures, increases the muscle thickness and simulates the
philtral column. (3) Subdermal suture placement: Catching the
subdermal layer at the midline of the philtrum, during muscle
approximation, helps to restore the philtral dimple. (4) Soft
tissue laxity: In addition to the increased muscle thickness
created by overlapping muscle approximation, the muscle
repair is made tighter than the overlying skin. This will
produce slightly excess skin during closure and is necessary
to reconstruct a bulging philtral column. The “excessive”
skin after muscle reconstruction should be preserved, as it
provides sufficient soft tissue laxity for a better philtral column
appearance.
Insertion of the WSR flap
Point CPHL and CPHL’ are approximated with 5–0 polydioxa-
none subcuticular suture followed by 7–0 polyglactin suture
for skin. Following the WSR contour, the width of the WSR is
measured and marked at the point CPHL. An incision, accord-
ing to the length of WSR flap, is carefully designed to place
the WSR flap tip at the horizontal groove of the lip contour
line, as advocated by Onizuka.13 The natural contour line is at
the upper margin of the WSR. This helps to restore the conti-
nuity and fullness of the WSR, in addition to leveling the
Cupid’s bow (Fig. 21.2.21A–D).
Incisions for the triangular vermilion flap
The vermilion flap, based on the lateral lip element, is marked
and incised on the OM flap. While the OM flap is held under
tension, a #11 blade is used to ensure an accurate cut. After
muscle approximation, the vermilion flap is inserted into the
medial lip incision, made along or above the red line beneath
the Cupid’s bow CPHL point. The main purpose of this ver-
milion flap is to correct the vermilion deficiency beneath the
Cupid’s bow, and not for increasing the tissue bulk on the
central free border. The tip of the vermilion flap should not
cross the natural lip tubercle that is always present in a uni-
lateral cleft. This natural tubercle should never be violated by
the vermilion flap (Fig. 21.2.22A,B).
Closure of the free border of the lip
The excess mucosa below the vermilion flap is trimmed
accordingly to approximate the free border of the lip edges
without excessive tissue. Careful attention during excision
of the excessive mucosa and muscle is important. The most
common error is to leave too much muscle or mucosa on
the free border. Incisions on the vermilion are closed with
continuous 7–0 polyglactin suture. The lateral lip buccal
mucosa is trimmed and closed with interrupted 5–0 poly-
glactin sutures. The upper edge of the buccal mucosa is
sutured to the lower edge of C-flap mucosa that bridges
the alveolar gap. This gives a complete mucosal closure
without tension.
Incisions on nasal floor
The medial tip of the C-flap is used to fill the defect on colu-
mella base after a Mohler incision; or, it is trimmed when
the cleft side lip due to tissue deficiency. The muscle sutures
are placed in such a way that the lateral muscle overlaps
above the medial muscle, increasing muscle thickness and
simulating a philtral column (Fig. 21.2.20B, inset).18 To help
restore the philtral dimple, the subdermal layer at the midline
of philtrum is captured during muscle approximation. The
muscle in OM flap is carefully sutured to avoid any depres-
sion in the vermilion post operatively.
Philtral column reconstruction
For a better aesthetic result of the philtral column, several
key steps are necessary. (1) Skin incision: The authors favor
the Mohler incision, which is more vertical and laterally
placed, compared to the traditional rotation-advancement. Its
A
Fig. 21.2.20  (A) A key suture is placed in the center of the muscle apposing of
points CPHL to CPHL′. This is to align the lip position by downward traction to
level the Cupid’s bow, making sure correct placement of each subsequent muscle
suture. (B) Orbicularis peripheralis muscle closure (with septal anchoring suture).
Inset: Overlapping the lateral muscle on the medial muscle for philtral column
reconstruction.
B

515
Operative techniques
A
B
Fig. 21.2.21  (A) The width of the WSR is measured and marked at the point CPHL following the WSR contour. (B) An incision line according to the length of WSR flap is
carefully designed to place the WSR flap tip at the horizontal groove of the lip contour line. (C) Careful insertion of the WSR flap to restore the natural lip contour line.
(D) The appearance of the lip contour line after wound closure.
C
D
using a simple rotation incision. The lateral edge of the C-flap
is brought laterally inside the nasal sill.
In an attempt to limit or eliminate incisions around the alar
base, no horizontal incisions on the lateral advancement flap
are made initially. At this point, the surgeon can better visual-
ize how to proceed. Incisions around the ala base leave con-
spicuous scars, an unnatural ala–facial groove, and should be
avoided. If the alar base on the cleft side lateral lip element is
high, an incision is made inside the cleft side nasal sill (Fig.
21.2.23A). This incision can vertically lengthen the lip and
level the alar base and Cupid’s bow. If the alar base is already
leveled after muscle reconstruction, a vertical nasal floor inci-
sion is made, as shown in Fig. 21.2.23B. Every attempt is made
to preserve the natural nasal sill. The nasal sill is unique
tissue, very difficult to reconstruct in secondary deformities,
and should be carefully preserved in primary repairs. During
the primary repair, the nostril width on the cleft side is slightly
over-corrected (2 mm narrower than the non-cleft side) as the
authors’ experience shows the cleft side nostril will widen
with time after the primary operation.6
Final skin closure on lip
The point CPHSL’ is sutured to CPHSL and the rotation flap
creates a suture line that mimics the philtral ridge. Excess skin
on the nostril floor is excised accordingly; however, careful
preservation of the nasal sill is maintained. The nasal floor is
closed with 5–0 polyglactin sutures and lip skin is closed with
7–0 polyglactin sutures (Fig. 21.2.24).
Adjustments during the final stage
The preoperative markings and measurements will differ
after adequate muscle dissection and approximation. There-
fore, these should be continuously checked while deciding the
necessary adjustments to achieve a satisfactory result. Every
cleft surgery is different; and, minor adjustments are neces-
sary in most patients – herein lies the enjoyment, yet challenge,
of each case.
Long vertical length of cleft side lip
A vertically long lateral lip is seldom encountered. It can be
avoided by the septal anchoring suture used to suspend the
lateral lip upward and trimming the excessive tissue from the
nasal floor.
Short vertical length of cleft side lip
This is a common problem in most complete clefts. Adequate
release and approximation of the orbicularis muscle will

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CHAPTER 21.2 • Rotation advancement cheiloplasty
Short horizontal length of cleft side lip
This problem is almost impossible to solve. After adequate
muscle dissection and approximation, the horizontal lip
length on the cleft side will usually increase by several mil-
limeters. A horizontally short lip is aesthetically acceptable
compared to a vertically short lip with peaking of the Cupid’s
bow.
Long vertical height of non-cleft side lip
Any vertical length exceeding 12 mm on the non-cleft side lip
(in a 3-month-old baby) is excessively long and difficult to
manage. Shortening this length could be performed by
increase the vertical length by 3–4 mm, while an additional
2 mm is provided by the WSR flap designed on the lateral lip.
If the lip is still short, point CPHL′ can be shifted 1 mm later-
ally without sacrificing much on the horizontal lip length.
This can also increase the length of the WSR flap, thus achiev-
ing further downward rotation. Lastly, a perialar incision can
be made, lengthening the vertical lip height with cheek tissue;
however, this should be avoided if possible.
Long horizontal length of cleft side lip
This is a relatively simple problem. Point CPHL′ can be moved
as lateral as necessary to shorten the horizontal length.
A
Fig. 21.2.22  (A) The vermilion flap is marked and incised on the OM flap while the OM flap is held under tension. The width of the vermilion flap should correct the
vermilion deficiency under the Cupid’s bow. The tip of the vermilion flap should not cross the natural lip tubercle. (B) Medially, the lip is incised on the red line beneath
the Cupid’s bow for insertion of the vermilion flap. The excessive tissues on both medial and lateral lips are carefully trimmed.
B

517
Operative techniques
excising a portion of a full-thickness lip segment (at the junc-
tion of the lip and nasal floor) and is seldom performed.
Free border of the lateral lip
If the lateral lip is too thin or deficient, the mucosa can be
released further (by extending the buccal sulcus incision) but
this seldom corrects the problem. A poorly placed septal
anchoring suture will pull the lateral lip too high and thus
worsen the problem. Lateral lip deficiency can be corrected
with lip augmentation using a temporoparietal fascia graft as
a secondary procedure.19 On the other hand, one often finds
a bulging free border in incomplete clefts. The most accurate
way of correcting this excessive tissue is to incise along the
DA
Fig. 21.2.23  (A) If the alar base and the peak of the Cupid’s bow on the cleft side
are still high, incision as the direction shown is made inside the cleft side nasal
floor. This incision can vertically lengthen the lip and level the alar base and
Cupid’s bow. (B) If the alar base is already leveled after muscle reconstruction,
incision is made as the direction shown to keep the alar base position.
DB
A
Fig. 21.2.24  (A) Complete wound closure with columella elongation achieved by
the Mohler’s rotation incision; note the laterally positioned philtral column. (B) Alar
transfixion sutures (ATS) using 5–0 absorbable monofilament are placed with
traction on the LLC. One suture is placed in the vestibular skin. The remaining
sutures catch the leading edge of the LLC, pass through the alar-facial groove and
back near the rim of the ala, and are tied on the inner side. Notching of the skin
disappears within 1–2 weeks.
ATS
B

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CHAPTER 21.2 • Rotation advancement cheiloplasty
through-and-through suture is placed on the medial crura,
lower than the first stitch, for further crural support.
Trimming the excessive skin
After repositioning of the LLCs, the columella on the cleft side
will be lengthened by recruitment of tissue along the medial
limb of the reverse U incision. There is always excess skin on
the upper part of the cleft side columella; and, this is respon-
sible for the soft triangle webbing found in secondary cleft
nasal deformities. This excessive skin is trimmed with sharp
scissors, and the wound is closed with 5–0 polyglactin sutures.
Alar base position
The most important factor in achieving alar base symmetry is
adequate release of the abnormally attached paranasal
muscles. The alar–facial groove is further accentuated by the
approximation of the lip musculature.
Creation of the alar–facial groove
Dissection between the skin and LLC releases the fibrous
attachments and leaves behind a significant dead space.
Furthermore, mobilization of the cleft side alar base will
accentuate the vestibular webbing within the nostril. Removal
of the fat pad (beneath the alar base) and two alar transfixion
sutures (correcting the intra-vestibular mucosal webbing)
help solve these problems while defining the alar–facial
groove. The lower suture obliterates the dead space and tacks
down the vestibular webbing. The upper suture catches the
leading edge of the LLC and provides support the LLC. Skin
dimpling from these sutures usually disappears 2 weeks after
surgery (Fig. 21.2.26).
Patient examples are shown as Figs. 21.2.27 and 21.2.28.
Rotation advancement cheiloplasty for
incomplete clefts
Surprisingly, incomplete cleft lips are sometimes as difficult
or more challenging to reconstruct.36 Moreover, the expecta-
tions for an excellent result are higher, and surgeons tend
red line, raise an inferiorly based mucosal flap with a thin
layer of marginalis muscle, and redrape the flap while trim-
ming the excessive tissue (Fig. 21.2.25).
Semi-open rhinoplasty
Many techniques have been reported for primary nasal
reconstruction in unilateral clefts.16,20–28 Several reports on
the long-term results in primary nasal correction have not
shown any adverse effect on nasal growth.29–34 For the past
30 years, several techniques have been used in the Chang
Gung Craniofacial Center for nasal reconstruction in uni-
lateral clefts.9,12,23,35 In the authors’ experience, a semi-open
rhinoplasty can achieve a precise and less traumatic dissection
of the cartilaginous framework, providing better visualiza-
tion and repositioning of the displaced cartilages. It can also
preserve and elongate the cleft side columella.
Incision
A rim incision on the non-cleft nostril and a reverse U incision
on the cleft nostril is marked. The reverse U incision is made
2 mm higher than the alar rim to achieve an over-correction
on the cleft nostril.
Release of fibrofatty tissue from LLCs
The nasal rim incisions (an inverted U Tajima incision on the
cleft side and an alar rim incision on the non-cleft side) are
made with #67 blade followed by dissection above the LLCs
with tenotomy scissors. The caudal edges of both LLCs can
be easily visualized through these incisions, thus avoiding
any risk of iatrogenic injury to the cartilaginous framework.
The fibrofatty tissue of the nasal tip is released from both
LLCs. This dissection pocket should be connected to the
earlier created pocket created by the intercrural space dissec-
tion. The cleft side nostril dissection should extend lateral to
the groove of the LLC caudal edge.
Repositioning of LLCs
The LLCs are approximated with a medial rotation of the
cleft side LLC cartilage, and united with 5–0 polydioxanone
mattress sutures. The stitches are placed 5 mm more later-
ally on the cleft side cartilage for over-correction. A second
Fig. 21.2.25  The most accurate way to correct the excess mucosa is to make incision along the extension of the red line from medial lip (A), raising an inferiorly based
mucosal flap with a thin layer of marginalis muscle (B), re-draping the flap and trimming the excess tissue (C).
A
B
C

519
Rotation advancement cheiloplasty for incomplete clefts
or a simple rotation-advancement, together with the C-flap
design. The incision on the advancement flap is made along
the cleft edge after designing the WSR flap (Fig. 21.2.29A).
Nasal floor incision
A transverse incision is made inside the nasal floor at the
junction of the skin and mucosa, leaving ample tissue on the
piriform area and premaxilla (Fig. 21.2.29B). A subperiosteal
dissection is performed from the nasal septum and along the
nasal floor towards the piriform rim, raising a mucoperiosteal
flap that will be used for correction of the nasal floor defi-
ciency. The authors have been using a technique of minimal
skin flap paring since the mid-1990s, as advocated by Koh;37
however, we feel that the nasal floor transverse incision is
to underestimate the pathology and do less of a procedure
during reconstruction. It is a common mistake to think that
a vertically long lateral lip exists and then try to shorten the
lip during the operation without proper repositioning of the
alar base. In fact, intraoperative measurements usually show
both vertical heights are equal. The appearance of a vertically
long lateral lip results from the downward displacement of
the cleft side alar base. Therefore, it is important to mobilize
completely the alar base and reposition it cephalically instead
of vertically shortening the lateral lip.
Markings and incisions
The rotation incision and muscle dissection are performed
similar to complete clefts, using either the Mohler technique
A
B
Fig. 21.2.26  (A) Semi-open rhinoplasty
with a reverse U incision on the cleft side
and a rim incision on the non-cleft side.  
(B) Exposure of the caudal edge of the lower
lateral cartilages (right upper). Release of
the fibrofatty tissue from both LLCs with
sharp dissection to avoid iatrogenic injury to
the cartilages. The fibrofatty tissue should be
completely released from the cartilages.  
(C) Careful trimming of the excess skin after
approximation of the LLCs (left). Additional
sutures on medial crura and the alar
transfixion sutures (ATS) (right).
ATS
C

520
SECTION I
CHAPTER 21.2 • Rotation advancement cheiloplasty
A
B
C
D
Fig. 21.2.27  (A,B) A 2-week-old boy with left complete cleft of primary and secondary palate. (C,D) 3 months after nasoalveolar molding, before lip repair.
essential for adequate alar base mobilization and restoring
nasal floor symmetry.
Dissection of muscle and elevation of OM flap
The technique and extent of muscle dissection is similar to
that performed in complete clefts. Less muscle dissection
tends to leave the abnormal muscle insertions to the alar base,
and results in a lateral and downward displacement of the
alar base, often seen in secondary deformities. The OM flap
is raised as in complete clefts.
Nasal floor reconstruction
The raised mucoperichondrial flap from the nasal septum
and the mucoperiosteal flap of piriform area is folded
over and sutured to each other, matching the height of
the nasal floor on non-cleft side nostril (Fig. 21.2.29C). The
alar base is turned inward, and its leading edge, at the
vestibular incision, is sutured to the mucosa on the nasal
floor as in complete clefts. Theoretically, placing Surgicel
under the periosteum of the cleft side nasal floor could
stimulate new bone formation, thus correcting the bony
deficiency in this area. However, in a study performed by
the authors, no benefit was achieved in the overall aesthetic
outcome.38
Muscle reconstruction
Muscle reconstruction is performed as in complete clefts,
using an anchoring suture to the septum for centralizing the
Cupid’s bow. Overlapping mattress muscle sutures are used
to reconstruct the philtral column ridge.
Nasal correction
Nasal correction is performed as in complete clefts with a rim
incision on non-cleft side nostril and reversed U incision on
cleft side. The cartilage dissection, cartilage repositioning, and
alar transfixion sutures are performed as mentioned above.
The cleft side nostril needs to be over-corrected (a higher and
narrower nostril).
Excessive free border
Although the “long lateral lip” is usually an illusion in incom-
plete clefts, it is not uncommon to have some excessive tissue

521
Rotation advancement cheiloplasty for incomplete clefts
E
F
(E,F) Postoperative views at the age of 7 years.
Fig. 21.2.27, cont’d
Continued
A
B
Fig. 21.2.28  (A,B) A 2-week-old boy with left complete cleft of primary and secondary palate.
(vermilion, orbicularis marginalis, and mucosa) along the free
border of the cleft side lateral lip after leveling the Cupid’s
bow. If it is too obvious, the excessive free border tissue can
be trimmed using the technique shown in Fig. 21.2.25.
A patient example is shown in Fig. 21.2.30.
Complete cleft of primary palate
Patients who present with complete clefts of primary palate
(complete cleft lip and alveolus anterior to the incisive
foramen, UCLA) are notorious for having inferior results,
when compared to their peers with unilateral complete

522
SECTION I
CHAPTER 21.2 • Rotation advancement cheiloplasty
C
D
A
CPHSL’
CPHL’
B1
B2
Fig. 21.2.29  (A) Markings for incision lines in incomplete clefts with incision made along the free edge of the skin. (B) The incision lines for C-flap and nasal floor: a
transverse incision is made inside the nasal floor at the junction of skin and mucosa leaving ample tissue on piriform area and premaxilla. (C) The local tissue on nasal
septum and piriform area (C1) is turned over (C2) and sutured with each other to match the height of the nasal floor on non-cleft side nostril (C3).
C1
C2
C3
(C,D) Postoperative views at the age of 7 years.
Fig. 21.2.28, cont’d

523
Rotation advancement cheiloplasty for incomplete clefts
A
B
Fig. 21.2.30  (A,B) A 3-week-old boy with left side incomplete cleft lip. (C,D) Postoperative views at the age of 7 years.
C
D
clefts of both the primary and secondary palate (UCLP).
These inferior results are because the protruding premax-
illa is resistant to movement during pre-surgical NAM. As
well, there often exists a short vertical lip height on the
cleft side (Fig. 21.2.31A–D). Quite often, a persistent down-
ward displacement of the nasal sill and alar base remains
after surgery.
The surgical modifications for patients with isolated com-
plete clefts of primary palate are:
■ Mainly using the vertical lip height to determine the
point CPHL’, i.e., by moving CPHL’ more laterally (Fig.
21.2.31E). As aforementioned, a short horizontal lip does
not look as obvious as compared with a short vertical lip
with peaking of the Cupid’s bow or downward
displacement of the alar base.
■ Using the septal flap, nasal floor tissue, and the L-flap for
nasal floor reconstruction. The nasal floor tissue and
L-flap are undermined subperiosteally (Fig. 21.2.31F,G).
A patient example is shown in Fig. 21.2.31H–K.
Microform cleft lip
Surgical correction of the microform cleft lip has received
less attention in the literature, likely because of its minor
deformity. Efforts have been made to eliminate the external
scar that results from traditional rotation-advancement or
straight-line closures. Cho39 advocated orbicularis muscle
interdigitation through an intraoral incision. Mulliken40 has
suggested the double uni-limb Z-plasties, muscle approxima-
tion, and philtral ridge augmentation with a retro-auricular
graft. The authors’ preference remains a modified rotation-
advancement cheiloplasty as discussed in incomplete cleft
lips. This is because with this technique the surgeon has the
ability to (1) release the misaligned muscle completely while
mobilizing the displaced alar base, (2) reconstruct the philtral
column in both height and direction, and (3) over-correct the
cleft side nostril. In addition, it allows for the excision of the
cleft groove or striae which is not parallel to the non-cleft side
philtral column. The repair also requires a WSR flap above the
non-cleft side Cupid’s bow to correct the high peaking of the
Cupid’s bow. Although scarring is the major concern, scars
are usually inconspicuous if surgery is performed early (i.e.,
at 3 months) and parents are compliant to the postoperative
scar care (Fig. 21.2.32
). A recent prospective randomized
controlled trial showed that intraoperative injection of Botu-
linum toxin A along the suture line helps to improve the scar
in primary lip repair.41
Fig. 21.2.32 appears online only.

523.e1
Postoperative care
A
B
Fig. 21.2.32  (A,B) A 2-week-old boy with left side occult cleft lip.
(C,D) Postoperative views at the age of 5 years old.
C
D

524
SECTION I
CHAPTER 21.2 • Rotation advancement cheiloplasty
A
B
C
D
E
F
Fig. 21.2.31  (A,B) A 2-week-old girl with right complete cleft of primary palate. (C,D) Same patient 3 months after nasoalveolar molding with poor effect of alveolar
molding. (E) Markings for the lip landmarks. The vertical height on the cleft side is more important in determining the point CPHL’. (F) Using septal flap, L-flap and local
nasal floor/piriform periosteal flaps for nasal floor reconstruction.
Postoperative care
Postoperative monitoring and care begins immediately in the
recovery room. The caregiver is allowed to enter the recovery
room to hold the baby and be briefed on the essentials of
maintaining a patent airway. Postoperative management is
continued by a specialized cleft nurse, giving further instruc-
tions about the airway and subsequent care upon returning
to the ward. These instructions include removal of oral and

525
Postoperative care
G
H
I
J
K
(G) The result of nasal floor reconstruction using the
aforementioned tissue. The height of the nasal floor is similar to the height in
non-cleft side. (H,I) A 2-week-old girl with left complete cleft of primary palate.
(J,K) Postoperative views at the age of 8 years.
Fig. 21.2.31, cont’d

526
SECTION I
CHAPTER 21.2 • Rotation advancement cheiloplasty
anchoring suture to affix the cleft side lateral lip medially, thus
centralizing the Cupid’s bow.
Fig. 21.2.34 appears online only.
Long-term result of nasal morphology
It is also important to document the long-term nasal morphol-
ogy following the integrated approach with pre-surgical
nasoalveolar molding, surgical refinement, and post-surgical
maintenance. Several studies conducted at Chang Gung
Craniofacial Center evaluating the long-term nasal morphol-
ogy outcomes. The initial study evaluated 25 patients oper-
ated on between 1997 and 1999. All these patients underwent
Liou’s technique of pre-surgical nasoalveolar molding. The
surgical technique for nasal reconstruction was performed as
described above, except no cartilage dissection or reposition-
ing was performed. Although the nasal shape was quite
symmetrical immediately following surgery, at 3 years
follow-up, there were significant differences among measure-
ments of nostril height, columellar length and nostril width.
The cleft side nostril and columellar height were significantly
shorter than the non-cleft side, while the cleft side nostril was
significantly wider (Fig. 21.2.35
).6 The next study included
a group of patients who received the modified Grayson
technique of nasoalveolar molding. The surgical technique
included repositioning of the LLCs through bilateral rim inci-
sions. This study demonstrated better results when compared
with the previous study; nonetheless, there was a similar
trend in terms of nasal relapse.47 Based on these observations,
the authors’ current practice includes performing a reverse U
incision on the cleft side and over-correction of the cleft side
columellar height, nostril height, and width. Postoperatively,
the cleft nostril needs to be maintained in the over-corrected
position using the modified silicone conformer. The third
study compared the outcome of primary nasal reconstruction
among four different techniques, namely, closed rhinoplasty
alone, NAM alone, NAM plus semi-open rhinoplasty and
NAM plus semi-open rhinoplasty with over-correction in a
group of 76 patients during 11 years. The final technique had
the best overall result including nostril height ratio, one-fourth
medial part of nostril height ratio, nasal sill height ratio,
nostril area ratio, nostril height to width ratio and panel
assessment.48
Fig. 21.2.35 appears online only.
Satisfaction of patients
Patient and parent satisfaction are largely dependent upon
psychosocial adaptation. A study performed in early 2000 at
the Chang Gung Craniofacial Center evaluated the results in
77 patients who underwent cleft lip repair in 1996.9 A total of
24% of patients required no further revision of the nose or lip;
36% required nasal correction, while 10% lip correction; 28%
required both nasal and lip revision. Approximately 60% of
the patients requested lip or nose revision before school age.
With our integrated approach and improvement in outcomes
in recent years, only a few patients request revision before
school age. Therefore, secondary nasal deformity correction
can usually be delayed until completion of facial growth and
the completion of psychological development. A large number
of our patients were satisfied with the outcome of primary
nasal reconstruction and did not request any secondary rhi-
noplasty procedure.
upper airway secretions, wound dressings of normal saline,
and bottle feeding with a “good flow” soft nipple. Feeding
can be started as soon as the baby desires. No arm restraints
are used.
Any blood clots or mucus on the wound is cleaned with
normal saline-soaked swabs every 2–6 h, and then antibiotic
ointment is applied to the suture line. It is important to keep
the incision from drying out or crusting. Normal saline dress-
ings also reduce pain and swelling. The baby and mother are
discharged home the day following surgery and return to the
outpatient department in 5 days. At that time, skin sutures are
removed under oral chloral hydrate sedation. Postoperative
scar care begins immediately with Micropore™ tape and sili-
cone sheet compression. The patient is usually seen monthly
for the first 3 months and then periodically. This is to ensure
that parents are compliant with postoperative scar care. Lip
scar massage is usually encouraged to hasten scar maturity
and correct any elevation of the Cupid’s bow secondary to
scar contracture.
Postoperative maintenance of nasal shape
Post-surgical nasal molding was first introduced in 1969 by
Osada42 and Skoog.43 Friede44 used an acrylic conformer and
demonstrated improvement in nasal contour. Matsuo8 first
reported pre-surgical molding in the unilateral incomplete
cleft with a silicone conformer which was continuously used
for 3 months and then only at night for up to 12 months of
age postoperatively. It is believed that the deformed nasal
cartilage can be easily molded and manipulated while it is still
malleable.
Subsequently, silicone nasal conformers have been used in
many centers to support the LLC during the healing phase
and prevent nasal contracture and stenosis. Silicone nasal
conformers have been used at the Chang Gung Craniofacial
Center since the late 1980s.45 At present, a modified set of
nasal conformers are used. This set contains five conformers
with increasing height (1 mm increments). Parents are
instructed to change to the next larger size conformer every
2–3 weeks until achieving the largest size of 4 mm on the cleft
side. The conformer is used at all times for 6 months to 1 year
postoperatively if possible. Success in nasal conformer appli-
cation depends much upon the cooperation and perseverance
of the parents (Fig. 21.2.33
).
Fig. 21.2.33 appears online only.
Outcomes, prognosis, and
complications
Long-term results of lip morphology
Lip symmetry is the main goal for cleft lip repair. A study was
performed at the Chang Gung Craniofacial Center evaluating
the long-term (at least 4 years follow-up) lip morphology in
19 complete unilateral cleft lip patients, who were operated
on in 2002. The surgical technique was similar to the technique
herein described, except no septal anchoring muscle suture
was placed. The results (with at least 4 years follow-up)
revealed that Cupid’s bow was deviated to the cleft side (Fig.
21.2.34
).46 Therefore, the authors routinely place a septal

526.e1
Summary
Fig. 21.2.33  Postoperative care with Micropore™ tapes across the lip and silicone
nasal conformer. The nasal conformer held in nostril with tape.
A
B
Fig. 21.2.34  Serial photographs of a boy with right complete cleft of primary and secondary palate. (A) 2 weeks old; (B) immediately after operation; (C) 1-year-old
before palate repair and (D) at the age of 5 years. The Cupid’s bow, though leveled, is deviated to the cleft side.
C
D

526.e2
SECTION I
CHAPTER 21.2 • Rotation advancement cheiloplasty
A
B
C
D
Fig. 21.2.35  Serial photographs of a girl with left complete cleft of primary and secondary palate. (A) 2 weeks old; (B) during nasoalveolar molding with Liou’s method;
(C) immediately after operation (without cartilage dissection and repositioning); (D) 1-year-old before palate repair; (E) at the age of 1.5 years; and (F) at the age of 3
years.
E
F

527
Summary
Complications
A total of 112 patients underwent unilateral cheiloplasty at the
Chang Gung Craniofacial Center from January 2008 to
November 2009, and were evaluated for postoperative com-
plications. No instances of wound dehiscence were encoun-
tered. There was one minor separation of the nasal floor and
two minor separations of the nasolabial junction which healed
uneventfully. There were no significant wound infections
reported except for five cases of stitch abscess (4.5%) and no
instances of postoperative bleeding. Hypertrophic scarring
was noted in only 3% of the patients.
Summary
The integrated approach to treating the cleft lip and nose
presented here is based on the vast experience at the Chang
Gung Craniofacial Center. It represents a 30-year ongoing
evolution, with periodic evaluation of our operative results
and refinements in treatment protocols. The pre-surgical
management has evolved from simple lip taping and prone
sleep position to very sophisticated nasoalveolar molding.
The surgical refinements include modifications of our
own technique and those adopted from other surgeons.
Postoperative care also has changed with time, aiming to
achieve the best result. Although our approach is based on
the Taiwanese population, these techniques have also been
tested in other racially diverse centers. In some locales
without the facilities and personnel for pre-surgical manage-
ment and postoperative maintenance, the surgical refine-
ments, as discussed above, can still produce consistently
improved results.
Fig. 21.2.1 (A) Modified Grayson molding device. (B) The device held in
proper position by elastics and tapes. Lip taping helps to approximate the
alveolus.
Fig. 21.2.2 (A) Liou’s (modified Figueroa) molding device. (B) The device
held in proper position by dental adhesives. Lip taping is also used.
Fig. 21.2.3 (A) Liou’s molding device with spring mechanism. (B) The device
held in place with dental adhesives. Lip taping is also used.
Fig. 21.2.4 (A) Nasal molding with silicone nasal conformer. (B) A set of nasal
conformers with different heights for cleft side. (C) A 10-day-old baby with right
incomplete cleft lip. Nasal shape before the nasal molding. (D) Same baby at
the age of 3 months before lip repair. The nasal shape after nasal molding.
Fig. 21.2.32 (A,B) A 2-week-old boy with left side occult cleft lip.
(C,D) Postoperative views at the age of 5 years.
Fig. 21.2.33 Postoperative care with Micropore™ tapes across the lip and
silicone nasal conformer. The nasal conformer held in nostril with tape.
Fig. 21.2.34 Serial photographs of a boy with right complete cleft of primary
and secondary palate. (A) 2 weeks old; (B) immediately after operation;
(C) 1-year-old before palate repair; and (D) at the age of 5 years. The Cupid’s
bow, though leveled, is deviated to the cleft side.
Fig. 21.2.35 Serial photographs of a girl with left complete cleft of primary and
secondary palate. (A) 2 weeks old; (B) during nasoalveolar molding with Liou’s
method; (C) immediately after operation (without cartilage dissection and
repositioning); (D) 1-year-old before palate repair; (E) at the age of 1.5 years;
and (F) at the age of 3 years.
Bonus images for this chapter can be found online at

6. Liou EJ, Subramanian M, Chen PKT, et al. The progressive changes
of nasal symmetry and growth after nasoalveolar molding: a
three-year follow-up study. Plast Reconstr Surg. 2004;114(4):858–864.
7. Chang CS, Wallace CG, Pai BCJ, et al. Comparison of two
nasoalveolar molding techniques in unilateral complete cleft lip
patients: a randomized, prospective, single-blind trial to compare
nasal outcomes. Plast Reconstr Surg. 2014;134(2):275–282.
9. Chen PKT, Noordhoff MS, Kane A. Repair of unilateral cleft lip. In:
Neligan P, ed. Plastic Surgery. 3rd ed. London: Elsevier-Saunders;
2012:517–549 [Chapter 23]. vol. 3.
13. Onizuka T, Ichinose M, Hosaka Y, Usui Y, Jinnai T. The contour
lines of the upper lip and a revised method of cleft lip repair. Ann
Plast Surg. 1991;27(3):238–252.
14. Mohler L. Unilateral cleft lip repair. Plast Reconstr Surg. 1987;80(4):
511–516.
16. Mulliken JB, Martinez–Perez D. The principle of rotation
advancement for repair of unilateral complete cleft lip and nasal
deformity: technical variations and analysis of results. Plast Reconstr
Surg. 1999;104(5):1247–1260.
26. Cutting CB, Dayan JH. Lip height and lip width after extended
Mohler unilateral lip repair. Plast Reconstr Surg. 2003;111(1):17–23.
28. Stal S, Brown RH, Higuera S, et al. Fifty years of the Millard
rotation-advancement: looking back and moving forward. Plast
Reconstr Surg. 2009;123(4):1364–1377.
31. Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-nose
repair: a 33-year experience. J Craniofac Surg. 2003;14(4):549–558.
48. Chang CS, Por YF, Liou EJW, et al. Long-term comparison of four
techniques for obtaining nasal symmetry in unilateral complete
cleft lip patients: a single surgeon’s experience. Plast Reconstr Surg.
2010;126:1276–1284.
Access the complete reference list online at

527.e1
References
References
1. Noordhoff MS, Huang CS, Wu J. Multidisciplinary management of
cleft lip and palate in Taiwan. In: Bardach J, Morris HL, eds.
Multidisciplinary Management of Cleft Lip and Palate. Philadelphia:
WB Saunders; 1990:18–26.
2. Huang CS, Cheng HC, Chen YR, et al. Maxillary dental arch
affected by different sleep positions in unilateral complete cleft lip
and palate infants. Cleft Palate Craniofac J. 1994;31(3):179–184.
3. Pool R, Farnworth TK. Preoperative lip taping in the cleft lip. Ann
Plast Surg. 1994;32(3):234–249.
4. Hotz MM, Gnoinski WM, Nussbaumer H, et al. Early maxillary
orthopedics in CLP cases: guidelines for surgery. Cleft Palate J.
1978;15:405–411.
5. Grayson BH, Santiago PE, Brecht LE, et al. Pre-surgical nasoalveolar
molding in infants with cleft lip and palate. Cleft Palate Craniofac J.
1999;36(6):486–498.
6. Liou EJ, Subramanian M, Chen PKT, et al. The progressive changes
of nasal symmetry and growth after nasoalveolar molding: a
three-year follow-up study. Plast Reconstr Surg. 2004;114(4):858–864.
7. Chang CS, Wallace CG, Pai BCJ, et al. Comparison of two
nasoalveolar molding techniques in unilateral complete cleft lip
patients: a randomized, prospective, single-blind trial to compare
nasal outcomes. Plast Reconstr Surg. 2014;134(2):275–282.
8. Matsuo K, Hirose T, Otagiri T, et al. Repair of cleft lip with
nonsurgical correction of nasal deformity in the early neonatal
period. Plast Reconstr Surg. 1989;83(1):25–31.
9. Chen PKT, Noordhoff MS, Kane A. Repair of unilateral cleft lip. In:
Neligan P, ed. Plastic Surgery. 3rd ed. London: Elsevier-Saunders;
2012:517–549 [Chapter 23]. vol. 3.
10. Noordhoff MS. Reconstruction of vermilion in unilateral and
bilateral cleft lips. Plast Reconstr Surg. 1984;73(1):52–61.
11. Mulliken JB, Pensler JM, Kozakewich HP. The anatomy of Cupid’s
bow in normal and cleft lip. Plast Reconstr Surg. 1993;92(3):395–403.
12. Noordhoff MS, Chen PKT. Unilateral cheiloplasty. In: Mathes ST,
ed. Plastic Surgery. Philadelphia: WB Saunders; 2006. vol. 4.
13. Onizuka T, Ichinose M, Hosaka Y, Usui Y, Jinnai T. The contour
lines of the upper lip and a revised method of cleft lip repair. Ann
Plast Surg. 1991;27(3):238–252.
14. Mohler L. Unilateral cleft lip repair. Plast Reconstr Surg. 1987;80(4):
511–516.
15. Noordhoff MS, Huang CS, Lo LJ. Median facial dysplasia in
unilateral and bilateral cleft lip and palate: a subgroup of median
cerebrofacial malformations. Plast Reconstr Surg. 1993;91:996–1007.
16. Mulliken JB, Martinez–Perez D. The principle of rotation
advancement for repair of unilateral complete cleft lip and nasal
deformity: technical variations and analysis of results. Plast Reconstr
Surg. 1999;104(5):1247–1260.
17. Patel KB, Mulliken JB. Correction of the vestibular web during
primary repair of unilateral cleft lip. Plast Reconstr Surg. 2014;134(4):
600e–607e.
18. Chen PK, Chang CS Comparison of philtral ridge morphology in two
different techniques of cleft lip repair. Presented in the 7th Asian-Pacific
Cleft Lip & Palate/Craniofacial Congress. Perth, Australia, March
11, 2011.
19. Chen PK, Noordhoff MS, Chen YR, et al. Augmentation of the free
border of the lip in cleft lip patients using temporoparietal fascia.
Plast Reconstr Surg. 1995;95(5):781–788.
20. Millard DR Jr, ed. Cleft Craft: The Evolution of Its Surgery. Boston:
Little, Brown; 1976. Vol. I.
21. McComb H. Treatment of the unilateral cleft lip nose. Plast Reconstr
Surg. 1975;55(5):596–601.
22. Salyer KE. Early and late treatment of unilateral cleft nasal
deformity. Cleft Palate Craniofac J. 1992;29(6):556–569.
23. Noordhooff MS, Chen YR, Chen KT, Hong KF, Lo LJ. The surgical
technique for the complete unilateral cleft lip-nasal deformity. Opera
Tech in Plast Reconstr Surg. 1995;2(3):167–174.
24. Byrd HS, Salomon J. Primary correction of the unilateral cleft nasal
deformity. Plast Reconstr Surg. 2000;106(6):1276–1286.
25. Byrd HS, Burt JD. Cleft lip: unilateral primary deformities. Plast
Reconstr Surg. 2000;105(3):1043–1055.
26. Cutting CB, Dayan JH. Lip height and lip width after extended
Mohler unilateral lip repair. Plast Reconstr Surg. 2003;111(1):17–23.
27. Van Beek AI, Hatfield AS, Schnepf E. Cleft rhinoplasty. Plast
Reconstr Surg. 2004;114(4):57e–69e.
28. Stal S, Brown RH, Higuera S, et al. Fifty years of the Millard
rotation-advancement: looking back and moving forward. Plast
Reconstr Surg. 2009;123(4):1364–1377.
29. McComb H. Primary correction of unilateral cleft lip nasal
deformity: a 10-year review. Plast Reconstr Surg. 1985;75(6):
791–797.
30. McComb H, Coghlan BA. Primary repair of the unilateral cleft lip
nose: completion of a longitudinal study. Cleft Palate Craniofac J.
1996;33(1):23–30.
31. Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-nose
repair: a 33-year experience. J Craniofac Surg. 2003;14(4):549–558.
32. Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-nose
repair-long term outcome. Clin Plast Surg. 2004;31:191–208.
33. Salyer KE, Xu H, Genecov ER. Unilateral cleft lip and nose repair;
closed approach Dallas protocol completed patients. J Craniofac
Surg. 2009;20(suppl 2):1939–1955.
34. Anderl H, Hussl H, Ninkovic M. Primary simultaneous lip and
nose repair in the unilateral cleft lip and palate. Plast Reconstr Surg.
2008;121(3):959–970.
35. Noordhoff MS The surgical technique for the unilateral cleft lip–nasal
deformity. DVD & Operative Syllabus. Noordhoff Craniofacial
Foundation, Taipei, Taiwan; 1997.
36. Lu TC, Lam WL, Chang CS, Chen PKT. Primary correction of nasal
deformity in unilateral incomplete cleft lip: a comparative study
between three techniques. J Plast Reconstr Aesthet Surg.
2012;65(4):456–463.
37. Koh KS, Choi JW, Kim H. Minimal paring of skin flaps for primary
repair of incomplete unilateral cleft lip. Plast Reconstr Surg.
2008;121(4):1382–1385.
38. Chen PKT, Yeow VK, Noordhoff MS, Chen YR. Augmentation of
the nasal floor with Surgicel in primary lip repair: a prospective
study showing no efficacy. Ann Plast Surg. 1999;42(2):149–153.
39. Cho BC. New technique for correction of the microform cleft
lip using vertical interdigitation of the orbicularis oris muscle
through the intraoral incision. Plast Reconstr Surg. 2004;114(5):
1032–1041.
40. Yuzuriha S, Mulliken JB. Minor-form, microform, and mini-form
cleft lip: anatomical features, operative techniques and revision.
Plast Reconstr Surg. 2008;5:1485–1493.
41. Chang CS, Wallace CG, Hsiao YC, Chang CJ, Chen PKT. Botulinum
toxin to improve results in cleft lip repair. Plast Reconstr Surg.
2014;134(3):511–516.
42. Osada M, Hashimoto K, Akiyama T. Application of intra and extra
nasal silicone prosthesis after the operation of nasal deformities. Jpn
J Plast Reconstr Surg. 1969;11:191.
43. Skoog T. Repair of unilateral cleft lip deformity: maxilla, nose, and
lip. Scand J Plast Reconstr Surg. 1969;3:109–133.
44. Friede H, Lilja J, Johanson B. Lip–nose morphology and symmetry
in unilateral cleft lip and palate patients following a two-stage lip
closure. Scand J Plast Reconstr Surg. 1980;14:55–64.
45. Yeow VK, Chen PKT, Chen YR, et al. The use of nasal splints in the
primary management of unilateral cleft nasal deformity. Plast
Reconstr Surg. 1999;103(5):1347–1354.
46. Lu TC, Chen PK Assessment of nasolabial symmetry in patients with
unilateral complete cleft lip and palate following modified rotation
advancement cheiloplasty. Presented at the 6th Asian Pacific Cleft Lip
and Palate Congress, Goa, India; Sept. 2007.
47. Chen IJ The progressive changes of nasal symmetry and growth after
nasoalveolar molding. Master thesis, Chang Gung University, Taiwan;
2008.
48. Chang CS, Por YF, Liou EJW, et al. Long-term comparison of four
techniques for obtaining nasal symmetry in unilateral complete
cleft lip patients: a single surgeon’s experience. Plast Reconstr Surg.
2010;126:1276–1284.

SECTION I • Clefts
21.3 
Extended Mohler repair
Roberto L. Flores
SYNOPSIS
■ Treatment philosophy
• Nasoalveolar molding
• Gingivoperiosteoplasty
• Tension-free reconstruction
• No lip adhesion
• Primary nasal reconstruction
• Closure of the nasal floor
■ Evolution of technique
■ Markings
■ Downward rotation of Cupid’s bow
■ Preparation of the medial lip element
■ L-flap dissection
■ Lateral lip element dissection
■ Intranasal mucosa reconstruction
■ Oral mucosa reconstruction
■ Primary rhinoplasty Part I
■ Alar base repositioning
■ Orbicularis oris repair
■ Upper lip skin and vermillion repair
■ Primary rhinoplasty Part II
■ Postoperative care
■ Results
Introduction
Aesthetic reconstruction of the upper lip is enhanced by
adherence to the subunit principles advocated by Burget and
Menick.1 Scar placement along the subunit borders are more
easily hidden and emphasize the geometric patterns recog-
nized by the eyes as structurally normal components of the
face. The Mohler cleft lip repair locates the final scars perfectly
along the subunit borders of the skin-bearing upper lip,
without the use of triangular flaps or curvilinear scars which
disrupt the harmony of upper lip aesthetics.
The extended Mohler repair, recently popularized by
Cutting, addresses some of the limitations of Mohler’s original
design and, in its current form, can be applied to any unilateral
cleft lip deformity regardless of severity of the defect or use
of pre-surgical orthopedics. Cutting’s popularization of the
Mohler repair, in addition to his technical modifications,
justify the appropriate description of the technique as the
Mohler Cutting repair. These modifications have led to the
widespread acceptance of the repair and have maintained its
popularity as one of the most common techniques used to
repair the unilateral cleft lip deformity.
Summary box
Primary cleft lip and nasal repair seeks to achieve lasting
symmetry to the lip and nose while camouflaging scars within
the contours of the face. This surgery is often the first step in
the larger treatment plan for cleft care, therefore the quality
of the repair sets the direction of the function and appearance
for the patient. As the surgeon should strive to effect the
most change with the least amount of surgery, nasoalveolar
molding should be pursued whenever possible. Primary
nasal repair has been demonstrated to be safe and should
be performed with slight overcorrection to the alar base
and nostril rim position. The nasal floor should be closed
to better prepare the patient for future alveolar bone graft.
Gingivoperiosteoplasty may be considered in experienced
centers. The Mohler Cutting repair, described herein, has the
advantage of placing the final scars perfectly along the subunit
borders. The technique can be applied to all patients with a
unilateral cleft, despite the width of the cleft, or the use of pre-
surgical orthopedics. The technique also has the advantage of
offering a medial approach to primary cleft rhinoplasty.

529
Treatment philosophy
as the developing teeth.24 Indeed, GPP has a variable success
rate across institutions,6,24 implicating the technical chal-
lenges of the procedure. The majority of the clinical reports
of gingivoperiosteoplasty are single institution experiences
limiting a large volume analysis. More importantly, there are
no published studies to date reporting on the effects of GPP
on anterior facial growth in the facially mature patient with a
cleft. Gingivoperiosteoplasty experienced resurgence after the
development of nasoalveolar molding and the initial NAM and
GPP patients of this resurgence have only recently achieved
the age of facial maturity. The eventual report of complete
facial growth after GPP will undoubtedly spark another active
debate on the indications and benefits of this procedure.
Tension-free reconstruction
The purpose of the suture is to join together vascularized
tissue so that normal healing can occur. Normal healing does
not occur when sutures a placed under tension. When consid-
ering the delicate reconstruction of the three dimensional
form of the lip and nose, this principle is taken a step further:
even mild amounts of tension will result in relapse of the cleft
deformity, cause widened scars, and predispose the patient to
further surgery to the lip and nose resulting in additional
scars in these areas. Tension on closure, even mild tension,
should not be addressed with sutures; this is a therapy, which
does not last. Tissues should be adequately freed until tension
is completely eliminated in the critical aesthetic areas of the
nose and upper lip skin. In cases where pre-surgical orthope-
dics is not used, extensive dissection may be required.
No lip adhesion
Lip adhesion is commonly advocated in cases where NAM or
a similar form of pre-surgical orthopedics cannot be employed.
This author’s experience is that lip adhesions are unnecessary,
even in the cases of very wide cleft lips, and can compromise
surgical outcomes. Three points deserve mention in this
regard:
1. L-flap reconstruction: The use of a lip adhesion
precludes the use of an L-flap, whether based on the
alveolus as described by Millard25 or pedicled on the
lateral nasal wall, as advocated by Cutting.26 Although a
lip adhesion can bring the lip and alveolar segments in
greater apposition, the alar base and nose are mildly
affected by this procedure. The lip adhesion, therefore,
may benefit lip reconstruction at the cost of nasal
reconstruction. Without an L-flap, a pyriform aperture
incision defect cannot be closed with mucosal tissue.
Therefore, the intranasal incision is not made at the time
of nasal repair or the incision is made but not
reconstructed. Both of these will compromise the quality
of nasal repair in the very patients who require the full
armamentarium of reconstructive techniques: patients
with wide cleft lip deformities.
2. Scar: In addition to eliminating certain flap options, a
lip adhesion produces a scar in the center stage of the
planned repair. Lip adhesion will therefore compromise
the quality of the lip tissue and this is appreciable at the
time of lip repair.
3. Complete cheek and nasal dissection: One of the great
challenges of wide cleft lip repair is medial
Treatment philosophy
Nasoalveolar molding
Primary cleft lip and nasal reconstruction has been made
more predictable by the development of nasoalveolar molding
(NAM).2 Although the Mohler Cutting repair can be applied
to any complete unilateral cleft lip deformity, regardless of
severity, NAM leads to greater nasal symmetry,3–5 facilitates
gingivoperiosteoplasty,6 and decreases the need for secondary
surgery. Through weekly to biweekly modifications of the
alveolar plate and nasal stent, NAM anatomically aligns the
alveolar segments, lengthens the columella, increases nasal tip
projection, folds the lower lateral cartilages towards its native
form, transposes the lower lip and alar base towards the
midline, and expands the intranasal lining. Therapy is usually
completed within 8–10 weeks in patients with a unilateral
cleft deformity. The summative effect of NAM is altering the
severity of the cleft towards a mild phenotype. Therefore, the
benefit of NAM lies in the ability for good surgeons to achieve
excellent results and for experienced surgeons to more con-
sistently obtain the near perfect result. In the author’s practice
pattern, NAM is used whenever feasible by the family.
As popularity has increased, a growing number of cleft
centers have reported the benefit of NAM or similar technical
variation.7–13 Currently, there is an ongoing debate between
the proponents and skeptics of NAM14,15 which will require
large population, multicenter analysis to resolve. Prospective
multicenter analysis of the surgical and quality of life out-
comes of NAM are currently ongoing, which will provide a
comprehensive analysis of the benefits and limitations of this
technique.
Gingivoperiosteoplasty
The “boneless” bone graft has variable numbers of supporters
and remained a topic of active debate. During primary cleft
lip repair or cleft palate reconstruction, the mucosal edges of
the alveolus may be connected to promote bony union
between the free alveolar segments. Gingivoperiosteoplasty
(GPP) was originally described by Skoog16 and later popular-
ized by Millard17 who used a Latham device to actively mold
the alveolus prior to GPP.
Proponents state that the procedure will avoid, in most
cases, the need for secondary alveolar bone graft. Indeed,
successful GPP is demonstrated in 60% of patients with a
unilateral cleft,18–20 circumventing the morbidity and financial
burden of an additional surgery.21 Anterior growth appears
to be unaffected through the age of mixed dentition.22
However, other reports have suggested some impairment of
midface growth after GPP.23 Furthermore, the procedure is
very technique dependent. Even a moderate dissection force
can fracture the thin alveolar bone and destroy underlying
tooth buds. Mucoperiosteal flap dissection must be limited
to the mesial and distal faces of the alveolus with no dis-
section of the lingual or buccal faces. This requires perfect
alignment of the alveolar segments and a gap of 1 mm.
Pre-surgical orthopedics, therefore, is a necessary adjunct to
gingivoperiosteoplasty.
Opponents state that gingivoperiosteoplasty has a limited
success rate and will damage anterior facial growth as well

530
SECTION I
CHAPTER 21.3 • Extended Mohler repair
2. Limited dissection: in the growing face, surgical
planning should take into account the immediate and
long-term effects of surgery. As adult cleft rhinoplasty
remains one of the formidable challenges in plastic
surgery, logic would suggest that limiting the amount of
scar present in the nose at the time of facial maturity
would be a wise investment for the patient. Therefore,
the art of primary cleft rhinoplasty should include
effecting the most change with the least surgery. This
philosophy falls somewhat counter to the culture of
plastic surgery, which tends to advocate more complex
and a greater number of procedures to reach the holy
grail of the perfect result.
3. Indications for secondary rhinoplasty: The ideal
treatment plan for patients with a cleft would be an
effective primary cleft rhinoplasty at the time of cleft lip
repair followed by a second rhinoplasty at the time of
facial maturity. This goal can be achieved in many
patients; however, several others may require a “touch
up” surgery prior to reaching facial maturity. It is the
opinion of the author that these patients are the ones
most at risk for the formation of excessive scars within
the nose. Secondary rhinoplasty on the growing face
should be considered if there is direct and clear request
by the patient or caregiver, not because the surgeon is
trying to improve their result. When performing
immature cleft rhinoplasty, consideration should be
given to the consequences of the procedure. Aggressive
cartilage dissection, resection of nasal tip fibrofat, and
cartilage implants can all look favorable for a time after
surgery; however, subsequent nasal reconstruction may
be compromised by overzealous application of these
techniques.
Nasal floor closure
A principle of cleft surgery, which lacks emphasis, is closure
of the nasal floor at the time of lip repair. The procedure
requires extra work and has no bearing on the aesthetic result
of the primary reconstruction. However, reconstruction of the
nasal mucosa over the area of the alveolar cleft will have
implications on future alveolar bone graft surgery. Nasal floor
closure is commonly the most challenging part of alveolar
bone graft surgery, and soiling of bone graft with nasal flora
is a known source of bone graft failure. Unfortunately, expo-
sure of the nasal floor defect during alveolar bone graft
surgery can be challenging due to obstruction by the alveolar
segments. At the time of primary lip repair, the nasal floor is
well exposed. The vomer and lateral nasal wall are available
for primary nasal floor reconstruction at the time of lip repair.
This added effort at the time of infancy will be a wise invest-
ment which will be appreciated during alveolar bone graft
surgery.
Evolution of technique
The Mohler Cutting repair evolved from an appreciation of the
limits of the Millard rotation advancement repair and a need
for a more aesthetic upper lip repair. In his signature repair,
Millard placed an incision along the philtral line on the cleft
side, which curves towards the philtral column on the non-cleft
transposition of the lateral lip and alar base to achieve a
tension-free closure. Although a lip adhesion can be
useful in achieving this end, one can simply perform
thorough cheek and lip dissection at the time of primary
repair and achieve the same surgical ends of lip and alar
base transposition, but without the cost of flap sacrifice
and scar. This dissection requires a generous pyriform
aperture incision and wide dissection across the face of
the maxilla as far superior as the infraorbital rim and as
far later as the medial canthus. A supraperiosteal
dissection plane is maintained to limit blood loss. This
dissection, by definition, will sacrifice the infraorbital
nerve; however, lip sensibility does return to the level of
the unaffected lip by the process of adjacent
neurotization.27
Primary nasal repair
Previous studies have demonstrated the aesthetic benefit to
primary cleft rhinoplasty28,29 as well as the safety of infant
rhinoplasty to subsequent nasal growth. Although primary
cleft rhinoplasty is advocated by most surgeons, not all rhi-
noplasties are created equal. The great enemy of the refined
soft tissue repair is scarring; therefore primary cleft rhino-
plasty should execute the best and most lasting change with
the least amount of dissection. Any surgeon can perform a
three layer nasal dissection at the time of infancy, then “touch
up” the nose with an open rhinoplasty and cartilage grafts
prior to elementary school, then refine the nose again (with
an open rhinoplasty, of course) at the age of adolescence.
However, one would predict that by the time facial maturity
is reached, the density of scar surrounding the lower lateral
cartilages and embedded in the nasal tip skin would preclude
any aesthetic or functional result in the patient beyond the
mediocre. Costal cartilage is advocated by many surgeons
who perform adult cleft rhinoplasty; however, even these
rigid grafts can be deformed by the steady, persistent force of
cicatrix.
Primary cleft rhinoplasty, therefore, should be directed and
limited in dissection. Although removal of fibrofat in the nasal
tip can certainly result in greater tip refinement at the time of
repair, will that same procedure be perceived as a benefit
when attempting to refine the scarred tip at the age of 22? The
benefit and detriment of different types of primary rhinoplasty
is an area that lacks scientific assessment. Active cleft surgeons
are familiar with the scarred nasal tip resulting from excessive
operations that resists the most acrobatic surgical repair. The
under-operated nose can be predictably improved, although
perfection is elusive. The over-operated, scarred nose can
produce unfortunate, complex, and insurmountable hurdles
to an already challenging operation which, in many cases, can
be avoided with proper planning and appreciation for the
larger picture.
There are several principles of care which are advocated to
produce the most change with the least potential harm:
1. Nasoalveolar molding: pre-surgical manipulation of the
nose and alveolus results in a more predictable primary
cleft rhinoplasty which requires less nasal (and facial)
dissection compared to patients who have not
undergone nasoalveolar molding. The requirement of
secondary “touch up” surgery is decreased while
increasing overall nasal symmetry.3

531
Markings
only in incomplete clefts.31 In Cutting’s variation, the apex of
the Mohler incision was extended to just beyond the midline
of the columella. The back cut was then brought down to
the opposite philtral column, but no further (Fig. 21.3.1).
This modification will achieve full downward rotation of the
Cupid’s bow in any unilateral cleft lip patient, regardless of
severity.
Markings
Surgical markings for the Mohler Cutting repair start with
standard tattooing of the white roll. The depth of Cupid’s bow
is marked on the white roll followed by the height of Cupid’s
bow on the non-cleft side. In patients with an indistinct phil-
tral line, care should be taken to avoid marking the philtrum
too wide. A wide philtrum will require a larger back cut for
complete rotation. The ethnic background of the patient
should also be considered as Caucasian people tend to have
more narrow philtrums compared to Asian, African, and
Hispanic people who tend toward wider philtrums. The dis-
tance between these two points is used to mark the height of
the Cupid’s bow on the cleft side. The white roll usually
becomes indistinct at this area. The cleft sided height of the
Cupid’s bow is marked just medial to the desired point as the
incision will pass lateral to this white roll point.
The white roll point on the lateral lip element is determined
by the vertical height of the lip on the non-cleft side. This
mark has been classically determined by measuring the dis-
tance from the commissure to the height of Cupid’s bow on
the non-cleft side and transposing this distance to the cleft
side.25 This method of marking, advocated by Millard, will
restore a symmetric horizontal width of the upper lip at the
sacrifice of vertical lip height at the philtral line. Even small
discrepancies of vertical lip height (1–2 mm) are visible at
conversation distance while discrepancies in horizontal width
are less easily noticed and correct over time.32,33 Another com-
monly advocated approach locates the lateral lip point to the
white roll over widest width of the vermillion, Noordhoff’s
point.34 In the incomplete and some complete cleft lip defor-
mities, this mark accurately restores vertical height of the lip.
However, in the cleft lip with a vertically short lateral lip,
Noordhoff’s point will produce a vertically short reconstruc-
tion. Therefore the vertical height of the lip on the non-cleft
side is used to determine the lateral lip point on the white roll.
This distance is about 10 mm in the 3-month-old child.
The back cut of the Mohler Cutting repair is angled, not
curved as drawn in the rotation advancement repair. There-
fore, the Mohler Cutting back cut is defined by only two
points: the apex of the back cut located on the columella and
the base of the back cut located at the junction of the columella
with the upper lip. Minor adjustments of these two points
affect the degree of achievable downward rotation, the pro-
portion of the surrounding tissue, and location of the final
scars. The apex of the back cut should be at least 1.5–2 mm
superior to the base of the columella, approximately 4 7 across
the columellar width, towards the non-cleft side. If the apex
is drawn too low then inadequate downward rotation will be
the result. If the point is too far towards the cleft side, the
C-flap will be narrow and inadequate to fill the defect created
by the downward rotation of Cupid’s bow. This may be the
cause of the narrow columella that some surgeons associated
side at the superior aspect of the medial lip element.25,30 This
curvilinear incision produced a back cut on the upper lip,
facilitating downward rotation of the medial lip element as
a near total philtral unit. Cupid’s bow, which is preserved
in the unilateral cleft deformity, rotates downward with the
medial lip element producing an anatomic reconstruction of
this aesthetic structure. Cupid’s bow, the philtral dimple, and
most of the philtral column was preserved and orthotopically
repositioned through this procedure. Downward rotation of
the medial lip composite resulted in elongation of the philtrum
on the cleft side and the resulting upper lip defect was filled
by medial advancement of the lateral lip element.
The major limitation of the Millard repair is in its violation
of the subunit borders at the superior third of the upper lip.
The incision line veers away from the philtral line on the cleft
side and curves towards the contralateral philtrum. This
violation becomes more apparent in children with wide clefts
who typically require a significant downward rotation of the
medial lip element and therefore, a larger back cut. A com-
pounding limitation is the use of the lateral lip element to fill
the defect created by downward rotation of Cupid’s bow. In
the cases of wide cleft lips, the lateral lip element may require
aggressive medialization to close the defect created by the
larger back cut. As a result, the attached alar base can be
excessively medialized, creating a micronostril, a deformity
that lacks a definitive means of correction. Some surgeons
have relied on perialar incisions in order to prevent the cre-
ation of a micronostril; however, scars in this area heal poorly
and are difficult to correct.
Mohler’s variation of the classic rotation-advancement
repair relocates the back cut, used for downward rotation of
Cupid’s bow, from the medial lip to the columella. The result
of this seemingly minor modification has powerful effects on
upper lip aesthetics and nasolabial form. As the back cut is
transposed from the lip to the nose, the defect created by the
downward rotation of the medial lip element is also relocated
to the columella. The inferior columellar skin, now part of the
medial lip element flap, is transposed inferiorly with the
medial lip to become the superior aspect of the philtrum,
completely restoring the aesthetic subunit of the philtrum.
The defect in the columella created by inferior rotation of the
medial lip element is filled by superior rotation of the C-flap.
The summation of these transpositions resembles an asym-
metric Z-plasty repair rather than a rotation advancement
repair. Superior rotation of the C-flap has the secondary
benefit of superior transposition of the depressed medial
crura and lengthening of the columella. As the lateral lip
element is not used to fill the defect created by the downward
rotation of Cupid’s bow, less medial advancement of the
lateral lip element is generally required, decreasing the risk of
creating a micronostril. Moreover, there is a limited differen-
tial degree of advancement that is required between the lateral
lip element (to fill the downward rotation of the Cupid’s bow)
and the alar base (to create an aesthetic and balanced nostril).
Therefore, there is little need to separate the lateral lip from
the alar with an unaesthetic perialar incision. A short, near
horizontal incision at the alar base is all that is needed.
In Mohler’s original design, the base of the back cut
ended at the superior border of the philtral dimple, limiting
the downward rotation of Cupid’s bow. Millard criticized
Mohler’s original description of his columellar back cut as
being inadequate for use in complete clefts and likely useful

532
SECTION I
CHAPTER 21.3 • Extended Mohler repair
Fig. 21.3.1  Mohler’s design.
with this technique. If the apex is placed too far towards the
non-cleft side then the philtrum will be narrow and unaes-
thetic at its superior aspect. If the base of the back cut is placed
lateral to the philtrum, then the upper lip will be lengthened.
If the point is placed on the philtrum but inferior to the
junction of the columella and upper lip then the final scars
will violate the subunits of the upper lip. The learning curve
of the Mohler Cutting repair is associated with appreciating
the effects of subtle changes of these two points on the total
repair.

533
Technical aspects of surgery
Final appearance of the cleft lip markings can be appreci-
ated in Fig. 21.3.2.
Technical aspects of surgery
Downward rotation of Cupid’s bow
The M-flap and C-flap are first mobilized with care to preserve
the underlying orbicularis oris. The Mohler back cut is then
incised through dermis only. A horizontal incision is then
made at the base of the columella (base of the Mohler back
cut) across the orbicularis oris (Fig. 21.3.3). If this incision is
made at the apex of the Mohler back cut then the medial crura
will be transected. The full thickness of upper lip muscle is
transected with preservation of the oral mucosa. Dissection
then proceeds deep to the orbicularis oris on the medial lip
element, freeing a cuff of muscle from the underlying oral
mucosa. This dissection plane should continue to the base of
the Mohler back cut. If further downward rotation is required,
a mucosal incision is made parallel to the frenulum then
across its base in a hockey stick fashion. This incision will
result in further downward rotation of the Cupid’s bow. The
frenulum defect is closed with the M-flap.
Preparation of the medial lip element
The skin of the medial element is sharply dissected from the
underlying orbicularis oris muscle as far as the philtral dimple
but no further. This small skin flap creates space for sutures
during orbicularis oris reconstruction and frees the medial
edge of the upper lip skin for further downward rotation of
Cupid’s bow.
A line is drawn connecting the apex of the back cut with
the height of Cupid’s bow on the cleft side. This line should
have a subtle convexity at the lower third of the lip to create
an aesthetic shield shape to the philtrum. At the base of the
philtrum, the line should pass just lateral to the point marking
the height of Cupid’s bow on the cleft side. If the line goes
through the white roll point then the tattoo point will be
incised and not visible during reconstruction. The apex and
base of the back cut are connected as a straight line and the
C-flap and M-flap are drawn in the standard manner. The
anterior border of the M-flap should be drawn perpendicular
to the white roll. It is important to include the maximum
amount of skin when marking the C-flap without incorporat-
ing mucosa. In cases in which pre-surgical orthopedics are not
used, the greater area of the C-flap will be used to fill the
defect in the columella. If mucosa is included in the C-flap
then this tissue may be transposed to the nose and upper lip.
An oblique line is drawn 1 mm inferior to the white roll at the
anterior border of the M-flap to the red line. This line should
be approximately 5 mm in length and is the receiving incision
for the Noordhoff triangular flap.
Attention is now drawn to the lateral lip element. A line is
drawn along the alar base crease at the border of the upper lip
skin within the nostril floor skin. This line should start medi-
ally at the mucosal border and extend laterally to the medial
border of the nostril rim. In the wide cleft lip with a short
vertical height of the lateral lip element, the upper lip skin can
be pulled into the nostril floor by aberrant attachments of the
pars superficialis to the periosteum of the piriform aperture.
Therefore, the medial border of the alar base crease may be
pulled slightly (1 mm) within the nose. It is important not to
over extend the medial border of the alar crease line into the
substance of the nostril floor as this will cause a micronostril
which is difficult to correct. The lateral border of the alar
crease line ends at the medial border of the nostril rim. No
perialar incision is used. The medial border of the lateral lip
element is drawn from inferior to superior, starting 1 mm
inferior to the white roll, on the vermillion. The line then
crosses the white roll, in a perpendicular fashion, just medial
to the white roll mark to a point 1 mm superior to the white
roll. Transecting the white roll at a right angle will prevent
notching of this anatomic structure. The line then quickly and
gracefully curves to meet the medial border of the alar crease
line at the base of the nose. This curved incision increases the
vertical height of the lateral lip at the cost of horizontal lip
length. Long term studies have demonstrated that discrepan-
cies in horizontal lip length can correct over time.32,33
A Noordhoff triangular flap34 is drawn on the vermillion to
restore fullness to the vermillion at the area of the tubercle,
prevent a whistling deformity and anatomically reconstruct
the red line of the upper lip. This last benefit is of particular
importance in Asian and African-American patients who
commonly have a distinct border between the mucosa and
vermilion. This flap capitalizes on the excess vermillion
usually present in the lateral lip and transposes this tissue to
the deficient medial lip element. As vermillion is delicate
tissue, care is taken to incorporate a generous amount of red
lip in the flap for easier handling. Excess vermillion and
mucosa can be later trimmed from the triangular flap or the
medial lip element. The inferior border of the L-flap is drawn
to meet the medial edge of the gingivobuccal sulcus on the
lesser segment.
Fig. 21.3.2  Complete Mohler Cutting markings for the unilateral cleft lip repair.
Note the back cut is placed on the columella rather than on the upper lip. The back
cut markings are extended as a dotted line onto the upper lip. Extension of the
incision onto the upper lip will lengthen the lip length on the non-cleft side.
Therefore, the back cut should be limited to the columella. Note the generous
Noordhoff triangular flap which incorporates the maximum amount of dry lip.

534
SECTION I
CHAPTER 21.3 • Extended Mohler repair
vertical incision should continue down to the bony edge of
the pyriform aperture. A horizontal, intranasal incision is then
made from posterior to anterior at the inferior border of the
lateral nasal wall, joining the inferior border of the L-flap
incision. Completing these two incisions will pedicle the
L-flap on the lateral nasal wall (Fig. 21.3.5). This modification
prevents oronasal fistula formation and aids in gingivoperi-
osteoplasty as well future alveolar bone grafting. A vomer flap
is raised at this time for eventual closure of the anterior nasal
floor. A gingivoperiosteoplasty can be performed at the dis-
cretion of the surgeon.
Lateral lip element dissection
The L-flap is tucked within the cleft-sided nostril and gingi-
vobuccal sulcus incision is made. This incision is connected
with the pyriform aperture incision by a supraperiosteal dis-
section across the face of the maxilla (Fig. 21.3.6). In patients
with incomplete clefts or patients who have undergone NAM,
there will be limited need for the gingivobuccal sulcus inci-
sion and supraperiosteal dissection. In patients with wide
cleft lips who have not undergone pre-surgical orthopedics,
dissection across the face of the maxilla can be extensive,
extending as far superior as the supraorbital rim and as far
lateral as the lateral canthus. Dissection along the medial
buttress of the nose is also important to free the cartilaginous
attachments from the pyriform rim. Dissection proceeds until
a tension free, orthotropic transposition of the ala can be
achieved. Even a small amount of tension at the time of
closure will result in relapse of the deformity, despite appear-
ances at the end of the procedure.
Intranasal mucosa reconstruction
All mucosal defects in the cleft sided nostril are closed with
mucosal flaps. The pyriform aperture incision is reconstructed
with the L-flap to prevent closure of this defect by secondary
intention which will result in relapse of the alar deformity
(Fig. 21.3.7). All excess L-flap should be meticulously trimmed
as redundancy in this reconstruction will result in excess
Fig. 21.3.3  Transection of the orbicularis oris is performed in a transverse manner
at the junction of the columella with the upper lip. Performing this incision at the
apex of the back cut will result in transection of the medial crura. A full-thickness
incision of the upper lip muscle is required to fully rotate the Cupid’s bow inferiorly.
Fig. 21.3.4  A vertical pyriform aperture incision is made at the junction of the
nasal mucosa with the squamous epithelium of the nostril.
Fig. 21.3.5  The L-flap is pedicled from the lateral nasal wall and not the alveolus.
This modification will prevent a persistent oronasal fistula and assist in
reconstruction of the nasal floor.
L-flap dissection
The L-flap is sharply dissected from the orbicularis oris with
care to preserve the muscle underlying the Noordhoff trian-
gular flap. Without the underlying muscle, the Noordhoff flap
will be flimsy and difficult to handle. As the base of the L-flap
is approached, near the gingivobuccal sulcus, the level of
dissection changes from a submucosal to a subperiosteal
plane. Using a small periosteal elevator, a pocket is made at
the inferior/lateral rim of the pyriform aperture, directly on
the bone. This dissection pocket is widened to include the
inferior aspect of the lateral nasal wall. A vertical, intranasal
incision is made in the lateral aspect of the cleft-sided nostril
at the junction of the squamous epithelium and nasal mucosa
(Fig. 21.3.4). This incision is made from superior to inferior to
meet the superior/posterior border of the L-flap incision. This

535
Technical aspects of surgery
Fig. 21.3.7  The forceps point to the trimmed L-flap which has been inset into the
pyriform aperture incision.
Fig. 21.3.8  The Mohler Cutting incision facilitates a medial approach rhinoplasty.
At the apex of the back cut, blunt scissor dissection is used to separate the medial
crura and gain access to the nasal tip.
Fig. 21.3.6  The oral sulcus incision will merge with the pyriform aperture incision.
Supraperiosteal dissection across the face of the maxilla will free the alar base. In
cases where NAM is not used, this dissection may extend widely across the maxilla.
The goal is to sufficiently release the displaced tissue as to eliminate all tension
during alar base repositioning.
mucosa bulging into the nose. The anterior floor of the nose
is reconstructed to facilitate bony reconstruction of the alveo-
lus. If a gingivoperiosteoplasty is performed at the time of
primary cleft lip repair then nasal floor closure will be
required. If a secondary bone graft is planned then closure of
the nasolabial fistula will result in an easier reconstruction
and in increased graft take. The vomer flap is sutured to
the inferior/medial edge of the L-flap. Horizontal mattress
sutures are placed from posterior to anterior to achieve a
water-tight seal to the floor of the nose.
Oral mucosa reconstruction
In patients with an incomplete cleft or well-opposed alveolar
segment, oral mucosa reconstruction is rarely a problem. In
patients with wide unilateral cleft lips, care must be taken to
prevent tension at the midline mucosa repair as this could
lead to dehiscence of the wound. At the lateral aspect of the
sulcus incision, aggressive medial transposition of the oral
mucosa can be achieved without risk to vascularization of the
flap. Oblique sutures are placed with decreasing tension from
lateral to medial. The goal is to achieve a tension-free closure
at the midline, which will result in healthy healing of the
intraoral lining.
Primary rhinoplasty Part I
An underappreciated benefit of the Mohler Cutting repair is
the position of advantage it offers to medial approach primary
cleft rhinoplasty. Access to the medial crura, nasal tip, and
lower lateral cartilages is facilitated by the apex of the back
cut, located on the columella. Converse scissors are inserted
between the medial crura at the apex of the Mohler back
cut and gentle spreading is used to separate these paired
structures (Fig. 21.3.8). A hemi-membranous incision is made
from the septal angle to the floor of the nose on the cleft side
(Fig. 21.3.9). The hemi-membranous incision is connected to
the dissection pocket created between the medial crura with
care not to damage the lower lateral cartilages. The Converse
scissors are then inserted underneath the nasal tip skin, over
the lateral crura and lateral crus. Gentle spreading will release
the skin over the upper and lower lateral cartilages on the
cleft and non-cleft side (Fig. 21.3.10). Dissection between
the lower lateral cartilage and nasal mucosal is unnecessary
and will only create additional scar. Fibrofat is not removed
from the nasal tip. The depressed lower lateral cartilage on
the cleft side is elevated to a super-corrected position with a
Ragnell retractor. The medial crura are affixed to each other
using a long-lasting absorbable suture (Fig. 21.3.11). These
sutures serve the secondary purpose of shaping the columella.
Several transfixion sutures are then used to close the hemi-
membranous septum incision. The columellar length on the
cleft side should equal that of the non-cleft side at the end of
this portion of this procedure. In patients with a wide cleft and
no pre-surgical orthopedics, a nostril rim incision is added

536
SECTION I
CHAPTER 21.3 • Extended Mohler repair
Fig. 21.3.9  A hemi-membranous incision is used to free the depressed medial
crura on the cleft side. This lower lateral cartilage will be elevated to a super-
corrected position.
Fig. 21.3.10  Gentle spreading is performed over the nasal tip cartilages.
Fig. 21.3.11  The depressed lower lateral cartilage is elevated to a super-corrected
position using a Ragnell retractor. Long-lasting absorbable sutures are used to affix
the medial crura in its new position and to shape the columella.
Fig. 21.3.12  The alar base is affixed to the caudal septum and medial crura on the
non-cleft side.
on the cleft side. The lower lateral cartilage is dissected from
the overlying skin and a suspension suture is placed between
the upper lateral and lower lateral cartilage. An intradomal
suture is also placed at this time. Excess nostril rim skin is
carefully trimmed and the nostril rim is closed.
Alar base repositioning
A flap of dermis and muscle is sharply dissected from the
nasal floor skin of the cleft sided alar base. This dermomus-
cular pennant is sutured to the crura footplate on the unaf-
fected side using two long-lasting absorbable sutures (Fig.
21.3.12). The caudal septum may be incorporated into the
suture to straighten the anterior septum.
Orbicularis oris repair
The skin of the lateral lip element is sharply separated from
the orbicularis oris as far laterally as the alar base. Excess
orbicularis oris is sharply trimmed towards the level of the
skin incision. The orbicularis oris is reconstructed using
buried sutures. If the muscle has been properly trimmed, the
upper lip skin edges will “kiss” once the orbicularis oris has
been reconstructed. This will eliminate all tension from the
upper lip skin repair.
Upper lip skin and vermillion repair
The upper lip skin and Noordhoff triangular flap are inset.
Excess mucosa on the medial lip element is trimmed to
prevent excess fullness in the area of the tubercle. The C-flap
is trimmed and used to fill the entire columellar defect created
by the downward rotation of the Cupid’s bow (Fig. 21.3.13).

537
Postoperative care
Postoperative care
Unilateral cleft lip repair is commonly performed as an out-
patient surgery. Parents are instructed to clean the upper lip
twice daily with soap and water as well as dilute hydrogen
peroxide. Arm braces which prevent bending at the elbows
are used for 3 weeks to protect the reconstructed site. These
braces are generally well tolerated. No pacifier is used during
this 3-week period and a special feeding bottle is used during
A straight line scar should extend along the entire length of
the philtrum on the cleft side. The lateral aspect of the C-flap
is united with the alar base skin to close the nostril floor. The
nostril floor should be closed in a stair-step fashion in relation
to the upper lip incision. This will avoid the convergence of
four skin corners at the base of the nose which can produce a
depressed scar. Proper skin dissection of both the C-flap and
the nasal floor flap on the lateral lip element will prevent the
formation of a micronostril even in cases where the C-flap is
deficient.
Primary rhinoplasty Part II
Lower lateral cartilage repositioning and vestibular web
obliteration is performed using internal retention sutures. An
oblique horizontal mattress is placed from the cleft sided
nostril to the non-cleft nostril and back again to elevate the
depressed lateral crura and address nostril apex overhang.
The point of maximum overhang on the nostril rim is sighted
and a suture is placed through the lower lateral cartilage, into
the dissection pocket underneath the nasal tip skin. The trajec-
tory of the suture is posterior and lateral. The suture then
passes through the lower lateral cartilage on the non-cleft side
and into the non-cleft nasal airway. The suture is then returned
to the cleft sided nostril, following a parallel trajectory, 2 mm
behind the first pass. Tying this oblique, nostril to nostril,
horizontal mattress suture will elevate the depressed lower
lateral cartilage and medialize the lateral crus. It is critical to
overcorrect the vertical height of the lower lateral cartilage in
anticipation for descent of this structure over time.5
The vestibular web is addressed without the use of external
bolsters or nasal packing. A long-lasting suture is placed
behind the vestibular web, and through the alar-facial groove
externally (Fig. 21.3.14). The same percutaneous hole is used
return the suture into the nose but anterior to the vestibular
web. Tying this suture will obliterate the vestibular web and
accentuate the alar-facial groove. Two or three sutures may be
required to achieve the full effect of this internal retention
suture (Fig. 21.3.15).
Fig. 21.3.14  Vestibular web obliterating sutures are placed intranasally behind the
web and through the alar–facial groove. The suture is returned through the same
percutaneous puncture and then intranasally in front of the web. Tying this suture
will obliterate the vestibular web and accentuate the deficient alar–facial groove.
Fig. 21.3.15  At the conclusion of primary rhinoplasty, the lower lateral cartilage
should be anatomically repositioned and the vestibular web obliterated.
Fig. 21.3.13  The C-flap is trimmed to fill the entire defect created by the
downward rotation of Cupid’s bow. Note this defect is located entirely within the
columella. The lateral lip element skin is not used to fill this defect.

538
SECTION I
CHAPTER 21.3 • Extended Mohler repair
the affected side. This concerning appearance will peak about
6–8 weeks postoperatively when the scar is at its most promi-
nent and firm state. As the scar eventually softens and
remodels, over the course of one year, the upper lip will
elongate. Scar massage is initiated 6 weeks postoperatively.
Symmetrical upper lip and nasal form can be achieved with
aesthetic placement of the upper lip scars along subunit
borders (Figs. 21.3.16–19).
this time. The patient may breastfeed normally. All permanent
sutures are removed 5–7 days postoperatively. Tape is then
applied to the upper lip to prevent micro-shearing at the
incision line. This tape will remain in place for 2 weeks.
Results
Long-term clinical outcomes of patients undergoing the
Mohler Cutting repair demonstrates restoration of the upper
lip height on the affected side.32 Surgeons and parents should
appreciate that the upper lip height will initially shorten on
Fig. 21.3.16  Frontal view of an infant with a complete unilateral cleft lip deformity
Fig. 21.3.17  Basal view the same infant in Fig. 21.3.16. Note the significant cleft
nasal deformity
Fig. 21.3.18  Postoperative view of the same infant depicted in Fig. 21.3.16. No
NAM was used in this patient. Note the placement of the final scars along the
subunit borders of the lip.
Fig. 21.3.19  Postoperative basal view of the same infant depicted in Fig. 21.3.16.
Note the significant improvement in nasal symmetry. A single procedure was
performed in this patient.

539
Results
2. Grayson BH, Cutting C, Wood R. Preoperative columella
lengthening in bilateral cleft lip and palate. Plast Reconstr Surg.
1993;92(7):1422–1423. The first report of nasoalveolar molding. In this
early report, the technique is applied to a patient with bilateral cleft lip
and palate.
15. Grayson BH, Garfinkle JS. Early cleft management: the case for
nasoalveolar molding. Am J Orthod Dentofacial Orthop.
2014;145(2):134–142. Dr. Grayson in his classic articulate fashion
describes the benefit of NasoAlveolar molding to the patient with a cleft
and reviews the supportive and non-supportive evidence to this therapy.
25. Millard DR Jr. Cleft Craft: The Evolution of its Surgery. Volume 1 - The
Unilateral Deformity. Vol. 1. Boston: Little, Brown, and Company;
1976. The technique of the rotation advancement repair, its development
and evolution is beautifully described in Millard’s tome of cleft care.
28. McComb H. Primary correction of unilateral cleft lip nasal
deformity: a 10-year review. Plast Reconstr Surg. 1985;75(6):791–799.
Harold McComb’s report demonstrates the safety and efficacy of primary
cleft rhinoplasty. It is this report which demonstrated that nasal
manipulation at the time of infancy is not harmful to nasal growth.
29. Salyer KE. Primary correction of the unilateral cleft lip nose: a
15-year experience. Plast Reconstr Surg. 1986;77(4):558–568.
30. Millard DR Jr. Transactions of the 1st International Congress of Plastic
Surgery, Stockholm. Baltimore: Williams and Wilkins; 1957. Ralph
Millard’s critique of the original design for the Mohler repair in which he
correctly points out that its ultility would be limited to patients with
incomplete unilateral clefts.
32. Cutting CB, Dayan JH. Lip height and lip width after extended
Mohler unilateral cleft lip repair. Plast Reconstr Surg. 2003;111(1):17–
23, discussion 24–16. Long-term outcomes of the Mohler Cutting repair
demonstrated a benefit to labial form and correction of horizontal
shortening of the upper lip.
33. Mulliken JB, LaBrie RA. Fourth-dimensional changes in nasolabial
dimensions following rotation-advancement repair of unilateral
cleft lip. Plast Reconstr Surg. 2012;129(2):491–498. Long-term outcomes
of the rotation advancement repair. Mulliken demonstrates that the alar
base lateralizes over time and that horizontal shortening of the upper lip
corrects over time.
34. Noordhoff MS. The Surgical Technique for the Unilateral Cleft Lip-Nasal
Deformity. Taipei: Noordhoff Craniofacial Foundation; 1997. The
Noordhoff (Chang Gung) unilateral cleft lip repair is described including
the vermillion triangular (Noordhoff) flap which prevents the whistling
deformity of cleft lip repair.
Access the complete reference list online at

539.e1
References
References
1. Burget GC, Menick FJ. The subunit principle in nasal
reconstruction. Plast Reconstr Surg. 1985;76(2):239–247.
2. Grayson BH, Cutting C, Wood R. Preoperative columella
lengthening in bilateral cleft lip and palate. Plast Reconstr Surg.
1993;92(7):1422–1423. The first report of nasoalveolar molding. In this
early report, the technique is applied to a patient with bilateral cleft lip
and palate.
3. Barillas I, Dec W, Warren SM, Cutting CB, Grayson BH.
Nasoalveolar molding improves long-term nasal symmetry in
complete unilateral cleft lip-cleft palate patients. Plast Reconstr Surg.
2009;123(3):1002–1006.
4. Gomez DF, Donohue ST, Figueroa AA, Polley JW. Nasal changes
after pre-surgical nasoalveolar molding (PNAM) in the unilateral
cleft lip nose. Cleft Palate Craniofac J. 2012;49(6):689–700.
5. Chang CS, Por YC, Liou EJ, et al. Long-term comparison of four
techniques for obtaining nasal symmetry in unilateral complete
cleft lip patients: a single surgeon’s experience. Plast Reconstr Surg.
2010;126(4):1276–1284.
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, discussion 1368–1359.
7. Abbott MM, Meara JG. Nasoalveolar molding in cleft care: is it
efficacious? Plast Reconstr Surg. 2012;130(3):659–666.
8. Suri S, Tompson BD. A modified muscle-activated maxillary
orthopedic appliance for pre-surgical nasoalveolar molding in
infants with unilateral cleft lip and palate. Cleft Palate Craniofac J.
2004;41(3):225–229.
9. Chavarria C, Chen JW, Teichgraeber JF. Use of pre-surgical nasal
alveolar molding appliance in treating cleft lip and palate patients.
Tex Dent J. 2004;121(10):976–981.
10. Singh GD, Levy–Bercowski D, Santiago PE. Three-dimensional
nasal changes following nasoalveolar molding in patients with
unilateral cleft lip and palate: geometric morphometrics. Cleft Palate
Craniofac J. 2005;42(4):403–409.
11. Pai BC, Ko EW, Huang CS, Liou EJ. Symmetry of the nose after
pre-surgical nasoalveolar molding in infants with unilateral cleft lip
and palate: a preliminary study. Cleft Palate Craniofac J. 2005;42(6):
658–663.
12. Da Silveira AC, Oliveira N, Gonzalez S, et al. Modified nasal
alveolar molding appliance for management of cleft lip defect. J
Craniofac Surg. 2003;14(5):700–703.
13. Mitsuyoshi I, Masahiko W, Masayuki F. Simple modified
preoperative nasoalveolar moulding in infants with unilateral cleft
lip and palate. Br J Oral Maxillofac Surg. 2004;42(6):578–580.
14. Hathaway RR, Long RE Jr. Early cleft management: in search of
evidence. Am J Orthod Dentofacial Orthop. 2014;145(2):135–141.
15. Grayson BH, Garfinkle JS. Early cleft management: the case for
nasoalveolar molding. Am J Orthod Dentofacial Orthop.
2014;145(2):134–142. Dr. Grayson in his classic articulate fashion
describes the benefit of NasoAlveolar molding to the patient with a cleft
and reviews the supportive and non-supportive evidence to this therapy.
16. 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.
17. Millard DR, Latham R, Huifen X, Spiro S, Morovic C. Cleft lip and
palate treated by pre-surgical 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.
18. Grayson BH, Santiago PE, Brecht LE, Cutting CB. Pre-surgical
nasoalveolar molding in infants with cleft lip and palate. Cleft Palate
Craniofac J. 1999;36(6):486–498.
19. Santiago PE, Grayson BH, Cutting CB, et al. Reduced need for
alveolar bone grafting by pre-surgical orthopedics and primary
gingivoperiosteoplasty. Cleft Palate Craniofac J. 1998;35(1):77–80.
20. Wang YC, Liao YF, Chen PK. Outcome of gingivoperiosteoplasty for
the treatment of alveolar clefts in patients with unilateral cleft lip
and palate. Br J Oral Maxillofac Surg. 2013;51(7):650–655.
21. Pfeifer TM, Grayson BH, Cutting CB. Nasoalveolar molding and
gingivoperiosteoplasty versus alveolar bone graft: an outcome
analysis of costs in the treatment of unilateral cleft alveolus. Cleft
Palate Craniofac J. 2002;39(1):26–29.
22. Lee CT, Grayson BH, Cutting CB, Brecht LE, Lin WY. Prepubertal
midface growth in unilateral cleft lip and palate following alveolar
molding and gingivoperiosteoplasty. Cleft Palate Craniofac J.
2004;41(4):375–380.
23. Hsieh CH, Ko EW, Chen PK, Huang CS. The effect of
gingivoperiosteoplasty on facial growth in patients with complete
unilateral cleft lip and palate. Cleft Palate Craniofac J. 2010;47(5):
439–446.
24. Matic DB, Power SM. Evaluating the success of
gingivoperiosteoplasty versus secondary bone grafting in patients
with unilateral clefts. Plast Reconstr Surg. 2008;121(4):1343–1353,
discussion 1368–1349.
25. Millard DR Jr. Cleft Craft: The Evolution of its Surgery. Volume 1 - The
Unilateral Deformity. Vol. 1. Boston: Little, Brown, and Company;
1976. The technique of the rotation advancement repair, its development
and evolution is beautifully described in Millard’s tome of cleft care.
26. Cutting C, Grayson B. The prolabial unwinding flap method for
one-stage repair of bilateral cleft lip, nose, and alveolus. Plast
Reconstr Surg. 1993;91(1):37–47.
27. Faivre S, Lim A, Dautel G, Duteille F, Merle M. Adjacent and
spontaneous neurotization after distal digital replantation in
children. Plast Reconstr Surg. 2003;111(1):159–165, discussion 166.
28. McComb H. Primary correction of unilateral cleft lip nasal
deformity: a 10-year review. Plast Reconstr Surg. 1985;75(6):791–799.
Harold McComb’s report demonstrates the safety and efficacy of primary
cleft rhinoplasty. It is this report which demonstrated that nasal
manipulation at the time of infancy is not harmful to nasal growth.
29. Salyer KE. Primary correction of the unilateral cleft lip nose: a
15-year experience. Plast Reconstr Surg. 1986;77(4):558–568.
30. Millard DR Jr. Transactions of the 1st International Congress of Plastic
Surgery, Stockholm. Baltimore: Williams and Wilkins; 1957. Ralph
Millard’s critique of the original design for the Mohler repair in which he
correctly points out that its ultility would be limited to patients with
incomplete unilateral clefts.
31. Millard DR Jr. Discussion: Unilateral Cleft Lip Repair. Plast Reconstr
Surg. 1987;80(4):517.
32. Cutting CB, Dayan JH. Lip height and lip width after extended
Mohler unilateral cleft lip repair. Plast Reconstr Surg. 2003;111(1):17–
23, discussion 24–16. Long-term outcomes of the Mohler Cutting repair
demonstrated a benefit to labial form and correction of horizontal
shortening of the upper lip.
33. Mulliken JB, LaBrie RA. Fourth-dimensional changes in nasolabial
dimensions following rotation-advancement repair of unilateral
cleft lip. Plast Reconstr Surg. 2012;129(2):491–498. Long-term outcomes
of the rotation advancement repair. Mulliken demonstrates that the alar
base lateralizes over time and that horizontal shortening of the upper lip
corrects over time.
34. Noordhoff MS. The Surgical Technique for the Unilateral Cleft Lip-Nasal
Deformity. Taipei: Noordhoff Craniofacial Foundation; 1997. The
Noordhoff (Chang Gung) unilateral cleft lip repair is described including
the vermillion triangular (Noordhoff) flap which prevents the whistling
deformity of cleft lip repair.

SECTION I • Clefts
21.4 
Unilateral cleft lip repair, anatomic subunit
approximation technique
David M. Fisher
SYNOPSIS
■ The non-cleft side bow peak is marked on the vermilion-cutaneous
junction where the straight part of the half bow meets the upper
convexity of the lateral lip element. The cleft side bow peak is then
placed an equal distance from the midline.
■ A natural undulation of the cutaneous roll can only be achieved if the
upwards convexity of the lateral lip element lateral to Noordhoff’s point
is preserved.
■ The transverse length of the cleft side lateral lip element need not and
should not be compromised to achieve vertical height.
■ Leveling of the Cupid’s bow is the result of a Rose–Thompson
lengthening effect in all cases. In most cases, a small triangle is also
placed above the roll.
■ Orientation of the lateral lip element incisions must vary depending on
the vertical height of the lateral lip element.
■ Vermilion deficiency below the cleft side half of Cupid’s bow should be
augmented with vermilion from the lateral lip element.
■ Medial incisions should be performed first. Lateral lip markings can be
adjusted if necessary.
■ Approximation of lip elements is along the seams of anatomic
subunits.
Preoperative assessment
It is essential to ensure that the infant is optimized prior to
surgery; the input of various pediatric specialists will be
required for patients with syndromes and co-morbidities.
Early liaison with the anesthesia team is recommended.
Failure to thrive is seen in approximately 40% of children with
a palatal cleft and 9% of those with an isolated cleft lip; thus
all cleft patients must be closely monitored preoperatively for
appropriate weight gains.1 Close communication between the
family and the cleft team (via the clinical nurse specialist,
dietician, feeding specialist, and social worker) is essential at
this stage.
Cleft lip repair is deferred until the age of 3–6 months to
allow for the optimization of underlying medical issues,
minimization of the risks of anesthesia, and the completion of
pre-surgical orthopedic treatment, if indicated.
A typical treatment pathway, from antenatal diagnosis to
adulthood, for a child with a complete unilateral cleft lip and
palate (cUCLP), as practiced at The Hospital for Sick Children
in Toronto, Canada, is outlined in Table 21.4.1. While a child
with an isolated incomplete cleft lip (iCL) may require just the
single operation, the burden of care in the case of a complete
cleft of the lip and palate is far more substantial.
Pre-surgical orthopedics
Pre-surgical infant orthopedics is indicated for all complete
clefts. It is not used for complete cases with a Simonart Band
or in incomplete cleft lip. Nasoalveolar molding (NAM) as
described by Grayson et al.2 is our preferred method. The
primary goal is improved alignment of the alveolar arches.
Once the alveolar cleft segments are aligned the nasal compo-
nent is added. The goal is anteromedial repositioning of the
cleft side dome. It is important that this is done gradually and
gently so as to avoid expansion of the cleft side nostril
circumference.
While it is our preference to employ pre-surgical orthope-
dics, the anatomic subunit approximation technique does not
require it. The greatest perceived benefit of pre-surgical ortho-
pedics is an improvement of the asymmetry of the nasal base
in the anteroposterior dimension and less relapse of the nasal
deformity. In bilateral cases where there is protrusion of the
premaxilla the benefits may be even greater.
Surgical plan: anatomical subunit
approximation technique
The anatomical subunit approximation technique3 borrows
the concept of anatomical subunits first described by Burget

541
Surgical plan: anatomical subunit approximation technique
vertical height, a commonly practiced compromise when
performing a rotation-advancement type repair.9–11 Note that
the lateral lip element is almost always short in its transverse
dimension when compared to the non-cleft side. As com-
monly seen in complete clefts, the vertical height of the lateral
lip is also short.12,13 The practice of moving the base of the
incision laterally to achieve vertical height is a compromise
that is not required by the anatomical subunit approximation
technique.
Readers are encouraged to refer to the initial description3
for a detailed description of the repair. Refer also to the
legends accompanying Figs. 21.4.1–21.4.6. The Cupid’s bow
and philtral column heights are marked with the cleft side
bow peak and philtral column heights being equidistant rela-
tive to the midline as the corresponding non-cleft side mark-
ings. Note that the non-cleft side Cupid’s bow peak is not
marked at the highest point of the curve of the lip, but rather
where the straight portion of the non-cleft side half bow meets
the convexity of the lateral lip element (Fig. 21.4.1). No such
convexity exists on the cleft side of the medial lip element.
The corresponding convexity on the cleft side will come from
the lateral lip element lateral to “Noordhoff’s point”.
Points are marked above each bow peak just above the
cutaneous roll at points above the lines perpendicular to the
vermilion-cutaneous junction. The medial lip cleft side philtral
column incision (equivalent to the “greater lip height”) (Fig.
21.4.2) will ascend from the point above the roll to the height
of the lip just below the lip-columellar crease. The incision line
Table 21.4.1  Typical surgical treatment pathway for a child with
a unilateral complete cleft lip and palate at the Hospital for Sick
Children, Toronto.
Age
Treatment
Prenatal diagnosis
Parental consultation with cleft
surgeon
2 weeks up to lip repair
Pre-surgical orthopaedics (if
indicated)
3–6 months
Cleft lip repair and primary nasal
correction
10–14 months
Palate repair ± myringotomy and
tubes
≥ 3 years
Lip revision (if indicated)
≥ 4 years
Surgical correction of VPI (if
indicated)
≥ 7 years
Lobule rhinoplasty (if indicated)
8–10 years (mixed dentition)
Alveolar bone graft
≥ 12 years
Definitive septorhinoplasty (if
indicated)
≥ 16–18 years (skeletal
maturity)
Orthognathic surgery (if
indicated)
Fig. 21.4.1  The non-cleft side Cupid’s bow peak is not marked at the highest point
of the curve of the lip. It is marked where the straight portion of the non-cleft side
half bow meets the convexity of the lateral lip element. Note that there is no such
convexity on the cleft side of the medial lip element. This curve of the bow on the
cleft side will come from the lateral lip element lateral to Noordhoff’s point. The
cleft side peak of Cupid’s bow is positioned on the vermilion-cutaneous junction on
the cleft side of the medial lip element equidistant from the midline of the bow.
“Noordhoff”s point” is identified on the vermilion–cutaneous junction where the
cutaneous roll and the vermilion–mucosal junction lines start to converge medially.
It is not necessarily the tallest portion of the red lip. At this point there is adequate
vermilion height (usually matching the height of vermilion below the non-cleft side
peak of Cupid’s bow) and good quality cutaneous roll. Both of these features,
vermilion height and quality of the cutaneous roll, diminish if this point is moved
medially. The upward convexity of the lateral lip element is lateral to “Noordhoff’s
point”.
Lateral point of closure
in nostril sill
Height of philtral column non-cleft side
Height of philtral column cleft side
Medial point of closure in nostril sill
Bow peak non-cleft side
Midline of Cupid’s bow
Bow peak cleft side
Noordhoff’s point
Midline at lip-columellar junction
and Menick for nasal reconstruction.4 The lip and nose
complex are viewed in terms of their anatomical subunits and
the repair aims to produce a cutaneous scar along the “ideal
line of repair” – along the seams of adjacent subunits. Inci-
sions cross the cutaneous rolls of the lip elements perpendicu-
lar to the rolls. The incision on the medial cleft side then
ascends from a point above the cutaneous roll such that it
mirrors the ridge of the non-cleft philtral column. It then
curves superolaterally just below and, thus, preserves the
lip-columellar crease to the medial point of closure in the
nostril sill. Lip length is achieved by two mechanisms: firstly,
a Rose–Thompson5,6 effect as angled lines straighten upon
approximation (which accounts for approximately 1 mm of
lengthening) and, secondly if required, a small inferior tri-
angle from the lateral lip element, which is positioned just
superior to the cutaneous roll (a modification of the Tennison–
Randall repair).6,7 The lengthening achieved by the Rose–
Thompson principle significantly reduces the size of the
inferior triangle that would otherwise be required had a tra-
ditional inferior triangle repair been performed. The technique
also utilizes Noordhoff’s lateral vermilion triangle flap8 to
augment the deficient vermilion height of the medial lip
element on the cleft side.
This technique has a number of advantages over the
inferior triangle and rotation-advancement repairs. In vari-
ance with the rotation-advancement techniques.9–11 there is
minimal scarring at the base of the nose. The cutaneous scar
is positioned along the seams of anatomical subunits with
the exception of, when required, a small triangle above the
cutaneous roll. Tension is ideally positioned above the roll
accentuating the pout of the lip. Continuity of the cutane-
ous roll is achieved by side-to-side approximation of the roll
elements. In common with the inferior triangle repair, lateral
lip transverse length need not be compromised to achieve

542
SECTION I
CHAPTER 21.4 • Unilateral cleft lip repair, anatomic subunit approximation technique
The point of origin of the opening incision for the medial
lip back cut (if indicated) is initiated just above the cutaneous
roll. The opening incision is drawn perpendicular to the
greater height incision.
The medial and lateral points of closure within the nostril
sill are not distinct anatomical points and are arguably the
hardest points to define in this repair. The medial point of
closure in the nostril sill is positioned lateral to the curve of
the lip-columellar crease. It will be positioned more medial in
complete cases and more lateral in incomplete cases. This will
allow the operator to adjust the length of the “third height”
and therefore take up less lateral lip height in a complete case
(where there is vertical height deficiency), or use up height of
the lateral lip height in an incomplete case (where there is
vertical height excess). The lateral point of closure in the
nostril sill is then chosen on the lateral lip element, relative to
the medial point of closure in the nostril sill, such that when
these two points are approximated, two goals are accom-
plished: 1) the nares are of equal circumference and 2) sym-
metry of the alar bases, from the anterior view, is achieved.
Gentle manipulation of the medial and lateral lip elements
should confirm acceptable positioning of these points. In
complete clefts where the lateral lip is tethered such that the
medial and lateral lip elements cannot be brought together, it
is advisable to release the lateral lip element before marking
the lip.
Calipers are used to measure the “total lip height” and the
“greater lip height”. The “total lip height” is measured with
the lip at rest and is defined as the height of the non-cleft side
philtral column from a point above the roll to a point just
Fig. 21.4.2  Pre-surgical markings. For a complete description, the reader is
encouraged to refer to DM Fisher. Unilateral cleft lip repair: An anatomical sub-unit
approximation technique.3 In minor clefts with minimal rotation of Cupid’s bow, an
opening incision and inferior triangle may not be necessary. When the lateral lip
element is long, a wedge excision of upper lateral lip skin is required. It is placed
below the lateral point of closure in the nostril sill and medial to subalare.
Greater lip height
Greater lip height
Lesser lip height
Vermilion triangle
3rd height
3rd height
Total lip height
Wedge excision of upper lateral lip
Fig. 21.4.3  Pre-surgical markings and measurements. The total lip height and the
greater lip height are each measured from points above the roll to the base of the
columella. The lesser lip height (base width of the small inferior triangle) is equal to
the total lip height minus the greater lip height less 1 mm. The 1 mm accounts for
the Rose–Thompson lengthening that occurs as the angled incision lines
approximate in the vertical.
a
b
b
c
Fisher 2000
a – b – 1 mm = c
±
Fig. 21.4.4  Lateral lip markings will vary depending on the vertical height of the
lateral lip element. In many complete clefts the vertical height of the lateral lip
element will be short. In such cases, the greater lip height incision will be more
horizontal and its lateral extreme may need to be coincident with the upper incision
of the inferior triangle which will require an upward pointing orientation. In contrast,
with many incomplete clefts, the vertical height of the lateral lip element may be
excessive. In this case, it is helpful to position both the medial and lateral points of
closure in the nostril sill more laterally. This essentially lengthens the third height. If
the lateral lip remains too long despite this maneuver, a medially based wedge
excision of upper lip can be performed below lateral point of closure in the nostril
sill. The position of the lateral point of closure in the nostril sill and of “Noordhoff’s
point” should not be compromised.
Short
Medial point of closure in nostril sill
Cupid’s bow peak cleft side
Lateral point of closure in nostril sill
Noordhoff’s point
Medial lip
Lateral lip
average
Long
then traverses superolaterally to the medial point of closure
in the nostril sill (equivalent to the “third height”). From the
point above the roll, the incision line continues caudally
perpendicular to the roll through the bow peak and vermilion
and across the free border of the lip into the mucosa.

543
Surgical plan: anatomical subunit approximation technique
produce a flattening of the Cupid’s bow when the back cut is
opened. The perpendicular back cut preserves tissue above
the roll and thus better conserves the curve of Cupid’s bow.
The base of the cutaneous incision on the lateral lip element
is marked according to the recommendations of Noordhoff.
“Noordhoff’s point” is marked along the vermilion-cutaneous
junction at the point where the cutaneous roll and red line
begin to converge medially (Fig. 21.4.2). The natural upward
convexity of the cutaneous roll lateral to Noordhoff’s point is
ideally suited for reconstruction of the cleft side curve of the
bow. A point is marked just above the cutaneous roll at a point
above “Noordhoff’s point” along a line perpendicular to the
vermilion-cutaneous junction. Between the lateral point of
closure in the nostril sill and the point above the roll three
lengths must be accommodated: the “greater lip height”, the
“lesser lip height”, and the “third height” (corresponding in
length to the line connecting the height of the cleft side philtral
column and the medial point of closure in the nostril sill). This
is readily achieved by placing the “greater lip height” caliper
on the lateral lip element such that its lower tip lies the “lesser
lip height” distance away from the point above the roll, and
below the lip-columellar crease. The “greater lip height” is
measured with gentle downward traction on the lip to unfurl
the medial lip. It is defined as the height of the cleft side
philtral column incision from a point above the roll to a point
just below the lip-columellar crease and it is positioned along
a line which mirrors the non-cleft side philtral column. The
“lesser lip height” (equivalent to the base width of the small
inferior triangle) is equal to the “total lip height” minus the
“greater lip height” and less 1 mm (Fig. 21.4.3). The 1 mm
accounts for the approximate length achieved by the Rose–
Thompson principle. If an inferior triangle is required, the
back cut for the opening incision is drawn perpendicular to
the “greater lip height” incision, and of a length equal to the
“lesser lip height” (the inferior triangle being equilateral).
Rotation of the bow is achieved by the combination of the
back cut and the Rose–Thompson effect (as the angled lines
straighten). The “lesser lip height” is usually between 1 and
1.5 mm and never exceeds 2 mm. For minor form incomplete
clefts, an inferior triangle is often not necessary. Note that the
back cut is made perpendicular to the greater height incision
and not parallel to the cutaneous roll. The latter would
Fig. 21.4.5  An example of the anatomic subunit approximation technique in a patient with an incomplete unilateral cleft. (A) preoperative appearance and markings at age
5 months; (B) appearance at one week postoperatively; (C) age 6 years.
A
B
C
A
Fig. 21.4.6  An example of the anatomic subunit approximation technique in a patient with a complete unilateral cleft lip and palate. (A) Preoperative appearance and
markings, age 6 months; (B) 1 week postoperative; (C) age 3 years.
B
C

544
SECTION I
CHAPTER 21.4 • Unilateral cleft lip repair, anatomic subunit approximation technique
can only partially improve the deformity (by correcting maxil-
lary segment misalignment while not addressing maxillary
hypoplasia); and, because primary bone grafting is not per-
formed, it is unrealistic to completely correct the nasal defor-
mity at the primary operation. A plea must be made for
patience. The potential risks of a primary rhinoplasty include
iatrogenic deformity to the skin envelope and cartilages and
the introduction of scar that may complicate subsequent
interventions. There will be future opportunities to augment
the skeletal base deficiencies at the time of alveolar bone graft-
ing and orthognathic surgery if indicated. This will set the
stage for definitive septorhinoplasty. At this time, deformities
such as a broad deviated nasal dorsum, which are only
obvious after maturity, may be addressed. Definitive second-
ary septorhinoplasty will be successful only if the cartilages
are intact and robust, and the skin envelope is complete and
free of scar.
The authors preferred primary rhinoplasty is relatively
aggressive at the nasal base and relatively conservative in the
lobule. Primary rhinoplasty is performed with the following
goals in mind:
1. Balanced alar bases (from the anterior view)
2. Columellar base mobilization to the midline
3. Caudal septal release and repositioning
4. Alar base release and repositioning
5. Release of the nasal attachments to the piriform margin
6. Anteromedial advancement of the cleft side dome and
lateral crus
7. Creation of the scroll – internal nasal valve plication
suture(s)
8. Lateralization of the cleft side lateral vestibular lining
– alar transfixion suture(s)
9. No external skin incisions
10. No excision(s) of skin envelope
A nasal stent is placed and secured with a trans-septal
suture. It is removed with the sutures at one week. The cur-
rently available stents do little to effect nasal tip position but
are perceived to be helpful to smooth out the nostril sill
closure.
Operative technique
Local anesthesia is limited to bilateral infraorbital nerve
blocks and for submucoperiosteal hydrodissection of the
caudal septum. In order to prevent errors in measurement and
in the perception of the balance of the repair, the lip elements
are not infiltrated.
It is important that the repair be performed in the proper
sequence to allow the operator to assess progress and make
modifications, if necessary. The medial lip incisions (without
the back cut) should be made first. The 1st Checkpoint is the
assessment of the length achieved by the Rose–Thompson
effect alone. The 1 mm of calculated lengthening is an esti-
mate. It will be greater when the slope of the bow is steeper;
the more rotated the bow, the more acute will be the angle
formed by the incision across the roll and the greater height
incision and, thus, the more lengthening will be achieved
as this angle opens to become 180°. Conversely, the more
level the bow the more obtuse will be the angle, and less
lengthening will be achieved by the Rose–Thompson effect.
its upper tip lies the “third height” distance away from lateral
point of closure in the nostril sill.
In complete clefts where there is a short vertical height to
the lateral lip element, the angle of the “greater lip height”
incision on the lateral lip will be more horizontal and, in
extreme cases, may be confluent with the upper limb incision
of the inferior triangle (Fig. 21.4.4). Alternatively, in an incom-
plete cleft that presents a relative excess of vertical height, the
“third height” may be lengthened by lateralizing the medial
and lateral points of closure within the nostril. If vertical
height excess persists in spite of this maneuver, it may be
necessary to perform a medially based wedge excision of the
upper lip below the lateral point of closure in the nostril sill.
The lateral apex of this wedge excision should never extend
laterally beyond subalare; this is unnecessary and leaves an
unsightly scar. Care should be taken not to alter the vertical
height of the lateral point of closure in the nostril sill as this
will compromise the final vertical position of the alar
insertion.
Any vermilion deficiency below the cleft side half of the
Cupid’s bow requires augmentation. An opening incision is
created along the vermilion–mucosal junction below the cleft
side half of the Cupid’s bow. This back cut will receive a later-
ally based vermilion triangular flap from the lateral lip
element as described by Noordhoff (Fig. 21.4.2).
In incomplete clefts, a wedge excision of the nostril sill
above the medial and lateral points of nostril sill closure is
performed. The excision should be sufficient to balance the
circumference of the nares, with great care taken not to over-
resect, as the resultant nostril stenosis presents a difficult
reconstructive challenge. The mucosa of the cleft margins is
removed by wedge excision; a short lateral upper buccal
sulcus advancement incision may be helpful on occasions.
In complete clefts, the mucosal incisions on the medial and
lateral lip elements extend cranially to the points of attach-
ment of each lip element to the greater and lesser alveolar
segments, respectively. An upper buccal sulcus incision
extending laterally from the point of attachment of the lateral
lip element is made. From the medial point of closure in the
nostril sill, the incision continues intranasally along the caudal
margin of the septum for a distance of up to 12 mm to facilitate
access for septal repositioning. The lateral free edge of the
septal flap will receive the medial free edge of the lateral
vestibular flap. The lateral vestibular flap is fashioned by
incising from the lateral point of closure in the nostril sill to
the attachment point of the lateral lip element to the alveolus,
and then along the piriform margin. This allows for supra-
periosteal mobilization of the alar base. An anteriorly based
inferior turbinate flap may be incorporated to cover the ves-
tibular lining defect in clefts with a significant anteroposterior
distance between the greater and lesser maxillary segments.
Primary nasal correction
The anatomic subunit approximation technique describes a
technique for cleft lip repair. It can be accompanied by most
previously describes techniques of primary rhinoplasty.
Because the cleft nasal deformity is the result of an underly-
ing skeletal deformity,14 it stands to reason that the skeletal
deformity needs to be corrected before any correction can be
fully realized in the nose. Because pre-surgical orthopedics

545
Postoperative care
muscle relative to the skin and release the lateral bulge of the
lip. Muscle approximation is made in a simple end to end
fashion.
Absorbable monofilament sutures are used for the mucosa
and muscular approximations. Skin is approximated with
non-absorbable sutures. Vermilion is approximated with
braided absorbable sutures. The cutaneous and vermilion
sutures are removed in the operating room one week
postoperatively.
Postoperative care
Elbow splints are to be worn for 2 weeks postoperatively.
Children may resume oral feeding immediately in the recov-
ery room following surgery. Patients are discharged on the
following day if they are clinically well and oral intake is
sufficient. Suture removal is undertaken on the seventh post-
operative day under general anesthesia. The incision line is
moistened with antibiotic ointment. Parents are instructed to
keep the suture line clean and moist with Vaseline®. A return
visit is scheduled at 3–4 weeks postoperatively, at which point
parents are given instructions regarding scar massage.
If the bow has been leveled by the Rose–Thompson effect, an
opening incision and inferior triangle will not be necessary. If
deemed appropriate, the opening incision is then made. It is
made of sufficient length to level the bow. The 2nd Checkpoint
is ensuring that the triangle that has been drawn on the lateral
lip element is of the exact size to fill the defect created by the
opening incision in the medial lip element once the bow has
been leveled. The size of the triangle can be adjusted at this
point provided the lateral lip incisions have not already been
performed. Finally, once the medial and lateral lip elements
have been fully mobilized from their skeletal attachments,
the 3rd Checkpoint is the approximation the medial point of
closure in the nostril sill with the lateral point of closure
in the nostril sill. Before committing to the lateral point of
closure, the surgeon will want to check that the nares are of
equal circumference and the cleft side alar base has been suf-
ficiently rotated to achieve symmetry with the non-cleft side
alar base.
On the medial lip element, dissection between skin and
muscle is limited to 1 mm from the incised margin so to
preserve any philtral dimple. Dissection between skin and
muscle on the lateral lip element is more extensive; skin is
freed from the underlying muscle sufficient to advance the
1. Pandya AN, Boorman JG. Failure to thrive in babies with cleft lip
and palate. Br J Plast Surg. 2001;54:471–475.
2. Grayson BH, Santiago PE, Brecht LE, Cutting CB. Pre-surgical
nasoalveolar molding in infants with cleft lip and palate. Cleft Palate
Craniofac J. 1999;36:486–498.
3. Fisher DM. Unilateral cleft lip repair: an anatomical subunit
approximation technique. Plast Reconstr Surg. 2005;116:61–71. This
article describes the author’s technique for unilateral cleft lip repair.
Individual markings are described in detail.
4. Burget GC, Menick FJ. The subunit principle in nasal
reconstruction. Plast Reconstr Surg. 1985;76:239–247.
5. Tennison CW. The repair of the unilateral cleft lip by the stencil
method. Plast Reconstr Surg. 1952;9:115–120.
6. Randall P. A triangular flap operation for the primary repair of
unilateral clefts of the lip. Plast Reconstr Surg Transplant Bull.
1959;23:331–347.
8. Noordhoff MS. The surgical technique for the unilateral cleft lip-nasal
deformity. Taipei, Taiwan: Noordhoff Craniofacial Foundation; 1997.
Noordhoff’s repair is a modification of Millard’s Rotation Advancement
repair. It avoids the circumalar incision. The repair incorporates a small
triangle above the cutaneous roll when required to level the Cupid’s bow
and a vermilion flap from the lateral lip element to augment central
vermilion deficiency.
13. Boorer CJ, Cho DC, Vijayasekaran VS, Fisher DM. Pre-surgical
unilateral cleft lip anthropometrics: implications for the choice of
repair technique. Plast Reconstr Surg. 2011;127:774–780. Pre-surgical
anthropometric measurements were taken in fifty consecutive patients
with unilateral cleft lip to determine the incidence of lateral lip element
hypoplasia. Combined vertical height and transverse length deficiency of
the cleft side lateral lip element was present in 62% of patients.
14. Fisher DM, Mann RJ. A model for the cleft lip nasal deformity. Plast
Reconstr Surg. 1998;101:1448–1456. The features of the primary cleft lip
nasal deformity are detailed. A model to describe the mechanisms of the
deformations is presented. The model supports an external deformation
theory rather than intrinsic hypoplasia.
Access the complete reference list online at

545.e1
References
References
1. Pandya AN, Boorman JG. Failure to thrive in babies with cleft lip
and palate. Br J Plast Surg. 2001;54:471–475.
2. Grayson BH, Santiago PE, Brecht LE, Cutting CB. Pre-surgical
nasoalveolar molding in infants with cleft lip and palate. Cleft Palate
Craniofac J. 1999;36:486–498.
3. Fisher DM. Unilateral cleft lip repair: an anatomical subunit
approximation technique. Plast Reconstr Surg. 2005;116:61–71. This
article describes the author’s technique for unilateral cleft lip repair.
Individual markings are described in detail.
4. Burget GC, Menick FJ. The subunit principle in nasal
reconstruction. Plast Reconstr Surg. 1985;76:239–247.
5. Tennison CW. The repair of the unilateral cleft lip by the stencil
method. Plast Reconstr Surg. 1952;9:115–120.
6. Randall P. A triangular flap operation for the primary repair of
unilateral clefts of the lip. Plast Reconstr Surg Transplant Bull.
1959;23:331–347.
7. Tennison CW. The repair of the unilateral cleft lip by the stencil
method. Plast Reconstr Surg. 1952;9:115–120.
8. Noordhoff MS. The surgical technique for the unilateral cleft lip-nasal
deformity. Taipei, Taiwan: Noordhoff Craniofacial Foundation; 1997.
Noordhoff’s repair is a modification of Millard’s Rotation Advancement
repair. It avoids the circumalar incision. The repair incorporates a small
triangle above the cutaneous roll when required to level the Cupid’s bow
and a vermilion flap from the lateral lip element to augment central
vermilion deficiency.
9. Millard DR Jr. Complete unilateral clefts of the lip. Plast Reconstr
Surg Transplant Bull. 1960;25:595–605.
10. Millard DR. Extensions of the rotation-advancement principle for
wide unilateral cleft lips. Plast Reconstr Surg. 1968;42:535–544.
11. Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg.
1987;80:511–517.
12. Pool R. The configurations of the unilateral cleft lip, with reference
to the rotation advancement repair. Plast Reconstr Surg. 1966;37:
558–565.
13. Boorer CJ, Cho DC, Vijayasekaran VS, Fisher DM. Pre-surgical
unilateral cleft lip anthropometrics: implications for the choice
of repair technique. Plast Reconstr Surg. 2011;127:774–780. Pre-
surgical anthropometric measurements were taken in fifty consecutive
patients with unilateral cleft lip to determine the incidence of lateral lip
element hypoplasia. Combined vertical height and transverse length
deficiency of the cleft side lateral lip element was present in 62% of
patients.
14. Fisher DM, Mann RJ. A model for the cleft lip nasal deformity. Plast
Reconstr Surg. 1998;101:1448–1456. The features of the primary cleft lip
nasal deformity are detailed. A model to describe the mechanisms of the
deformations is presented. The model supports an external deformation
theory rather than intrinsic hypoplasia.

SECTION I • Clefts
22 
Repair of bilateral cleft lip
John B. Mulliken
SYNOPSIS
■ A child born with bilateral cleft lip should not have to suffer because of
an ill-conceived and poorly executed primary repair. The operative
principles for synchronous nasolabial repair are established:
• Maintain symmetry
• Secure primary muscular continuity
• Design proper philtral size and shape
• Construct median tubercle from lateral labial elements
• Position/secure lower lateral cartilages and sculpt nasal tip and
columella.
■ The techniques based on these principles are within the repertoire of a
well-trained surgeon whose practice is focused on children with cleft
lip. Formation of philtral columns and dimple are just beyond the
surgeon’s craft.
■ Preoperative dentofacial orthopedic manipulation of the premaxilla is
necessary to permit synchronous closure of the primary palate. The
surgeon must repair the bilateral cleft lip and correct the nasal
deformity in three dimensions based on knowledge of anticipated
changes in the fourth dimension. Modifications of the techniques used
in repair of the most common complete form are needed for the less
common bilateral variants, such as binderoid, complete with intact
secondary palate, symmetrical incomplete, and asymmetrical
complete/incomplete.
■ Outcomes can be assessed using preoperative and serial photography
and documentation of revision rates. Direct anthropometry is the “gold
standard” for quantification of the changing nasolabial features; however,
it requires training and experience. Intraoperative anthropometry is
used to record baseline dimensions and is repeated as the child
grows. Two-dimensional photogrammetry is applicable for certain
linear and angular measurements if properly scaled. Computerized
three-dimensional photogrammetry is a new methodology for
quantifying nasolabial appearance. It is both accurate and reliable, and
can be employed in intra- and inter-institutional comparative studies.
Access the Historical Perspective section online at

Introduction
James Barrett Brown and his colleagues wrote that a bilateral
cleft lip is twice as difficult to repair as a unilateral cleft and
the results are only half as good.1 Now, over half a century
later, many surgeons still seem resigned that the appearance
of their patients after bilateral cleft lip repair cannot match
those with repaired unilateral cleft lip. Too many infants born
with bilateral cleft lip undergo old-fashioned, often multi-
staged procedures and later have to endure sundry revisions
throughout childhood and adolescence. Despite the surgeon’s
efforts, the stigmata of the repaired bilateral cleft lip and nose
remain painfully obvious – even at a distance.
To the contrary, I have written that the appearance of a
child with repaired bilateral cleft lip should be comparable to,
and in many instances surpass, that of a repaired unilateral
complete cleft lip.2 This optimistic statement is based on two
major advances in the management of bilateral cleft lip over
the past quarter century. First is the recognition of the need
for preoperative manipulation of the protuberant premaxilla.
Second is the acceptance of the principles and techniques of
bilateral labial repair and especially the importance of syn-
chronous correction of the nasal deformity.
Principles
Surgical principles, once established, usually endure, whereas
surgical techniques continue to evolve. The following princi-
ples for repair of bilateral cleft lip were induced based
on study of the literature and observations of residual
deformities3:
1. Maintain nasolabial symmetry. Even the slightest
differences between the two sides of the lip and nose
will become more obvious with growth. Symmetry is
the one advantage a bilateral cleft lip has over its
unilateral counterpart.
2. Secure muscular continuity. Construction of a complete
oral ring permits normal labial function, eliminates

547
Presentation
growth.2,6,7 There is also the unpredictable fourth-dimensional
factor of central incisal show. Despite the surgeon’s effort to
craft a full median tubercle, augmentation may be necessary
after eruption of the permanent central incisors and after the
maxilla is in normal sagittal position.
Presentation
Bilateral cleft lip presents in three major anatomic forms:
bilateral symmetrical complete (50%); bilateral symmetrical
incomplete (25%); and bilateral asymmetrical (complete/
incomplete) (25%).45 The extent of the palatal cleft usually
corresponds to the severity of the labial clefts. Bilateral com-
plete cleft of the primary palate (lip and alveolus) is almost
always associated with a bilateral complete cleft of the sec-
ondary palate. Bilateral symmetrical incomplete cleft lip is
usually seen with minor or absent notching of the alveolar
ridge with an intact secondary palate. There is more variation
in palatal clefting in the asymmetrical bilateral forms: the
palate can be either bilateral complete or unilateral complete
on the major side.
Terminology for the contralateral bilateral asymmetric cleft
lip requires further refinement. In general, the term “incom-
plete” cleft lip usually denotes that there is cutaneous continu-
ity between the medial (nasomedial process) and the lateral
(maxillary process). Incomplete cleft lip presents in a spec-
trum. At the severe end, there is a thin cutaneous band that
some would argue constitutes a “complete” cleft lip. At the
other end of the spectrum are the lesser-forms of incomplete
cleft lip. Yuzuriha and Mulliken classified and defined these
lesser-forms as minor-form, microform, and mini-microform as
determined by the degree of disruption at the vermilion–
cutaneous junction.46
Minor-form cleft lip extends 3–5 mm above the normal
Cupid’s bow peak, i.e., 50% or less of the normal
cutaneous labial height. Other features are: deficient
vermilion on medial side of the cleft; cutaneous groove
and muscular depression; hypoplastic median tubercle;
and minor nasal deformity.
Microform cleft lip is characterized by a notched vermilion–
cutaneous junction with an elevated Cupid’s bow peak less
than 3 mm above normal. The other features are the same
as in a minor-form, but they are less obvious. Nasal
deformities include small depression of the sill, slightly
slumped alar genu, and 1–2 mm lateral displacement (and
often under-rotation) of the alar base.
Mini-microform cleft lip is distinguished by a disruption of
the white roll (vermilion–cutaneous junction) without
elevation of the Cupid’s bow peak. Usually there is a notch
at the free mucosal margin. Muscular depression
(particularly noticeable below the nostril sill) is variable as
is the cleft nasal deformity.
This detailed subcategorization of the contralateral side in an
asymmetrical bilateral cleft lip is important because the extent
of vermilion–cutaneous disjunction determines the operative
strategy. Synchronous bilateral nasolabial repair is indicated
for a contralateral incomplete cleft lip, including a minor-
form. Correction of a contralateral microform or mini-
microform is usually deferred until closure on the greater
side. The type of contralateral (lesser-form) cleft lip not only
lateral bulges, and minimizes philtral distortion and
interalar widening.
3. Design the philtral flap of proper size and shape. The
philtrum rapidly elongates and widens, particularly at
the columellar–labial junction.
4. Construct the median tubercle using lateral vermilion–
mucosal elements. There is no white roll in the prolabium.
Retained vermilion lacks normal coloration and fails to
grow to full height.
5. Position the slumped/splayed lower lateral cartilages and
sculpt excess soft tissue in nasal tip and columella. These
maneuvers are necessary to establish normal nasal
projection and columellar length/width.
Principles 1–4 needed definition, interpretation, and confir-
mation. Principle 5, primary correction of the nasal deformity,
was a fundamental change in surgical strategy. The so-called
“absent columella” is an illusion; nearby labial tissue need not
be recruited to build it. “The columella is in the nose” became
this author’s shibboleth. The columella can be exposed by
anatomic positioning and fixation of the lower lateral carti-
lages and sculpting expanded skin in the soft triangles and
upper columella.4
Third and fourth dimensions
Analogous to a sculptor working in marble, the surgeon must
construct three-dimensional nasolabial features in flesh.
Unlike sculpture in stone, the repaired bilateral lip and nasal
deformity change with time – there will be normal growth, as
well as abnormal alterations of these features. The nasolabial
stigmata are attributable to the three-dimensional primary
repair and the subsequent fourth-dimensional distortions.
Farkas and colleagues used direct anthropometry to docu-
ment the normal patterns of nasolabial growth in Caucasians
from age 1–18 years.5 Fast-growing nasolabial features attain
more than 75% of adult dimensions by age 5 years. For
example, nasal height and width develop early, reaching a
mean of 77% and 87% of adult size, respectively, by age 5
years. All labial landmarks grow rapidly, reaching approxi-
mately 90% of adult proportions by age 5 years. In contrast,
tip protrusion and columellar length are slow-growing fea-
tures; they reach a mean of only two-thirds of adult size by 5
years of age. These differences in nasolabial growth explain
the well-recognized nasal stigmata and labial misproportions
of a repaired bilateral cleft lip. The fast-growing features
become overly long or too wide, i.e., interalar distance and
philtral length and width. In an early study of a small number
of patients, it was determined that from time of initial closure
to age 5 years, the philtrum widened by a factor of 2.5 at the
top and expanded two-fold between the peaks of Cupid’s
bow.3 In contrast, nasal tip protrusion and columellar length
remain abnormally short following conventional bilateral
labial repair.
Applying a posteriori reasoning, the nasolabial features
programmed for rapid growth in early childhood must be
crafted on a small scale, whereas slow-growing features
should be made slightly larger than the normal dimensions
for an infant. Construction of the median tubercle is the excep-
tion to these guidelines. This normally fast-growing feature
reaches 87% of adult height by age 5 years, but after bilateral
cleft lip repair, the tubercle lags behind. Therefore, it must be
fashioned to be as full as possible, anticipating insufficient

547.e1
Historical perspective
Historical perspective
The premaxilla
The projecting premaxilla has long been the stumbling block
to closure of the bilateral complete cleft lip. From the Renais-
sance until the early 20th century, aggressive surgeons would
resect the protruding intermaxillary bone, either preserving
the prolabium, shifting it upward to elongate the columella,
or dispensing with it altogether. In an effort to retrude the
premaxilla, Gustav Simon introduced the technique of paring
the edges of the prolabium and constructing bilateral labial
adhesions. His method is probably the source of the dubious
eponym “Simonart’s bands”.8 Premaxillary “set-back” by
vomerine resection was described in the 19th century and
continued to be practiced well into the 20th century by
Veau,9 Brown, McDowell and Byars,1 Browne,10 Cronin,11 and
Monroe.12 The history of this procedure is detailed by Millard
in Vol. II of Cleft Craft.13
Desault in the late 18th century described the use of com-
pressive linen bandages to pressure the premaxilla backwards.
These clumsy headcaps and compressive contrivances to
reposition the premaxilla presaged the development of passive
(removable) and later active (fixed) dentofacial orthopedics in
the latter half of the 20th century.
Labial closure
Techniques for labial repair of the bilateral deformity were
adapted from those used for the more common unilateral cleft
lip. Textbooks and articles well into the mid-20th century
recommended staged bilateral repair: one side of the cleft
(usually the widest) and then the other side. Conspicuous
asymmetry was the predictable result. Surgeons believed that
the diminutive prolabial element lacked the potential for full
growth, and, therefore, had to be lengthened. Thus, various
techniques employing rectangular-shaped lateral labial flaps
inserted beneath the cutaneous prolabium were described by
König, Hagedorn, Mirault, and later by Barsky.13 Insertion of
cutaneous lip below the prolabial flap resulted in an unnatu-
rally long lip; this iatrogenic deformity was not well appreci-
ated until the mid-20th century. Alternatively, triangular flaps
from the lateral labial elements were interdigitated into the
prolabial segment to increase philtral height.1,14–18 LeMesurier
transposed bilateral quadrilateral flaps below the prolabium;
however, later he utilized the entire prolabium without inter-
digitating flaps.19 All these methods resulted in curious geo-
metric labial scars (which were often asymmetrical, especially
if one side was closed first), a vertically long lip, and a tight
lip from side-to-side. In time, surgeons began to recognize
that the philtrum has a remarkable capacity for vertical growth
once it is attached to the lateral labial elements.20–22 Minor
variations on a straight-line type (Veau III) labial closure
became the standard design.11,23 Although this method dimin-
ished elongation of the central lip, the result was typically an
abnormally wide, shield- or keystone-shaped philtrum. This
was attributed to the failure to attain muscular continuity and
to properly design the philtral flap in expectation of growth,
especially in the transverse dimension.3
There has been a longstanding dispute about how to form
the median tubercle. The alternatives are either to preserve
the prolabial vermilion (resulting in a scar on each side of the
median tubercle), retain a tiny strip of central vermilion, or
excise it completely and build the tubercle from lateral
vermilion-mucosal flaps. If the prolabial vermilion-mucosa is
preserved, the free margins of the lateral labial elements tend
to hang like swags, flanking a deficient median tubercle that
is covered by a thin strip of vermilion and exposed chapped
mucosa (“whistling lip deformity”). In profile, the upper lip
is flat or convex, lacking a pout. This abnormal contour is
further accentuated by an everted lower lip and weak chin.
This “cleft lip lower lip deformity” is caused by the child’s
struggle to obtain bilabial closure over a protrusive, retro-
clined, and vertically elongated premaxilla.24
Muscular closure
Little attention was given to closure of the orbicularis
oris muscle until the middle half of the 20th century; the
early advocates were Schultz,20 Browne,10 and Glover and
Newcomb.25 Manchester held to the traditional belief that
joining muscle from the lateral elements across the midline
would inhibit premaxillary growth.26 He sutured the orbicu-
laris oris to the central subcutaneous tissue to minimize
tension on the premaxilla. Without muscular continuity,
whenever the child puckers, a bulge appears on each side of
the lip. Primary muscular closure is necessary to minimize
fourth-dimensional distortions, i.e., lateral drift of the alar
bases and widening of the philtrum. Perhaps equally impor-
tant, the child is unhappy about being unable to whistle.
With increasing attention to muscular closure in the unilat-
eral deformity, reports began to underscore the importance of
orbicularis oris repair in bilateral clefts.13,27–31
Nasal inattention
Surgeons focused on closure of the bilateral labial cleft while
correction of the nasal deformity was postponed. Possibly this
was out of fear of risking the philtral blood supply or, perhaps,
there was concern that manipulation of the nasal cartilages
would interfere with growth. The most likely reason was that
the short (“absent”) columella was intimidating. Surgeons
conceded to the complexity of the bilateral nasal deformity
and deferred any attempts to correct it.
Bilateral labial closure produces and accentuates the “bilat-
eral cleft lip nasal deformity”. The nasal tip is overly broad.
The medial crura are pulled into an inferoposterior position;
this further dislocates the splayed alar domes and causes the
genua to buckle (“recurvatum” deformity) and the alae nasi
to flare (“cat’s knees” deformity). The caudal margin of the
drooping lower lateral cartilages protrudes into the lateral
vestibules producing an oblique ridge or web. Without
amends for the vertically long lateral labial elements and
normal muscular attachments to the alar bases, an unnatural
elevation of the alae nasi occurs, which becomes more pro-
nounced whenever the child smiles.32 In short, conventional
bilateral labial repair worsens the nasal deformity. Further-
more, the deformed and displaced lower lateral cartilages are
more difficult to correct secondarily.3
Secondary nasal correction
Conventional teaching was that the columella was lacking in
a bilateral cleft lip. Numerous secondary procedures were

547.e2
SECTION I
CHAPTER 22 • Repair of bilateral cleft lip
devised to elongate the “short columella”.33 There were two
major technical strategies, and curiously, both were published
in 1958. The first in print, the Cronin method, involves rotat-
ing bipedicled strap flaps from the nostril sills.34 This proce-
dure results in modest columellar length, and there is a
tendency for loss of the initial gain in height. The second
method is the forked flap procedure, devised and popularized
by Millard.13,35 There are two variations on the forked flap
theme. For infants with a wide prolabium, the tines of the
forked flap can either be transposed directly into the columella
or banked below the sills and “cashed in” later in early child-
hood. Alternatively, if the prolabium is relatively narrow,
Millard preferred three-stage columellar lengthening: (1)
bilateral labial adhesions to expand the prolabium; (2) eleva-
tion, rotation, and banking the tines while narrowing the
philtrum (around age 18 months); (3) retrieval of the prolabial
prongs and elevation, along with the medial crura, to lengthen
the columella (at age 2 years).
Millard’s forked flap, like all secondary procedures, causes
tertiary distortions peculiar to the particular technique.4 Most
secondary methods introduce a nexus of scars across the
columellar–labial junction. This scarring causes a transverse
nasolabial crease that deepens with smiling and is extremely
difficult to surgically correct. There is a circumferential philtral
scar that causes a bulge rather than a dimple. Secondary
recruitment of tines from each side of the philtrum in an older
child usually results in thickened and wide philtral scars.
Even in skilled hands, the forked flap procedure results in an
unusual-appearing nose. The characteristics include: (1) rect-
angular columella with a broad base and absent waist; (2)
sharp columellar–labial angle; (3) abnormally elongated/
enlarged nostrils; (4) columellar over-elongation with a dis-
proportionate ratio of nostril length-to-nasal tip; and (5)
downward drift of the columellar base.4,36,37 Furthermore, the
medial crura becomes unnaturally positioned in the nasal tip,
resulting in a slight break at the columellar–lobular connec-
tion. Thus, some surgeons began to wonder whether labial
skin really belongs in the columella. Others questioned
whether the columella was really deficient at all. Maybe it
would be possible to correct the nasal deformity along with
the labial closure. About this same time, nasal correction
during repair of unilateral cleft lip was becoming more
credible.
Primary repair of the bilateral cleft lip
nasal deformity
Nasal dissection of stillborn infants with bilateral labial cleft-
ing revealed that the alar domes and middle crura are splayed
and subluxed from their normal moorings to the upper lateral
cartilages.32 The columella only appears short because of
the malpositioned lower lateral cartilages. Furthermore, the
investing domal skin is expanded; there is no reason to bring
in more tissue. Broadbent and Woolf described a case of
primary medial advancement of the alar domes combined
with excision of skin from the broad nasal tip.38 But it was
McComb who led the advance toward primary columellar
elongation. Initially, he tried first elevating a forked flap,
followed by second-stage labial closure.39 He published a
follow-up assessment 11 years later, including measurements
of columellar growth.40 However, by this time, he had become
disenchanted with this strategy and presented a new two-
stage technique for columellar construction using the tissue
in the splayed nasal tip for repair – without a forked flap.37 In
the first stage, he used an external incision (“flying bird”) to
open the nasal tip and to appose and suspend the splayed
genua. His tip incision, which extended almost to the columel-
lar base, was closed V-to-Y fashion, thus shifting the alar
margin into the tip and lengthening the upper columella.
Long bilateral labial adhesions were part of his first operation;
1 month later, the lip was re-entered for definitive repair. The
columellae looked near normal in McComb’s longitudinal
assessment at 4 years,41 and equally good at 18–19 years,
although the slight depression caused by the nasal tip scar is
noticeable.42
I was also focused on early positioning of the lower lateral
cartilages. Overly influenced by Millard’s teachings, I banked
the tines of the forked flap below the sills during bilateral
labial repair. The second stage was a critical departure from
Millard; the banked tines were transposed intranasally to
allow the genua and medial crura to ascend. A vertical nasal
tip incision was used to appose the domes, and bilateral rim
incisions were used to suspend and secure the lateral crura.
Anthropometric measurements in these children showed that
nasal length, tip protrusion, and columellar length were
within normal limits.4 However, the interalar dimension was
overly wide, the mid-columella was broad, and the upper lip
was too long. The alar domes often buckled slightly, and there
were two instances of nostril stenosis related to the intranasal
transposition of the tines. By 1987, it had become obvious that
prolabial tines were unnecessary, and soon thereafter, the
vertical incision in the nasal tip was also abandoned. Primary
columellar lengthening and normal nasal tip projection were
achieved solely by apposition of the genua, elevation and
fixation of the lower lateral cartilages to the ipsilateral upper
lateral cartilages, and sculpting tissue from the soft triangles
and upper portion of the columella.4,32
Other surgeons were also on the trail to primary repair of
the primary palate. Trott and Mohan were working in Malay-
sia where socioeconomic factors made multistaged bilateral
cleft lip repair impractical. They devised a single-stage naso-
labial repair using an open rhinoplastic exposure of the dislo-
cated lower lateral cartilages.43 The prolabial–columellar flap
was based on the paired columellar arteries. The flap was
dissected on the ventral surface of the medial-middle crura.
Cutting and associates described another variation on the
open-tip approach following presurgical stretching to elon-
gate the columella and nasal lining.44 The prolabial–columellar
flap was incised along the membranous septum, leaving the
medial-middle crura in the flap; the genua and medial crura
were apposed by transfixion mattress sutures.
McComb offered a delightful anatomic explanation for the
diminutive columella: “… it has been unzipped and its com-
ponent parts lie within the broad nasal tip”.37 The old, non-
anatomic techniques that involved secondary recruitment of
prolabial skin into the columella were wrong. The lower
lateral cartilages should be placed and fixed in anatomic posi-
tion followed by trimming and redraping the soft tissues of
the nasal tip. No longer would columellae be overly elongated
with (often hair-bearing) labial skin, nor would the nasolabial
junction be transgressed by a scar that completed encircle-
ment of the philtrum.

548
SECTION I
CHAPTER 22 • Repair of bilateral cleft lip
labor-intensive and slow. There is no expansion of the maxil-
lary elements with NAM; it is difficult to retract the premaxilla
into alignment with the lesser segments. Unless there is ade-
quate space in the arch, the premaxilla will abut the labial
surface of the segments.
Complications with NAM include inflammation of the oral
and nasal mucosa, blistering of the cheeks, trouble in feeding
the infant, and difficulty in centralizing a badly torqued pre-
maxilla. The skin of the columellar–labial junction can ulcerate
if the horizontal prolabial band is too tight. There is also a
potential risk that the molding plate could become dislodged
and obstruct the airway; infants are obligatory nasal breathers
until about age 3 months. A 5 mm diameter hole is placed in
the center of the molding plate to minimize the possibility of
this complication.49
The active-type dentofacial orthopedic device in current
use is based on the prototypic design by Georgiade and
associates,50 later refined and popularized by Millard and
Latham.51 The Latham appliance is constructed from a plaster
cast of the upper jaw taken in the office. In the past, the
appliance was fabricated in London, ON, Canada. A local,
skilled prosthetist can also fabricate the custom device. The
appliance is pinned to the maxillary shelves with the infant
under general anesthesia. An elastic chain on each side is
connected to a transvomerine wire that is looped under a
roller in the posterior–superior section of the appliance and
attached to cleats at the anterior edges of the maxillary plate.
The parents turn the ratcheted screw daily to expand the
anterior palatal segments. Visits are necessary at 1, 3, and 5
weeks to assure appropriate fit and to adjust the bilateral
elastic chains that retrocline the premaxilla. The process nor-
mally takes 6–8 weeks. The Latham appliance is effective in
correcting premaxillary position in the sagittal plane; however,
the movement is more retroclination than retroposition. The
appliance can also rectify premaxillary rotation through dif-
ferential traction, although there is little effect on vertical
position (Fig. 22.2).
The merits of passive versus active dentofacial orthopedics
continue to be debated by proponents of each approach.
Critics of active premaxillary orthopedics argue it causes
guides the primary repair, it also foretells what revisions are
likely to be necessary (Fig. 22.1).45
Preoperative dentofacial orthopedics
Alignment of the three maxillary elements sets the skeletal
stage for synchronous bilateral nasolabial repair. After retru-
sion and centralization of the premaxilla, the philtral flap can
be designed in proper proportions, the nasal tip cartilages can
be anatomically positioned, and the alveolar clefts can be
closed, which stabilizes the maxillary arch and usually elimi-
nates oronasal fistulas. Furthermore, premaxillary retroposi-
tioning minimizes the nasolabial distortions that occur during
the rapid growth of early childhood.
There are two dentofacial orthopedic strategies: passive
and active. A passive molding plate is retained by undercuts
and maintains the transverse width of the maxillary segments.
An external force is needed to retract the premaxilla, such as
adhesive tape from cheek to cheek or an elastic band attached
to a headcap. Bilateral labial adhesions have been tried since
the mid-19th century; however, they often dehisce because of
tension and the absence of prolabial muscle. Cutting and
Grayson have popularized a more sophisticated version of a
passive plate and taping called “nasoalveolar molding”
(NAM).44,47,48 Their plate produces differential pressure on the
maxillary segments by selective reduction on the inner sur-
faces and addition of soft acrylic on the outer surfaces. After
the alveolar gap is reduced to 5 mm, nasal molding begins.
The nostrils are pushed upward by a bilobed acrylic nubbin
on stainless steel prongs that are attached to the palatal plate.
A soft denture material is added across the nasolabial junction
and a vertical tape is placed from prolabium to appliance, to
give a downward counterforce to the upward force applied
to the nasal tips that stretch the columella. The premaxilla is
gradually retracted by serial application of tape across the
outrigger to the cheeks or to the labia. These tapes are changed
daily by the parents. The apparatus must be adjusted weekly
to modify the alveolar molding plate so as to narrow the
maxillary segments. Although usually effective, NAM is
Fig. 22.1  Examples of asymmetrical bilateral cleft lip with a contralateral lesser-form. (A) Left complete and right minor-form; (B) left complete and right microform;
(C) left incomplete and right mini-microform.
A
B
C