Video Atlas Phẫu Thuật Khe Hở Môi Và Vòm Miệng

International Surgical Outreach Initiatives: Planning, Execution, and Safety
35
Appendix 3–2
Global Smile Foundation (GSF) Checklist for
Site-Specific Emergency Preparedness
Power Outage
[  ]  Each team member carries his or her own
flashlight at all times
[  ]  Each OR has a flexible flashlight
[  ]  Ensure availability of backup generators and
determine time required to regain electricity
[  ]  Ensure all ventilators, capnographs, monitors
have backup batteries, recharge each night
[  ]  Ensure availability of bulb suction
Fire
[  ]  Identify all fire exits and stairwells
[  ]  Identify all fire extinguishers in the OR, PACU,
and all relevant patient floors
Oxygen Supply
[  ]  Ensure availability of additional functioning
oxygen tanks in proximity to OR/PACUs
Blood Bank
[  ]  Identify location and hours of local blood bank
(on or off-site). If blood bank unstaffed during
certain hours, obtain key or contact information
for access to emergency products
[  ]  Identify type and quantity of available blood
products

36
Video Atlas of Cleft Lip and Palate Surgery
Appendix 3–3
Global Smile Foundation (GSF) Emergency Response Protocol
Team Roles and Responsibilities
General
• ECC is brought to PACU in the morning by the
overnight on-call anesthesiologist
• ECC is kept in PACU until last patient sent to floor
in stable condition
• ECC is kept in possession of on-call
anesthesiologist overnight
Power Outage
• All team members carry portable, high-illumination
flashlights on person at all times
• Anesthesiologist:  Maintain airway/breathing
with bag ventilation as needed. All monitors
including capnographs automatically revert to
battery power
• OR nurse:  Notify float nurse and float
anesthesiologist, activate battery-powered backup
light source to illuminate anesthesia/operative
fields, assist with bag ventilation as needed
• Float nurse:  Notify administration staff, return to
ORs to assist as needed
• Administration:  Work with host staff to
immediately activate backup power generators (if
not automatically activated), then assist in OR and
PACU as needed
• Surgeon:  Continue operation with backup light
source and electrocautery; if conditions do not
allow, obtain urgent hemostasis and expeditiously
close wounds
• Float anesthesiologist:  Circulate between ORs and
PACU to triage resources and assist with patient
safety as needed, bring ECC to OR if needed
• PACU nurse(s):  Activate individual flashlights,
continue perioperative care, and reassure patients/
families
• No new OR cases are begun until power
reestablished
Fire in OR
• Anesthesiologist:  Maintain airway, turn off
supplementary oxygen if airway fire
• Surgeon:  Stop use of electrocautery, extinguish
flames with heavy blankets
• OR nurse:  Obtain fire extinguisher and extinguish
flames, notify float nurse and float anesthesiologist
• Float nurse:  Assist with postfire care (deliver
medications/fluids, apply ointments/dressings)
• Float anesthesiologist:  Coordinate ICU transfer
and mechanical ventilation in ICU as needed
Fire in PACU or Floor
• PACU nurse(s):  Obtain fire extinguisher and
extinguish flames, notify float OR nurse and float
anesthesiologist
• Float nurse:  Assist with postfire care (deliver
medications/fluids, apply ointments/dressings)
• Any available surgeon:  Begin providing acute burn
care as needed to any injured patient/staff
• Float anesthesiologist:  Ensure adequate airway
of any patient/staff suffering airway edema or
inhalation toxicity, coordinate ICU transfer and
mechanical ventilation in ICU as needed
Oxygen Failure in OR and/or PACU
• Anesthesiologist:  Maintain airway and ventilation
with room air, notify OR team
• OR nurse:  Notify float nurse and float anesthesiologist
• Float nurse:  Work with local staff and
administration to secure backup oxygen tanks and
bring to OR(s)
• Float anesthesiologist:  Evaluate airway/
oxygenation of all PACU patients, assist in PACU
and OR as required
Abbreviations:  ECC = Emergency “crash” cart.

International Surgical Outreach Initiatives: Planning, Execution, and Safety
37
• PACU nurse(s):  Protect airway, monitor
oxygenation, assist with ventilation if needed and
minimize narcotic usage
• Surgeon:  Expeditiously continue operation; if poor
oxygenation obtain hemostasis and close operative
wounds
Operative Bleed and Need for
Emergency Transfusion
• Surgeon or anesthesiologist requesting transfusion: ​
Notify OR nurse of need
• Surgeon:  Apply pressure, pack wounds, and obtain
hemostasis
• Anesthesiologist:  Begin volume resuscitation as
needed and able
• OR nurse:  Notify float nurse and anesthesiologist
of blood bank need, then assist with volume
resuscitation and medication administration
• Float nurse:  Work with administration and host
staff to immediately secure blood products from
blood bank and bring them to OR
• Float anesthesiologist:  Assist anesthesiologist,
resuscitate with blood products, and coordinate
ICU care as needed
Medical/Surgical Emergency in OR
• OR team:  Immediately retrieve emergency crash
cart
• Primary anesthesiologist:  Team leader, maintains
airway
• OR nurse:  Notify floater nurse of scenario,
establish IV access, deliver medications (eg, PALS
medications, vasopressors, dantrolene, intralipid)
• Secondary anesthesiologist/anesthesia
resident:  Assist OR nurse
• Primary surgeon:  Close wound, assist in chest
compression
• Assistant surgeon:  Start chest compression
• Nurse floater:  Notify PACU team, administrative
personnel, and pediatrician of scenario; coordinate
flow of equipment, supplies, and staff (eg, obtain
ice for malignant hyperthermia
• Pediatrician:  Assist in emergency response upon
arrival to OR
• No additional case is started in any OR until
emergency situation controlled
Medical/Surgical Emergency in PACU
• PACU team:  Immediately retrieve emergency crash
cart (within PACU)
• Primary PACU nurse:  Maintain airway (retract
tongue stitch after palate/pharyngeal operations,
bag-mask ventilation, adjust FiO2, etc) and apply
pressure for bleeding
• Secondary PACU nurse:  Immediately notify
nursing floater, anesthesia floaters and
administrator, then assist primary PACU nurse
with medication administration (eg, Narcane™
administration for narcotic overdose)
• Administrator:  Locate and notify pediatrician to
arrive STAT to PACU
• Floater anesthesiologist:  As team leader run code
and maintain airway
• Primary surgeon or available surgeon:  Perform
emergency tracheotomy if upper airway
obstruction with oxygen desaturation and no
secure airway by anesthesiologist
• Secondary surgeon or surgery resident:  Assist with
tracheostomy as needed
• Secondary surgeon or anesthesiologist (attending,
fellow, or resident):  Assist with chest compression,
bleeding control
Medical/Surgical Emergency on Floor
• Floor/perioperative nurse or (if none)
pediatrician:  Immediately notify floater
anesthesiologist and administrator
• Administrator/any team member:  Immediately
rush emergency crash cart to floor
• Pediatrician:  As team leader runs code
• Floater anesthesiologist:  Secure and manage
airway
• Administrator:  Notify all OR and PACU staff
• PACU/perioperative nurse:  Administer IV fluids
and medications
• Pediatrician or any surgeon/
anesthesiologist:  Perform chest compressions
• No other cases are started in OR until emergency
situation controlled

(Trang không có chữ)

Section II
Presurgical Treatment of the
Cleft Lip and Palate Child

(Trang không có chữ)

41
Chapter 4
The Role of Pediatric Dentists and
Orthodontists in the Presurgical Treatment of
Infants Born with Cleft Lip and Palate
Barry H. Grayson, Mohammad Mansoor Ahmed, and Serena N. Kassam
Abstract
The concept of presurgical orthopedics has been employed
in the treatment of cleft lip and palate (CLCP) patients for
centuries. In 1993, Grayson et al1 described a new technique
to presurgically mold the alveolus, lip, and nose in infants
born with cleft lip and palate. The objective of nasoalveolar
molding (NAM) is to reduce the severity of CLCP deformi-
ties in the nose, lip, and alveolar processes prior to the initial
surgical repair. NAM can achieve presurgical reduction in
nasal cartilage deformity and size of the alveolar gap, approx-
imate the lip segments at rest, increase the surface area of
nasal mucosal lining, and provide nonsurgical elongation of
the columella. It has been reported that there is a reduction
in the number of secondary surgeries needed, especially if
NAM is combined with gingivoperiosteoplasty.2–4 The goals
of NAM include improvement of long-term nasal aesthetics
and reduction of cost and suffering to the patient and society
by reducing the need for secondary bone grafts and num-
ber of secondary surgical revisions and hospital admissions.
NAM is used by almost 40% of cleft palate teams in the
United States.5 The practice of NAM by pediatric dentists,
orthodontists, and other dental specialists enables the treat-
ing provider to initiate the first stages of anticipatory guid-
ance, create the foundation for oral prevention, and establish
the “cleft dental” home. As a limited number of published
resources exist explaining the role of the pediatric dentist
and orthodontist in the treatment of the infant with NAM,
this chapter will describe the role of NAM, its indications,
appliance design, fabrication, biomechanics, complications,
and patient management.
Background
Cleft lip and palate can present with considerable vari-
ation in severity and form. Generally, the wider, more
extensive clefts are associated with more significant naso-
labial deformity. These clefts, deficient in hard and soft
tissue elements, present a significant surgical challenge
to achieve a functional and cosmetic outcome. Even the
mildest incomplete unilateral cleft lip, in the absence of
a cleft palate, can be associated with a nasal deformity
that tends to worsen as nasal growth continues.6
The concept of presurgical orthopedics is not new;
it has been employed in the treatment of cleft lip and
palate patients for centuries. The earliest techniques
focused on elastic retraction of the protruding premax-
illa followed by stabilization after surgical repair. Hoff-
mann in 1689 demonstrated the use of facial binding to
narrow the cleft and prevent postsurgical dehiscence
of the soft tissue closure. Similarly, Desault in 1790
also used facial binding to retract the maxilla before
surgical repair in patients with bilateral cleft repair.7 In
1844, Hullihen stressed the importance of presurgical
preparation of clefts using an adhesive tape binding.8
Esmarch and Kowalzig used a bonnet and strapping
to stabilize the premaxilla after surgical retraction.9 In
1927, Brophy demonstrated the passing of a silver wire
through both the ends of the cleft alveolus, and then
progressively tightened the wire to approximate the
ends of the alveolus before lip repair.10
In 1950, McNeil modernized presurgical infant
orthopedics. He utilized a denture-like prosthesis that

42
Video Atlas of Cleft Lip and Palate Surgery
was delivered soon after birth, which brought about
reduction of the alveolar arch deformity prior to sur-
gical intervention.11 His technique was further popu-
larized by Burston.12 Since then, a wide variety of
appliances to control the presurgical alignment of the
cleft maxillary arch segments have been described,13–20
from the active pin retained appliance introduced by
Georgiade and Latham in 21 to the passive orthopedic
plate described by Hotz in 1987.22
In 1993, Grayson et al1 described a new technique
to presurgically mold the alveolus, lip, and nose in
infants born with cleft lip and palate (Figure 4–1). Naso-
alveolar molding (NAM) therapy placed emphasis on
reducing the severity of deformity in the nasal soft tis-
sue, the nasal cartilages, and the alveolar processes or
gum pads. The molding of nasal cartilage was inspired
by reports of pediatric auricular cartilage molding.23
Matsuo described the cartilage in newborns as soft and
lacking elasticity; hence, long-term correction of the
ear deformity was possible if treatment started within
6 weeks of birth. Similarly, active molding and shape
correction of the nasal cartilages take advantage of the
plasticity of cartilage in the newborn infant. The tem-
porary plasticity of cartilage is believed to be caused
by high levels of estrogen at the time of birth, which
correlates to increasing levels of hyaluronic acid, a com-
ponent of the proteoglycan intercellular matrix found
circulating in the infant for several weeks after birth.24–26
The objective of NAM is to reduce the sever-
ity of CLCP deformities in the nose, lip, and alveolar
processes prior to the initial surgical repair. Most sur-
geons agree that a patient with a milder cleft deformity
will obtain a better cosmetic surgical outcome than a
patient with a more severe presurgical cleft deformity.
NAM can achieve presurgical reduction in nasal carti-
lage deformity and size of the alveolar gap, approxi-
mate the lip segments at rest, increase the surface
area of nasal mucosal lining, and provide nonsurgi-
cal elongation of the columella. It has been reported
that there is a reduction in the number of secondary
surgeries needed, especially if NAM is combined with
gingivoperiosteoplasty.2–4
Impression Technique
(Video of Nasoalveolar Molding)
An impression of the infant with cleft lip and palate is
routinely obtained within the first week of birth, pro-
vided the infant is in good health. The impression pro-
cedure can carry some risks to the infant if performed
incorrectly; hence, meticulous precaution must be
taken. The impression is performed in a clinical setting
such as a hospital, where medical or dental personnel
are prepared to handle an infant airway emergency.
After fitting and selection of an appropriate-sized
impression tray, the infant is held upside down by the
surgeon and the impression performed. The infant is
held in an inverted position to prevent the tongue from
falling back to allow fluids to drain out of the oral cav-
ity, and to provide optimal direct vision of the maxillary
alveolar processes and cleft for the operator. A heavy-
bodied silicone impression material is used to take the
initial impression (Figure 4–2). Once the material is set
(approximately 4 minutes), the tray is gently removed.
Upon removal, the oral cavity is immediately exam-
ined for residual impression material and swabbed
with wet gauze to ensure that no detached pieces of
impression material are left behind. The impression is
then poured with dental stone to create a model of the
maxillary alveolar arches and palatal cleft.
Appliance Fabrication and Design
The molding plate is fabricated on the dental stone
model. All undercuts around the alveolus and cleft
spaces are blocked with wax. Separating medium is
Figure 4–1.  Nasoalveolar molding appliance (NAM). The appli-
ance is made up of (A) an intraoral molding plate, (B) reten-
tion buttons, and (C ) nasal stent, collectively forming the NAM
appliance.

The Role of Pediatric Dentists and Orthodontists in the Presurgical Treatment of Infants Born with Cleft Lip and Palate
43
applied to cover the entire arch. Hard self-cure acrylic
(clear power + liquid) is mixed and then applied uni-
formly to a thickness of 2 to 3 mm to provide structural
integrity and permit adjustment during visits. The
dental stone with the applied hard acrylic is placed in
a pressure pot and set on 27 psi for 20 minutes. After
removal from the pressure pot, the hard acrylic plate
is separated from the dental stone, finished, and pol-
ished. The borders of the plate are relieved by 1 mm,
in addition to the areas corresponding to the labial and
buccal frenal attachments, to ensure adequate clear-
ance for the intraoral soft tissues. A retention button
is fabricated and positioned anteriorly at an angle of
30° to 40° to the alveolar plane. In the unilateral appli-
ance, only one retention button is used (Figure 4–3),
whereas two are employed in the appliance for treat-
ment of bilateral cleft (Figure 4–4). The exact location of
the retention button(s) is determined at chair side. They
are positioned so as not to interfere with approxima-
tion of the cleft lip segments. The vertical position of
retention buttons should be at the junction of the upper
and lower lips. When two buttons are employed, they
must diverge to accommodate the nipple of a bottle or
pacifier. The retention buttons adequately secure the
molding plate to the roof of the mouth with the help of
orthodontic elastics and surgical tapes.
A small opening measuring 6 to 8 mm in diameter
is made on the palatal surface of the molding plate to
provide a patent airway in the event of vertical entrap-
ment of the plate intraorally. The nasal stent construc-
tion is delayed until the cleft of the alveolus is reduced
to about 5 to 6 mm in width. As the alveoli are slowly
molded toward one another, the soft tissue alar base
on the cleft side becomes less tense and more able to
be elevated with a nasal stent, without stretching and
unnecessarily increasing its circumference.
Appliance Insertion and Taping
Before insertion, the molding plate appliance is checked
for sharp or rough surfaces that may irritate the soft tis-
sues. It is also examined for overextension in the area
of the vestibular folds as well as along the posterior
border. The appliance is then secured in the mouth
A
B
Figure 4–2.  A. Illustrates the inverted infant position while impression is made to prevent the tongue from falling back and pre-
vent fluid aspiration. B. Impression of a unilateral cleft patient using a custom tray and heavy-body silicone impression material.

44
Video Atlas of Cleft Lip and Palate Surgery
with the aid of surgical tapes that are adhered to the
cheeks bilaterally. Orthodontic elastics are connected
to the ends of the surgical tapes to engage the retention
button(s) on the appliance. The use of skin barrier tapes
on the cheeks, such as hydrocolloid base tape, is advo-
cated to reduce irritation. The elastics (inner diameter
0.25 inch, wall thickness heavy) should be stretched
approximately two times their resting diameter for
proper activation force of about 100 gms (see Figure 4–3).
The amount of force could vary depending on clinical
objective and the intraoral mucosal tolerance to pres-
sure and resistance to ulceration. Additional “cover
tapes” may be employed to secure and protect the
elastic surgical tapes. Parents/caregivers are instructed
to keep the plate in the infant’s mouth continuously
except for daily cleaning. The infant may require 1 or
2 days to adjust to feeding with the NAM appliance.
Appliance Adjustments
The adjustment of the appliance begins on the day of
delivery by selectively removing hard acrylic from spe-
cific locations along the interior walls of the molding
plate, while adding soft denture base material in cor-
responding proportions. This results in approximation
of the position of alveolar segments. These modifica-
tions to the tissue facing surfaces of the molding plate
should be restricted to 0.5 to 1.0-mm increments to
prevent tissue irritation and ensure appliance seating/
retention. The infant is seen weekly for incremental
adjustments of the molding plate. The goal is to direct
the alveolar segments into optimal position and form
during the 3- to 6-month presurgical period. As this is
achieved, there will be a corresponding reduction in
the lip gap and alar base width. Care must be taken to
prevent incomplete seating of the molding plate and
potential deformation of the alveolus, by not allowing
the soft denture material to build up on the interior of
the molding plate in the region corresponding to the
height of the alveolar crest.
Incorporation of the Nasal Stent
The nasal stent system is composed of a 0.36-round
stainless steel wire, hard acrylic, and soft acrylic. The
wire has a distinct curvature that projects outward
Figure 4–3.  Unilateral NAM appliance. (A) Hydrocolloid base
tapes. (B) ¼-inch diameter surgical tapes attached to an orth-
odontic elastic that is engaged around the button. (C ) Note the
red elastic on patient’s right is stretched to twice its resting
diameter. This results in greater force to move the plate toward
the cleft side (patient right side). (D) The lower lobe of the nasal
stent is seen exiting at the nostril apex while the upper lobe of
the nasal stent is within the nose and lifting the right nasal dome.
Figure 4–4.  Bilateral NAM appliance. Note the two retention
buttons that are used to engage the elastics and tape to the
cheeks. (A) Columella band connecting the inferior lobes of the
nasal stents and crossing the columella. Note the active stretch-
ing of the columella as the appliance is seated, which is further
activated by the downward pull of the prolabium tape. (B) The
prolabium tape is activated by its connection to the horizontal
elastic (arrow C ) that is suspended by the two retention buttons.

The Role of Pediatric Dentists and Orthodontists in the Presurgical Treatment of Infants Born with Cleft Lip and Palate
45
from the appliance and then back into the nose. The
appliance for the treatment of bilateral clefts has two
stents projecting into the nostril apertures, whereas the
appliance for a unilateral cleft defect utilizes one. The
length of the curved wire allows flexibility for adjust-
ment of the intranasal stent as the nose and face grow
(Figure 4–5). The distal end of the nasal stent wire is
shaped into a loop for retention of the hard acrylic,
which acts as the core foundation of two nasal stent
“lobes.” The hard acrylic component is shaped into a
bilobed form that resembles a kidney. A layer of soft
denture liner is added to the hard acrylic to form a bar-
rier that protects the sensitive intranasal mucosa from
irritation. The inferior nasal lobe is positioned adjacent
to the columella and emerges from the nostril, pushing
the nasal apex forward, medially, and slightly upward.
The superior lobe is positioned inside the nose and
converges medially, projecting the nasal tip (dome) for-
ward. The elasticity of the soft denture liner also acts as
a source of activation by stretching and expanding the
nasal mucosal lining tissue with every 0.5 to 1.0 mm
incremental addition.
Nonsurgical Columella Lengthening
in Bilateral Cleft Lip and Palate
The nasal deformity in bilateral cleft lip and palate
(BCLP) is unique from that of unilateral cleft lip and
palate (UCLP). In BCLP, the flattened nasal tip is teth-
ered directly to the prolabium by a severely deficient
or absent columella. The lower lateral alar cartilages
are flared and concave where they should be convex.
The greatest challenge for aesthetic reconstruction is
the absent or deficient columella.
The nasal stent components of NAM, specifically
the columella band (see Figure 4–4) are used to non-
surgically elongate the deficient or absent columella.
The forces generated when the nasal stent pushes up
on the nostril apex and the medial crux of the nasal car-
tilages result in a reciprocal force directed downward
by the columella band against the base of columella,
allowing for its gradual elongation. The horizontal col-
umella band is constructed from soft denture liner that
joins the two inferior lobes of the nasal stent. It has a
gentle curvature on the inferior surface that sits at the
columella/philtral junction and defines this angle as
the nasal tip continues to be lifted and projected for-
ward. A second force is generated with prolabial tape
that is adhered to the prolabium and stretches down-
ward to engage the retention buttons with elastics (see
Figure 4–4). Taping downward on the prolabium helps
to lengthen the columella and vertically lengthen the
often small prolabium.
A
B
Figure 4–5.  A. Nasal stent seated in nose supporting and pro-
jecting the nasal dome in the direction of the arrow. B. Illus-
tration describing how the length of the curved wire allows
flexibility for adjustment of intranasal stent as the midface
grows vertically.

46
Video Atlas of Cleft Lip and Palate Surgery
Primary Surgical Repair of the
Alveolus, Lip, and Nose
The objective of NAM therapy is accomplished before
the primary surgical repair (Figures 4–6 and 4–7). Sur-
gical closure of the lip and nose is performed from 3 to
4 months of age for UCL. Patients with bilateral cleft
lip and palate tend to need 1 to 2 additional months
to achieve the presurgical clinical objectives. Approxi-
mation of the alveolar segments permits the surgeon
to perform gingivoperiosteoplasty. Reshaping of the
deformed alar cartilage and stretching of the nasal
mucosa can enhance the surgeon’s ability to achieve a
good surgical repair. The surgical technique should be
modified to take advantage of the NAM outcomes.27–29
Complications
NAM complications can be characterized as soft tissue,
hard tissue, and compliance-related.30 Soft tissue com-
plications include ulceration/irritation to the “pregin-
gival” alveolar tissue and oral or nasal mucosa. They
can be caused by rough internal surfaces of the mold-
ing appliance that were not properly contoured during
adjustments or can be due to excessive pressure of the
appliance against the mucosa. Relieving the acrylic
plate corresponding to the areas of insult usually
resolves the irritations or ulcerations. Another soft tis-
sue complication is candida infection, which can arise
if the molding plate is not cleaned regularly, especially
since it is worn 24 hours a day. The intranasal lining of
Figure 4–6.  Unilateral cleft lip and palate treated with NAM.
A. Pre-NAM. Note the concave nasal cartilage on the cleft side,
deviation of the columella to the noncleft side, and large alveo-
lar gap. B. NAM appliance seated for 3 months. Note the nasal
stent elevating and molding the nostril apex and nasal dome.
The columella is taking a more upright position. C. Post-NAM.
Note the nasal cartilages have retained a convex form on the
cleft side, the columella is more upright, and the alveolar gap
has been eliminated.

The Role of Pediatric Dentists and Orthodontists in the Presurgical Treatment of Infants Born with Cleft Lip and Palate
47
the nasal tip can become inflamed if the upper lobe
of the nasal stent applies excessive force. The area
under the horizontal columella band can become ulcer-
ated if the band is too tight. Nasal stent complications
can also arise if the stents are not positioned properly,
which can lead to creation of an overexpanded nostril
or petechiae in area of excessive pressure. The oral and
nasal cavities of the infant should be carefully exam-
ined in each visit for these possible complications,
which should subsequently be followed by the appro-
priate adjustments to the NAM appliance. The most
common area of soft tissue irritations is the skin of the
cheek. Extreme care should be taken while removing
the cheek tape to avoid tearing or irritation of the skin.
Figure 4–7.  Bilateral cleft lip and palate treated with NAM. A.
Pre-NAM. Note the absent columella and ectopic, extraorally
positioned premaxilla with asymmetric left and right alveolar
gaps. B. NAM appliance seated for 5 months. Note the colu-
mella band elongating the columella and nasal stents project-
ing the nasal dome upward and forward. C. Post-NAM. Note
the presurgically constructed columella and the nasal carti-
lages retaining bilateral convexity and symmetry. Also, note the
intraoral and symmetrically positioned premaxilla and absence
of alveolar cleft gaps.

48
Video Atlas of Cleft Lip and Palate Surgery
Skin barriers, such as hydrocolloid tapes, are recom-
mended to protect the skin. Slight relocation of the
position of the tape during treatment can also provide
rest and time for recovery of the skin.
One hard tissue complication of NAM is misalign-
ment of the alveolar segments during the molding pro-
cess. Careful molding plate adjustments made during
the weekly visits ensure proper movement and align-
ment of the segments. Another common complication
may be the premature eruption of primary maxillary
incisors, sometimes resulting from pressure exerted
by the molding plate.31 In this case, relief of the NAM
appliance can be made to accommodate the prema-
turely erupted tooth. The presence of a neonatal or
ectopic tooth bud is usually managed by extraction if
the tooth is mobile and presents the risk of aspiration.
An important factor that can result in complica-
tions during NAM treatment is caregiver/parental
compliance. Failure to apply the recommended amount
of elastic force can result in insufficient movement of
the alveolar segments. Application of excessive force
may result in soft tissue ulcerations and irritation. The
removal of an appliance for extended periods of time
(several hours per day or for several days) will result in
an appliance that becomes maladapted to the patient’s
alveolar arch. Poor skin and appliance hygiene can lead
to inflammation and discomfort. Failure to show up for
regularly scheduled appointments will delay the prog-
ress of treatment. Successful treatment is dependent on
complete commitment and compliance of the parents/
caregivers. However, they must be provided with the
knowledge and skills to deliver the appropriate home
care, essential to the success of NAM.
Benefits of Nasoalveolar Molding
NAM plays a significant role in reducing the extent of
CLCP deformity in the period immediately prior to the
primary cleft surgical repair. The literature has estab-
lished that NAM improves nasal cartilage deformity
and nasal symmetry, expands the nasal mucosal lin-
ing, and achieves nonsurgical elongation of the colu-
mella.32–41 These presurgical enhancements have been
found to reduce the need and number of surgical revi-
sions due to excessive scar tissue, oronasal fistulas, and
nasolabial deformities.42 Moreover, if the alveolar seg-
ments are approximated and gingivoperiosteoplasty
performed, the resultant formation of a bony bridge can
improve the conditions for eruption and periodontal
support of teeth along the former cleft margins. San-
tiago et al43 reported that 60% of patients that under-
went NAM and gingivoperiosteoplasty (GPP) did not
require secondary bone grafting. Sato et al44 found that
in the remaining 40% that did need a bone graft, there
was more bone remaining in the graft site compared
with patients who did not previously undergo gingivo-
periosteoplasty. Henkel reported that in 68% to 73% of
patients in whom a Millard-type GPP was performed,
a secondary bone graft was not required.45
Conclusion
Nasoalveolar molding in infants has aims that go
beyond the traditional goals of presurgical orthopedics.
These aims include improvement of long-term nasal
aesthetics and reduction of cost and suffering to the
patient and society by reducing the need for second-
ary alveolar bone grafts and the number of secondary
surgical revisions and consequent hospital admissions.
References
1. Grayson B, Cutting C, Wood R. Preoperative columella
lengthening in bilateral cleft-lip and palate. Plast Reconstr
Surg. 1993;92(7):1422–1423.
2. Cutting C, Grayson B, Brecht L, Santiago P, Wood R,
Kwon S. Presurgical columellar elongation and primary
retrograde nasal reconstruction in one-stage bilateral
cleft lip and nose repair. Plast Reconstr Surg. 1998;​101(3):​
630–639.
3. Grayson B, Cutting C, Wood R. Preoperative columella
lengthening in bilateral cleft lip and palate. Plast Reconstr
Surg. 1993;92(7):1422–1423.
4. Grayson BH, Santiago PE, Brecht LE, Cutting CB. Presur-
gical nasoalveolar molding in infants with cleft lip and
palate. Cleft Palate Craniofac J. 1999;36(6):486–498.
5. Sischo L, Chan JW, Stein M, Smith C, van Aalst J, Broder
HL. Nasoalveolar molding: prevalence of cleft centers
offering NAM and who seeks it. Cleft Palate Craniofac J.
2012;49(3):270–275.
6. Latham R. Development and structure of the premaxil-
lary deformity in bilateral cleft lip and palate. Br J Plast
Surg. 1973;26(1):1–11.
7. Millard DR. Bilateral and rare deformities. In: Millard
RD, ed. Cleft Craft: The Evolution of Its Surgery. Boston,
MA: Little Brown & Co;1977.
8. Goldwyn RM, Hullihen SP. Pioneer oral and plastic sur-
geon. Plast Reconstr Surg. 1973;52(3):250–257.

The Role of Pediatric Dentists and Orthodontists in the Presurgical Treatment of Infants Born with Cleft Lip and Palate
49
9. Millard DR. Clefts of the alveolus, hard and soft palates.
In: Millard RD, ed. Cleft Craft: The Evolution of Its Surgery.
Boston, MA: Little Brown & Co;1980.
10. Brophy TW. Cleft lip and cleft palate. J Am Dent Assoc.
1927;14:1108.
11. McNeil C. Orthodontic procedures in the treatment of
congenital cleft palate. Dent Records. 1950;70:126–132.
12. Burston WR. The early orthodontic treatment of cleft pal-
ate conditions. Dent Pract. 1958;9:41.
13. Huddart AG. Presurgical dental orthopedics. Trans Brit
Soc Orthod. 1961;107–118.
14. Georgiade NG, Mladlick RA, Thorne FL. Positioning of
the premaxilla in bilateral cleft lips by oral pinning and
traction. Plast Reconstr Surg. 1968;41(3):240–243.
15. Jacobson BN, Rosenstein SW. Early maxillary orthopedics:
a combination appliance. Cleft Palate J. 1965;2:369–376.
16. Mylin WK. The pin retained appliance in cleft palate
orthodontics. Cleft Palate J. 1968;5:219–227.
17. Hotz M. Pre- and early postoperative growth — guidance
in cleft lip and palate cases by maxillary orthopedics.
Cleft Palate J. 1969;6:361–372.
18. Fish J. Growth of the palatal shelves of post alveolar cleft
palate infants. Effects of stimulation appliances. Br Dent
J. 1972;132(12):492–501.
19. Ross RB, Johnston MC. Cleft lip and palate. Baltimore, MD:
Williams & Wilkins; 1972:242–245.
20. Peat HP. Early orthodontic treatment for complete clefts.
Am J Orthod. 1974; 65:28–38.
21. Georgiade NG, Latham RA. Maxillary arch alignment in
the bilateral cleft lip and palate infant, using pinned coax-
ial screw appliance. Plast Reconstr Surg. 1975;56(1):52–60.
22. Hotz M, Perko M, Gnoinski W. Early orthopaedic stabili-
zation of the premaxilla in complete bilateral cleft lip and
palate in combination with the Celesnik lip repair. Scand
J Plast Reconstr Surg Hand Surg. 1987;21(1):45–51.
23. Matsuo K, Hirose T, Tomono T, Iwasawa M, Katohda S,
Takahashi N, et al. Nonsurgical correction of congenital
auricular deformities in the early neonate: a preliminary
report. Plast Reconstr Surg. 1984;73(1):38–51.
24. Matsuo K, Hirose T. Nonsurgical correction of cleft lip
nasal deformity in the early neonate. Ann Acad Med Sin-
gapore. 1988;17(3):358–365.
25. Matsuo K, Hirose T, Otagiri T, Norose N. Repair of cleft
lip with nonsurgical correction of nasal deformity in the
early neonatal period. Plast Reconstr Surg. 1989;​83(1):​
25–31.
26. Matsuo K, Hirose T. Preoperative non-surgical over-
correction of cleft lip nasal deformity. Br J Plast Surg.
1991;44(1):5–11.
27. Cutting C, Bardach J, Pang R. A comparative study of the
skin envelope of the unilateral cleft lip nose subsequent
to rotation-advancement and triangular flap lip repairs.
Plast Reconstr Surg. 1989;84(3):409–417.
28. 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.
29. Smile Train. Smile Train Virtual Surgery Video. Cleft lip
and palate. Available at:
medpro/training/training_cds.htm
30. Levy-Bercowski D, Abreu A, DeLeon E, Looney S, Stock-
still J, Weiler M, et al. Complications and solutions in
presurgical nasoalveolar molding therapy. Cleft Palate
Craniofac J. 2009;46(5):521–528.
31. Ziai MN, Bock DJ, Da Silveira A, Daw JL. Natal teeth: A po-
tential impediment to nasoalveolar molding in infants with
cleft lip and palate. J Craniofac Surg. 2005;16(2):​262–266.
32. Ezzat CF, Chavarria C, Teichgraeber JF, Chen JW, Strat-
mann RG, Gateno J, et al. Presurgical nasoalveolar mold-
ing therapy for the treatment of unilateral cleft lip and
palate: a preliminary study. Cleft Palate Craniofac J. 2007;​
44(1):8–12.
33. Spengler AL, Chavarria C, Teichgraeber JF, Gateno J, Xia
JJ. Presurgical nasoalveolar molding therapy for the treat-
ment of bilateral cleft lip and palate: a preliminary study.
Cleft Palate Craniofac J. 2006;43(3):321–328.
34. Jaeger M, Braga-Silva J, Gehlen D, Sata Y, Zuker R, Fisher
D. Correction of the alveolar gap and nostril deformity
by presurgical passive orthodontia in the unilateral cleft
lip. Ann Plast Surg. 2007;59(5):489–494.
35. 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.
36. Pai BC, Ko EW, Huang CS, Liou EJ. Symmetry of the nose
after presurgical nasoalveolar molding in infants with
unilateral cleft lip and palate: a preliminary study. Cleft
Palate Craniofac J. 2005;42(6):658–663.
37. Lee CT, Garfinkle JS, Warren SM, Brecht LE, Cutting CB,
Grayson BH. Nasoalveolar molding improves appear-
ance of children with bilateral cleft lip-cleft palate. Plast
Reconstr Surg. 2008;122(4):1131–1137.
38. Liou EJ, Subramanian M, Chen PK. Progressive changes
of columella length and nasal growth after nasoalveolar
molding in bilateral cleft patients: a 3-year follow-up
study. Plast Reconstr Surg. 2007;119(2):642–648.
39. Liou E, Subramanian M, Chen P, Huang CS. The progres-
sive changes of nasal symmetry and growth after naso-
alveolar molding: a three-year follow-up study. Plast
Reconstr Surg. 2004;114(4):858–864.
40. Meazzini MC, Rossetti G, Morabito A, Garattini G, Bru-
sati R. Photometric evaluation of bilateral cleft lip and
palate patients after primary columella lengthening. Cleft
Palate Craniofac J. 2010;47(1):58–65.
41. Maull DJ, Grayson BH, Cutting CB, Brecht LL, Bookstein
FL, Khorrambadi D, et al. Long-term effects of nasoalveo-
lar molding on three-dimensional nasal shape in unilat-
eral clefts. Cleft Palate Craniofac J. 1999;36(5):391–397.
42. Lee C, Grayson B, Cutting C. The need for surgical colu-
mella lengthening and nasal width revision before the
age of bone grafting in patients with bilateral cleft lip fol-
lowing presurgical nasal molding and columella length-

50
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ening. In: Program and Abstracts of the 56th Annual Session
of the American Cleft Palate — Craniofacial Association. 1999;
Scottsdale, AZ.
43. Santiago PE, Grayson BH, Cutting CB, Gianoutsos
MP, Brecht LE, Kwon SM. Reduced need for alveolar
bone grafting by presurgical orthopedics and primary
gingivoperiosteoplasty. Cleft Palate Craniofac J. 1998;35(1):​
77–80.
44. Sato Y, Grayson B, Barillas I, Cutting C. The effect of gin-
givoperiosteoplasty on the outcome of secondary alveo-
lar bone graft. In: Program and Abstracts of the 59th Annual
Session of the American Cleft Palate — Craniofacial Associa-
tion. 2002; Seattle, WA; p. 51.
45. Henkel K, Gundlach K. Gingivoperiosteoplasty: an alter-
native to osteoplasty of alveolar clefts. Mund Kiefer Gesi-
chtschir. 2002;6(4):261–265.

Section III
Primary Cleft Lip Repair with Rhinoplasty

(Trang không có chữ)

53
Chapter 5
Anthropometry:  Evaluation and Planning
Kamlesh B. Patel, Kyle R. Eberlin, and Raj M. Vyas
Abstract
Surgeons rely on precise measurements to perform a cleft lip
repair. Fortunately, we are armed with normal anthropomet-
ric data for the lip and nose by Dr. Leslie Farkas and others.
This chapter introduces nasolabial anthropometry and its
application for patients with a cleft lip.
“When you can measure what you are speaking about,
and express it in numbers, you know something about
it, when you cannot express it in numbers, your knowl-
edge is of a meager and unsatisfactory kind” (Lord
Kelvin, Electrical Units of Measurement, Lecture to the
Institution of Civil Engineers, 1883).
Anthropometry is the measurement of the human indi-
vidual, permitting one to compare the relative parts
under normal and abnormal conditions. Dr. Leslie Far-
kas, father of medical anthropometry, is responsible for
providing the normative measurements of the lip and
nose.1,2 Cleft surgeons are obligated to critically follow
their aesthetic outcomes, and anthropometry allows for
the application of statistical data to measure and opti-
mize the primary operation. This method is exempli-
fied by Dr. John B. Mulliken in his approach for repair
of a patient with a bilateral cleft lip.3 His understanding
of the fourth-dimension (growth) allows him to tailor
the primary operation. This chapter will introduce the
terminology used in nasolabial anthropometry and its
application for the cleft surgeon.
Landmarks1–4 (Figures 5–1 and 5–2)
Nose
Alare (al):  The most lateral point of each alar base.
Subnasale (sn):  The midpoint of the angle
between the columella base and upper lip.
Highest point of the columella (c):  The point of
each columella that is level with the top of the
corresponding nostril.
Subalare (sbal):  The lowest point of the alar base.
Figure 5–1.  Nasal and labial anthropometric points.

54
Video Atlas of Cleft Lip and Palate Surgery
Lip
Crista philtri superior (cphs):  Top of the philtral
column at the same horizontal line drawn
through subnasale (sn).
Crista philtri inferior (cphi):  Analogous to the
peak of Cupid’s bow.
Labiale superius (ls):  The midpoint of the upper
vermilion line (the trough of Cupid’s bow).
Stomion (sto):  Point corresponding to the vertical
facial midline and the free margin of the upper lip.
Cheilion (ch):  The point located at each labial
commissure.
Measuring
Anthropometric measurements can be obtained by
direct or indirect methods. Direct anthropometry is the
gold standard, but it requires experience and a coop-
erative patient to allow for accurate marking and mea-
suring. For the young patient with a cleft lip, this is
most accurately obtained in the operating room under
general anesthesia.
Indirect anthropometry can be obtained by two-
dimensional (2D) photography, but it requires the
image to be standardized and to include some type of
calibration to allow for linear measurements. Neverthe-
less, 2D photography can be applied when obtaining
proportions and angles. Alternatively, 3D photography
removes many of these errors and allows for the image
to be analyzed using manufactured software provided
by the 3D camera systems (eg, 3DMDface and Vectra
3D). This has proved to be a popular alternative to
direct anthropometry in the pediatric population, as
images can be captured as quickly as 3.5 milliseconds.
Wong and colleagues evaluated the validity and reli-
ability of nasolabial anthropometric points using 3D
photography in comparison to direct anthropometry.5
They found the linear measurements correlated highly
and the overall precision of the 3D measurements to be
within 1 mm of direct measures.
Application of Nasolabial
Anthropometry
Nasolabial dimensions pertinent to patients with a
cleft lip are shown in Table 5–1. Understanding future
growth is crucial when performing a primary cleft lip
repair. The goal for the surgeon is to normalize the
nasolabial measurements, not at the time of repair, but
when the child reaches 5 to 10 years of age.
Unilateral Cleft Lip
The objective of the surgeon is to obtain long-term
symmetry in a patient affected by a unilateral cleft lip.
Regardless of the technique used, the primary goal is to
achieve lip height (sn-cphi and sbal-cphi) on the cleft side
to match the noncleft side. Failure will present in the
older child with shortening of the vermilion-cutaneous
junction on the cleft side.
Mulliken and LaBrie noted how the hemina-
sal width (sn-al) will increase more on the cleft side
than the noncleft side at 6 years of age compared to
postoperative measurements.4 Lateral drift of the alar
base was also described by Millard, and he secured the
alar base to the caudal septum to reduce “alar creep.”6
Byrd’s method is to preserve a muscular roll below the
alar base that is then sutured to the soft tissue adjacent
to the anterior nasal spine and contralateral medial
crura footplate.7 The cleft surgeon has to remember to
correctly secure and position the alar base to prevent
the appearance of a wide alar base.
Figure 5–2.  Base view of nasal anthropometric points.

Anthropometry:  Evaluation and Planning
55
Blair delineated the stigmata of the cleft lip nasal
deformity: Deviation of the tip and caudal septum
to the noncleft side, dislocated lower lateral carti-
lage, obtuse angle between middle and lateral crura,
posterior-laterally displaced alar base, and short colu-
mella on the cleft side.8 Primary correction of the nasal
deformity is integral to repair of a unilateral cleft lip,
with direct and indirect anthropometry documenting
improved nasal symmetry.9–12 The authors prefer to
use a “semiopen” approach for primary nasal repair.
Through this rim incision, the lower lateral cartilage
on the cleft side is elevated and secured to the contra-
lateral genu and ipsilateral upper lateral cartilage with
interdomal and intercartilaginous sutures.13
Bilateral Cleft Lip
The long-term appearance of a poorly planned repair
in a patient with a bilateral cleft lip is well known and
sadly still seen today: Flat nasal tip, short columella,
increased nasal width, wide prolabium, and soft tis-
sue deficiency of the median tubercle (“whistling
deformity”).14 Using and understanding nasolabial
anthropometry can free cleft surgeons from this curse
and improve their long-term results. Mulliken and col-
leagues described making slow-growing structures
such as nasal tip projection (sn-prn) and columel-
lar length (sn-c) longer than age, gender, and ethnic-
matched subjects at the time of the primary operation,
while making fast-growing features such as nasal width
(al-al) and prolabial width (cphs-cphs and cphi-cphi) nar-
rower than normative subjects.3 Vermilion-mucosal
height is a fast-growing structure but is intentionally
made longer due to concern for deficiency of tissue in
the median tubercle and the patient having a “whistle
lip deformity.”
Table 5–1.  Linear Nasolabial Measurements Pertinent to Patients with a Cleft Lip
Nose
Unilateral Cleft Lip
Bilateral Cleft Lip
Heminasal width
Nasal width
Nasal tip projection
Columellar length
Columellar width
(sn-al)
(al-al)
(sn-prn)
(sn-c)
(c-c)
Labial height
Lip length
(sn-cphi)
(sbal-cphi)
(cphi-ch)
Upper prolabial width
Lower prolabial width
Prolabial length
Upper lip length
Vermilion/mucosa height
(cphs-cphs)
(cphi-cphi)
(sn-ls)
(sn-sto)
(ls-sto)
References
1. Farkas LG. Anthropometry of the Head and Face. New York,
NY: Raven Press; 1994.
2. Farkas LG, Posnick JC, Hreczko TM, Pron GE. Growth
patterns of the nasolabial region: a morphometric study.
Cleft Palate Craniofac J. 1992;29:318–324.
3. Mulliken JB, Burvin R, Farkas LG. Repair of bilateral
complete cleft lip: intraoperative nasolabial anthropom-
etry. Plast Reconstr Surg. 2001;107:307–314.
4. Mulliken JB, LaBrie RA. Fourth-dimensional changes in
nasolabial dimensions following rotation-advancement
repair of unilateral cleft lip. Plast Reconstr Surg. 2011.
5. Wong JY, Oh AK, Ohta E, Hunt AT, Rogers GF, Mulliken
JB, Deutsch CK. Validity and reliability of craniofacial
anthropometric measurement of 3D digital photogram-
metric images. Cleft Palate Craniofac J. 2008;45:232–239.
6. Millard DR, Jr. Earlier correction of the unilateral cleft lip
nose. Plast Reconstr Surg. 1982;70:64–73.
7. Byrd HS, Salomon J. Primary correction of the unilateral cleft
nasal deformity. Plast Reconstr Surg. 2000;​106:​1276–1286.
8. Blair VP. Nasal deformities associated with congenital
cleft of the lip. JAMA. 1925;84:185–187.
9. Farkas LG, Hajnis K, Posnick JC. Anthropometric and
anthroposcopic findings of the nasal and facial region
in cleft patients before and after primary lip and palate
repair. Cleft Palate Craniofac J. 1993;30:1–12.
10. Wong GB, Burvin R, Mulliken JB. Resorbable internal
splint: an adjunct to primary correction of unilateral cleft
lip-nasal deformity. Plast Reconstr Surg. 2002;110:385–391.
11. Barillas I, Dec W, Warren SM, Cutting CB, Grayson BH.
Nasoalveolar molding improves long-term nasal symme-
try in complete unilateral cleft lip-cleft palate patients.
Plast Reconstr Surg. 2009;123:1002–1006.
12. Chang CS, Por YC, Liou EJ, Chang CJ, Chen PK, Noord-
hoff MS. 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.

56
Video Atlas of Cleft Lip and Palate Surgery
13. 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;104:1247–1260.
14. Millard DR. Cleft Craft: The Evolution of Its Surgery. Bos-
ton, MA: Little, Brown; 1976.

57
Chapter 6
Repair of the Unilateral Cleft Lip Deformity
Dunia Abdul-Aziz and Usama S. Hamdan
Abstract
Restoring lip and nasal symmetry as well as natural lip
function are the primary goals of a successful cleft lip repair.
Unilateral cleft lip repair must address the lip abnormalities
related to the inappropriate attachment and discontinuity
of the orbicularis oris muscle. Repair involves challenges,
such as an absent philtral ridge and vermilion border at
the cleft, as well as nasal deformities, including a flattened
lower lateral cartilage and short columella. Primary repair
of the unilateral cleft lip must address both the lip and nasal
deformities. The aim of this chapter is to provide a detailed
step-by-step description for repair of incomplete and com-
plete unilateral cleft lip. We describe a modified approach to
Millard’s rotation-advancement repair of the unilateral cleft
lip. The technique is based on development of two flaps: a
medial rotation (R) flap from the noncleft side that is rotated
down from the columella to achieve lip length, and a lateral
advancement (A) flap that is advanced medially to fill the
cleft defect. Primary rhinoplasty involving undermining of
the soft tissue overlying the lower lateral cartilage is per-
formed at the time of initial lip repair. For lip closure, we
describe the Hamdan sliding V-cheiloplasty technique, which
ensures adequate lip length and provides alar base support
by reducing the lateralizing forces of healing. Nasal symme-
try is achieved through a cartilage-sparing technique, using
an alar base flap and suspending suture (ABFSS), double
interdomal sutures, and suspending and transfixion nasal
sutures. Repair should be performed with the least amount
of scarring to ensure satisfactory long-term outcomes. The
surgeon’s skill and experience as well as his/her attention to
detail are crucial factors for satisfactory results. Beyond a
textbook description of the procedure, the chapter offers tech-
nical nuances that have been gained from the senior author’s
25 years refining this procedure.
Repair of a cleft defect in the lip and nose must address
functional and aesthetic goals. Functionally, the sur-
geon must realign the mucosal and muscular layers of
the lip systematically and with appropriate release of
tension to enable lip animation. Structurally, the sur-
geon seeks to achieve symmetry of the lip and nose that
requires lengthening of the foreshortened philtrum,
forming the vermilion tubercle, and reshaping of the
nostril and alar base. Historically, the repair of a uni-
lateral cleft lip has undergone evolution from straight-
line closure to complex geometric rearrangements of
the tissue. Ambriose Paré, one of the fathers of mod-
ern surgery dating back to the 16th century, is credited
for providing one of the first illustrations of repair of
the unilateral cleft lip via vertical closure.1 This tech-
nique was the basis for cleft lip repair until the 19th
century. Although achieving lip closure, this procedure
often resulted in scar contracture and lip notching. The
use of geometric tissue rearrangement in the repair of
cleft lip was first introduced by Germanicus Mirault in
1844, who described the insertion of a triangular flap
from the lateral side into the medial side of the cleft to
achieve lip lengthening.1 Tissue rearrangement has rev-
olutionized the modern-day management of cleft lip
defects, and many modifications have been proposed,
including Arthur Baker LeMesurier’s quadrilateral
flap repair,2 C.W. Tennison’s triangular flap,3 and Mil-
lard’s rotation advancement flap;4 all aim to bring in
tissue to the deficient side and orient it to achieve lip
lengthening.5 Geometric tissue rearrangement allows
greater displacement of tissue but violates the curved
philtral column. Millard’s rotation advancement flap
has gained most favor but various modifications have
been published.
In this chapter we describe a modified approach to
Millard’s rotation advancement flap. We also outline the

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Video Atlas of Cleft Lip and Palate Surgery
Hamdan sliding V-cheiloplasty approach to achieve lip
lengthening through inferior and medial advancement
of the orbicularis oris muscle fibers. This technique also
allows medial mobilization of the ala, thus minmizing
the lateral vectors of healing that contribute to postop-
erative displacement of the alar base. The mucosal flaps
are crisscrossed to reconstruct the anterior nasal floor in
the complete cleft lip or to prevent bucconasal fistulae in
the incomplete cleft lip. We also describe the placement
of the alar base flap suspension suture (ABFSS), dou-
ble interdomal suture, alar crease transfixion sutures,
and anterior soft tissue angle suspending sutures that
allow restoration of nasal symmetry. Finally, a vermil-
ion border flap is inferiorly rotated from the cleft side to
achieve symmetric alignment of the Cupid’s bow peaks.
Surgical Indications
• Patients with unilateral complete or incomplete
cleft lip deformity, with or without cleft palate.
Surgical Contraindications
• Medically unstable patient:  Inability to
tolerate general anesthesia (in the case of
infants and children), malnutrition, anemia,
and/or current infections.
• Genetic and other associated abnormalities:
As cleft lip and palate deformities
sometimes occur in association with other
congenital abnormalities (incidence and
type of associated congenital anomaly
varies depending on the study, and ranges
from 3% to 60%), the surgeon must be
vigilant of possible complications.6,7 A full
assessment by a pediatrician and pediatric
anesthesiologist is mandatory prior to
performing surgical repair.
• Preoperative workup includes a physical
examination to screen for possible cardiac,
neurologic, and other congenital abnormalities.
Classification
Kernahan’s striped “Y” classification for cleft lip and
palate deformities provides a common framework to
outline the extent of the cleft.8 This classification sys-
tem was subsequently modified by Millard and others
to address the extent of associated nasal deformities
(Figure 6–1).4,9
Cleft lip deformities are further divided into
microform (forme fruste), incomplete, and complete
cleft lip:
• Microform (forme fruste):  Defect is
predominantly limited to the lip, defined
by a notched vermilion. The orbicularis
oris muscle is partially intact. There is no
involvement of the nasal sill or alveolus.
• Incomplete:  More extensive defect in the
vertical lip but with an intact nasal sill
(Simonart band) and alveolus (primary
palate). Associated nasal deformity is
common secondary to the vertical lip
deficiency.
• Complete:  Defect of the lip that extends
into the nasal sill. The cleft involves the
lip, alveolus, and nose and often occurs in
association with a secondary cleft palate.
The cleft lip deformity entails the following ana-
tomic abnormalities of the lip, which are present to
varying degrees in each patient:
1. Partial or complete discontinuity of the orbicularis
oris muscle.
2. Inappropriate orientation and attachment of the
orbicularis oris muscle onto the nasal alar base.
3. Malrotation of Cupid’s bow and lip upward on the
cleft and noncleft sides.
4. Absent or incomplete philtral ridge on the cleft side.
5. Absent or lack of projection of vermilion tubercle.
6. Short lateral lip segment due to deficient and
retracted orbicularis oris muscle fibers.
In addition, it is associated with the following cleft
nasal deformities (Figure 6–2):
1. Short columella.
2. Depressed and flared nasal tip.
3. Depressed and downwardly displaced lower lat-
eral cartilage on the cleft side.
4. Stretched and thinned out lateral crus.
5. Septal deviation to the noncleft side.
6. Contracted or absent out-flaring of medial crural
footplate on cleft side.
7. Asymmetry in the relative position of the alar
bases, downwardly displaced on the cleft side,
especially in complete unilateral clefts.

59
Figure 6–1.  Millard’s modification to
Kernahan’s striped “Y” classification
(adapted from Millard, 1976). Accord-
ing to this classification, the extent of
the deformity is delineated by shading
of the respective boxes. The central
circle represents the incisive foramen.
For example, a right unilateral complete
cleft lip and palate may be represented
with shading of the right triangles and
boxes 1 to 4, 9 to 11. A left incomplete
cleft lip that does not involve the nasal
floor may be represented by shading of
box 6. In turn, a cleft palate involving
the soft palate only would be repre-
sented with shading of box 11.
Figure 6–2.  Associated cleft nasal
deformities: (1) Short columella,
(2) Depressed and flared nasal tip,
(3) Depressed and downwardly dis-
placed lower lateral cartilage on the
cleft side, (4) Stretched and thinned out
lateral crus, (5) Septal deviation to the
noncleft side, (6) Contracted or absent
out flaring of medial crural footplate on
cleft side, (7) Asymmetry in the relative
position of the alar bases, downwardly
displaced on the cleft side, especially in
complete unilateral clefts, (8) Asymmet-
ric nostril axes (cleft [C] and noncleft
[NC]), (9) Poor support of anterior soft
tissue angle on cleft side.

60
Video Atlas of Cleft Lip and Palate Surgery
8. Asymmetric nostril axes (cleft and noncleft).
9. Poor support of anterior soft tissue angle on cleft
side.
Goals of Repair
Despite the unique characteristics of each deformity, in
any cleft lip and/or nasal repair, whether primary or
secondary, there are 11 basic tenets that should be met
(Figure 6–3):
1. Symmetry of Cupid’s bow in relation to the lip,
with the two high points being equidistant from
the low point.
2. Symmetry of Cupid’s bow in relation to the nose,
with matching of the two high points in relation to
the nostril base.
3. Continuity of the orbicularis oris muscle: The
muscle fibers should flow smoothly throughout
the upper lip without any residual deficiency or
notching.
4. Symmetry of the philtral ridges and adequate full-
ness of the philtral tubercle.
5. Symmetry of the nasal domes.
6. Adequate nasal tip support and projection.
7. Symmetric out-flaring of the medial crural footplates.
8. Symmetric width and shape of the nostrils.
9. Nostril axes symmetry.
10. Anterior soft tissue angle symmetry.
11. Symmetry of the nasal base along the horizontal
plane.
Presurgical Orthopedic Care
Both passive and active presurgical orthopedic proto-
cols have been endorsed to optimize tissue alignment
and bone growth at time of repair. These procedures
can commence when the patient is a few weeks of
age. Passive methods include lip taping and intra-
oral appliances. Lip taping is a facile approach that
entails approximating the lip segments together when
more advanced treatment methods are not available.
Although passive intraoral palatal appliances do not
actively close the alveolar clefts, they do prevent the
tongue forces from further displacing the palatine
shelves.
More advanced methods, such as nasoalveolar
molding (NAM), entail placement of an appliance
that actively approximates the alveolar segments and
molds the nasal cartilage (see Chapter 4).10,11 Through
expansion, NAM can lengthen the columella that is
particularly deficient in unilateral clefts or often absent
in bilateral cleft lip deformities. Although NAM is not
currently available in all cleft centers worldwide, it is
recommended based on our improvement in outcomes
(nasal cartilage lengthening and approximation of the
alveolar segments) where trained craniofacial pediatric
dentists, orthodontists, and prosthodontists can pro-
vide such presurgical care.
Preoperative lip adhesion performed at 6 to 8
weeks of age to aid in tissue approximation at time of
definitive repair has fallen out of favor given inconclu-
sive evidence to support its benefit and the potential
for scarring and tissue misalignment.12 However, it is
sometimes used to aid in closure of wide clefts.
Timing of Repair
Although optimal timing of repair is controversial,
most surgeons perform unilateral lip repair at approxi-
mately age 10 to 12 weeks. The rule of 10’s (hemoglobin
10 g/dL, weight 10 lbs, and 10 weeks of age) coined by
Drs. Hans Wilhelmsen and Ross Musgrave is used as
a reference that considers the anesthetic complications
of general anesthesia in infants.13 In many parts of the
Figure 6–3.  Postoperative schematic outlining the goals of
repair that must be kept in mind throughout the procedure.

Repair of the Unilateral Cleft Lip Deformity
61
developing world, there are large numbers of adoles-
cents and adults with cleft deformities awaiting surgi-
cal repair. In these cases, the same surgical principles
outlined herein apply.
Surgical Equipment and Tools
• Measuring caliper
• Castroviejo fine tissue forceps
• Ribbon-handled suture scissors
• Strabismus scissors
• Skin hooks
• Bipolar cautery forceps (Jeweler’s fine tip)
and bipolar electrosurgical unit
Anesthesia
• Infants and young children require general
anesthesia through oral intubation.
• Patients over the age of 12 years, especially in
poor resource settings, can undergo cleft lip
repair under local anesthesia with or without
IV sedation after thorough patient and family
counseling.
• Regardless of age, local anesthesia is
important for both analgesic effects and
vasoconstrictive properties.
Local Anesthesia Technique
We use a mixture of short- and long-acting local anes-
thetics that ensures the analgesic effects are effective
both intraoperatively and up to 8 hours postopera-
tively. This combination significantly minimizes the
need for opioid-based or other systemic analgesics in
the recovery room and ensures a smooth early postop-
erative course with little pain and secondary tension on
the repaired muscle.14
Prior to local infiltration of the lip, facial nerve
blocks are performed by injecting the: (1) infraorbital
nerve, a terminal branch of the V2 maxillary nerve that
exits the infraorbital canal to provide sensation to the
lower eyelid, lateral aspect of the nose and upper lip,
and the (2) external nasal nerve, a branch of the V1
ophthalmic nerve that pierces the upper lateral carti-
lage to provide sensation to the nasal tip.15
The following landmarks and techniques are used
to achieve the blocks (Figure 6–4):
• Infraorbital nerve block:  The nerve is located
along a perpendicular line that goes through
the midpupil and lateral oral commissure
and is 0.5 to 0.75 cm below infraorbital rim. In
children, the infraorbital foramen is located
more medially. For injection, the surgeon
places his/her index finger over infraorbital
rim for eye protection. The needle is aimed
posterosuperiorly and 0.5 cm lateral to alar
rim, toward the infraorbital foramen. The
needle should not go through the foramen
to avoid injury to the nerve fibers with
secondary long-term paresthesia.
• External nasal nerve block:  Located at the
midpoint between the nasal dorsum and
the lateral nasal wall at the inferior tip of the
nasal bone. The needle penetrates the skin
perpendicularly; once the bevel is under
the skin, the surgeon uses the traction of the
needle to pull off the skin and gently inject the
anesthetic mixture. A bleb should form. This
maneuver prevents the needle from being
deep into the nasal cavity.
The dose of combination anesthetic is determined
by the patient’s weight, with the maximum allowable
dose calculated by the anesthesiologist and confirmed
by the surgeon. In children below the age of 12 years,
infraorbital (0.5 to 0.75 cc) and external nasal (0.25 to
0.5 cc) nerve blocks are performed with 1:1 ratio of bupi-
vacaine 0.25% in 1:200,000 epinephrine and lidocaine
0.5% in 1:200,000 epinephrine (1 cc/kg of mixture).
This half-strength mixture is prepared in 5 cc syringes,
and a green label with the mixture’s strength is placed
on each syringe. For patients above the age of 12 years,
the adult dosage of local anesthetic mixture is used,
comprised of 1:1 ratio of bupivacaine 0.5% in 1:200,000
epinephrine and lidocaine 1% in 1:100,000 epinephrine
(0.5 cc of anesthetic mixture/kg). The full-strength mix-
ture is prepared in a 10-cc syringe, with a red label on
the syringe indicating the full mixture strength. These
safety measures prevent the inadvertent mistakes that
might happen when using half- or full-strength bupi-
vacaine and lidocaine. For patients over 12 years of
age undergoing the procedure using local anesthesia
alone, infraorbital (0.5 to 1 cc) and external nasal (0.5
to 0.75 cc) nerve blocks are performed in the holding
area. No larger than a 25-gauge needle is used for nerve
blocks in adults to minimize discomfort.

62
Video Atlas of Cleft Lip and Palate Surgery
Surgical Procedure
Repair of Unilateral Complete Cleft Lip
(Video of Repair of Unilateral
Complete Cleft Lip Deformity)
1. A surgical timeout is performed following a stan-
dard patient safety checklist prior to administering
anesthesia. We use a surgical safety protocol modi-
fied from the World Health Organization (WHO)
surgical safety checklist (Figure 6–5).16,17
2. Anesthesia:  If the patient is under 12 years of age,
cleft lip repair is performed under general anes-
thesia via a preformed oral endotracheal (ET) tube.
The preformed ET tube curvature minimizes pos-
sible interference with access to the surgical site.
The ET tube is secured to the skin with fluid-resis-
tant tape. The tube should be taped at midline just
under the lower lip so that it does not affect the
shape or position of the upper and lower lips. Tape
is used to close the eyelids for protection.
3. Prophylactic intravenous antibiotics are administered.
4. A throat pack, tied to a silk suture and moistened
with saline, is placed. As a safety measure, the
nursing team and anesthesia team separately docu-
ment when the throat pack is inserted. At the end
of the case prior to extubation, the throat pack must
be removed, with verbal confirmation between the
surgeon, anesthesiologist, and nurse.
5. The patient is placed in supine position. The oper-
ating table is set in reverse Trendelenburg position.
A shoulder roll is placed to extend the neck and to
ensure that ET tube does not interfere with surgical
dissection of the upper lip. The head is supported
in a soft silicone gel head rest.
6. The connections of the ET tube are kept within
visualization of the surgical field to allow for moni-
toring and avoidance of accidental disconnection.
7. A second patient safety checklist pause is performed.
8. Markings:  Analysis of the cleft defect begins with
marking key landmarks with a fine marking pen as
illustrated (Figures 6–6 and 6–7).
A. Noncleft side:  Starting on the noncleft side,
the following markings are made:

i. The low point of Cupid’s bow is marked
first (1). It may sometimes be difficult
to visualize the low point; visualization
from the head of the patient aids in
highlighting the precise location of this
point.
Figure 6–4.  Nerve block injection locations.

Repair of the Unilateral Cleft Lip Deformity
63
ii. The high point on the noncleft side is
marked (2).
iii. The distance between the high point and
low point is measured with a caliper
and transposed medially. This point is
marked (3).
iv. The junction of the columellar-labial
angle is marked at the crease (4). The
Figure 6–5.  Surgical safety checklist (modified from the WHO surgical safety checklist).
Figure 6–6.  Surgical markings.
Figure 6–7.  Flap design.

64
Video Atlas of Cleft Lip and Palate Surgery
endpoint of this junction is where the
columella finishes and should not cross
the philtral ridge.
v. The alar base on the noncleft side is
marked (5).
vi. The rotation flap (R flap) is outlined by
connecting point 3 to the columellar base.
This line should simulate the curvature of
the philtral ridge as it slopes down from
the end of the columellar base to the high
point marked on the cleft side (3).
vii. The columellar base flap (C flap) is then
outlined, extending precisely at the
mucocutaneous junction. The C flap
should be wide enough to allow the
re-creation of the medial crural footplate
and its natural out-flaring.
viii. The medial mucosal flap (M flap) on the
noncleft side is then outlined, approxi-
mately 2 to 3 mm in width. This mucosal
flap is raised as a pedicle flap that will be
used to reconstruct the nasal floor.
B. On the cleft side, these markings are made:

i. The high point of Cupid’s bow is marked
(6). It corresponds to the end of the white
roll as a 3-dimensional structure on the
cleft side and where the dry vermilion
tapers off medial to this point. The
distance from this point (6) to the com-
missure is approximately equidistant to
the distance between the commissure and
point 2 on the noncleft side; however, this
comparison is not always reliable given
differences exerted by the underlying
muscle.
ii. The medial most point of the lateral cleft
segment is marked (7).
iii. The alar base on the cleft side is
marked (8).
iv. The advancement flap (A flap) is out-
lined. Note that the lateral extension of
the flap does not go beyond the level of
the inner surface of the ala once it has
been mobilized to its repaired position,
thereby avoiding a scarring incision at
the alar crease.
v. The corresponding lateral mucosal flap
(L flap) on the cleft side is outlined. This
flap is also raised as a pedicled flap to
recreate the nasal floor lining.
vi. The alar base flap is outlined, stopping
2 mm lateral to the posterior edge of the
lateral crural cartilage and falling right
along the upper edge of the vibrissae.
This line is usually parallel to the alar
rim and should be kept away from the
mucocutaneous junction to ensure the
preservation of the alar valve.18
9. Local anesthesia is infiltrated to achieve the infra-
orbital nerve block and external nasal nerve block,
as well as locally at the lip and nostril. The authors
recommend waiting for 12 minutes to allow the
vasoconstrictive effects of epinephrine to set in.
We have observed that this method significantly
minimizes intraoperative bleeding.
10. The face is prepped with colorless antiseptic solu-
tion followed by application of sterile drapes.
Lip Dissection, Noncleft Side
11. Beginning on the noncleft side, the incisions along
the R flap and C flap are made using a #15 blade
knife going through the skin into the subcutane-
ous layer to ensure adequate flap thickness. The
pedicled M flap is then raised, starting from the
base of the pedicle toward the tip in order to avoid
stretching of the tissue (Figure 6–8).
12. With a double-prong retractor placed in the nostrils
and a double hook and converse retractor placed
at the noncleft side to provide tension, a #15 blade
knife is used to make an incision at the gingivobuc-
cal sulcus. The incision is extended approximately
3 cm in length and can be extended further if addi-
tional medial mobilization of the flap is needed.
The periosteum is preserved. The surgeon should
Figure 6–8.  Raising the mucosal M flap.

Repair of the Unilateral Cleft Lip Deformity
65
always keep a spatial orientation of the location of
the infraorbital nerve and avoid any dissection in
that area (Figure 6–9).
13. Using curved strabismus-type scissors, the orbicu-
laris oris muscle is separated from the overlying
skin (Figure 6–10). The surgeon’s finger is main-
tained at the outside of the lip, palpating the skin
to avoid accidental buttonholing. The muscle is
separated from the alar base on the noncleft side
in a gradual and downward fashion toward the
vermilion border, stopping 1 mm above the high
point on the noncleft side (point 3). Avoid carrying
the dissection into the buccal fat pad by limiting
the upper level of dissection to the upper level of
the orbicularis oris muscle fibers. Also, avoid carry-
ing the dissection into the noncleft philtral ridge as
this will eliminate this aesthetic anatomic lip struc-
ture and is not necessary for additional lip rotation.
The surgeon should keep the shape of the philtral
dimple in mind as dissection is being carried out
(Figure 6–11).
14. Holding the noncleft lip in hand, the mucosa is
separated from the underlying muscle at the edge,
1 mm circumferentially around the muscle (Fig-
ure 6–12). The mucosa should not be extensively
stripped from the muscle, as this is unnecessary
Figure 6–9.  Gingivobuccal incision for flap mobilization.
Figure 6–10.  Orbicularis oris dissection.
Figure 6–11.  Incisions and flap design delineating the extent of undermining.

66
Video Atlas of Cleft Lip and Palate Surgery
and can lead to an irregular contour and hematoma
formation.
15. Rather than using back cuts at the junction of the
columellar base with the noncleft philtral ridge,
further rotation of the R flap is achieved by using
sharp scissors to release the subcutaneous tissue at
the junction of the philtral ridge and the columella,
making sure not to penetrate the skin.
Rhinoplasty, Flap Elevation
16. At this point, attention can be turned to the rhi-
noplasty (Figure 6–13). Sharp scissors are inserted
between the columellar skin and the inferior base
of the transverse crural cartilages. A higher level
of entry can damage the crural attachments to the
caudal end of the septum. Thereafter, curved stra-
bismus-type scissors are used to avoid skin punc-
ture. Using scissors to cut (rather than spread), the
overlying nasal skin is raised from the underlying
lower lateral cartilage on the cleft side, with the
goal of allowing medial mobilization of the lateral
crus on the cleft side. The limits of flap elevation
are the scroll (junction of the upper and lower car-
tilage) superiorly, the alar crease laterally, the dome
of the noncleft side medially, and the lower border
of the lateral crus inferiorly.
Lip Dissection, Cleft Side
17. Skin incisions on the cleft side are made with a
#15 blade scalpel. The advancement flap (A flap)
is kept thick by ensuring that the incision goes into
the subcutaneous layer and then separated from
underlying muscle with sharp ribbon handle scis-
sors. Flap thickness is essential when the transverse
suture is then placed to advance the advancement
(A) over the rotational (R) flaps.
18. The lateral mucosal flap (L flap) is then elevated.
A gingivobuccal incision is made and the orbicu-
laris oris muscle is dissected in the same manner as
on the noncleft side, ensuring that the attachments
to the alar base are separated. Muscle dissection
from overlying skin is done in a downward and
graduated manner and stops at level of vermilion
border. Dissection is carried out with cutting tech-
niques. Avoid extensive undermining of the lip,
which can disrupt anatomic landmarks and result
in postoperative lip edema.
19. The alar rim is then retracted with a wide double
hook. An incision is made at the upper edge of the
vibrissae approximately 2 mm posterior to the pos-
terior border of the lower lateral cartilage, parallel-
ing the alar rim (Figure 6–14).
20. Blunt scissors are used to release the attachments
at the alar base (Figure 6–15). The integrity of the
alar valve is maintained by avoiding extension of
the incision into the mucosa.
21. The extent of dissection is assessed by evaluating
the degree of mobility of the alar base toward the
midline (Figure 6–16). The goal is to have the ala
move into the midline with the least possible ten-
sion that might contribute to postoperative lateral-
ization of the alar base, asymmetric nostrils, and an
inadequate outcome.
Figure 6–12.  Mucosal-muscle dissection.
Figure 6–13.  Rhinoplasty flap elevation.

Repair of the Unilateral Cleft Lip Deformity
67
Closure:  Hamdan Sliding V-Cheiloplasty Technique and
the Alar Base Suspending Suture (ABFSS)
22. Closure begins with securing the mucosal flap
across the alveolar defect (Figure 6–17). M and L
flaps are crisscrossed with tips gently trimmed to
create triangular edges and sutured to the oppo-
site periosteum with 5-0 Vicryl™ on an RB-1 nee-
dle. Typically, the L flap is placed inferior to the M
flap and anchored to the periosteum on the cleft
side away from nasal valve area to avoid potential
stenosis and long-term nasal obstruction. Another
suture is applied at the midpoint of the two flaps.
These flaps will create an anterior nasal floor in
complete cleft lip repair and prevent a bucconasal
fistula from occurring in incomplete cleft lip repair.
23. The buccal mucosal flaps are then approximated
using 5-0 Vicryl™ on an RB-1 needle. Make sure
that the flaps are equidistant by comparing the
distances of both sides from the wet-dry vermilion
junction. A triangular suture is applied between
the buccal mucosal flaps and the distal edge of
the L flap to ensure adequate closure in the sulcus
area and prevent bucconasal fistulae in incomplete
clip lip repair. Only 2 to 3 buccal mucosal sutures
are applied to allow further mucosal trimming at
the end of the procedure, where needed, to avoid
notching at the repair site.
Figure 6–14.  Alar incision is made at the upper edge of the
vibrissae.
Figure 6–15.  Release of attachments at the alar base.
Figure 6–16.  Mobilization of the alar base.

Figure 6–17.  Closure of M and L flaps for reconstruction of
the nasal floor.

68
Video Atlas of Cleft Lip and Palate Surgery
24. A sliding V-cheiloplasty technique has been devel-
oped by the senior author as an optimal method
for cleft lip closure (Figures 6–18 and 6–19). This
V-shaped closure technique lengthens the upper
lip, thus releasing much of the pressure at the sur-
gical margin. It also mobilizes the ala on the cleft
side medially with significant relief of pressure
from the vectors of healing that tend to lateralize
the ala postoperatively.
Hamdan Sliding V-Cheiloplasty (Figures 6–18 and 6–19):
A. The technique refers to the relative placement
of the sutures during approximation of the
rotation (R) and advancement (A) flaps. As
one ascends superiorly in the lip, the suture is
placed farther apart, thus creating the “V.”

i. The first suture is placed in the vermilion
component of the orbicularis oris muscle
(Vicryl™ suture on RB-1 needle), making
sure that both entry and exit level of the
needle are under the vermilion border
Figure 6–18.  Hamdan sliding V-cheiloplasty. Muscle sutures
are placed starting inferiorly and ascending superiorly with
each suture placed more lateral to the previous suture in order
to achieve lip lengthening.
Figure 6–19.  Each suture symmetrically aligns and unites the muscle fibers to achieve continuity.

Repair of the Unilateral Cleft Lip Deformity
69
to ensure proper muscle and vermilion
border alignment (Figure 6–20).
ii. In the pediatric age group, 5-0 or 4-0
Vicryl™ suture on RB-1 needle is used,
depending on the age of the infant or child.
iii. In older patients, 4-0 or 3-0 Vicryl™
suture on RB-1 needle is used.
iv. The second suture is placed 1 to 2 mm
above the vermilion border and 3 to
5 mm lateral to the edge of the orbicularis
muscle, making sure that the entry and
exit levels are equidistant on both sides.
v. The third suture is placed in a V-shaped
manner 2 mm above the second suture
and 5 to 7 mm lateral to the muscle edge
(Figure 6–21).
vi. The fourth suture is the uppermost
suture and is placed at the junction of the
orbicularis oris muscle and the nostril
floor. It is placed 7 to 10 mm lateral to the
muscle edge.
25. The C flap is rotated into place at the base of colu-
mella, making sure that the lateral part of the flap
is left wide enough to mimic the fullness and out-
flaring of the medial crural foot plate on the non-
cleft side.
Placement of the Alar Base Flap and Suspending Suture
(ABFSS) (Figure 6–22)18
26. The alar base suture (4-0 Vicryl™ suture on RB-1
needle) is placed in an inferior-cephalad direc-
tion and sutured in an inverted fashion directly
under the most distal point of the out-flaring of the
medial crural foot plate on the noncleft side. The
double knot tie is applied, and the suture is held by
small mosquito forceps (Figure 6–23).
Rhinoplasty, Continued
27. Two interdomal sutures are placed at the lower and
upper edge of the dome using 4-0 or 5-0 Monocryl™
on PS-2 needle (in the pediatric and adult age group)
to provide tip elevation and support (Figure 6–24).
Figure 6–21.  Third suture is placed in a V-shaped manner.
Figure 6–22.  Alar base flap suspension suture (ABFSS) medi-
alizes the displaced ala on the cleft side.
Figure 6–20.  First suture is placed in the vermilion component
of the orbicularis oris muscle.

70
Video Atlas of Cleft Lip and Palate Surgery
The suture is passed, starting from the noncleft
dome, through the cleft-sided dome, and back to
the noncleft side where the suture is tied. Starting
on the noncleft side allows the vector pull of the
cleft-sided dome toward the normal position of the
noncleft-sided dome. The second suture is placed 1
to 2 mm above the first interdomal suture for better
tip support (Figure 6–25).
28. A 4-0 or 5-0 Monocryl™ on PS-2 transfixion suture
is then applied at the level of the transverse
crura to prevent their posterior displacement
postoperatively.
29. A 5-0 or 4-0 Vicryl™ transverse suture is placed 2
to 3 mm behind the tip of the advancement flap.
This is followed by applying an inverted suture at
the recipient site, usually just medial to where the
ABFSS was placed.
30. A triangular suture is then placed at the base of the
nostril sill to approximate the medial edge of the
alar base flap, the base of the medial crural foot
plate, and the opposing upper edge of the advance-
ment flap.
31. Alar base transfixion suture(s) using 6-0 Monocryl™
are then placed in the alar crease to minimize
potential space for hematoma formation in the dis-
sected alar base flap area and to preserve normal
alar thickness. Make sure that the suture is not tied
too tightly to avoid long-term dimpling in that area
(Figures 6–26 and 6–27).
32. To address anterior soft tissue angle tissue redun-
dancy, 1 to 2 suspending suture(s) are applied
between the anterior soft tissue angle and the
upper lateral cartilage (same side or opposing
Figure 6–23.  Closure using alar base flap suspending suture
(ABFSS).
Figure 6–24.  Location of interdomal and transfixion sutures.
Figure 6–25.  Second suture is placed 1 to 2 mm above the
first interdomal suture for better tip support.
side) depending on angle and degree of suspen-
sion needed (Figure 6–28). This suture is crucial
in reducing the soft tissue redundancy at the level
of the anterior soft tissue angle and eliminates
the need for skin resection. 5-0 Monocryl™ suture
on PS-2 needle is used in children, and 4-0 or 5-0
Monocryl™ suture on a straight Keith needle is
used in the adult patients. The sutures are placed
2 to 3 mm behind the rim of the anterior soft angle
passing through the skin and reenter through the
same hole, thereby suspending the soft tissue to

Repair of the Unilateral Cleft Lip Deformity
71
the upper lateral cartilage. The trajectory of the
needle is in an ipsilateral or contralateral direction
depending on needed elevation.
33. Final tightening of the ABFSS is then performed to
ensure maximum nostril symmetry (Figure 6–29).
Beware of nostril narrowing as the second knot is
Figure 6–27.  Alar crease transfixion suture (side and frontal
views).
Figure 6–28.  Suspending suture between the anterior soft tissue and ipsilateral
or contralateral upper lateral cartilage.
Figure 6–26.  Alar crease transfixion suture (basal view).

72
Video Atlas of Cleft Lip and Palate Surgery
placed, a common mistake when this technique is
first utilized, especially when using monofilament
sutures. Nostril narrowing alters nostril sill sym-
metry and is very difficult to repair at an older age,
sometimes requiring composite grafts.
34. Vermilion flap rotation is created to ensure sym-
metric heights of the high points of Cupid’s bow
and avoid any notching at that level (Figures 6–30
and 6–31):
A. A 1-mm V-shaped vermilion flap is raised on
the lateral aspect of the high point on the cleft
side (point 6) using curved ribbon handle
suture scissors. Subcutaneous dissection
ensures that the flap is free to rotate inferiorly.
B. An opposing 0.5 to 0.75-mm cut is then made
at the mid-portion of the vermilion border at
the junction of white and red skin to allow
insetting of V-shaped vermilion flap. Subcuta-
neous dissection is also crucial here to ensure
that recipient site is free and allows the high
point on the cleft side to rotate to the same
horizontal level of the opposing high point of
Cupid’s bow.
35. Multiple sutures are applied to the remaining por-
tions of the vermilion component of the orbicularis
oris muscle to ensure proper alignment of the tubu-
lar shaped muscle fibers. 5-0 Vicryl™ or 5-0 or 6-0
Monocryl™ are used for these final muscle sutures
(Figure 6–32).
A. Proper muscle alignment is a crux of cleft
repair and ensures that the framework of
the lip is well placed. When attention is not
directed toward proper muscle alignment, the
result is muscle deficiency, which is commonly
Figure 6–30.  Vermilion flap. Step 1: Incisions are made along the vermilion border
as illustrated. Step 2: The flap from the cleft side is repositioned into the V created on
the cleft side at the vermilion border.
Figure 6–29.  Tightening of alar base flap.

Repair of the Unilateral Cleft Lip Deformity
73
labeled as a whistle deformity. These muscle
deficiencies cannot be corrected by dermal
grafts or Z-plasties. These techniques do not
restore muscle continuity and usually contract
postoperatively (Figure 6–33).
36. The buccal mucosa can be trimmed to ensure that
the resultant closure does not produce any tissue
invagination at the repair site. Closure is done with
5-0 Vicryl™ suture on an RB-1 needle.
37. Subcutaneous layer can be closed with inverted 6-0
or 5-0 Monocryl™ or Vicryl™ sutures (Figure 6–34).
The epidermis is closed with running 5-0 or 6-0
fast-absorbing plain gut™ suture on a PC-1 needle.
38. Dermabond™ is finally applied over the skin por-
tion of the cleft lip repair.
39. The lip and nose are analyzed throughout the sur-
gical procedure, keeping in mind symmetry out-
lined in the goals of repair (Figure 6–35).
40. Upon completion of surgery, the throat pack is
removed, the surgical counts confirmed, and the
patient is turned over to the anesthesia team for
extubation.
Figure 6–33.  Final interdigitating muscle sutures placed in the vermilion component
of the orbicularis oris muscle.
Figure 6–31.  Vermilion border flap.
Figure 6–32.  Closure of orbicularis oris muscle.

74
Video Atlas of Cleft Lip and Palate Surgery
Analysis of postoperative outcomes is essential for
assessing the success of repair and adjustment as neces-
sary. Illustrative outcomes of unilateral cleft lip repair
are highlighted in Figures 6–35 and 6–36.
A
B
Figure 6–35.  (A) Pre- and (B) Postoperative photos following repair of unilateral complete cleft lip.
Figure 6–34.  Closure of epidermis.
Repair of Unilateral Incomplete Cleft Lip
(Video of Repair of Unilateral
Incomplete Cleft Lip Deformity)
The unilateral incomplete cleft lip deformity is repaired
using the same surgical techniques described herein
for the complete cleft lip, but with the following
modifications:
Lip Repair
The markings and flaps are outlined as in the case of a
complete cleft lip repair.
• Mucosal flaps:  As an incomplete cleft lip
by definition has an intact nasal floor, the
mucosal L and M flaps are not required.
• Rotation and advancement flaps:  Rotation
flap is outlined in same manner as in the
complete cleft lip. This is necessary to provide
adequate rotation on the noncleft side to

Repair of the Unilateral Cleft Lip Deformity
75
achieve height symmetry. Advancement flap
incision is also outlined in same manner as
in the complete cleft. The abundance of skin
on the advancement flap provides easier
tension-free skin repair.
• Buccal mucosal flaps should be released
through incisions in gingivobuccal sulcus to
allow closure without secondary notching.
• Sliding V-cheiloplasty technique is used for
muscle repair after separating the orbicularis
oris muscle from the alar bases bilaterally.
• Adequate rotation of Cupid’s bow could
be challenging in incomplete cleft lips.
The vermilion flap is usually very useful
in achieving the desired horizontal height
symmetry of both high points.
Rhinoplasty
Dissection and realignment of lower lateral cartilage,
nasal tip, and alar base are important in achieving optimal
results in both complete and incomplete cleft lip repair.
• Nasal tip:  Dissection of lower lateral cartilage
is done in the same manner as the complete
repair through the columella with ribbon
handle and strabismus-type scissors to allow
medial mobilization of the lower lateral
cartilage. Double interdomal and transverse
crural sutures are applied in the same manner
as in complete cleft lip repair.
• Alar base:  Vestibular incisions are most
often not necessary in incomplete cleft lips.
However, there is often malposition of the alar
base that is addressed through dissection of
the alar base from the underlying maxilla to
free up all attachments that interfere with free
medial mobilization of the ala. ABFSS is then
applied to anchor the cleft side ala into a more
medial position to achieve nostril symmetry.
• Nasal sill:  Incisions extending into the nasal
floor may not be necessary. However, often
the nasal floor of the cleft side is wide compared
to the noncleft side secondary to the widening
forces of muscles and the cleft. In this case, a
A
B
Figure 6–36.  (A) Pre- and (B) Postoperative photos following repair of unilateral complete cleft lip.

76
Video Atlas of Cleft Lip and Palate Surgery
small skin wedge can be removed from the
floor of the nostril sill, keeping in mind not to
overresect, as this will result in a small nostril
that is challenging to correct later on.
Cleft Lip Repair Under Local Anesthesia
Worldwide, we have encountered many adults with
unrepaired cleft lips. To address the limitations in sur-
gical and anesthesia facilities, we have demonstrated
that local anesthesia alone via blocks and at the lip are
able to provide anesthesia to carry out lip repair in the
awake, adult patient.14 We follow similar surgical steps
as detailed previously in cleft lip repair under general
anesthesia. The difference lies in preparing the patient
for the procedure:
1. The patient and family are thoroughly counseled pre-
operatively about the procedure, expectations, and
course of surgery. Written consent is then obtained.
2. 5 mg of diazepam can be given to the patient 1 hour
preoperatively if the patient is mildly anxious.
3. A heparin-lock IV is inserted upon admission to
the holding area in case IV access is needed for
emergency intervention or to provide monitored
anesthesia care via IV sedation if the surgical pro-
cedure is taking longer than expected or the patient
is uncomfortable.
4. Room temperature is adjusted to suit the patient’s
comfort.
5. Patient safety check list is performed as previously
described.
6. Infraorbital and external nasal nerve blocks are
administered with a 30-gauge needle as detailed in
the local anesthesia section (Figure 6–37).
7. The patient is positioned in reverse Trendelenburg
with a comfortable head rest.
8. No shoulder roll is needed because patient is awake
and can hyperextend the neck when needed.
9. Surgical markings are carried out.
10. Infiltration of local anesthetic mixture is performed
using 25-gauge needle. By this time, 15 minutes
would have lapsed between nerve blocks and lip
infiltration allowing adequate time for the nerve
block to be in effect.
A
B
Figure 6–37.  Local anesthesia injection in an adult patient. (A) Infraorbital and (B) External nasal nerve blocks.

Repair of the Unilateral Cleft Lip Deformity
77
11. Surgery is started 12 minutes after lip infiltration of
the local anesthetic.
Figure 6–38 exemplifies the surgical procedure
and key steps in repair of a unilateral cleft lip in the
adult awake patient. We are able to achieve successful
repair of cleft lip deformities, even when performed in
the grown adult patient, giving promise to many indi-
viduals who lacked the opportunity for such repair
during infancy (Figure 6–39).
Figure 6–38.  Surgical steps in the repair of a unilateral incomplete cleft lip under local anesthesia.  continues

78
Figure 6–38.  continued
A
B
Figure 6–39.  Repair of unilateral cleft lip in adult patient: (A) preoperative and (B) postoperative view.

Repair of the Unilateral Cleft Lip Deformity
79
Postoperative Considerations
• Lip care:  All lip sutures are absorbable. When
anchoring sutures using 6-0 Monocryl™
are used (at the vermilion border, at tip of
the C flap, and the quadrangular nasal sill
sutures), they can be removed at 7 to 10 days
postoperatively. Topical antibiotic ointment
is applied at the nasal sill with a Q-tip for
the first 10 days only in cases of significant
crusting along the incision. Avoid using
topical antibiotic over Dermabond™, which
might cause its early resorption.
• Feeding:  We recommend the use of a soft
catheter-tip syringe or a teaspoon for feeding
during the initial 7 to 10 days. Thereafter,
breast or bottle feeding can be resumed.
• Activities:  For the first 10 days, we routinely
use elbow immobilizers in children. They
must be removed several times per day when
the infant is under supervision to minimize
the risk of trauma to the lip. Pacifiers are not
encouraged for the first 10 days.
Complications
• Unsatisfactory outcomes may result from
improper technique, most commonly:
(1) inadequate muscle dissection for rotation
and lip lengthening resulting in vermilion
notching, (2) insufficient dissection and
freeing of the alar base, resulting in a
laterally displaced ala and nostril asymmetry,
(3) inadequate rhinoplasty with a redundant
anterior soft tissue angle, and (4) an
insufficient rotation of the (R) flap resulting
in a shortened lip.
• Dehiscence is a rare complication that
may result from inadvertent injury to the
lip postoperatively. Dehiscence is more
commonly seen with surgeons inexperienced
in cleft lip surgery and the necessity for
layered closure. Revision should not be
performed for at least 6 months, and
preferably 1 year, to allow for adequate tissue
healing.
• Excess scar formation and secondary notching
can result from closure under tension or
superimposed infection.
• Hematoma formation is rare given the limited
dissection of the skin from the underlying
orbicularis oris muscle.
Pearls and Pitfalls
Cleft care requires a multidisciplinary approach with
the need for pre- and postoperative orthopedic care,
speech pathology intervention, psychosocial support,
nutritional education, genetic counseling, and often
palatal surgery repair when indicated. The following
pearls and pitfalls should be heeded:
• Preoperative pediatric and anesthesia
evaluation to ensure optimal patient health,
age, and nutritional status for surgery.
• Infraorbital and external nasal nerve blocks
significantly reduce postoperative pain.
In adult patients, these are useful tools to
perform cleft lip repair or revision solely
using local anesthesia.
• Adequate hemostasis is essential for clear
surgery. To this end, the authors recommend a
firm 12-minute wait following local anesthetic
injection. This method achieves good
hemostasis and avoids the use of cautery.
• Avoid using monopolar cautery and use
bipolar cautery very judiciously to avoid
tissue trauma and scarring.
• Handle the soft tissue gently, with the least
usage of forceps to avoid tissue trauma.
Retract gently, especially in areas where
dissection involves superficial layers of
subcutaneous tissue. Use suction minimally
(blotting with cotton tip is preferable).
• Do not extend the incision into the alar crease.
The lateral most extent of the skin incision
for the upper edge of the advancement flap
is along the nostril floor. This incision should
not extend beyond a perpendicular line
drawn through the inner fold of alar lobule to
avoid alar base scarring that becomes more
prominent with facial growth.
• The C flap should be kept wide enough to
simulate the out-flaring of the medial crural
cartilage footplate.
• Back cuts can be used to aid in the rotation
of the R flap, and can be adjusted to increase
rotation. However, it should not extend
beyond the philtral ridge.

80
Video Atlas of Cleft Lip and Palate Surgery
• Rhinoplasty should be performed at time of
initial lip repair, with repositioning of the
collapsed lower lateral cartilage to aid in nasal
symmetry.
• Combination techniques for cleft rhinoplasty
as described in this chapter restore normal
nasal anatomy while avoiding cartilage
resection, delivery techniques, or concentric
intranasal incisions that would risk stenosis
and require long-term use of postoperative
nasal plugs. No nasal plugs are used
postoperatively.
• Always maintain integrity of the alar valve to
avoid long-term nasal obstruction.
• Aim at matching nostril symmetry and avoid
narrowing the cleft nostril.
• Sliding V-cheiloplasty allows adequate lip
lengthening and provides alar base support
with minimal skin incisions.
• Alignment of the orbicularis oris muscle is
necessary to create an intact oral sphincter.
Supraperiosteal dissection along the cleft
and noncleft sides is important to release
the abnormal muscle attachments to the
alar bases and skin and to allow adequate
mobilization of the lip.
• Dissection of the muscle from the
overlying lip should be limited to the areas
described previously. Extensive dissection
is unnecessary, predisposes to hematoma
formation, and risks loss of contour at the
philtral ridge.
• The V-shaped vermilion flap at the vermilion
border helps optimize the positioning of the
vermilion.
• Use of absorbable sutures eliminates the need
for suture removal.
References
1. Bhattacharya S, Khanna V, Kohli R. Cleft lip: The histori-
cal perspective. Indian J Plast Surg. 2009;42(suppl):S4–S8.
2. Le Mesurier AB. A method of cutting and suturing the lip
in the treatment of complete unilateral clefts. Plast Recon-
str Surg. 1949;4:1–12.
3. Tennison CW. The repair of unilateral cleft lip by the sten-
cil method. Plast Reconstr Surg. 2952;9:115.
4. Millard DR Jr. Cleft craft. Vols 1, 2, 3. Boston, MA: Little
Brown & Company; 1976.
5. Sitzman TJ, Girotto JA, Marcus JR. Current surgical prac-
tices in cleft care: unilateral cleft lip repair. Plast Reconstr
Surg. 2008;121(5):261e–270e.
6. Shprintzen R, Siegel-Sadewitz VL, Amato J, Goldberg
RB, Opitz JM, Reynolds JF. Anomalies associated with
cleft lip, cleft palate, or both. Am J Med Genet. 2985;20(4):​
585–595
7. Milerad J, Larson O, Hagberg C, Ideberg M. Associated
malformations in infants with cleft lip and palate: a pro-
spective, population-based study. Pediatrics. 2997;100(2 pt
1):180–186.
8. Kernahan DA. The striped Y — a new classification for
cleft lip and palate. Plast Reconstr Surg. 2971;47:469–470.
9. Elsahy NI. The modified striped Y — a systematic clas-
sification for cleft lip and palate. Cleft Palate J. 2973;10:​
247–250.
10. Grayson BH, Cutting CB. Presurgical nasoalveolar ortho-
pedic molding in primary correction of the nose, lip, and
alveolus of infants born with unilateral and bilateral
clefts. Cleft Palate Craniofac J. 2001;38(3):193–198.
11. Da Silveira AC, Oliveira N, Gonzalez S. Modified nasal
alveolar molding appliance for management of cleft lip
defect. J Craniofac Surg. 2003;14(5):700–703.
12. Salyer KE, Genecov ER, Genecov DG. Unilateral cleft lip-
nose repair — long-term outcome. Clin Plast Surg. 2004;​
31(2):191–208 .
13. Wilhelmsen HR, Musgrave RH. Complications of cleft lip
surgery. Cleft Palate J. 2966;3:223–231.
14. Eberlin KR, Vyas RM, Abi-Haidar Y, Sethna N, Hamdan
U. Adult cleft lip repair under local anesthesia: an effec-
tive technique in resource-poor settings. Cleft Palate Cra-
niofac J. 2013;50(1):59–63.
15. Salloum ML, Eberlin KR, Sethna N, Hamdan US. Com-
bined use of infraorbital and external nasal nerve blocks
for effective perioperative pain control during and after
cleft lip repair. Cleft Palate Craniofac J. 2009;46(6):629–635.
16. WHO surgical safety checklist; Safe Surgery Saves Lives.
Retrieved from:
surgery/en/index.html .
17. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat
AH, Dellinger EP. A surgical safety checklist to reduce
morbidity and mortality in a global population. N Engl J
Med. 2009; 360:491–499.
18. Numa W, Eberlin K, Hamdan US. Alar base flap and
suspending suture: a strategy to restore symmetry to the
nasal alar contour in primary cleft-lip rhinoplasty. Laryn-
goscope. 2006;116(12):1271–1277.

81
Chapter 7
Repair of the Bilateral Cleft Lip Deformity
Dunia Abdul-Aziz and Usama S. Hamdan
Abstract
Bilateral cleft lip with associated nasal deformity presents the
surgeon with the challenge of establishing normal form and
function in the setting of a protruding premaxillary segment,
prolabium that lacks muscle and normal attachment, discon-
tinuity of the orbicularis oris, splayed out alar bases, concave
and widened lower lateral cartilages across the cleft, and a
shortened columella. A surgeon performing bilateral cleft lip
repair must stay abreast with the most up-to-date techniques
and maintain a critical perspective regarding both short- and
long-term outcomes of his/her repair to adjust the technique
accordingly. A surgeon without experience or understanding
of the principles of bilateral cleft lip repair should not attempt
primary correction, as an inadequate initial repair will be
difficult to revise and will permanently impact the patient’s
outcome. The techniques for repair continue to be modified.
Historically, repair has evolved from multistage repair of the
prolabium and lip elements to combined single-stage repair
of the lip and nose. Along with this evolution in technique,
presurgical orthopedic care that brings together the alveo-
lar processes, retropositions the protuberant premaxilla, and
lengthens the columella has gained importance in optimiz-
ing the bony and cartilaginous framework of the lip–nasal
unit. We provide a step-by-step description of combined
repair of the bilateral cleft lip and nasal deformity. Emphasis
is placed on achieving symmetry, establishing a competent
oral sphincter, preserving a white roll at the central Cupid’s
bow, and realigning the nasal cartilages. The surgeon’s expe-
rience, attention to detail, and willingness to retrospectively
and critically inspect outcomes are crucial factors for satis-
factory results. This chapter offers perspective on the evo-
lution of the surgical procedure across surgeons and time
and details the senior author’s technical nuances, pearls, and
pitfalls gained from years devoted to critically refining this
procedure.
The role of the cleft surgeon is to restore anatomic form
and function, which in cases of cleft lip deformities
entails the establishment of a competent oral sphincter,
a symmetric Cupid’s bow with vermilion border, and
a refined nose. In cases of bilateral cleft lip, challenges
of initial repair involve a protruding premaxilla sur-
rounded by collapsed lateral alveolar shelves, a defi-
cient columella, absent prolabial muscle, stretched alae
flared across the cleft, and a shortened lip length.
Various procedures to address these challenges in
bilateral cleft lip repair have evolved from initial tech-
niques that discarded the protruding premaxilla and
consequently yielded an unsatisfactory retracted mid-
face. Other surgical procedures to address the protrud-
ing premaxilla involved fracture or partial resection of
the vomer or premaxilla; these procedures similarly
compromised midfacial growth. Subsequent attempts
at premaxillary preservation focused on soft tissue
alignment, at times requiring a multistage procedure
to enable closure.1 Over time, procedures have been
proposed that vary in the extent of prolabium dissec-
tion, soft tissue origin of the central vermilion, mus-
cular continuity, methods for columellar lengthening,
and nasal reconstruction. Initial procedures included
direct approximation of the lateral lip elements with
the premaxillary segment2; yet, these failed to address
the deficiency in nasal cartilage and columellar length.
Other approaches proposed are to align the lateral lip
elements and to use the excess prolabial soft tissue
(“forked flaps”) to lengthen the columella.3 However,
the results were unsatisfactory as the reconstructed col-
umella lacked cartilage support for the additional soft
tissue. Approaches to repair also differed in whether
to achieve orbicularis oris muscular continuity. The
Veau III technique for straight-line closure proposed
direct approximation of the lateral lip elements with
the prolabial skin without restoring muscle continuity.

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Video Atlas of Cleft Lip and Palate Surgery
The columellar deficiency in these cases could be
addressed in a second stage nasal repair in which the
columella was lengthened from the stretched out pro-
labium using a V–Y technique. Millard’s repair entailed
elevation of the prolabium and creation of muscle con-
tinuity.4 Millard’s technique also sought to address the
columellar deficiency using banked forked flaps made
up of lateral segments of the prolabium that were used
in later nasal repair and lengthening of the columella.
Although initial efforts focused on the lip recon-
struction alone with delayed reconstruction of the
nasal cartilage framework, simultaneous repair of the
lip and nose has become one of the principles of bilat-
eral cleft repair. This evolution in technique toward
incorporation of the premaxilla and prolabium during
a combined repair of the lip and nose was based on
the realization of the distorted growth of the uncor-
rected nose in the long term and the challenge of its
repair.5 The importance of correcting the nasal cartilagi-
nous structure at time of initial repair has gained favor
over soft tissue-only approaches. Harold McComb, a
pioneer of primary nasal reconstruction, proposed a
gullwing incision at the alar rim to access and realign
the soft tissue draping the lower lateral cartilages. He
also refined the nasal tip by bringing the medial aspect
of the cartilage together via interdomal and mattress
sutures.6 He proposed a two-stage repair: The first stage
involved nasal floor repair, nasal cartilage reconstruc-
tion, and lip adhesion, and the second stage entailed
formal lip repair.7 John B. Mulliken has modified his
initial bilateral repair approach, doing away with
forked flap-based reconstruction of the columella and
achieving columellar lengthening by bringing together
the splayed lower lateral cartilages at the genu.8 Mul-
liken’s repair involves maintaining a central flap on
the prolabium to recreate the philtrum; orbicularis oris
muscle fibers are brought in laterally to achieve muscle
continuity beneath the flap. Bilateral alar rim incisions
are used to elevate the soft tissue overlying the lower
lateral cartilages, and tip definition as well as columel-
lar lengthening is achieved by suturing the lower lat-
eral cartilages at the genu and by placing suspension
sutures from each dome to the ipsilateral scroll. The
wide nostrils are corrected by alar base incisions to
allow medial mobilization of the alae.8
The evolution of bilateral cleft lip repair has been
significantly advanced by the use of preoperative
orthodontic care, in particular nasoalveolar molding
(NAM), which repositions and lengthens the nasal
cartilage and aligns the maxillary and alveolar seg-
ments.9,10 We detail a procedure for repair of the bilat-
eral cleft lip and nasal deformity that combines the
previously mentioned historical principles with the
technical nuances gained by the senior author. Empha-
sis is placed on repair of the cleft defect and rhinoplasty
in a single-stage procedure.
Surgical Indications
• Patients with bilateral cleft lip deformity, with
or without cleft palate.
Surgical Contraindications
• Medically unstable patient: Inability to
tolerate general anesthesia (in the case of
infants and children), malnutrition, anemia,
and/or current infections.
• Genetic and other associated abnormalities:
Cleft lip deformity is associated with other
congenital abnormalities, which must be
anticipated in evaluation of each patient.
• Preoperative workup by a pediatrician or
pediatric anesthesiologist includes a physical
examination to assess general health condition
and to screen for possible cardiac, neurologic,
and other congenital abnormalities.
Classification
Preoperative investigation of a patient with a bilat-
eral cleft lip entails analysis of the extent of the cleft
deformity and degree of involvement of the lip, alveo-
lus, palate, and nose. Kernahan’s striped “Y” classifi-
cation for cleft lip and palate deformities provides a
common framework in outlining the extent of clefting
and is used in classifying both unilateral and bilateral
clefts of the lip and palate.11 This classification system
was subsequently modified by Millard and others
to address the extent of associated nasal deformities
(Figure 7–1).4 As with unilateral cleft lip, the extent of
the bilateral cleft lip can range from a small notching
of the upper lip seen in the microform cleft to a separa-
tion of the soft tissue as well as alveolus (primary pal-
ate) in the complete cleft lip. Incomplete clefts of the
lip retain maxillary/alveolar attachment across all seg-
ments. Disruption of the alveolus is seen in complete
bilateral cleft lip cases. Approximately half of bilateral

Repair of the Bilateral Cleft Lip Deformity
83
clefts of the lip present with symmetric complete cleft
defects on both sides; approximately one quarter dem-
onstrate incomplete clefts bilaterally. The remaining
quarter have asymmetric clefting (e.g., complete and
incomplete).8,12 The degrees of relative asymmetry
can vary, including complete or incomplete defects on
one side accompanied by contralateral incomplete or
lesser-formed clefts. The repair of asymmetric bilateral
clefts of the lip can be approached in single-stage or
double-stage fashion, and there are advocates for both
approaches.12,13 We present a step-by-step approach to
repair the asymmetric complete/incomplete bilateral
cleft lip to allow comparison in technical modifica-
tions involved in addressing complete versus incom­-
plete defects.
Goals of Repair
Important anatomic challenges must be attended to
in bilateral clefts. Most importantly, the protruding
premaxilla lies anterior to the lateral lip segments and
results in flattening and widening of the nose. Along
with deficiency in the vertical height of the lip, there is
no muscle in the prolabium. Given the bilateral nature
of the cleft, philtral columns and Cupid’s bow are
absent. The bilateral cleft and prolabium lead to nasal
distortions that are often the tell-tale signs of a bilat-
eral cleft, even after successful lip repair. The nose is
wide and flat, manifested by a shortened columella and
widened, concave, lower lateral cartilages. In addition
Figure 7–1.  Millard’s modification to
Kernahan’s striped “Y” classification
(adapted from Millard, 1976). Accord-
ing to this classification, the extent of
the deformity is delineated by shading
of the respective boxes. The central
circle represents the incisive foramen.
For example, a right unilateral complete
cleft lip and palate may be represented
with shading of the right triangles and
boxes 1 to 4, 9 to 11. A left incomplete
cleft lip that does not involve the nasal
floor may be represented by shading of
box 6. In turn, a cleft palate involving
the soft palate only would be repre-
sented with shading of box 11.