Video Atlas Phẫu Thuật Khe Hở Môi Và Vòm Miệng

Orthognathic Surgery in the Cleft Patient
185
Anesthesia
• Nasal intubation is a requirement; it is
prudent to review preoperative CT scans to
determine which naris is wider and therefore
more amenable to a nasal intubation.
• Typically mild hypotensive anesthesia is
preferred, with a mean pressure of 60 mmHg.
• A decision is made after discussion with the
anesthesia team as to the need for placement
of an arterial line to monitor blood pressure
during periods of hypotensive anesthesia.
• Foley catheter is placed when surgical time is
anticipated to be more than 3 hours.
Surgical Procedure
Le Fort Osteotomy
Basic Technique in Noncleft Patient or Cleft Patient with
Consolidated Alveolar Cleft Bone Graft
1. Patient is positioned supine, in slight Trendelen­
burg position with a shoulder roll placed. Prepping
and draping is completed in the standard fashion
for maxillofacial surgery.
2. Infiltration of Lidocaine 1%, 1:100,000 epinephrine
is infiltrated to the bilateral maxillary vestibule;
approximately 7 to 10 cc can be used.
3. The incision design is a standard vestibular inci­
sion from the left maxillary first molar to the
right maxillary first molar. Typically a needle tip
bovie cautery is appropriate. The initial incision is
through mucosa and then down through perios­
teum to reveal the anterior maxillary wall.
4. Once dissection is completed to the anterior maxil­
lary wall, subperiosteal dissection is performed to
expose the bilateral anterior and lateral maxilla.
5. Care is taken to identify and protect the infraorbital
nerve bilaterally.
6. Dissection of the nasal mucosa is also completed.
7. Utilizing a reciprocating saw, a standard Le Fort 1
osteotomy is completed. The level of the osteotomy
is apical to the root tip of the maxillary canine. Typ­
ically, it starts just under the zygoma and extends
to the piriform rim bilaterally. A Freer elevator is
often placed in the piriform rim to protect the nasal
mucosa.
8. The osteotomy is extended along the lateral maxil­
lary walls as well.
9. Lateral nasal osteotomes marked at 25 mm are
placed into the site of the piriform osteotomies.
10. Utilizing a mallet, the osteotomes are gently tapped
through the lateral nasal walls.
11. A nasal floor osteotome is utilized to separate the
nasal mucosa from the nasal floor.
12. A gentle curved osteotome is utilized to separate
the pterygoid plates.
13. Utilizing a bone hook placed in the piriform with
Smith separators placed in the Le Fort osteotomy, the
maxilla is down-fractured in a controlled fashion.
14. The posterior wall of the maxilla is fractured using
Rowe disimpaction forceps, and the maxilla is then
mobilized.
15. Inspection of the nasal mucosa is performed, and
any tears are repaired with a 4-0 chromic suture.
16. The presurgically fabricated splint is inserted, and
the maxilla and mandible are wired to the splint,
placing the maxilla in the ideal presurgically deter­
mined position.
17. The maxilla and mandible complex are then repo­
sitioned superiorly, with any bony interferences
removed, with care not to distract the mandibular
condyles.
18. Once the maxilla is positioned adequately, it is
rigidly fixated bilaterally. Care should be taken to
check for any occlusal cant or midline shift.
19. The wires and splint are released, and the occlu­
sion is checked. If correct, then the incisions can be
closed utilizing 3-0 chromic sutures.
Modifications to Le Fort Procedure for a
Unilateral Cleft Patient3
(Video of Alveolar Cleft Repair with Tibial Bone Graft)
In comparison to a noncleft Le Fort patient or a cleft
patient with a successfully repaired alveolar cleft, the
unilateral cleft patient with an unrepaired or poorly
grafted/repaired alveolar cleft has some additional
considerations for the surgeon. These include a resid­
ual oro-nasal fistula, bony alveolar defects, and soft tis­
sue scarring. The aforementioned fistulae can be labial
or palatal. The alveolar defect is often associated with
an unrepaired alveolar cleft or one in which there was
loss of bone graft. This bony defect often extends from
the alveolus into the hard palate/floor of the nose.

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Video Atlas of Cleft Lip and Palate Surgery
Modifications to the standard surgical technique
for the Le Fort osteotomy are required (Figures 14–1
through 14–7).
1. In addition to the standard vestibular incision,
extensions are made vertically along the alveo­
lar cleft and oro-nasal fistula to the palatal aspect
of the fistula, thus separating the oral and nasal
mucosa. The palatal aspect of these incisions must
be undermined to provide for a tension-free clo­
sure. However, the palatal mucosa must remain
intact to avoid any interruption of blood flow.
2. Osteotomies are completed as normal. However,
with an unrepaired unilateral alveolar cleft, once
the Le Fort osteotomy is completed, the maxilla is
now in two pieces.
3. Down-fracture is done by hand with gentle finger
pressure, and the posterior wall is fractured with
Tessier hooks. This avoids trauma to the palatal
mucosa from Rowe forceps.
4. The deviated nasal septum and vomer are often
trimmed.
5. Typically the alveolar dental defect is closed by
moving the two segments of the maxilla together
with the aid of the surgical splint.
6. Cancellous bone graft may be utilized to fill any
residual defects in alveolus and nasal floor. Corti­
cocancellous blocks can be utilized to fill voids in
the Le Fort osteotomy.
7. The incisions are primarily closed with care to com­
pletely close the oronasal fistula in a watertight
fashion.
8. If there is a significant degree of bone grafting,
some authors advocate keeping the patient in max­
illomandibular fixation for 4 to 6 weeks to prevent
loss of graft.
Figure 14–1.  The underlying bony alveolar cleft defect is larger
than what appears from looking at the soft tissue defect.

187
A
B
Figure 14–2.  A. In addition to the standard vestibular incision,
extensions are made vertically along the alveolar cleft and oro-
nasal fistula to the palatal aspect of the fistula, thus separating
the oral and nasal mucosa. B. Soft tissue dissection is carried
out in a similar fashion as is described for repair of a nasoal-
veolar cleft. C. The buccal and palatal aspect of these incisions
must be undermined carefully to provide for a tension-free clo-
sure and to preserve the viability of the tissue edges, which will
be closed over the bone graft.
C

188
Figure 14–4.  The pterygoid plates are fractured from the
maxillary tuberosities as is usually done.
Figure 14–3.  Standard horizontal osteotomies are completed.
The deviated nasal septum is separated from the maxillary crest
with a guarded V-shaped osteotome.
A
B
Figure 14–5.  A. The maxilla is down-fractured by hand with gentle finger pressure, and the posterior wall is fractured with Tes-
sier hooks. This avoids trauma to the palatal mucosa from Rowe forceps. The maxilla is now in two pieces. B. As the result of the
original repair of the cleft palate, the nasal mucosa will need to be separated from the palatal mucosa with sharp dissection. All
openings that are produced in the nasal mucosa must be closed, whether a bone graft is used or not, to prevent the formation of
oral–nasal fistulae. Typically, the alveolar dental defect is closed by moving the two segments of the maxilla together with the
aid of the surgical splint.

189
Figure 14–6.  Premade acrylic splint is seen in place, wired to the
maxillary teeth to stabilize the maxillary segments in the position as
planned by the model surgery (arrow ). The cancellous bone is placed
from the posterior aspect of the palate forward including the alveo-
lar cleft defect. If the maxilla has been repositioned downward and
forward, corticocancellous blocks can be utilized to fill voids in the
Le Fort osteotomy.
A
B
Figure 14–7.  The incisions are closed primarily with care to completely close the oronasal fistula in a water tight fashion.
A. Vestibular incision closed. B. Palatal incision closed.

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Video Atlas of Cleft Lip and Palate Surgery
Modifications to Le Fort Procedure for a
Bilateral Cleft Patient4
Bilateral cleft patients have a maxillary dysplasia with
hypoplastic lateral segments, often a mobile premax­
illa that is malpositioned, residual oronasal fistulae,
bony defects, and soft tissue scarring. The following
modifications are suggested (Figures 14–8 through
14–17):
1. Vestibular incisions extend from the zygomatic
buttress region to the alveolar defects, then down
the mesial line angles of the canine defects.
2. The premaxillary segment incisions are placed
adjacent to the distal line angle of the incisor tooth
on each side and connected palatally.
3. The nasal and oral mucosa are separated. Care
must be taken to maintain the labial vestibule of
the premaxillary segment.
4. Osteotomies are completed as normal. However,
with an unrepaired bilateral alveolar cleft, once the
Le Fort osteotomy is completed, the maxilla is now
in three pieces.
5. Down-fracture is done by hand with gentle finger
pressure, and the posterior wall is fractured with
Tessier hooks. This avoids trauma to the palatal
mucosa from Rowe forceps.
6. The deviated nasal septum and vomer are often
trimmed.
7. Premaxillary segment is osteotomized from a pala­
tal approach with an osteotome, with concomitant
removal of vomer bone.
8. The lateral segments are brought into contact with
the premaxillary segment utilizing a prefabricated
splint. This closes the alveolar cleft defect.
9. Cancellous bone is placed into any voids in the
alveolus.
10. Cortico-cancellous blocks are interposed in areas of
bony voids along the Le Fort osteotomy.
11. Primary closure of all incisions is performed.
12. Maxillomandibular fixation may be considered to
stabilize bone graft.
Figure 14–8.  The bilateral cleft defect. In this illustration,
the premaxillary segment is located in a satisfactory vertical
position.
Figure 14–9.  Vestibular incisions extend from the zygomatic
buttress region to the alveolar defects, then down the mesial
line angles of the canine defects. The premaxillary segment
incisions are placed adjacent to the distal line angle of the
incisor tooth on each side and connected palatally.

191
Figure 14–10.  The nasal and oral mucosa of the premaxillary
segment are carefully elevated. This may be difficult due to
mobility of the premaxillary segment and scarring from pre-
vious procedures. Care must be taken to maintain the labial
vestibule tissue of the premaxillary segment as it is the main
blood supply to this segment.
Figure 14–11.  Osteotomies are completed as normal. How-
ever, with an unrepaired bilateral alveolar cleft, once the Le Fort
osteotomy is completed, the maxilla will be in three pieces.
Figure 14–12.  Down-fracture is done by hand with gentle finger
pressure, and the posterior wall is fractured with Tessier hooks
avoiding trauma to the palatal mucosa from Rowe forceps.

192
A
B
Figure 14–13.  A. Premaxillary segment is osteotomized from a palatal approach with an osteotome, with concomitant removal
of vomer bone and separation of the remainder of the septum from the maxilla if necessary. B. Down-fracture is done by hand
with gentle finger pressure.
Figure 14–14.  The lateral segments are brought into contact
with the premaxillary segment utilizing a prefabricated splint
that closes the alveolar cleft defect, and cancellous bone is
placed in the defects.
Figure 14–15.  The maxilla is repositioned and secured with
osteotomy plates. Corticocancellous bone can be placed in
voids along the Le Fort 1 osteotomy.

Orthognathic Surgery in the Cleft Patient
193
A
B
Figure 14–16.  The movements of the segments of the maxilla during the Le Fort osteotomy. A. Preoperative. B. Postoperative.
Figure 14–17.  Primary closure of all incisions is performed.
Postoperative Considerations
• As with all orthognathic surgery patients,
airway security in the immediate
postoperative phase is essential.
• Adequate pain control, antibiotic coverage,
and the use of prophylactic steroids are also
indicated. Once the patient is stabilized
and awake oral intake and ambulation is
encouraged.
• The Foley catheter (if placed) should be
removed as well with monitoring of urine
output.
• Specific to the cleft Le Fort patient, monitoring
of gingival perfusion of the anterior maxilla
is indicated, checking for adequate capillary
refill.
• Typically patients are stable for discharge 1 to
2 days after surgery.
• Home care includes maintaining adequate
oral fluid intake to avoid dehydration as

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Video Atlas of Cleft Lip and Palate Surgery
well as maintaining oral hygiene to avoid
infection.
• Caloric intake is also essential. A plan should
be given to the patient to ensure proper
nutrition during the initial 2 to 3-week
postoperative period until masticatory
function returns.
• For patients in maxillomandibular fixation,
this is usually released 3 to 4 weeks
postoperatively with mouth stretching
exercises and light elastics to maintain
occlusion.
• Orthodontic care may resume at
approximately 6 to 8 weeks after surgery.
Complications
• Relapse is the primary concern in this patient
population and is more likely compared to
the noncleft orthognathic patient due to a
much tighter and less-forgiving soft tissue
envelope found in the cleft patient. Relapse
will require a second orthognathic procedure
to correct.
• Velopharyngeal dysfunction after maxillary
advancement can occur, requiring corrective
surgery. Assessment of speech and
velopharyngeal function via nasoendoscopy
is important in the preoperative stage.
Pearls and Pitfalls
• Controlled hypotension preferred, mean
blood pressure at 60 mmHg.
• Preoperative CT scan with 3D reformation.
• Accurate presurgical planning (models,
mounting, splint fabrication, facebow
transfer).
• Mobilization of maxilla once down-fractured.
• Consider distraction osteogenesis if maxillary
advancement >8 mm.
• Adequate presurgical orthodontics.
• Consider surgically assisted rapid palatal
expansion if transverse discrepancy of maxilla
>5 mm.
References
1. Phillips JH, Nish I, Daskalogiannakis J. Orthognathic sur­
gery in cleft patients. Plast Reconstr Surg. 2012;129:535e.
2. Wolford LM. Effects of orthognathic surgery on nasal
form and function in the cleft patient. Cleft Palate Cranio-
fac J. 1992;29:546.
3. Posnick JC. Maxillary deficiency: Unilateral cleft lip and
palate. In: Ferraro J, ed. Fundamentals of Maxillofacial Sur-
gery. New York, NY: Springer; 1997:293–299.
4. Posnick JC. Maxillary deficiency: Unilateral cleft lip and
palate. In: Ferraro J, ed. Fundamentals of Maxillofacial Sur-
gery. New York, NY: Springer; 1997:300–305.

Section VII
Revision Cleft Lip and Palate Surgery

(Trang không có chữ)

197
Chapter 15
Revision Cleft Lip Repair
Usama S. Hamdan, Blake C. Alkire, Sami U. Hamdan, and Kenneth R. Pellegrino
Abstract
Despite improvements in primary cleft care, secondary cleft
lip deformities are unfortunately common. Secondary cleft
lip deformities, with or without cleft nasal deformity, are
constant stigmata that continue to affect many cleft patients
following their primary repair. Residual cleft lip deformities
are subject to the success and comprehensiveness of the pri-
mary repair, as well as the effect of expected tissue growth.
Consequently, cleft lip revision should be considered an
integral part of cleft management and represents a techni-
cal challenge for the cleft surgeon. Due to the multifactorial
etiology and wide variety in cleft appearance, each secondary
deformity has its own characteristics and peculiarities that
add challenges to its correction. Therefore, it is essential to
conduct a thorough preoperative analysis and assessment of
each deformity and design the appropriate surgical procedure
for the correction of that specific residual deformity. A suc-
cessful result depends on the surgeon’s experience in obtain-
ing a detailed and systematic evaluation of each anatomic
deformity, creating a carefully conceived treatment plan, and
executing the proper technique at the time of surgery. This
chapter introduces a practical classification system for sec-
ondary cleft lip deformities based on the involved anatomical
structures, along with basic surgical goals that should be
achieved to restore muscular balance, symmetry, and har-
mony of the aesthetic subunits.
Residual cleft lip deformities vary from mild to severe
and may include nasal deformities. To facilitate pre-
operative assessment and develop an appropriate
treatment plan, a surgical classification system is used
based on the extent of involvement of skin, mucosa,
muscle, and the nose:
A. Type I:  Involves the repair of skin and subcutane-
ous tissue (Z-plasty, V–Y flaps, linear excision and
closure) without the need for muscular, mucosal, or
nasal correction (Figure 15–1).
B. Type II:  Involves repair of the orbicularis oris mus-
cle and overlying mucosa, without the need for skin
or nasal correction (Figure 15–2).
C. Type III:  Involves repair of orbicularis oris muscle,
skin, and mucosa without the need for nasal correc-
tion (Figures 15–3 and 15–4).
D. Type IV:  Involves repair of muscle, mucosa, skin,
and the nose — a major lip revision (Figures 15–5
and 15–6).
Common secondary cleft lip and nasal deformi-
ties defined by the current classifications are divided
according to the involvement of subunits, such as the
vermilion or lip, and describe scarring subtypes for
each subunit. Some examples of vermilion deformities
include whistle deformity, lateral vermilion deficiency,
excessive lateral vermilion, or malalignment. Deformi-
ties of the lip are defined as a tight, short, long, or wide
lip, or an orbicularis oris derangement, such as a bulge
or diastasis. Similarly, scar deformities are classified
as wide, hypertrophic, depressed, or irregular. These
deformities can vary significantly between unilateral
and bilateral cleft deformities.
Secondary cleft nose deformities are more compli-
cated to describe due to the wide variety of presentations.
There are common anatomic–pathologic deformities in
every unilateral cleft lip that are summarized grossly by
the lateral displacement of the cleft-side ala, deviation
of the nasal tip to the cleft side, and deviation of the
base of the septum to the noncleft side resulting in loss
of definition of the nasal tip. Some recent classifications
correlated the anatomical anomaly of the nasal carti-
lages to the nasal deformity, implicating its possible role
in surgical planning,1 and one study introduced a clas-
sification of the alar base depression and the possible
surgical solution for each specific grade of deformity.2

198
Figure 15–1.  Type I residual cleft lip deformity.
Figure 15–2.  Type II residual cleft lip deformity.
Figure 15–3.  Unilateral Type III residual cleft lip deformity.
Figure 15–4.  Bilateral Type III residual cleft lip deformity.
Figure 15–5.  Unilateral Type IV residual cleft lip deformity.
Figure 15–6.  Bilateral Type IV residual cleft lip deformity.

Revision Cleft Lip Repair
199
Preoperative planning is of paramount importance
in the correction of secondary cleft lip and nasal defor-
mities. A fundamental component of planning is careful
evaluation of the structures involved in the procedure.3
In addition, a successful correction depends on a detailed
and systematic evaluation of the anatomical imbalance
of all components of the cleft deformity, along with
meticulous technical execution at the time of repair.4
The classification system described previously for
cleft lip and nasal revision surgery facilitates the imple-
mentation of a surgical plan for correction of residual
cleft lip deformities, whether unilateral or bilateral.
1. Unilateral cleft lip — Common residual lip deformi-
ties include:
a. Orbicularis muscle deficiency with secondary
notching and lip asymmetry. This deformity
can vary from mild (Figure 15–7) to moderate
(Figure 15–8) to severe (Figure 15–9), depend-
ing on the extent of muscle deficiency.
b. Asymmetric Cupid’s bow with the high point
on the cleft side higher than the noncleft side
(Figure 15–10), or missing Cupid’s bow on the
cleft side due to previous repair
(Figure 15–11).
Figure 15–9.  Severe secondary notching and lip asymmetry.
Figure 15–10.  Asymmetric Cupid’s bow with the high point on
the cleft side higher than the noncleft side.
Figure 15–7.  Mild secondary notching and lip asymmetry.
Figure 15–8.  Moderate secondary notching and lip asymmetry.

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Video Atlas of Cleft Lip and Palate Surgery
c. Scarring of the upper lip with secondary
retraction, simulating a residual incomplete
cleft (Figure 15–12).
d. Lip dehiscence due to a wide cleft that was not
adequately treated with presurgical orthope-
dics and/or resulting from infection, trauma,
or poor surgical technique (Figure 15–13).
e. Laterally displaced nasal ala on the cleft side
(Figure 15–14).
f. Poor nasal tip definition due to lack of tip
support, thinned and laterally stretched lower
lateral cartilage on the cleft side, and a poorly
defined dome (Figure 15–15).
g. Overhanging anterior soft tissue angle on the
cleft side (Figure 15–16).
h. A short columella (Figure 15–17).
i. Septal deviation toward the non-cleft side
(Figure 15–18).
Figure 15–13.  Lip dehiscence due to a wide cleft that was not
adequately treated with presurgical orthopedics and/or result-
ing from infection, trauma, or poor surgical technique.
Figure 15–14.  Laterally displaced nasal ala on the cleft side.
Figure 15–11.  Missing Cupid’s bow on the cleft side due to
previous repair.
Figure 15–12.  Scarring of the upper lip with secondary retrac-
tion, simulating a residual incomplete cleft.

201
Figure 15–15.  Poor nasal tip definition due to lack of tip sup-
port, thinned and laterally stretched lower lateral cartilage on
the cleft side, and a poorly defined dome.
Figure 15–16.  Overhanging anterior soft tissue angle on the
cleft side.
Figure 15–17.  Short columella.
Figure 15–18.  Septal deviation toward the non-cleft side.

202
Video Atlas of Cleft Lip and Palate Surgery
j. Short C-flap with secondary contracted or
shortened medial crural footplate on the cleft
side (Figure 15–19).
2. Bilateral cleft lip — common residual lip deformi-
ties include:
a. Wide (Figure 15–20) and/or scarred philtrum
(Figure 15–21).
b. Asymmetric Cupid’s bow (Figure 15–22).
c. Prolabial flap that has been sutured above its
normal anatomical position (Figure 15–23).
d. Scarred and poorly defined Cupid’s bow
(Figure 15–24).
e. Scarred and poorly defined philtral tubercle
(Figure 15–25).
f. Midline orbicularis oris muscle deficiency
(Figure 15–26).
g. Lip dehiscence: Either unilateral or
bilateral due to projected premaxilla that
was not adequately treated with presurgical
orthopedics and/or resulting from infec-
tion, trauma, or poor surgical technique
(Figure 15–27).
h. Outstretched and poorly healed prolabium
due to projected premaxilla that has not
been mobilized posteriorly due to contracted
secondary palatine shelves (Figure 15–28).
i. Healed but separated upper lip that detached
from the premaxilla and slipped under it due
to improper closure under extreme tension
(Figure 15–29).
j. Wide nostril bases (Figure 15–30).
k. A short columella (Figure 15–31).
l. Poor tip definition (Figure 15–32).
Figure 15–20.  Wide philtrum.
Figure 15–21.  Scarred philtrum.
Figure 15–19.  Short C-flap with secondary contracted or
shortened medial crural footplate on the cleft side.

203
Figure 15–23.  Prolabial flap has been sutured above its nor-
mal anatomic position.
Figure 15–22.  Asymmetric Cupid’s bow.
Figure 15–24.  Scarred and poorly defined Cupid’s bow.
Figure 15–25.  Scarred and poorly defined philtral tubercle.
Figure 15–26.  Midline orbicularis oris muscle deficiency.
Figure 15–27.  Lip dehiscence due to projected premaxilla that
was not adequately treated with presurgical orthopedics and/
or resulting from infection, trauma, or poor surgical technique.

204
Figure 15–28.  Outstretched and poorly healed prolabium due
to projected premaxilla that has not been mobilized posteriorly
due to contracted secondary palatine shelves.
Figure 15–29.  Healed but separated upper lip that detached
from the premaxilla and slipped under it due to improper clo-
sure under extreme tension.
Figure 15–30.  Wide nostril bases.
Figure 15–31.  A short columella.
Figure 15–32.  Poor tip definition.

Revision Cleft Lip Repair
205
Timing
No revision should be performed until at least 6 months
after the last surgical procedure. However, a waiting
period of 12 months or more is preferable to allow
adequate tissue healing. In cases of lip dehiscence and
depending on the age of the patient, more time might
be needed for revision surgery to allow proper presur-
gical orthopedic treatment to be implemented and for
adequate tissue growth.
Goals
Despite the unique characteristics and peculiarities of
each deformity, there are 11 basic principles that should
be met in any cleft lip repair, whether primary or sec-
ondary (Figure 15–33):
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 foot-
plates and adequate columellar length.
8. Symmetric width and shape of the nostrils.
9. Symmetry of the nostril axes.
10. Symmetry of the anterior soft tissue angle.
11. Symmetry of the nasal base along the horizontal
plane.
Surgical Indications
• Patients with residual unilateral or bilateral
cleft lip deformities.
Surgical Contraindications
• Similar to those for primary cleft lip repair
(see Chapters 6 and 7).
• Immature scarring.
• Patient is too young for lip revision.
• No bilateral cleft lip revision procedures
should be performed before implementing
presurgical orthopedic care in patients, where
the unsatisfactory outcome is due to lack of
such proper presurgical treatment.
Presurgical Orthopedic Care
Refer to primary cleft lip repair (Chapters 6 and 7) for
detailed text on presurgical orthopedic care.
Surgical Equipment and Tools
• Measuring caliper
• Castroviejo fine tissue forceps
• Ribbon-handle suture scissors
• Strabismus scissors
Figure 15–33.  Diagram depicting principles of revision cleft
lip repair.

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Video Atlas of Cleft Lip and Palate Surgery
• 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.
Surgical Procedure
Type I Repair
• Involves the repair of skin and subcutaneous
tissue (Z-plasty, V–Y flaps, linear excision
and closure) without the need for muscular,
mucosal, or nasal correction.
Z-plasty
1. Z-plasty is commonly used to realign vermilion
border asymmetries (Figure 15–34).
2. This technique is useful for 1 to 3 mm Cupid’s
bow and vermilion border asymmetries, both in
unilateral and bilateral cleft lip (BCL) revision pro-
cedures. In the BCL, the two high points are com-
monly seen rotated superiorly with interdigitating
red vermilion in between. The two high points can
be rotated inferiorly with bilateral Z-plasties, when
indicated.
3. The misaligned tissue is marked with a fine surgi-
cal marking pen.
4. Local anesthesia is infiltrated with a 27- or 30-gauge
needle, and a 12-minute waiting period is utilized
to ensure maximum vasoconstrictive effect of the
local anesthetic.
5. Incision is made with fine #62 Beaver® blade or the
tip of a #11 blade.
6. Sharp angled ribbon-handled scissors are used
to elevate the flaps, preferably without the use
of forceps to avoid shearing. This is feasible by
angling the scissors at a right angle to the flaps
and including skin and subcutaneous tissue as one
component.
7. Undermining of the tissue is carried out with the
same scissors with sharp cutting dissection and by
avoiding blunt and wide spreading maneuvers of
the scissors.
8. Make sure that the skin flaps are thick enough to
include adequate subcutaneous tissue.
9. Flaps are realigned into their appropriate anatomi-
cal positions with fine Castroviejo tissue forceps.
10. Subcutaneous sutures are then applied with 5-0 or
6-0 Vicryl™ or Monocryl™ sutures.
11. Skin suturing is performed with 5-0 or 6-0 fast-
absorbing plain gut by Ethicon™.
12. Dermabond™ is applied after ensuring that the
wound is dry.
The V–Y Flap
The V–Y flap is useful for vermilion border realign-
ment, especially along Cupid’s bow and along the wet
vermilion (Figure 15–35).
1. Misaligned left Cupid’s bow high points with wide
and depressed scar extending into wet–dry vermil-
ion junction.
Figure 15–34.  Z-plasty preoperative marking.

Revision Cleft Lip Repair
207
2. Medial component of high point on cleft side is
notched superiorly.
3. Two V-shaped flaps are marked: The lower one
incorporating the typical vermilion border V-flap
previously described in primary lip repair and a
more superiorly based skin V-flap that incorpo-
rates a recipient site just above the vermilion fold.
4. The same surgical steps 1 through 11 are then
followed as in the Z-plasty section previously (Fig-
ure 15–36).
Linear Excision
(Video of Type I Revision Cleft Lip Repair)
Linear excision of wide and/or depressed scar involv-
ing only skin and subcutaneous tissue with or with-
out vermilion extension but with an intact underlying
muscle.
Note:  This is applicable to both skin and vermil-
ion components of the lip. Linear excision is commonly
used in BCL revision procedures to narrow the wide
and at times severely scarred philtrum. A common mis-
take by novice cleft surgeons is to use more than the
standard 2 to 2.5 mm width for the low to high point
measurement. Subsequently, the philtrum widens sig-
nificantly with the patient’s growth. Linear excision of
the excess skin results in a narrower and more aestheti-
cally pleasing upper lip. Make sure to design the inci-
sions to fall into the proper anatomic location of the
philtral ridges. The central part of the prolabial flap can
be gently debulked subcutaneously to mimic a philtral
dimple. Be careful not to jeopardize the blood supply
to the prolabial flap by careful and judicious debulking
of the central portion of the flap.
The same surgical steps 1 through 11 are then fol-
lowed as in the previous sections.
Type II Repair
(Video of Type II Revision Cleft Lip Repair)
• Type II involves repair of the orbicularis oris
muscle and overlying mucosa, without the
need for skin or nasal correction.
• Typically, these patients present with an
orbicularis oris muscle deficiency resulting
in lip contour deformity and notching,
commonly referred to as a “whistle
deformity.” This deformity is usually due
to an inadequate repair of the muscle fibers
during the primary surgical correction.
• If the muscle deficiency does not extend
above the vermilion border, this can be
corrected via muscle suturing and a V–Y
mucosal flap closure.
Note:  In Type II classification, for unilateral clefts,
the muscle deficiency should not extend beyond the
vermilion border and should not be associated with
Cupid’s bow asymmetry (Figure 15–37). The most
common Type II bilateral cleft is a midline muscle defi-
ciency that does not extend beyond the vermilion bor-
der and is associated with a well-aligned Cupid’s bow
(Figure 15–38).
Figure 15–35.  Preoperative V–Y flap markings.
Figure 15–36.  Postoperative result of V–Y flap.

208
Figure 15–37.  Unilateral Type II revision cleft lip repair.

Revision Cleft Lip Repair
209
1. The upper lip is gently retracted superiorly and
the area of muscle deficiency is marked in a
V-shaped manner, with the upper points of the V
not bypassing the wet–dry vermilion line. Make
sure that the two limbs of the V are marked 1 mm
lateral to the outer edge of the invagination of
the mucosa to avoid leaving behind excess
mucosa. The base of the V usually extends within
the wet mucosa, almost to the level of the gingivo-
buccal sulcus.
2. Local anesthesia is infiltrated with a 25-gauge
needle, and a 12-minute waiting period is utilized
to ensure maximum vasoconstrictive effect of the
local anesthetic.
3. The upper lip is retracted with two double hooks,
and a mucosal incision is made with a #15 blade
following the marked V-outline.
4. Sharp angled ribbon-handled scissors are used
to elevate the V-mucosal flap, preferably without
using forceps to avoid shearing effect.
5. Mucosal flap elevation stops at the wet–dry vermil-
ion mucosal line.
6. The orbicularis oris muscle deficiency is identified,
and the intermuscle scar is resected.
7. Muscle fibers are then realigned and sutured with
interrupted 4-0 or 5-0 Vicryl™ sutures. Remem-
ber to address the whole muscle circumference to
ensure correction of the muscle deficiency.
8. Buccal mucosal flap is then sutured in a Y fashion
with interrupted 5-0 Vicryl™ sutures. The junction
of the three limbs of the Y is usually at the halfway
point of the length of the defect (Figure 15–39).
Type III Repair (Video of Type III
Revision Unilateral Cleft Lip Repair)
• Many of the residual cleft lip deformities
affect skin, vermilion, and muscle continuity
with or without associated nasal deformities.
• In Type III cleft lip revision, mucosal,
muscular, and skin deformities are corrected
without any associated nasal procedures.
• In a large portion of these patients, a Type
IV repair might be considered, but the nasal
repair is postponed to a later stage for one of
the following reasons:
1.  The final open rhinoplasty is indicated in a
few years.
2.  The patient is too young for open rhinoplasty.
3.  Concomitant nasal surgery might interfere
with flap vascularization or oppose the
vectors of healing of the revised lip. This is
especially true in Type III bilateral residual
clefts that might be associated with extensive
upper lip scarring and possibly compromised
blood supply. Under these circumstances, it
is best to delay nasal revisions for at least 1
year to provide the revised lip with the best
chance of healing and scar maturation.
Figure 15–38.  Bilateral Type II revision cleft lip repair.

210
Video Atlas of Cleft Lip and Palate Surgery
Unilateral Cleft Lip Revision
(Figures 15–40 and Figure 15–41)
This patient presents with residual cleft lip deformity,
including significant orbicularis muscle deficiency
extending from vermilion component of the muscle
into skin baring area, prominent right upper lip scar
with poor definition of Cupid’s bow, retracted right
high point, interdigitating upper lip skin and vermilion
tissue, and wide right nostril.
1. The low point and the two high points of Cupid’s
bow are measured and marked.
2. The matching high point on the cleft side is marked.
The distances between both nostril sills and the
high points are measured, factoring in the length
of the vermilion flap that will correct the height
deficiency in the upper lip.
3. The misaligned tissue is marked with a fine surgi-
cal marking pen, including the wide upper lip scar
and deficient muscle extending into the vermilion
and buccal mucosa.
4. Local anesthesia is infiltrated with 25-gauge nee-
dle, and a 12-minute waiting period is utilized to
ensure maximum vasoconstrictive effect of the
local anesthetic.
5. Incision is made with #15 blade through skin and
subcutaneous tissue.
6. Sharp angled ribbon-handled scissors are used to
excise the upper lip scar.
7. Orbicularis oris muscle deficiency is identified and
intermuscle scar is resected.
8. Skin is undermined a distance of 1 to 3 mm with
ribbon-handled suture scissors and #15 blade.
9. Muscle fibers are then realigned and sutured with
interrupted 4-0 or 5-0 Vicryl™ sutures, ensur-
ing that the vermilion borders are well aligned.
Remember to address the whole muscle circumfer-
ence to ensure correction of the muscle deficiency.
10. Buccal mucosal flaps are then sutured with inter-
rupted 5-0 Vicryl™ sutures.
11. Subcutaneous sutures are then applied with 5-0 or
6-0 Vicryl™ or Monocryl™ sutures.
12. Skin suturing is performed with 5-0 or 6-0 fast-
absorbing plain gut (by Ethicon™). A vermilion
border flap (Figure 15–42) can be rotated into place
if the Cupid’s bow high point is still misaligned and
notched superiorly. The length of this flap is depen-
dent on the remaining difference in the height of the
upper lip to ensure equidistant symmetry between
the nostril sills and the high points bilaterally.
13. Dermabond™ is applied after ensuring that the
wound is dry.
Bilateral Cleft Lip Revision
(Video of Type III Revision Bilateral Cleft Lip Repair)
Type III bilateral deformities include a wide upper lip
scar, wide philtrum, poorly defined Cupid’s bow with
Figure 15–39.  V–Y orbicularis and mucosal Type II repair for bilateral residual cleft lip deformity. The junction of the three limbs
of the Y is usually at halfway point of the length of the defect.

211
A
B
Figure 15–40.  A. Patient status post cleft lip repair during infancy with the following deformities: 1. Asymmetric Cupid’s bow
with the left high point much higher than the right (noncleft side) high point, 2. Low point of Cupid’s bow is higher than the
right (noncleft side) high point, 3. Significant whistle deformity due to deficiency of the orbicularis oris muscle, 4. Very thin and
inward rotated orbicularis oris muscle on cleft side. B. Nasal deformities from basal view: 5. Stretched left lower lateral cartilage,
6. Asymmetric alar bases due to hypoplasia of left piriform aperture base, 7. Poor nasal tip definition.
A
B
C
D
E
F
Figure 15–41.  A. The surgical site is outlined. In this case, the wide scar should be excised with tapering toward the vermilion
border. B. Skin incisions are made through epidermis and dermis down to subcutaneous tissue in one continuous sweep. C. Skin
is separated from the underlying orbicularis oris muscle on the advancement flap side. D. Note the lateral margin of the skin inci-
sion on the advancement flap side not going into the alar base crease to avoid prominent future scars. E. The scar tissue between
the buccal mucosa and underlying orbicularis oris muscle is then released. F. The skin incision on the rotation flap is being gently
extended toward the philtral ridge but never bypassing it.  continues

212
Figure 15–41.  continued  G. The scar tissue pulling on the nostril sill is being released with ribbon-handled scissors. H. The scar
between the edges of the orbicularis muscle contributing to the whistle deformity is clearly visualized and resected. I. 4-0 Vicryl™
suture on RB-1 needle is then placed in an ascending V-shaped manner and is used to approximate the muscle fibers in an ascend-
ing V-shaped fashion. J. Diagram depicting Hamdan sliding V-cheiloplasty. K. The tubular structure of the vermilion component
of the orbicularis oris muscle necessitates that multiple sutures are placed along its perimeter to approximate the various fibers
of this segment of the muscle. A 5-0 Monocryl™ suture is placed in the lowest aspect of the orbicularis oris muscle immediately
under the vermilion, thus producing a smooth and continuous lip margin. Vermilion border flap is rotated into place and sutured
with 5-0 fast-absorbing plain gut™ suture. L. Preoperative. M. Postoperative.
G
H
I
J
K
L
M

Revision Cleft Lip Repair
213
asymmetrical high points, philtral dimple, orbicularis
oris muscle deficiency, short columella, poor tip defi-
nition, and wide asymmetric nostrils. Nasal revision
was not incorporated into the surgical plan due to the
potential risk that the flaps raised during this proce-
dure might be compromised with concomitant open
cleft rhinoplasty (Figures 15–43 and 15–44).
1. Low point and the two high points of Cupid’s bow
are measured and marked.
Figure 15–42.  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.
A
B
Figure 15–43.  A. New philtrum outline with incurving of the lines to accommodate the lateral vectors of healing. B. Flaps raised.
continues

214
C
D
Figure 15–43.  continued  C. Skin, vermilion, and intramuscular scar excised. Orbicularis oris muscle repaired with interrupted
Vicryl™ sutures. D. Upper portion of muscle repaired. Philtral flap sutured at its two matching high points. E. Muscle repaired, and
philtral flap sutured. F. Low point of Cupid’s bow reconstructed through a triangular suture. Vermilion sutured with interrupted
5-0 Vicryl™ sutures. G. Preoperative. H. Postoperative.
E
F
G
H

Revision Cleft Lip Repair
215
2. Matching high points on both cleft sides are marked.
3. The scarred tissue along the poorly defined philtral
ridge is marked with a fine surgical marking pen,
including the wide upper lip scar and deficient mus-
cle area extending into vermilion and buccal mucosa.
4. A symmetrical Cupid’s bow was outlined with 3
mm width on each side.
5. The natural vermilion white roll was preserved,
and incision was marked 0.5 mm below the white
roll in a V-shaped manner.
6. Local anesthesia is infiltrated with a 25-gauge
needle, and a 12-minute waiting period is utilized
to ensure maximum vasoconstrictive effect of the
local anesthetic.
7. Incision is made with a #15 blade through skin and
subcutaneous tissue
8. Sharp angled ribbon-handled scissors are used
to raise the upper lip scarred flaps. They are left
attached to their base at the junction of columella
with nostril sills for potential columellar lengthen-
ing at the end of the procedure.
9. The prolabial flap is elevated and gently debulked
centrally to create a philtral dimple. The thickness
of the philtral ridges is preserved bilaterally.
10. Orbicularis oris muscle deficiency is identified, and
intermuscle scar is resected.
11. Skin is undermined a distance of 1 to 3 mm with
ribbon-handled suture scissors and a #15 blade
along the lateral skin flaps.
12. Muscle fibers are then realigned and sutured with
interrupted 4-0 or 5-0 Vicryl™ sutures, ensur-
ing that the vermilion borders are well aligned.
Remember to address the whole muscle circumfer-
ence to ensure correction of the muscle deficiency.
13. Buccal mucosal flaps are then sutured with inter-
rupted 5-0 Vicryl™ sutures.
14. The prolabial flap is then sutured to the lateral skin
flaps: Subcutaneous sutures are applied using 5-0
or 6-0 Vicryl™ or Monocryl™ sutures. A triangular
suture is used at the junction of the vermilion edge
immediately under the low point and the opposing
vermilion flaps.
15. The scarred upper lip flaps are then trimmed, leav-
ing 3-mm triangular flaps that are used to lengthen
the columella and mimic the natural out-flaring of
the medial crural footplates.
16. Skin is sutured with 5-0 or 6-0 fast-absorbing plain
gut (by Ethicon™). The vermilion border flaps can
be rotated into place if the Cupid’s bow high points
are still misaligned and notched superiorly (Figure
15–42).
17. Dermabond™ is applied after ensuring that the
wound is dry.
Type IV Repair
• Used for complex residual cleft lip deformities
involving skin, mucosa, vermilion, muscle,
and the nose and can be applied to various
age groups (Figure 15–45).
• Does not include open cleft rhinoplasty.
• The scope of nasal revision includes alar
base flaps and interdomal, transfixion, and
anterior soft tissue angle-suspending sutures.
These techniques can also produce significant
columellar support and lengthening without a
columellar strut.
A
B
C
Figure 15–44.  A. Patient with wide philtrum, asymmetrical Cupid’s bow, and deficient orbicularis oris muscle and philtral tubercle.
Excess philtral scars marked. Surgical plan to narrow the philtrum, re-anastomose the orbicularis oris muscle, and enhance philtral
tubercle appearance. B. Preoperative. C. Postoperative.

216
Video Atlas of Cleft Lip and Palate Surgery
• Desirable outcomes when columellar
lengthening is warranted but the timing is not
right for open cleft lip rhinoplasty.
• The same guidelines for the choice of
anesthetic options are applicable for primary
repair and cleft lip revision.
Unilateral Cleft Lip Revision (Video of Type IV
Revision Unilateral Cleft Lip Repair)
This patient presents with residual left cleft lip and
nasal deformities including orbicularis muscle defi-
ciency, poor definition of Cupid’s bow, retracted left
high point, prominent upper lip scar, wide left nostril,
poor tip definition, collapsed columella, and deficiency
of left nostril sill (Figures 15–46 through 15–69).
1. The low point and the two high points of Cupid’s
bow are measured and marked.
2. The matching high point on cleft side is marked.
3. The misaligned tissue is marked with a fine surgi-
cal marking pen, including the wide upper lip scar
and deficient muscle area extending from the white
skin bearing area of upper lip into the vermilion
and buccal mucosa. Rotation and advancement
flaps are also marked.
4. Nerve blocks are performed, and local anesthesia
is infiltrated with a 25-gauge needle. A 12-min-
ute waiting period is utilized to ensure maximum
vasoconstrictive effect of the local anesthetic.
5. Incision is made with a #15 blade through skin and
subcutaneous tissue.
6. Sharp angled ribbon-handled scissors are used to
excise the upper lip scar.
7. Advancement and rotation flaps are elevated.
8. Orbicularis oris muscle deficiency is identified, and
intermuscle scar is resected.
9. The left alar base is freed from underlying scarred
tissue to allow medial rotation, utilizing an alar
base flap suspending suture.
A
B
Figure 15–45.  A. Preoperative photo of Type IV revision unilateral cleft lip repair. B. Postoperative photo.

217
Figure 15–46.  Patient with residual left cleft lip and nasal
deformity including orbicularis muscle deficiency, poor defini-
tion of Cupid’s bow, retracted left high point, prominent upper
lip scar, wide left nostril, poor tip definition, collapsed colu-
mella, and deficiency in left nostril sill.
Figure 15–47.  Bilateral infraorbital and external nasal nerve
blocks are performed. Same local anesthetic mixture is used for
lip infiltration.
Figure 15–48.  Diagram depicting nerve block injection locations.
Figure 15–49.  Diagram depicting incision and undermining.

218
Video Atlas of Cleft Lip and Palate Surgery
Figure 15–52.  Diagram depicting Hamdan sliding V-cheiloplasty.
10. The lower lateral cartilage is freed from overlying
skin with sharp ribbon-handled scissors that are
introduced through the columella.
11. Muscle fibers are then realigned and sutured with
interrupted 4-0 or 5-0 Vicryl™ sutures making
sure that the vermilion borders are well aligned.
Remember to address the whole muscle circumfer-
ence to ensure correction of the muscle deficiency.
12. Two interdomal sutures are applied with 4-0
Monocryl™ on a PS-2 needle to enhance tip support.
13. Anterior soft tissue angle prolapse is corrected with
two suspending sutures utilizing 3-0 Monocryl™ on
Figure 15–50.  Incision is made with #15 blade through skin
and subcutaneous tissue. Sharp angled ribbon-handled scissors
are used to excise the upper lip scar.
Figure 15–51.  Left alar base is freed from underlying scar tis-
sue to allow medial rotation utilizing alar base flap suspending
suture.

Revision Cleft Lip Repair
219
a straight Keith needle. Make sure that the alar rim
is intact after sutures are tied to avoid alar notching.
14. Alar base flap suspending suture is then applied
for medial rotation of the ala and to correct the
depression in the nostril sill area.
15. A transverse suture is applied subcutaneously
2 mm behind the tip of the advancement flap and
sutured in place.
16. Buccal mucosal flaps are then sutured with inter-
rupted 5-0 Vicryl™ sutures.
Figure 15–55.  Diagram of Cutting interdomal suture.
Figure 15–53.  Lower lateral cartilage is freed from overlying
skin with sharp ribbon-handled scissors introduced through the
columella.
Figure 15–54.  Two interdomal sutures are applied with 4-0
Monocryl™ on PS-2 needle to enhance tip support.
Figure 15–56.  Diagram of transverse crural suture to prevent
posterior displacement of lower lateral cartilages.

220
Figure 15–57.  Two interdomal sutures
are applied with 4-0 Monocryl™ on PS-2
needle to enhance tip support.
Figure 15–58.  Anterior soft tissue angle prolapse is corrected with two suspending
sutures utilizing 3-0 Monocryl™ on straight Keith needle. Make sure that alar rim is
intact after sutures are tied to avoid alar notching.
Figure 15–59.  Diagram depicting sus-
pending suture between anterior soft tis-
sue and ipsilateral or contralateral upper
lateral cartilage.
Figure 15–60.  Diagram depicting alar
base flap suspension suture.
Figure 15–61.  Alar base flap suspend-
ing suture is then applied for medial
rotation of the ala and to correct the
depression in the nostril sill area.
Figure 15–62.  C-flap rotated to base of columella achieving
needed fullness in columellar–labial angle.
Figure 15–63.  Advancement flap suture.

Revision Cleft Lip Repair
221
17. Subcutaneous sutures are then applied with 5-0 or
6-0 Vicryl™ or Monocryl™ sutures.
18. Skin suturing is performed with 5-0 or 6-0 fast-
absorbing plain gut (by Ethicon™). A vermilion
border flap can be rotated into place if the Cupid’s
bow high point is still misaligned and notched
superiorly (Figure 15–42).
19. Dermabond™ is applied to the skin-baring area
after ensuring that the wound is dry.
Figure 15–66.  Remaining orbicularis oris sutures.
Figure 15–67.  Skin suturing is performed with 5-0 or 6-0
fast-absorbing plain gut (by Ethicon™). A vermilion border flap
can be rotated into place if needed.
Figure 15–65.  Buccal mucosal flaps are then sutured with
interrupted 5-0 Vicryl™ sutures. Subcutaneous sutures are then
applied using 5-0 or 6-0 Vicryl™ or Monocryl™.
Figure 15–64.  Transverse suture applied subcutaneously 2 mm
behind tip of the advancement flap.

222
Figure 15–68.  Diagram of postoperative result after Type IV cleft lip repair.
A
B
Figure 15–69.  Photos of postoperative result after Type IV cleft lip repair. Frontal view: A. Pre-
operative. B. Postoperative. Basal view: C. Preoperative. D. Postoperative.
C
D

Revision Cleft Lip Repair
223
Bilateral Cleft Lip Revision
(Video of Type IV Revision Bilateral Cleft Lip Repair)
The patient presented with a wide upper lip scar, wide
philtrum, poorly defined Cupid’s bow with asym-
metrical high points, philtral dimple, orbicularis oris
muscle deficiency, short columella, poor tip definition,
and wide and asymmetric nostrils (Figures 15–70 and
15–71).
1. The low point and the two high points of Cupid’s
bow are measured and marked.
2. Scarred tissue along the poorly defined philtral
ridges is marked with a fine surgical marking
pen, including the wide upper lip scar and deficient
muscle area extending into vermilion and buccal
mucosa.
3. A symmetrical Cupid’s bow is outlined with 3 mm
width on each side.
4. Philtral ridges are marked in an inward curvilin-
ear fashion from the base of the columella to the
respective high points.
5. The scarred natural vermilion white roll is pre-
served, and the incision site is marked 0.5 mm
below the white roll in a V-shaped manner.
6. Local anesthesia is infiltrated with 25-gauge nee-
dle, and a 12-minute waiting period is utilized to
ensure maximum vasoconstrictive effect of the
local anesthetic.
7. Incision is made with a #15 blade through skin and
subcutaneous tissue.
8. Sharp angled ribbon-handled scissors are used to
excise the upper lip scar.
9. The prolabial flap is elevated and gently debulked
centrally to create a philtral dimple. The thickness
of the philtral ridges is preserved bilaterally.
10. Orbicularis oris muscle deficiency is identified, and
intermuscle scar is resected.
11. Skin is undermined a distance of 1 to 3 mm with
ribbon-handled suture scissors and #15 blade along
the lateral skin flaps.
12. Tip rhinoplasty:
A. Sharp ribbon-handled scissors are then intro-
duced via the columella to separate the lower
lateral cartilages from the overlying nasal skin.
The plane of entry through the columella is
between columellar skin and the inferior
border of the transverse crura in order to
preserve the fibrous attachments between the
upper edges of the transverse crura and the
septum.
B. Two interdomal sutures are then applied
using 4-0 Monocryl™ on a PS-2 needle.
C. Two intranasal suspending sutures are then
applied between the anterior soft tissue angle
and the contralateral upper lateral cartilage to
eliminate the redundancy along that angle. Make
Figure 15–70.  Patient status post bilateral cleft lip repair
with residual scarring of philtrum and vermilion, absent philtral
tubercle, loss of landmarks of Cupid’s bow, deficient orbicularis
oris muscle, nasal asymmetry with wide right nostril, poor tip
definition, and wide nasal tip.
Figure 15–71.  Surgical markings to narrow philtrum, excise
bilateral upper scars along the philtral ridges, excise central
vermilion scar, and narrow right nostril.

224
Video Atlas of Cleft Lip and Palate Surgery
sure to place the suture 2 to 3 mm away from
the alar rim to prevent any alar rim notching.
13. Muscle fibers are then realigned and sutured with
interrupted 4-0 or 5-0 Vicryl™ sutures, making
sure that the vermilion borders are well aligned.
Remember to address the whole muscle circumfer-
ence to ensure correction of the muscle deficiency.
14. Buccal mucosal flaps are then sutured with inter-
rupted 5-0 Vicryl™ sutures.
15. The prolabial flap is then sutured to the lateral skin
flaps: Subcutaneous sutures are applied using 5-0
or 6-0 Vicryl™ or Monocryl™ sutures. A triangular
suture is used at the junction of the vermilion edge
immediately under the low point and the opposing
vermilion flaps.
16. Skin is sutured with 5-0 or 6-0 fast-absorbing plain
gut (by Ethicon™). Vermilion border flaps can be
rotated into place if the Cupid’s bow high points
are still misaligned and notched superiorly (see
Figure 15–42).
17. Dermabond™ is applied after ensuring that the
wound is dry (Figure 15–72).
Postoperative Considerations
• Adequate pain control is achieved
postoperatively through infraorbital and
external nasal nerve blocks.
• Massage of the upper lip should be
initiated at the beginning of the 4th to 6th
postoperative week. The revised area should
be gently massaged 3 to 4 times per day,
A
B
Figure 15–72.  Type IV repair for residual bilateral cleft lip deformity. A. Preoperative. B. Postoperative.

Revision Cleft Lip Repair
225
for 2 minutes at a time to break down any
impending scar contracture. Massages can be
maintained for 3 to 4 months postoperatively.
This can be performed with or without skin
moisturizer.
• Sun protection with sunscreen and
hats should be used up to 6 months
postoperatively to avoid scar
hyperpigmentation.
• Remove any anchor 6-0 Monocryl™ upper lip
skin sutures and alar crease sutures within
7 days.
• Remove any nasal suspending sutures by
2 weeks.
Complications
• Infection can be prevented with prophylactic
perioperative antibiotic therapy for 3 to 5 days.
• Orbicularis oris muscle deficiency with
secondary notching can be avoided by
diligent suturing of the various edges of
the tubular-shaped vermilion component of
orbicularis oris muscle.
• Scar retraction is encountered when the alar
base-to-high point distance on the cleft side is
shorter than the noncleft side.
• Lip dehiscence can occur when:
• The lip is repaired under moderate–
severe tension and is usually encountered
with a projected premaxilla that should
have been pretreated with presurgical
orthopedics.
• In some cases of bilateral cleft lips and
when needed presurgical orthopedics were
not properly instituted, the repaired lip
separates from the projected premaxilla
and slips under it, preventing posterior
retraction of the premaxilla. This requires
separating the lip and implementing
presurgical orthopedics until the premaxilla
is properly positioned followed by lip
revision. Such unsatisfactory outcomes
should be avoided by implementing proper
presurgical orthopedics when indicated.
• The lip sustains direct trauma with
significant force.
• There is inadequate layered closure,
especially of the muscular layer.
• Alar lobule notching is usually encountered
with lateral dissection of the lower lateral
cartilage and disrupting of the natural alar
crease line.
• Nostril stenosis is encountered with
narrowing of the nostril sill during primary or
revision cleft surgery and can be avoided by
meticulous repair of the cleft nostril.
• Alar valve collapse or stenosis is encountered
when the alar valve is violated during
primary or revision cleft surgery with
incisions extending into the anatomical
mucocutaneous area of the alar valve.
• Retracted columella is encountered when:
• The C-flap is not adequately fashioned
and positioned to lengthen the shortened
columella along with utilization of the
various suspending and transfixion nasal
sutures.
• Presurgical orthopedics were not
implemented in bilateral cleft lips with
secondary short columella.
• There is absent cartilaginous tip support.
Pearls and Pitfalls
• Think of lip repair and lip revision as two
major time blocks: One to achieve muscular
symmetry and the other to achieve nasal
symmetry.
• Muscle framework is the building block
for any successful lip repair or revision.
Without proper approximation of all the
orbicularis oris muscle fibers in a tension-
free manner, the scaffold of the lip will
be deficient and result in secondary lip
notching, asymmetry, and subsequent
increase in the lateralizing forces of healing
(especially on the alar lobule). Think
of the orbicularis oris muscle repair as
nerve grafting, especially in its vermilion
component: All the nerve fascicles need to
be perfectly anastomosed to achieve the
best functionality and repair. Half of the
surgical time is spent on achieving this goal.
• The other half of the surgical time is spent
on achieving nasal symmetry and ensuring
that the repair or revision does not result in
nostril stenosis or alar valve collapse, both

226
Video Atlas of Cleft Lip and Palate Surgery
of which are detrimental for acceptable
nasal patency and airflow.
• Maintain adequate width of the C-flap,
especially along its lateral margin to preserve
enough tissue for proper out-flaring of the
footplate. Narrowing the lateral edge of
the C-flap will result in an asymmetrical
appearance of the nostrils from a basal view
with flattening of the columellar base on the
cleft side.
• Avoid extending the lateral aspect of
advancement flap beyond the base of the
alar lobule. This is achieved by dropping
an imaginary perpendicular line from the
inner fold of the alar lobule and marking its
junction with the advancement flap.
• Avoid any lateral cartilage dissection through
the alar lobule. Such lateral dissection
disrupts the natural alar crease line and
results in unacceptable alar notching,
commonly seen in this surgical approach.
• Final rhinoplasty is performed on cleft lip
nasal deformities when the patient reaches her
or his growth spurt, usually around 15 to 18
years in females and 16 to 19 years in males.
This is essential to allow the nasal structures
to achieve adequate growth maturation. Prior
to this rhinoplasty, the surgeon should aim
at achieving nasal symmetry at the time of
primary repair or during lip revision. This
can be adequately accomplished through
presurgical nasoalveolar molding (NAM)
therapy in newborns, cartilage-sparing
primary rhinoplasty techniques (such as alar
base flap suspending suture during primary
cleft lip repair), and with interdomal and alar
crease transfixion sutures and anterior soft
tissue angle-suspending sutures.
• When tying the alar base flap suspending
suture, be careful not to tighten the suture too
much during the application of the second
knot, an inadvertent pitfall commonly seen
if the surgeon is not careful while tying
the second knot. This can result in nostril
narrowing and secondary stenosis as the
patient ages.
• If given the choice between a slightly wider
nostril on the cleft side or a narrower one,
the surgeon should choose the former. It is
always easier to revise a wider nostril sill and
achieve the desired symmetry at an older age.
In contrast, it is much more difficult to widen
a stenosed nostril, a complicated procedure
requiring composite grafting and intranasal
flap rotation.
• Sun protection for at least 6 months
postoperatively will avoid hyperpigmentation
of the upper lip scar.
• If the orbicularis oris muscle fibers have
not been well approximated, there will be a
residual muscle deficiency and secondary
notching. The surgeon should step away
from the OR table for a minute at the end of
the procedure and then reassess the repair
outcome. More muscle sutures might need
to be applied to address any residual muscle
defect. Z-plasties or dermal grafts are not
adequate to correct muscle deficiencies due
to improper muscle approximation. An
additional option is to have a mounted HD
video camera above the patient connected
to a monitor, whereby the assistant surgeon
has a constant view from an additional
angle. This is helpful when working on the
final refinement of nostril symmetry and
orbicularis oris muscle symmetry.
• Adhere to the 12-minute waiting period
between lip infiltration with local anesthetic
and initiation of surgery to ensure maximum
vasoconstrictive effect of epinephrine
and consequently reduce the need to use
electrocautery.
• The combination of lidocaine and
bupivacaine ensures up to 8 hours of minimal
to no postoperative pain and reduces the need
for opioid therapy in the recovery room.
• Whenever possible, performing lip revision
under local anesthesia for patients older
than 12 years of age, with or without mild
sedation, provides a safe alternative to general
anesthesia — especially in limited resource
settings.
• The use of absorbable sutures (fast-absorbing
plain gut by Ethicon™) for skin closure
eliminates the need for a return visit to the
operating theater for suture removal in the
pediatric age group.
• Dermabond™ should be applied judiciously
over the skin portion of the sutured lip and
only after ensuring that the surgical field is
completely dry. Avoid applying Dermabond™
over the mucosal portion of the vermilion.

Revision Cleft Lip Repair
227
References
1. Li A, Sun Y, Wang G. Classification of secondary nasal
deformities associated with unilateral cleft lip. Zhonghua
Kou Qiang Yi Xue Za Zhi. 2000;35(3):194–196.
2. Zhang L, Lu L, Li ZJ, Liu Q, Yang ML, Wang XK, et al.
Classification and surgical management of secondary
nasal deformity of unilateral cleft lip. Zhonghua Zheng
Xing Wai Ke Za Zhi. 2010;26(6):409–414.
3. Stal S, Hollier LH. Secondary deformities of the cleft lip,
nose, and palate. In: Mathes S, Hentz V, eds. Mathes Plas-
tic Surgery. Philadelphia, PA: Elsevier; 2006.
4. Pantaloni M, Salomon J. Cleft lip II: secondary deformi-
ties. Selected Readings in Plastic Surgery. 2001;9(22).

(Trang không có chữ)

229
Chapter 16
Revision Cleft Palate Repair
Lawrence T. Herman, Sara H. Runnels, and Kyle J. Chambers
Abstract
When proper technique, surgeon experience, or healing
on the part of the patient fail to meet expectations, a less
than desirable cleft palate repair may be encountered. These
patients present surgical challenges sometimes far exceeding
those seen with a virgin cleft. The presence of excessive scar-
ring, fistulae, altered blood supply, and often major tissue
loss present enormous difficulties for the surgeon attempting
revision. A thorough preoperative evaluation of the present-
ing defect becomes essential in establishing a viable treatment
plan. A full evaluation of the extent of the defect, analysis of
viable tissue within and surrounding the defect, and consider-
ation of distant tissue that can be mobilized and delivered to
the defect are the important points involved in the decision-
making process. If less than ideal conditions present them-
selves for surgical repair, then consideration of nonsurgical
options must take precedence. These would include obtura-
tion with a prosthetic appliance or consideration of alloplas-
tic implants. No option for repair of a poorly treated and
subsequently poorly healed cleft deformity will result in ideal
outcomes. All subsequent attempts at repair will have decid-
edly compromised conditions associated with the end result.
Treating the cleft patient correctly and comprehensively at
the initial attempt will always provide the best chance for
a result approaching normal anatomy. Revision procedures
continue to be fraught with compromises. Mobilized pedicled
flaps are often quite utilitarian in closing the oral component
of these defects. Nasal side closure is usually much more eas-
ily achieved. This chapter will outline the various options
available for treating the failed cleft palate. Emphasis will be
placed upon the utilization of mobilized local tissue.
Three anatomic areas where breakdowns are generally
seen will be identified with options for correction:
1. Anterior hard palate with extension into the alveo-
lar cleft.
2. Mid-hard palate extending to the junction of the
hard and soft palate.
3. Soft palate only.
Local and distant flaps available for correction of these
defects will be outlined. Consideration will be given
to the blood supply and the limitations upon length
and distance of mobilization. Postoperative issues of
venous return, oral hygiene, and need for tertiary pro-
cedures will be addressed.
Surgical Indications
A full and thorough evaluation of the presenting defect
and associated anatomy will be important in establish-
ing a treatment plan. All oral–nasal defects will require
a two-layer closure. This cannot be taken lightly. Any
one-layer attempt at closure will ultimately result in
failure with additional scarring and tissue loss. The
only exception to this rule would be an inferiorly
rotated temporalis muscle flap. Free grafts will also
fail. Healthy tissue with robust blood supply should
be the only options considered for revision surgery.
The patient has suffered wound breakdown with tis-
sue damage; further surgical attempts should be pre-
dictable and well planned. Nasal layer closure of most
defects is usually not difficult. This can be accom-
plished by reflection of tissue within or immediately
adjacent to the defect. Oral side closure presents a
much greater challenge. Options for oral side closure
would include1–6:
1. Buccal finger flaps.
2. Buccal advancement flaps.
3. Locally rotated palatal alveolar mucosa flaps.
4. Rotated or advanced island flaps.

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Video Atlas of Cleft Lip and Palate Surgery
5. Superiorly based pharyngeal flaps.
6. Anteriorly or posteriorly based tongue flaps.
7. Temporalis muscle flaps.
8. Combination of two of the foregoing flaps.
Surgical Equipment and Tools
• Dingman retractor and three blades
• Leibinger side retractor and two blades
• Towel clips
• Jeter needle holder (Lorenz)
• Jeter dissectors (Lorenz)
• Long straight needle holder with fine tip
• Short snaps (one straight and one curved)
• Long snaps (one straight and one curved)
• McKesson type suction tip (4-mm tip × 7")
• Frazier tip suction (#10)
• Small double skin hook
• Small single skin hook
• Senn retractor (blunt, three prongs)
• Small retractor (Ace)
• Minnesota retractor
• Dental aspirating syringe
• Periosteal elevators
• Curved Freer elevator
• Small awl (Ace)
• Small curved Allis
• Dental mirror
• Long pickups (one with teeth, one without)
• Short Adson pickups (one with teeth, one
without)
• College pliers (curved)
• Semken tissue forcep
• #7 knife handle
• #5 round style handle with angle
• #12 Locklin scissor (16 cm)
• Iris scissor (delicate tip, curved)
• Reynold’s curved scissor
• Curved Metzenbaum scissor 14.5 cm
• 16-cm curved Kelly scissor
• Bandage scissor
• Small bite blocks (small adult and child)
• Bone file
• Pediatric extraction forcep
• Small rongeur
• Large rongeur
• Small mallet
• Set of seven small osteotomes
• Dental extraction elevator
• Olsen–Heger needle holder
• 12.5-cm Ryder vascular needle holder
• 15.5-cm Ryder vascular needle holder
• Curved probe with eye
• Joseph nasal scissors, curved
• Fine caliper (0 to 40 mm)
• Bishop–Harmon tissue forcep
Anesthesia
• An oral Rae® tube facilitates good access to
the nose and alveolar cleft itself. At times, a
nasal intubation may be considered in the
noncleft naris.
• The patient is placed in Trendelenburg
position with a shoulder or neck roll utilized
to hyperextend the head for enhanced
visualization of the defect.
Surgical Procedure
The three major anatomic areas of concern will be out-
lined and dealt with individually. Specific problems
and associated solutions are presented.
General Considerations
1. The patient is prepped and draped in the usual
manner.
2. The surgeon positions himself or herself at the
head of the operating table and usually wears a
headlight.
3. A Dingman or Leibinger retractor can be utilized
for visualization of the defect.
4. Local anesthesia is administered, containing a
vasoconstrictor, into the soft tissues surrounding
the defect. Wait at least 7 minutes for maximal
vasoconstrictor effect.
5. Place a throat pack for airway protection.
6. While waiting for the local anesthesia, “sound” the
margins of the defect with a probe or periosteal
elevator; this will help determine the full extent of
the cleft/defect. This information is of great impor-
tance when designing the flaps.
7. Remove any inflamed, gelatinous, or redundant
soft tissue from the margins of the cleft/defect.
This is done surgically with a #11 and/or #15 blade.
This helps visualize the entire extent of the defect.

Revision Cleft Palate Repair
231
If you cannot visualize the full extent of the defect,
you cannot get proper two-layer closure.
8. Remove any carious, malpositioned, or supernu-
merary teeth (within the cleft/defect) that may
interfere with clean two-layer closure. Without a
tension-free watertight closure, the site is likely to
break down.
9. In developed countries, such teeth should be
removed at least 8 weeks prior to surgery to ensure
full soft tissue healing.
Anterior Palatal Fistula With or Without
Extension into the Alveolar Cleft
(Video of Revision Repair of Anterior Palatal
Defect with Advanced Island Flap)
This is a defect often seen just palatal to the anterior
teeth. It can be quite large and extend anteriorly into
the alveolar cleft (unilateral or bilateral) or posteriorly
into the cleft palate. It usually results from breakdown
at the anterior aspect of the oral- or nasal-side closures
of the cleft palate. Frequently, extension anteriorly of
the nasal and/or oral layer flaps is inadequate with clo-
sure under tension. The end results are necrosis, loss
of tissue, and oral–nasal communication. This is par-
ticularly disabling for the patient with constant escape
of liquids and solids into the nose. Speech may also
be affected. Scarring is present circumferentially to the
defect as a result of necrosis of the original palatal flaps.
Two-layer closure will be required for proper healing of
the site. The suggested approach for correction of this
defect will be as follows:
Nasal Layer Closure
This side of the defect is usually easy to close. Tissue
is reflected off the margins of the defect and rotated
superiorly up into the nose. All redundant, inflamed,
or friable tissue is first stripped from the margins of
the fistula. This maneuver will create better visibility
into the fistula and allow for full assessment of the
defect. Be certain to leave adequate tissue on the walls
of the defect as excess tissue is excised. Do not excise
redundant tissue down to bone. This is important to
allow for intact tissue, with periosteum attached, to
be reflected into the fistula. Small dissecting instru-
ments and a headlight are best utilized for these cases.
The nasal layers once freed and approximated can be
sutured with 5-0 Vicryl™ sutures on a small needle. The
epithelialized side of this flap is turned into the nose. If
the defect extends into the alveolus, consideration can
be given for a simultaneous bone graft. Two-layer soft
tissue closure, however, is adequate for good healing.
Most patients in developing countries will not have
orthodontics or dental implants as an option; these
patients are thus well served with a healthy, watertight
soft tissue closure of the fistula/alveolar cleft.
The specifics of surgical closure are as follows:
1. Mark the edges/margins of the defect with a
marking pen. Pay close attention to the edge of the
defect to be sure you leave enough of a margin/
cuff of soft tissue to suture without tension. This
tissue will form the nasal layer (Figure 16–1).
2. Once the incision is marked, use a #11 or #15 blade
(an angled blade handle is helpful) to make the
incisions. The flaps will be full thickness within the
Fistula of Posterior Palate
Fistula of Anterior Palate
Figure 16–1.  Nasal-side closure of fistulae.

232
Video Atlas of Cleft Lip and Palate Surgery
defect and therefore down to bone (where present).
As the cuts move posteriorly into the previously
repaired cleft palate, a split-thickness technique will
be necessary (as no bone exists within this region).
3. Care must be exercised at the palatal (distal) lim-
its of the surgical site as mobilization of flaps and
suturing are particularly challenging in these areas.
4. The buccal portion of the incision may extend into
the alveolar cleft and should remain superficial.
Once the incision is made, the layers can be devel-
oped with the use of fine cutting scissors. The tissue
in this area is more mobile; therefore, less dissection/
undermining is needed to approximate the margins.
5. The incisions should cover the entire extent and
anatomy of the defect in a circumferential manner.
Any failure to accomplish this goal will ultimately
result in residual fistulae.
6. Carefully roll/reflect the tissues toward the medial
portion of the defect using a periosteal or other ele-
vator (Jeter or Woodson). Work posterior to ante-
rior (palatal to buccal) ensuring you have sufficient
tissue to close the nasal mucosal layer without ten-
sion. If the tissues on one side of the defect are thin
or deficient, you can roll the thicker side toward
the weaker side. This will often compensate for fri-
able or less than ideal tissue on one side of the cleft.
The key is to establish full closure along the entire
length of the residual cleft, thereby securing sepa-
ration of the nasal cavity from the oral cavity.
7. Dissection must be carried up to the height of the
floor of nose for the best functional result.
8. Excess tissue at the margins of the flaps may be
carefully trimmed using fine scissors. This allows
for clean, neat margins that facilitate surgical
approximation of the flaps.
9. At this point, the entire nasal layer of the defect
must be well visualized and the edges easily and
passively brought together in the midline. It is now
possible to proceed with tension-free closure of the
nasal layer. Begin closure at the palatal-most aspect
of the defect, working toward the buccal using 5-0
Vicryl™ suture on a P-2, P-3, or fishhook needle.
Sutures may be mattresses or interrupted. The goal
is to create a watertight nasal mucosal layer. One
can check this by instilling saline, with or without
methylene blue, into the naris on the side of the
defect. You should not see a leak at this point.
Oral Layer Closure
As noted earlier in the chapter, oral-side closure of
palatal defects (fistulae) is the most challenging aspect.
Two-layer closure is again emphasized. It is therefore
critical to identify and mobilize healthy tissue onto the
defect from the oral side. In the anterior palatal region
this can be best accomplished by searching for tissue
from:
a. Adjacent palatal mucosal shelves.
b. Buccally advanced via finger or advance-
ment flaps.
c. Island flaps pedicled off the greater palatine
artery.
d. Anteriorly based tongue flap.
e. A combination of two of the foregoing.
The surgical specifics of these options are as follows:
Rotation of Tissue Off Adjacent Palatal Mucosal
Shelves
Examine the palatal tissues carefully for scarring and
assess the full extent/anatomy of the defect. This
will provide direction regarding the amount of tissue
required for closure of the full defect; it will also assist
with decisions as to the best location for harvesting of
this tissue. Look for available sources of tissue from
the palatal shelves for oral layer closure. This will be
the best location for finding viable tissue. It will gener-
ally be keratinized and thus obviate the need for exces-
sively long buccal finger or rotational flaps. Buccal
flaps are nonkeratinized and therefore less than ideal
for coverage of the defect. Flap length also needs to be
addressed; violation of the 1:3 (base-to-length) ratio can
result in necrosis at the tip of longer flaps. Rotational
flaps off the palatal shelves or island flaps pedicled
off the greater palatine artery are excellent options for
coverage of large fistulae, especially those that extend
deep into the hard palate. These palatal flaps will often
need to be utilized in conjunction with smaller buccal
advancement flaps. For very large and anatomically
difficult palatal fistulae, oral-side closure may often
only be possible with the use of a tongue flap.
Technique
1. The flaps adjacent to the defect are advanced medi-
ally (technically difficult due to scarring) over the
palatal aspect of the defect and sutured (Figure 16–2).
Palatal tissues are generally scarred down due to
past repair of the hard palate. Mobility, therefore,
may often be gained only via delicate separation
with sharp scissors from the now closed nasal layer.
2. Once separation from the nasal layer is achieved in
the region of the palatal fistula, the tissue is elevated
subperiosteally from adjacent areas where palatal

Revision Cleft Palate Repair
233
bone exists. This is achieved most efficiently with
the use of a periosteal elevator. This may be done
on only one or both sides of the defect dependent
on the amount of tissue available and the degree of
mobility required to cover the palatal extension of
the defect/fistula.
3. When developing flaps and assessing mobility of
said flaps, lateral releasing or posterior releasing
incisions may be helpful. These releasing incisions
can be made full thickness over the palatal bone
and carefully developed using a periosteal eleva-
tor in a subperiosteal plane. Blood supply, how-
ever, to any such flap, must be carefully evaluated
and all efforts made to prevent necrosis. Judicious
planning of flap design prior to incision will elimi-
nate failure of poorly designed oral mucosal flaps.
Flaps with excessive amounts of scar tissue will
not provide good blood supply.
4. The lateral releasing incision is made full thick-
ness over bone and close to the necks of adjacent
teeth. This is done to maximize the breath of the
flap. Often, the amount of tissue available is lim-
ited, and therefore maximizing the width/breadth
of the flap is very important.
5. Lateral releasing incisions will allow for more
medial rotation of the flap but will not aid in
anterior movement. In fact, these types of palatal
flaps will have a tendency to move slightly pos-
terior when rotated medially over the defect. This
must therefore be accounted for when planning the
design of such a flap. As these palatal rotational
flaps move medially and posteriorly, they will
therefore cover less of the anterior aspect of the
defect. This then necessitates the need for a buccal
flap to cover the anterior aspect of the defect.
6. Lateral releasing incisions may be extended as far
posteriorly as necessary and frequently as far back
as the tuberosity.
7. Care must be taken when extending any of these
flaps posteriorly to avoid damage to the greater
palatine artery, the major blood supply to the flaps.
8. A small posterior triangular releasing incision may
allow for some minimal anterior movement of the
flap as well as facilitating medial movement.
9. The defects (over bone) created by medial move-
ment of palatal tissue will be left to granulate in
the postoperative period. It is not necessary to pack
these defects with Surgicel® or other hemostatic
agents unless excessive bleeding ensues.
Buccally Advanced Tissue 
Examine the size and extent of the buccal defect to
assist with the decision-making process regarding the
amount of tissue necessary for coverage. It is impor-
tant to close as much of the palatal extension of the
defect/fistula as possible prior to creating the buccal
flaps. All flaps need to be tension-free, have good blood
supply, and ideally provide keratinized tissue. Buccal
flaps are not good sources of keratinized tissue; utilize
as much keratinized palatal tissue as possible for oral
closure of these defects. To gain freedom and mobility
A
B
Figure 16–2.  Lateral palatal flap with posterior triangular releasing incision.