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normal philtral column that you must achieve on the cleft side. You also need to establish the normal width of the nostril floor. To do this, mark the midpoint of the columellar base and subalare. This distance must equal the distance between subalare on the cleft side and your midline columellar base mark. The defect in the nasal floor will need to be closed to close this distance. At the junction of the nasal floor and the lip skin, mark off a proposed “wedge excision” (two marks here) that will achieve this. Noordhoff’s point: the point at which the white roll begins to fade and where the vermillion begins to thin toward the cleft must now be marked. In the Millard repair, the incision is made through the vermillion to the new Cupid’s bow peak and then up toward the columellar midpoint. A back-cut via “cut-as-yougo” is then made toward the open circle. This releases the lip, thereby lengthening the noncleft side. Care must be taken to avoid crossing the noncleft philtral column. On the cleft

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side, the incision is carried through the vermillion and Nordhoff point, to the superior-medial most point on the cleft lip, then back laterally toward subalare along the skin/nostril sill junction. Nasal dissection for primary rhinoplasty is then performed through these incisions. Once the muscle is dissected free of the skin and mucosa, and disinserted from its abnormal attachments, it can be reapproximated transversely in the midline. The mucosa is also closed in a separate layer, using the M-flap, and then the Lflap is used for nasal lining. The C-flap rotates toward the columella for inset, and closure of the lip commences with the white roll. A, advancement flap; R, rotation flap.

Incorporates the Z-plasty superiorly “Cut-as-you-go” technique Medial lip rotated downward C-flap (“c” is for columella): C-flap back-cut is variable and is determined intraoperatively

Rotated to create the nasal sill or used to lengthen the columella (more common)

L-flap: Nasal lining is repaired with L-flap from mucosal portion of lateral segment (“l” is for lining)

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This is required because the cleft ala is posteriorly displaced (Fig. 13-2). When ala advanced forward to desired position, mucosal defect must be filled to prevent contraction. May also be filled with turbinate flap.

M-flap: Gingivolabial sulcus is augmented with M-flap from mucosal portion of medial segment (“m” is for mucosa). Scar follows the line of philtral column and preserves Cupid’s bow. Orbicularis oris muscle repair is important to restore dynamic lip function.

Muscle fibers are inappropriately inserted into the alar base and columella. Must be completely disinserted and repaired in a transverse position.

Primary rhinoplasty

Diffuse undermining of alar cartilage Transnasal suture techniques to secure desired position

May use nasal conformers to maintain shape Common pitfall: inadequate rotation and inadequately corrected vertical lip height on noncleft side; “whistle deformity”

Mohler repair

Similar to Millard but the back-cut is moved from the medial lip element to the columella

Allows for scar to simulate the unaffected philtral

column End result appears more like an asymmetric Z-plasty repair than rotation advancement

Fisher repair (anatomic subunit, Fisher DM; Plast Reconstr Surg. 2005) (Fig. 13-5)

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Figure 13-5 Unilateral cleft lip Fisher repair. The height of the greater lip

segment is measured from white roll to the apex of philtral column “a.” The height of the lesser lip segment is similarly measured “b.” The difference between “a” and “b” is made up with a triangle from the cleft lip element “c.” Because of the Rose-Thomson effect, 1 mm is subtracted from triangle “c.” Noordhoff point is marked on the cleft side. From the proposed location of the

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philtral column apex on the cleft side, the length “b” is marked with a compass so that it coincides with Nordhoff point and the triangle “c.” A back-cut is made beneath “a” to admit the triangle “c.” A similar triangle may be required in the vermillion to augment the thickness of the vermillion on the medial aspect of the cleft.

Markings are similar to Millard but closure lines are placed along anatomic subunits Stresses the importance of complete leveling of the Cupid’s bow a = greater lip heightb = lesser lip heightc = difference between “a” and “b” A white roll triangular flap (a “Nordhoff triangle” or “c”) is used to achieve Cupid’s bow symmetry The equation: a − b − 1 mm = c

Accounts for 1 mm lengthening effect

“Rose-Thompson” effect: lip repair via closure as

an ellipse will “automatically” lengthen the incision Vermilion height is equalized by using a similar triangle as a vermilion flap

BILATERAL CL REPAIR—MILLARD (FIG. 13-6)

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Figure 13-6 Bilateral cleft lip deformity, with preoperative markings. The most

inferior point on the prolabium is marked; this will become the trough of the Cupid’s bow. The proposed peaks of the Cupid’s bow are marked ~3 mm lateral, on each side, to this point. The center of the columellar-labial junction is also marked, and 2 mm lateral to this, on each side, a mark is also made. Draw a neck-tie that connects these dots. On the lateral lip elements, Nordhoff points are defined and marked above the white roll.

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About 3 mm lateral to these points, a mark is made that will allow (a) and (a’) to coincide upon closure. Mark subalare bilaterally. The height of the philtrum (b) is transferred to each lateral lip element (b’). Line (c) is marked extending into the nasal floor and (c’) is made to equal length. A similar concept to the unilateral repair is applied to the nasal floor in the bilateral repair, in that a wedge must be taken from the floor to narrow it. This corresponds to (f) and (f’). The prolabial skin inside of the original markings is discarded and the mucosa is used for lining. Lines (e) and (e’) are made to close the distance in vertical lip height to subalare. The lateral lip elements rotate downward, forming the tubercle in the midline.

Prolabium is used to create the philtrum only

Prolabial white roll and vermillion are discarded; the remaining prolabial mucosa is rolled inward to reconstruct the central gingivolabial sulcus Prolabial vermillion lacks minor salivary glands→using this tissue results in dry, chapped, keratotic “patch” Prolabial vermillion previously used in Manchester repair (of

historical interest) Tip: make width of philtral flap near columella 1-2 mm narrower than inferior portion near white roll to allow for subsequent widening

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Cupid’s bow and tubercle reconstructed from lateral lip segments, which are advanced medially beneath the elevated philtral flap Alar cinch suture to reposition alar bases Common pitfall(s)

Inadequate columellar length

Poor projection of tubercle

May have significant widening of the prolabium

POSTOPERATIVE CARE

GENERAL CONSIDERATIONS

Early postoperative airway monitoring is required. Nerve blocks may be used to help with postoperative pain control. Arm restraints are often used but have not been shown to affect complication rates.

COMPLICATIONS

Early: airway obstruction, hematoma, infection, dehiscence Late

Hypertrophic scars: consider massage, silicone sheeting,

and/or steroid injections

Short scar/lip

May be amenable to the addition of Z-plasty Likely requires complete revision

Deficient tubercle

Most commonly encountered following bilateral repair If deficiency is minor, can consider dermal or frat graft If deficiency is larger, will likely require Abbe flap

Lip sharing procedure from the lower lip

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Usually performed after maxillary growth or Le Fort I advancement

SECONDARY RHINOPLASTY

May be performed at any age, but commonly at skeletal maturity Open approach requires creative use of preexisting incision or judicious planning of transcolumellar incisions Requires stable bony foundation for the base of nasal pyramid (ie, previously suitable alveolar bone grafting to address maxillary deficiency) Must address poor tip projection and abnormal alar position Columella and caudal septum may require repositioning to the cleft side and suturing to the ANS Requires addition of anatomic and nonanatomic cartilage grafts Alar contour grafts

Onlay tip grafts

L-strut grafts

Severe septal deviation may require aggressive submucous

resection of ethmoid in addition to septal cartilage (used for

grafts) Spreader grafts often needed for airway patency at internal nasal valve (see Chapter 60: Rhinoplasty)

QUESTIONS YOU WILL BE ASKED

1. Describe basic CLP epidemiology a. Asians>Whites>Blacks b. Left:right:bilateral; 6:3:1

2. What are key timepoints and events in CLP embryology? a. 4-7 weeks, critical period b. Cleft lip: failure of fusion medial nasal process and maxillary

prominence

c. Cleft palate: failure of fusion palatal shelves

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3. What is most common CLP syndrome and what are the findings? a. Van der Woude b. Autosomal dominant with lip pits and CLP

4. What is pathologic anatomy of cleft nasal ala? a. Posterior and superior displacement b. Loss of convexity of lower lateral cartilage

5. What is primary goal of unilateral CL repair? a. Increase the height of medial CL segment b. Restore continuity of orbicularis c. Reposition alar base(s)