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21 Unilateral Cleft Lip Repair
277
wing, and the muscle in the medial lip between the midline and the cleft is hypoplastic [14]. The curves of the normal upper lip have been likened to the shape of
Cupid’s bow throughout history [15]. In the normal lip, the cutaneous vermillion
junction, or white roll, appears to be histologically related to the pars marginalis of
the orbicularis oris [15]. The philtral columns are histologically related to decussating orbicularis oris muscle bers with musculocutaneous insertions [15]. In patients
with cleft lip, the pars marginalis of the orbicularis oris is underdeveloped; therefore, the white roll is not present around the cleft [15].
Indications
Treatment of cleft lip requires surgical repair. This typically involves a multidisciplinary team and can involve a course in presurgical orthopedics. The timing of
surgical repair and the decision of whether to address the nasal deformity at the time
of cleft lip repair is something that is debatable and inuenced by surgeon preference and case-specic variables [1, 16–18]. In regards to the timing of repair, the
rule of 10s has been proposed [19]. This requires the patient to weigh 10 pounds,
have a hemoglobin of 10mg/ dL, a white blood cell count of less than 10,000/m3,
and an age of 10weeks [1, 19]. Worldwide, it has been found that 66% of surgeons
repair cleft lip when the patient is 3–6months of age, while 33% of surgeons repair
the cleft lip when the patient is less than one month old [16]. The advantages of
waiting until 3–6months of age include allowing for a course of presurgical orthopedics and also to allow for additional growth. While some argue that anesthetic
risks are decreased, others argue that the anesthetic risk is not different between a
3-month-old child and a healthy full-term newborn [1, 16, 20]. Multiple groups
have reported good aesthetic outcomes with cleft lip repair during the rst month of
life in healthy full-term babies and have argued for the benets of improved feeding
and improved psychological effects for the family [16, 20].
During the rst part of the twentieth century, repair of the cleft lip nasal deformity was delayed for fear of disturbing growth. However, over the past several
decades, the safety and efcacy of primary rhinoplasty during the cheiloplasty have
been well reported on [18, 21, 22]. With the advent of nasoalveolar molding and
postoperative nasal stenting, long-term aesthetic results have improved beyond
what primary rhinoplasty alone could achieve. In a retrospective study examining
nostril height and width ratios at 5years of age after primary rhinoplasty, nasoalveolar molding, or nasoalveolar molding and primary rhinoplasty, it was found that
patients who underwent both nasoalveolar molding and primary rhinoplasty with
overcorrection of nostril height had improved outcomes [23]. Managing the bilateral cleft nasal deformity is particularly challenging, and the utility of presurgical
orthopedics in these patients has been described as well [17, 24].
278
A. Namin and R. F. Brown
Preoperative Planning
Patients with cleft lips should be under the care of a multidisciplinary team, including a pediatrician, dietician, feeding/speech specialist, orthodontist, and social
worker. Weight gain should be carefully monitored in the preoperative period.
Patients with syndromes or comorbidities should be under the care of appropriate
pediatric specialists.
Efforts to minimize the cleft lip deformity preoperatively with the goals of
improving the ease of repair and hopefully long-term outcomes have long been
attempted [25–28]. It was noted that the cleft lip nasal deformity was largely due to
deformity of the lower lateral cartilage and nasal base and that auricular deformities
could be successfully managed in a nonoperative fashion in neonates [28].
Subsequently, nasal molding was undertaken to partially correct the nasal deformity
prior to denitive repair. Lip taping and adhesion were also described in attempts to
narrow wide clefts [25, 26]. While lip adhesion did narrow the cleft width, the disadvantages of lip adhesion being a separate general anesthetic and the potential for
scarring that would potentially impair or limit denitive repair have led this technique to be utilized less frequently during the current era [25]. Lip taping did not
require an anesthetic but did not have an effect on the nasal form or alveolar deformity. Lip taping is commonly utilized with nasoalveolar molding. The objectives to
improve the nasal, lip, and alveolar deformity prior to denitive repair eventually
led to the description and more widespread use of nasoalveolar molding.
An important consideration in preoperative planning is presurgical orthopedics
and, more specically, nasoalveolar molding, which was introduced by Grayson in
the late 1990s [27, 29]. It was found that molding techniques could improve the
nasal deformity in cleft lip prior to repair and, therefore likely improve the longterm outcome [28]. In nasoalveolar molding, an orthodontic device is made to mold
to the alveolar segments that narrow the gap and also have a nasal component that
extends from the alveolar device on a wire to mold the shape of the lower lateral
cartilage and nasal base [29–31]. The Grayson and Figueroa techniques are the two
most commonly utilized techniques in nasoalveolar molding, and a study comparing the outcomes of these techniques found no signicant differences in the longterm postsurgical outcomes [29]. The vast majority of studies support that
nasoalveolar molding improves the outcomes of cleft lip repair and that better outcomes can be achieved in more severe deformities [27, 30, 31]. The nasolabial
deformity in the bilateral complete cleft lip is particularly challenging to address,
and patients who have undergone preoperative nasoalveolar molding were found to
have signicantly improved columellar length and require signicantly less secondary nasal surgery [32].
Instruments/Equipment
• Bipolar electrocautery
• Skin hooks
21 Unilateral Cleft Lip Repair
279
• Forceps (Adson, 0.5mm, Bishop-Harmon, etc.)
• Fine-tipped dissecting scissors (tenotomy, converse, curved iris, etc.)
• Frazier tip suction
• Caliper
• Needle driver
• Elevator (Cottle, Freer)
• Dissolvable sutures
Surgical Technique
Marking
The surgical procedure begins with the marking of the anatomical landmarks with a
Caliper. Methylene Blue can be used, but the authors like to use a 25- or 27-gauge
needle and stab the tip of the needle into the tip of a blue marking pen. This tends to
run less than Methylene Blue. The needle can then be used to mark the lip landmarks and tattoo the dermis. If the tip of the needle penetrates the dermis of the skin,
then the surgical prep will not remove the markings.
The markings (see Fig.21.1) that are made include:
1. The depth of cupid’s bow (1).
2. The height of cupid’s bow on the noncleft side (2).
3. Then, use the distance between the depth of the cupid’s bow on the non-cleft side
and then mark the same distance from the cupid’s bow on the cleft side (3).
4. Measure the height of the philtral column on the noncleft side (4 to 2). Then
measure the philtral column on the cleft side (5 to 3).** The difference between
these two philtral columns will be the length/width of the C-ap.
5. Mark 1mm up on the columella, 3/5th of the way on the columella away from
the cleft. (The cutting line will be from 3 to 6).
6. Mark the back cut from the point marked on the columella at a 90-degree angle
(point 7). The length of the back cut will be the length of the C-ap measured in
step #4. (If there is a large asymmetry and a long C-ap is needed, the back cut
should not cross the philtral column, but once the philtral column is reached, the
cut should follow the philtral column inferiorly.)
7. Take the measurement from the noncleft side philtral column (4 to 2), and with
the caliper, nd a point medial to the alar base and vermillion on the cleft side
and mark that and the point on the cleft-side vermillion that equals that measurement (8 to 9).
8. Measure the visible lip where the cut through the red lip will happen on the cleft
and noncleft sides and try to have them match.
9. The aps in the surgery can be marked. The authors prefer to use the above
points and make dots, as they nd it less messy and does not smear as much. But
aps can be drawn out once the above points have been marked. The C-ap will
be skin only and is lateral to the 3–6 philtral column cut and does not include lip
280
A. Namin and R. F. Brown
6
4
7
2
1
5
C
M
3
8
L
9
Fig. 21.1 Markings for unilateral cleft lip repair
mucosa. It should be based just posterior to the cleft-side medial crura in the
nose. The M-ap is the lip mucosa and vermillion just inferior to the C-ap skin
on the noncleft side. It is a superiorly based ap. The M-ap (medial ap) can be
used to help repair the nasal oor in a wide cleft. But it is best to save all tissue
until you are sure that it is not needed. The L-ap (lateral ap) is the lip vermillion and mucosa just medial to the planned philtral column cut on the cleft side
(8 to 9). It is a superiorly based ap and is always used to add tissue underneath
the nostril rim, so that the ala can be curved on the cleft side. It can also be used
to repair a nasal oor defect.
21 Unilateral Cleft Lip Repair
281
The lip is then injected with local anesthetic with epinephrine to decrease
bleeding. The authors like to use a mixture of 1% lidocaine with 1:100,000 epinephrine and 0.25% plain Marcaine. The face is then prepped, and the patient is
draped in the usual sterile fashion (See Fig.21.2).
Surgical Steps/Incisions
1. Incise from the height of Cupid’s bow on the cleft side to the point marked on the
columella and then cut the measured length of the back cut (3 to 6). The authors
like to use an 11 blade to be able to make nice straight cuts along the planned
incision lines.
2. Cut along the vermillion lateral from the 3 to 6 cut (do not include any) and raise
the C-ap. Keep the C-ap thick so that it is well-vascularized. Extend the elevation of the ap to just posterior to the footplate of the medial crura in the cleftside nostril.
3. Raise the M-ap. If it is a complete cleft lip, then the M ap can be continued
posteriorly into the nose and onto the septum. This can be used to close a wide
nasal oor defect. Elevation of the septal ap is best done with a caudal or freer
elevator and should be elevated right on top of the cartilage.
4. Make the cut along the cleft-side that was marked 8 to 9. Once you reach the
vermillion it is possible to save a V shape of extra vermillion that can be used to
plump up the central lip.
Fig. 21.2 Pre-op markings and post-op result
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A. Namin and R. F. Brown
5. Cut along the upper gingival buccal sulcus of the cleft side. Then, elevate the soft
tissue that overlies the maxilla. The width of the cleft will determine how aggressive you need to be in this elevation. It is best to put a nger on the eye because
the distance is not far in infants. Care should be taken to not damage the infraorbital nerve. The authors prefer a supraperiosteal dissection.
6. Raise the L-ap. This is a mucosal ap. The superior cut of the ap will be cut
right up to the superior lateral edge of the head of the inferior turbinate and the
ap is based on the inferior turbinate. This cut should extend down to the piriform aperture and the soft tissue can be freed-up supraperiostally off of the maxilla and join the elevation that occurred through the upper gingival buccal sulcus
incision. This should free up the cleft side lip so that it can be advanced without
tension (See Fig.21.3).
7. Using ne-tipped scissors (curved iris or converse), insert them between the
medial crura and separate them. Then turn the scissors and come up over the
domes and over the lower lateral cartilages. Separate the overlying skin from the
cartilage. This will allow you to reposition the lower lateral cartilages more symmetrically. The cleft-side lower lateral cartilage, which is long and attened, can
nish being separated from the overlying skin by dissecting from the piriform
and upper gingival-buccal sulcus cuts. A completely dissected tunnel should
exist along the cleft side lower lateral cartilage and ala to break up abnormal
attachments and allow it to be repositioned. All muscle attachments to the alar
base on the cleft side should be removed.
8. Dissect free orbicular oris muscle pendants on both sides of the lip, but do not
dissect past the philtral columns.
Closing/Suturing
1. Inset the L-ap into the piriform aperture incision. This will provide extra tissue
to be able to curve the ala. If the nasal oor has a defect, the L-ap can be inset
into the piriform aperture incision but also bent over at its midpoint and attached
to the M-ap/septal ap on the non-cleft side. If present, the nasal oor defect
should be xed with a combination of the M-ap/septal ap and L-ap, and any
extra tissue should then be trimmed. Chromic or Vicryl suture can be used for
this step. It is an important step to ll in the nasal oor defect, as it an area hard
to reach in later cleft palate repair, and can leave an anterior stula.
2. Using a 3-0 or 4-0 Vicryl suture, grab the lateral gingiva-buccal tissue and
advance it medially and secure to the gingival periosteum. This will help take
tension off of the repair.
3. Close the orbicularis oris muscle together. Make sure that you rotate and advance
the lip and see where the muscle should line up on each side. Mattress sutures
can be used to try to evert the muscle to aid in creating a philtral column if
desired. Vicryl or Monocryl suture can be used. If the muscle is reapproximated
correctly, this should almost completely align the cleft side ala.
4. Place a deep layer of dissolvable suture such as Vicryl or Monocryl.
21 Unilateral Cleft Lip Repair
283
C
1
ML
2
Fig. 21.3 Appearance of lip after making initial surgical incisions. (1) Non-cleft side of lip will
rotate down. (2) Cleft side of lip will advance forward. This is why it is called a rotation advancement procedure. Note that the rectangular defect at the base of columella will be lled by the “C
ap”. The “M ap” and the “L ap” will be used to close the nasal oor defect
5. Now inset the C-ap. With the noncleft side being rotated down, the 90-degree
back cut should open to create a rectangular defect. The C-ap is inset in this
defect, and the extra tip of the C-ap is trimmed.
6. Close the skin. Skin sutures should not provide any strength to the closure; there
should be no tension on the closure from the deep sutures. The skin sutures are
to align the skin and ensure that the skin on both sides of the repair is at the same
level. Either permanent sutures or dissolvable fast-gut sutures can be used.
284
A. Namin and R. F. Brown
Permanent sutures will likely require another brief anesthetic to remove (see
Figs.21.4, 21.5, and 21.6).
A dissolvable suture such as a 4-0 Monocryl or PDS can be used to straighten the
medial crura and reattach them to each other. The needle is passed from high on the
noncleft side medial crura to low on the opposite medial crura of the cleft side, and
L
M
C
Fig. 21.4 Appearance at the end of suturing. Note that the “C ap” has lled in the columellar
defect. This hides the incisions within the base of the columella and avoids the non-anatomic curving incision of the traditional Millard repair. Note that no incisions have been made along the nasal
ala on the cleft side which can create visible scars. The “M ap” and “L ap” are not seen from the
outside, but are reconstructing the anterior nasal oor which will prevent an anterior stula during
the cleft palate repair which can be very hard to repair
21 Unilateral Cleft Lip Repair
Fig. 21.5 Pre and post-op photos for left-sided unilateral cleft lip
285
Fig. 21.6 Pre and post-op photos for right-sided unilateral cleft lip
286
A. Namin and R. F. Brown
then back high on the cleft side and out high on the noncleft side and tied. If the
cleft-side ala needs to be elevated at the end of the procedure, then dome elevation
sutures can be placed. A Monocryl or PDS suture on a long, curved needle can then
be passed from underneath the lower lateral cartilage on the non-cleft side, up over
the tip, through the cleft-side lower lateral cartilage and into the cleft-side nostril.
Then go back in from underneath the cleft-side lower lateral cartilage, over the
domes, back through the upper cleft-side lower lateral cartilage and into the noncleft side nostril. Tie this suture, and it will help elevate the attened ala. This can
be repeated as needed. The angle of turning the needle blindly over the tip is difcult but worth learning to improve the symmetry of the nostrils.
Postoperative Management
Postoperative care includes routine incisional care of gently cleaning the incisions
with saline every 2–6hours, and then antibiotic ointment is applied to keep the incisions moist. It is important to show the parents how to clean the incision gently to
avoid damaging the repair. Feeding begins when the baby desires. If an infant, then
they can breastfeed, use a syringe or a soft-tipped bottle. Only breast milk or formula should be given. Paciers should not be used. If an older child, then very soft
or pureed food should be given. Forks, straws, and other utensils should be avoided.
Parents should strongly be encouraged to use arm splints/restraints for 2–3weeks
in younger patients so that they cannot reach the lip repair and damage it. Infants
should be placed to sleep on their backs to avoid the incision being rubbed against
anything while sleeping.
Infants are typically discharged on postoperative day 1. Older children could
potentially be performed as an outpatient depending on their health and
circumstances.
Three to four weeks after surgery, Vitamin E oil or other products could be used
to help improve scarring.
Postoperative nasal molding can be employed for up to 1year postoperatively to
improve the form of the lower lateral cartilage. Long-term follow-up into adolescence is important to assess aesthetic and functional results and identify patient
desires for revisional procedures to improve the aesthetic outcome.
References
1. Shkoukani MA, Chen M, Vong A.Cleft lip—a comprehensive review. Front Pediatr. 2013;1:53.
2. Jones MC. Prenatal diagnosis of cleft lip and palate: detection rates, accuracy of ultrasonography, associated anomalies, and strategies for counseling. Cleft Palate Craniofac
J. 2002;39(2):169–73.
3. Bhattacharya S, Khanna V, Kohli R.Cleft lip: the historical perspective. Indian J Plast Surg.
2009;42(Suppl):S4–8.
4. Boo-Chai K.An ancient Chinese text on a cleft lip. Plast Reconstr Surg. 1966;38(2):89–91.
5. Perko M.The history of treatment of cleft lip and palate. Prog Pediatr Surg. 1986;20:238–51.