Unilateral Cleft Lip Repair An Anatomical Subunit.9

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Unilateral Cleft Lip Repair: An Anatomical

Subunit Approximation Technique
David M. Fisher, F.R.C.S.C., F.A.C.S.
Toronto, Ontario, Canada
qgexsrbaP570SW0/B on 11/24/2023
Background: A technique of unilateral Conclusions: A technique of unilateral

cleft lip repair is described. The repair cleft lip repair is described. The repair al-
draws from a variety of previously described lows for a repair line that ascends the lip at
repairs and adheres to a concept of ana- the seams of anatomical subunits. (Plast.
tomical subunits of the lip. Cases from Reconstr. Surg. 116: 61, 2005.)
within the spectrum of the deformity have
been chosen from a series of 144 consec- SURGICAL TECHNIQUE
utive cases to demonstrate the applicability After satisfactory induction of anesthesia and
of the technique in all forms of unilateral placement of a conformed oral endotracheal
cleft lip. tube fixed on the chin in the midline, the
Methods: Incisions cross the lip perpendic- patient is placed in the supine position with the
ular to the cutaneous roll at the cleft side neck slightly extended using a small shoulder
peak of Cupid’s bow of the medial lip and roll. The operating table is tilted into a slight
at the base of the philtral column of the reverse Trendelenburg position. Presurgical
lateral lip. Above this level, incisions ascend photographs and measurements are obtained.
the lip to allow for approximation along a The face is prepared and draped.
line symmetrical with the non– cleft-side
philtral column. Incisions then ascend su- Markings
perolaterally bordering the lip columellar Medial lip. The midline and height of the
crease to the point of closure in the nostril non– cleft-side philtral column are marked at
sill. A Rose-Thompson lengthening effect the lip-columellar crease (points 1 and 2) (Fig.
occurs just above the level of the cutaneous 1). Point 3, the height of the cleft side philtral
roll. If necessary, a small triangle positioned column, is marked on the lip-columellar crease
just above the cutaneous roll is often used. to mirror point 2 relative to point 1. The upper
Any central vermilion deficiency is aug- lip midline and peaks of Cupid’s bow are
mented by a laterally based triangular ver- marked at the vermilion-cutaneous junction
milion flap from the lateral lip element. (points 4, 5, and 6). Along lines perpendicular
Results: Since January of 2000, this tech- to the vermilion-cutaneous junction and pass-
nique has been used in 144 consecutive ing through the peaks of Cupid’s bow, points 7
unilateral cleft lip repairs. The inferior tri- and 8 are marked just above the cutaneous roll
angle is small (average, 1.24 mm; range, 0 (at the junction between the cutaneous roll and
to 2 mm). The technique can be applied to the “flat” portion of the upper lip). Line 3– 8
all degrees of unilateral cleft lip. should mirror the non– cleft-side philtral col-
umn (line 2–7) in its upper part. The opening
From the Division of Plastic Surgery, The Hospital for Sick Children, and the Department of Surgery, University of Toronto. Received for
publication April 9, 2004; revised August 23, 2004.
Presented at the American Cleft Palate–Craniofacial Association meeting, in Chicago, Illinois, March 19, 2004, and at the Canadian Society
of Plastic Surgeons/Société Canadienne des Chirurgiens Plasticiens meeting, in Hamilton, Ontario, Canada, June 3, 2004.
DOI: 10.1097/01.PRS.0000169693.87591.9B
61
62 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2005
incision in the red lip that will accept a laterally
based vermilion flap from the lateral lip
element.
The markings on the medial lip vary little
from case to case. The position of point 3 and
therefore of the slope of line 3– 8 will vary

between cases to exactly mirror the position

and slope of the non– cleft-side philtral col-
umn. For minor clefts, the degree of downward
rotation of the cleft-side peak of Cupid’s bow
may be minimal, and therefore an inferior tri-
angle may not be necessary. In such cases, the
required lengthening (of 1 mm or less) can be
achieved by a Rose-Thompson type effect
alone.
Nasal floor. Right and left subalare (the most
inferior point on the curve of the alar-lip junc-

tion) are marked (points 13 and 14). Because
the cleft-side ala is laterally rotated into a more
vertical position (more so in complete clefts),
the cleft-side subalare is marked after rotating
the alar insertion with digital pressure predict-
ing the final position of the lip and ala after lip
repair. Point 16 represents the height of the lip
at the site of proposed closure in the nostril sill.
It is drawn at a point along the lip-columellar
crease symmetric with point 15. These latter two
marks are somewhat arbitrary, and one needs to
consider the amount of skin lateral to the cleft-
side columellar base and medial to the cleft-side
alar insertion. If there is a deficiency of lateral
lip element tissue medial to the alar insertion,
point 16 needs to be positioned more laterally
to avoid a constricted naris. If there is ample
lateral lip element tissue medial to the alar in-
sertion, point 16 can be, and ideally should be,
more medially placed at the base of the
columella.
FIG. 1. (Above and center) Key landmarks and surgical

Measurements and Calculations
plan outlined with pen and gentian violent ink. See text Measurements are taken from the heights of
(Surgical Technique) for description. (Below) Immediate
postoperative appearance.
the philtral columns at the lip-columellar
crease to the points marked above the peaks of
cut on the medial lip skin is marked above the Cupid’s bow above the cutaneous roll; line 2–7
cutaneous roll along a line initiated at point 8, represents the total lip height, line 3– 8 repre-
running perpendicular to the philtral column sents the greater lip height. The total lip height is
(line 3– 8) and terminating at point 9 before the measured with the lip at rest. The greater lip
midline of the philtrum. The “red line” is height is measured with gentle downward trac-
marked at three points (10, 11, and 12) below tion on the lip to unfurl the medial lip and
the midline and below the peaks of Cupid’s predict the tension on the lip after repair. The
bow. Points 8, 6, and 12 should form a straight lesser lip height (base width of the small inferior
line running perpendicular to the free margin triangle) is equal to the total lip height minus
of the lip. Line 10 –12 represents the opening the greater lip height and minus 1 mm (Fig. 2):
Vol. 116, No. 1 / UNILATERAL CLEFT LIP REPAIR 63
side peek of Cupid’s bow. Point 17 is positioned
along the vermilion-cutaneous junction at the
point where the cutaneous roll and red line
(vermilion-mucosal junction) begin to con-
verge medially. At this point, there will be ad-
equate vermilion height and the remaining lat-

eral cutaneous roll will be of optimal quality.
Moving this point medially will result in central

vermilion deficiency and will leave a cutaneous
roll of poor quality. If this point is moved lat-
erally, lateral lip transverse length, which is
most often deficient, will be further compro-
mised. Furthermore, there is a natural antero-
superior convexity of the cutaneous roll that
can be preserved if point 17 is placed according
to Noordhoff’s recommendations and will pro-
vide for a more natural appearing lip. Along a

line perpendicular to the vermilion-cutaneous
junction and passing through point 17, point 18
is marked just above the cutaneous roll. Lines
6 – 8 and 17–18 will meet and therefore should
be of equal length. The point of proposed clo-
sure in the nostril sill (point 19) is then posi-
FIG. 2. The base width of the inferior triangle (c) is cal- tioned as far medial and superior from point 14
culated. The total height (a) and greater height (b) are mea- as point 15 is from point 13. Ultimately, the
sured from points just above the cutaneous roll above the position of point 19 should be positioned rel-
peaks of Cupid’s bow to the height of the philtral column in ative to point 16 such that when they are ap-
the lip-columellar crease. Approximately 1 mm of lengthen-
proximated, the cleft-side nostril circumfer-
ing occurs by a Rose-Thompson type effect, thereby reducing
the required size of the inferior triangle. a ⫺ b ⫺ 1 mm ⫽ c. ence will equal that of the non– cleft-side and
such that the alar bases will lie in the same
vertical level. The distance between points 18
Lesser lip height and 19 will then dictate the pattern of the re-
maining markings on the skin of the lateral lip.
⫽ 共total lip height兲 ⫺ 共 greater lip height兲 ⫺ 1 mm
Using calipers, points 20 and 21 are then placed
⫽ base width of the small inferior triangle between points 18 and 19. Point 22 is positioned
(1) relative to points 18 and 20 to complete an
isosceles triangle; lines 18 –22 and 20 –22 are
With the opening of the opening incision (line equal to line 8 –9 and the base width of the
8 –9), the cleft side peak of Cupid’s bow is triangle equals the lesser lip height. If the lateral
rotated caudally. There is additional length lip is short (Fig. 3), point 20 can be positioned
gained, approximately 1mm, as the angle lateral to the sagittal plane passing through
formed by line 3– 8 and line 6 – 8 opens fully to point 18 and segment 20 –22 can be coincident
180 degrees. The lesser lip height is usually with the lower portion of line 21–20. The re-
between 1 and 1.5mm and should be kept less quired length will be gained as the angle 21–
than 2mm. For minor clefts, an inferior trian- 20 –22 opens from 0 to 90 degrees. If the lateral
gle may not be necessary. lip is vertically long (Fig. 3), point 20 should be
Lateral lip. The markings of the lateral lip positioned along a straight line joining points
require adjustment for the vertical height of the 18 and 21. If the lip is still too long (Fig. 3), a
lateral lip. Having said this, one should not medially based wedge excision of upper lip can
compromise on the base of the philtral column be performed below point 19. The upper limb
or on the point of proposed closure in the nos- of this wedge excision should be positioned
tril sill. As described by Noordhoff,1 it is best to within the medial extent of the alar crease and
use vermilion height to determine the point on its lateral extreme; the lateral apex of this wedge
the lateral lip that will form the base of the excision should never extend laterally beyond
philtral column and meet point 6 at the cleft subalare (point 14). A lateral rhinotomy inci-
FIG. 3. The vertical limb (greater height) of the repair will vary in slope to mirror the non– cleft-side philtral
column. With minor clefts, the inferior triangle above the cutaneous roll may not be required. Lateral lip markings
will vary depending on the vertical height of the lateral lip element. The positions of the point of closure in the
nostril sill and of “Noordhoff’s point” should not be compromised.
sion along the alar crease is never used. It is formed. The distance between points 16 and 19
unnecessary and leaves an unsightly scar. Alter- (or 19') should be 1 mm less than the difference
ing the vertical level of point 19 to accommo- in the circumference of the cleft-side and non–
date the vertical length of the lateral lip is dis- cleft-side nares (1 mm less to avoid a constricted
couraged. Any adjustment will compromise the cleft-side naris). To determine this, I size the
final vertical position of the alar insertion. Point nares with Hegar cervical dilators. These dila-
21 is placed between points 19 and 20 so that tors are numbered according to their diameter.
lengths 21–19 and 21–20 equal lengths 3–16 Multiplying the difference in diameter by 3 (ap-
and 3– 8, respectively, and such that angle 19 – proximately ␲) will equal the maximum amount
21–20 approximates angle 16 –3– 8. Point 23 is of allowable excision of nostril sill. Mucosa of the
marked along the red line below point 17. The cleft margins is removed by wedge excision, with
lateral vermilion flap is then marked. Along a the peak above the level of the cleft. Occasionally,
line joining points 17 and 23, point 24 is marked a short lateral upper buccal sulcus advancement
such that the length of line 17–24 equals that of incision is helpful.
line 6 –12. Lengths 23–25 and 24 –25 are equal Complete clefts. The upper aspect of the pos-
to the length of the opening incision along the terior closure is accomplished using a medial
red line of the medial lip (line 10 –12), and flap from the medial segment, a modified lat-
the base width of the triangle should equal the eral flap from the lateral segment, and an in-
amount of vermilion augmentation required ferior turbinate flap (Fig. 4). A broadly based
(the length of line 5–11 minus the length of line medial flap extends from point 16 to the upper
6 –12). extent of the mucosal incision. It generally
Incomplete clefts. Above points 16 and 19 (or needs to be only 1 to 2 mm in length, enough
19'), a wedge excision of nostril sill is per- to receive sutures. Above point 19 (or 19'), a
rectangular lateral flap is marked. In contrast to
Millard’s lateral flap, it is superolaterally based
at the level alar vestibular skin. Its base extends
from point 19 (or 19') to just below the antero-
lateral extreme of the inferior turbinate. The
distal margin of the flap is initially the upper

portion of the vertical mucosal incision; how-
ever, it is generally trimmed of distal mucosa

and is then composed of skin only. From the
upper limit of the mucosal incision and extend-
ing only as much as necessary, a lateral upper
buccal sulcus advancement incision with or
without a back-cut is made. If there is significant
anteroposterior distance between the greater
and lesser maxillary segments, an anteriorly
based inferior turbinate flap1 is used. It will
rotate caudally and anteriorly and will be uni-

fied with the lateral flap. It will be used to cover
the mucosal defect created by the anteromedial
advancement of the lateral lip, and its distal
margin will span the alveolar cleft above the
level of the gingiva.
Maneuvers
Sterile tapes are placed over the closed eye-
lids. Key landmarks are tattooed with gentian
violet dye and a 25-gauge needle. Bilateral in-
fraorbital nerve blocks are performed, and the
cleft-side alar base, piriform rim, and inferior
turbinate are infiltrated with 1% lidocaine with
epinephrine 1:200,000 (maximum dose, 0.5
ml/kg). No infiltration of the lip is performed.
After placement of a moist mouth pack, dissec-
tion begins on the medial lip. Incisions are
made with scalpel and completed with scissors.
The opening incision above the cutaneous roll
is through skin and subcutaneous tissue and
not through muscle. Cleft marginal tissue is
discarded. Dissection frees the muscle from the
overlying skin and vermilion and from the un-
derlying mucosa. Dissection between skin and
muscle is limited to 1 mm from the cut edge to
preserve the philtral dimple. The orbicularis is
freed from its upturned insertion in the region
FIG. 4. With complete clefts, an inferior turbinate flap (t), of the columellar base and upper alveolar cleft
medial flap (m), and modified lateral flap (l) are used for the margin. The lip and columellar base are posi-
posterior lamella of closure. The turbinate flap is unified with tioned to predict the final position, and an
the lateral flap along their adjacent borders. The turbinate
flap resurfaces the raw area produced by anterior reposition- appropriate downward rotation of the cleft
ing of the cleft-side alar base and its distal margin crosses the side peak of Cupid’s bow is verified. Lateral lip
alveolar cleft above the level of the gingiva. This distal margin markings can then be altered if necessary.
will approximate with the medially advanced upper buccal Dissection continues with the lateral lip. In-
sulcus incision margin of the lateral lip element. The lateral cisions are made with scalpel and completed
flap will be trimmed of distal mucosa and will meet with the
medial flap. with scissors. For complete clefts, it is helpful to
start with the mucosal incisions, as this will
release the tether of the lip from the region of
the upper alveolar cleft margin and lower piri-
form rim. Cleft marginal tissue is discarded.
Dissection frees the muscle from the overlying
skin and vermilion and from the underlying
mucosa. On the lateral lip element, dissection
between skin and muscle is more extensive,

extending laterally as far as the alar base to

relieve the orbicularis muscle bulge. Orbicu-
laris is freed from its upturned insertion in the
region of the alar base and upper alveolar cleft
margin. Dissection deep to muscle and in an
extraperiosteal plane frees the alar base from
the underlying maxilla. The vestibular web,
formed by the caudal margin of the lower lat-
eral cartilage’s lateral crus, the accessory carti-
lages, and investing perichondrium, is released
from its posterolateral attachment to the piri-

form rim (Fig. 5). When this release from the
piriform rim is sufficient, the alar base can now
be advanced anteromedially without accentu-
ating the buckling of the alar rim and of the
lateral alar flare. If there is significant antero-
posterior distance between the greater and
lesser maxillary segments, anteromedial ad-
vancement of the alar base will leave a large
raw periosteal surface at the upper alveolus
and lower piriform margin that is best covered
with an inferior turbinate flap. The inferior
turbinate flap is elevated and rotated inferiorly
and then anteriorly. The turbinate flap donor FIG. 6. Minor unilateral cleft. Surgical markings (above)
site is cauterized. Adjacent margins of the lat- and postoperative result at 7 days (below). Note that for minor
eral flap and inferior turbinate flap are sutured clefts, an inferior triangle above the cutaneous roll may not
together. The originally medial margin and be required. A vermilion flap from the lateral lip element is
usually required.
now posterior margin of the turbinate flap is
then sewn to the free margin of the upper
alveolar and lower piriform area incision (Fig.
4). The distal margin of the lateral flap is ro-
tated across the cleft and sutured to the medial
flap. The upper buccal sulcus incision is su-
tured closed. The distal margin of the turbi-
nate flap will be sutured to the upper edge of
the lateral lip mucosa in the interval of the
alveolar cleft. Closure continues caudally with
approximation of the medial and lateral lip
element mucosa. From within the nasal vesti-
bule, forceps are used to reposition the cleft-
side dome anteromedially and to grasp the
caudal margin of the upper lateral cartilage.
One or two internal nasal valve plication su-
tures are placed to maintain the anteromedial
advancement of the lateral crus and to create
FIG. 5. In this incomplete cleft, the cleft-side dome is re- the normal overlap of the lower lateral carti-
tracted anteromedially, placing the vestibular web under ten-
sion. The vestibular web formed by the lower lateral cartilage lage and the upper lateral cartilage. With a
accessory cartilage complex and investing perichondrium is Ragnell retractor, the cleft-side dome is re-
released from its attachment to the piriform margin. tracted anteromedially, and alar transfixion su-
approximation, internal nasal valve pexy su-
tures, alar transfixion sutures, and deep dermis
approximation; 7-0 Prolene for skin, and 7-0
Vicryl for vermilion. Despite avoiding infiltra-
tion of the lip, bleeding is not excessive and is
easily controlled with direct pressure on the lip

and electrocautery. Infants can breast or bottle

feed already in the recovery room. Lip sutures
are removed at 5 to 7 days from the
cheiloplasty.
RESULTS
One hundred forty-four consecutive unilat-
eral cleft repairs (73 incomplete and 71 com-
plete) form the present series. Example cases
are shown (Figs. 6 through 15). In 50 patients

aged 3 to 6 months treated consecutively dur-
ing the latter half of this experience, the mean
discrepancy in vertical height (measured from
subnasale to the peak of Cupid’s bow) was 2.41
mm (range, 0.5 to 3.5 mm) and the mean base
width of the inferior triangle was 1.24 mm
(range, 0 to 2 mm).
FIG. 7. Halfway incomplete unilateral cleft. Surgical

markings (above) and postoperative result at 7 days (below).
tures are placed to obliterate any dead space

created by the release of the vestibular web
from the piriform rim and to maintain antero-
medial advancement of the lateral crus. The
columellar base and cleft-side alar base are
approximated with an “alar cinch stitch.” Care-
ful placement of this suture will allow the alar
bases and columellar base to be positioned in
the appropriate horizontal plane. Muscle ap-
proximation is performed. Skin is approxi-
mated with deep dermal and then simple in-
terrupted sutures. The lateral vermilion flap is
debulked of underlying muscle, trimmed to
size, and inset into the opening incision along
the red line of the medial lip. Antibiotic oint-
ment is applied to the suture line. The throat
pack and eyelid tapes are removed. Elbow
splints are placed and maintained for 2 weeks.
The patient is awakened from general anesthe-
sia and extubated.
Presently, I use 5-0 and 6-0 chromic catgut
suture for the mucosa; 4-0 polydioxanone for FIG. 8. Complete unilateral cleft. Surgical markings
the alar cinch stitch; 5-0 Monocryl for muscle (above) and postoperative result at 7 days (below).
FIG. 9. Complete unilateral cleft. Surgical markings FIG. 10. Minor unilateral cleft. Preoperative appearance
(above) and postoperative result at 7 days (below). (above) and postoperative result at age 3 years (below).
DISCUSSION straight-line repairs. He augmented medial lip

When we consider the challenge of cleft lip deficiency with tissue from the lateral lip ele-
repair, the ultimate goal should be a lip and ment. This principle has been preserved in
nose of normal form and function. Regardless subsequently devised repairs.
of how close we may come to achieving this Realizing that the rotation incision alone was
goal, we still must accept a cutaneous scar that often inadequate, Millard modified his original
may heal less predictably than we may wish and repair4 by introducing a back-cut in the upper
that is permanent. Various techniques of lip lip beginning at the extreme of the rotation
repair have been described, each of which po- incision.5 Noordhoff1 modified Millard’s rota-
sition the cutaneous scar uniquely. Applying tion advancement by adding a small triangle
the principle of anatomic subunits2 to cleft lip that he pared off the lateral lip just above the
repair, the “ideal line of repair” should be one cutaneous roll and that was then inset into an
that ascends the lip from the cleft-side peak of opening incision in the medial lip, again posi-
Cupid’s bow to the base of the nose along a tioned just above the cutaneous roll. This
line exactly mirroring the non– cleft-side phil- achieved the necessary rotation and avoided
tral column and that then continues superolat- the increase of scar at the base of the nose that
erally bordering the lip-columellar crease to accompanies the back-cut. I was impressed by
the point of closure in the nostril sill. This is how ineffective the rotation incision can be
possible with minor clefts; however, with most and how frequently Noordhoff used his little
overt clefts, the medial lip is deficient in verti- triangle above the cutaneous roll. I was also
cal height. In the mid 1800s, Mirault3 intro- impressed by the effect of this triangle; it pro-
duced a technique of cleft lip repair that rep- vides a small amount of tension just above the
resented a significant advance over previous cutaneous roll that accentuates the pout of the
FIG. 11. Halfway incomplete unilateral cleft. Preoperative FIG. 12. Complete unilateral cleft. Preoperative appear-
appearance (above) and postoperative result at age 3.5 years ance (above) and postoperative result at age 14 months
(below). (below).
FIG. 13. Complete unilateral cleft. Appearance before presurgical orthodontics (left) and postop-
erative result at age 12 months (right).
FIG. 14. Complete unilateral cleft. Appearance before FIG. 15. Complete unilateral cleft. Appearance before
presurgical orthodontics (above) and postoperative result at presurgical orthodontics (above) and postoperative result at
age 9 months (below). age 12 months (below).
lip. Thomson6 modified the inferior triangle and to optimally position the tension of the lip
techniques of Tennison7 and Randall8 to limit repair. The required length having been
the base width of the inferior triangle to only 2 achieved, the incision lines can then be placed
mm. After training with Noordhoff and to allow for approximation along the seams of
Thompson, I questioned whether it would be anatomical subunits.
possible to plan on a small triangle just above In designing a rotation-advancement repair
the cutaneous roll at the outset and then avoid when the lateral lip element is short in vertical
the rotation incision altogether to place the height, it may be necessary to compromise the
majority of the scar along the “ideal line of position of the base of the philtral column on
repair.” This formed the basis of the described the cleft side (by moving it laterally) and in
repair. doing so compromise lateral lip transverse
The described technique is reliable because length to achieve vertical height. This is rarely
it is based on previously described repairs and if ever necessary with this repair (as in the
principles. A Rose-Thompson lengthening9,10 classic inferior triangle repairs) because appro-
occurs as the sloped incisions crossing the cu- priate triangulation with calipers can almost
taneous roll of the medial and lateral lip ele- always accommodate the available height of
ments approximate in the vertical. This allows the lateral lip. Underrotation is rare using this
for a smaller triangle than would be required technique despite using such a small triangle.
by a classic inferior triangle technique. The Common to all inferior triangle repairs, there
inferior triangle is positioned according to is some tendency to flatten Cupid’s bow. This
Noordhoff’s description, above the cutaneous seems a reasonable compromise because a
roll, to allow for better continuity of the roll shallow Cupid’s bow is seen also in the noncleft
population and is not itself a stigma of clefting. CONCLUSION
The cutaneous scar on the nose is minimized A technique of unilateral cleft lip repair is
and is essentially limited to the cleft-side nostril described that allows for approximation of the
sill. Primary rhinoplasty is performed with the medial and lateral lip elements almost entirely
intent of improvement and the realization that along the seams of anatomical subunits of the
complete correction of the nasal deformity de- lip and nose.
pends on augmentation of the alar base and David M. Fisher, F.R.C.S.C., F.A.C.S.
piriform margin skeletal deficiencies, which 555 University Avenue
may have to wait to be addressed at the time of The Hospital for Sick Children
alveolar bone grafting. The achievable goals of Toronto, Ontario M5G 1X8, Canada
this primary rhinoplasty then are (1) central- [email protected]
ization of the columellar base, (2) symmetrical
alar base repositioning in the craniocaudal REFERENCES
plane, (3) nostril margins of equal circumfer- 1. Noordhoff, M. S. The Surgical Technique for the Unilateral
ence, (4) release of the attachments of the Cleft Lip-Nasal Deformity. Taipei: Noordhoff Craniofa-
cial Foundation, 1997.
lower lateral cartilage–accessory cartilage com-
2. Burget, G. C., and Menick, F. J. The subunit principle

plex from the lateral piriform rim to allow for in nasal reconstruction. Plast. Reconstr. Surg. 76: 239,
some anterior repositioning of the alar base 1985.
without accentuation of the nostril rim buckle 3. Blair, V. P., and Brown, J. B. Mirault operation for single
and lateral alar flare, and (5) anteromedial harelip. Surg. Gynaecol. Obstet. 15: 81, 1930.
4. Millard, D. R. Complete unilateral clefts of the lip. Plast.
advancement of the cleft-side lateral crus and Reconstr. Surg. 25: 595, 1960.
dome concurrent with (6) creation of the nor- 5. Millard, D. R. Extensions of the rotation-advancement
mal overlap of the caudal margin of the upper principle for wide unilateral cleft lips. Plast. Reconstr.
lateral cartilage by the cranial margin of the Surg. 42: 535, 1968.
6. Thomson, H. G. Unilateral cleft lip repair. Oper. Tech.
lateral crus. Dissection is not performed in the Plast. Reconstr. Surg. 2: 175, 1995.
tip of the nose. Dome approximation and def- 7. Tennison, C. W. The repair of the unilateral cleft lip by
inition, and correction of the nasal septal and the stencil method. Plast. Reconstr. Surg. 9: 115, 1952.
pyramid deviations, will await formal secondary 8. Randal, P. A triangular flap operation for the primary
open septorhinoplasty. The examples shown repair of unilateral clefts of the lip. Plast. Reconstr. Surg.
23: 331, 1959.
will have had various combinations of the fol- 9. Rose, W. On Harelip and Cleft Palate. London: HK Lewis,
lowing as indicated by severity of the primary 1891.
deformity: presurgical nasoalveolar molding,11 10. Thompson, J. E. An artistic and mathematically accu-
alar base release, lateral piriform release, infe- rate method of repairing the defect in cases of harelip.
rior turbinate flap, internal nasal valve plica- Surg. Gynaecol. Obstet. 14: 498, 1912.
11. Grayson, B. H., Santiago, P. E., Brecht, L. E., and Cutting,
tion sutures, alar transfixion sutures, columellar C. B. Presurgical nasoalveolar molding in infants
base–alar base cinch stitch, and postoperative with cleft lip and palate. Cleft Palate Craniofac. J. 36:
nasal stenting. 486, 1999.

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Unilateral Cleft Lip Repair: An Anatomical

Background: A technique of unilateral Conclusions: A technique of unilateral

therefore of the slope of line 3– 8 will vary

between cases to exactly mirror the position

inferior point on the curve of the alar-lip junc-

FIG. 1. (Above and center) Key landmarks and surgical

equate vermilion height and the remaining lat-

Moving this point medially will result in central

vide for a more natural appearing lip. Along a

distal margin of the flap is initially the upper

ever, it is generally trimmed of distal mucosa

rotate caudally and anteriorly and will be uni-

between skin and muscle is more extensive,

extending laterally as far as the alar base to

from its posterolateral attachment to the piri-

easily controlled with direct pressure on the lip

and electrocautery. Infants can breast or bottle

are shown (Figs. 6 through 15). In 50 patients

FIG. 7. Halfway incomplete unilateral cleft. Surgical

tures are placed to obliterate any dead space

DISCUSSION straight-line repairs. He augmented medial lip

2. Burget, G. C., and Menick, F. J. The subunit principle

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