unilateral cleft lip repair

preoperative
intraoperative

postoperative

Unilateral Cleft Lip Repair

The rotational advancement method can be used for the entire spectrum of unilateral cleft lips. The technique is described for a complete cleft lip. The following section summarizes the principal steps of the technique.
The landmarks of the lip are marked with a vital dye as follows:
Point 1: The base of the nasal ala on the normal noncleft side
Point 2: The high point of the Cupid's bow on the noncleft side
Point 3: The midpoint of the cupid's bow
Point 4: The high point of the cupid's bow on the cleft side, determined by measuring the distance between points 2 and 3
Point 5: The peak of the cupid's bow on the lateral cleft segment, usually placed where the white roll (vermilional cutaneous junction) begins to attenuate
Point 6: The superior extent of the advancement flap. The distance between points 5 and 6 should be equal to the height of the lip in the noncleft side. Final determination of point 6 may have to wait until the rotation incision is completed in some cases.
Point 7: Located along the alar crease so that the distance between points 5 and 7 equals the distance between points 1 and 2
Point 8: The superior extent of the rotation incision, which can be extended to point 9, if necessary, and should not cross the philtral column on the noncleft side
Point 9: The extent of the area back cut‌ incision (if needed). This may be necessary to achieve adequate downward rotation of the medial lip segment.


The distance between points 1 and 2 represents the height of the lip on the noncleft side and should equal the ultimate height of the lip on the cleft side; this measurement is also useful as a guide in determining the length of the curvilinear incision between points 4 and 8. The position of this incision can be facilitated with the use of a curved 26-gauge wire to mark an incision that begins at point 4 and ascends along the vermilional cutaneous junction and then swings across the lip to where the columella meets the lip at point 8. It is important that this line not extend or cross into the normal philtral column.
After marking and infiltration of a small amount of local anesthetic containing epinephrine, the skin incisions are scored and incised, beginning with the rotation flap. Completion of the rotation incision allows point 4 to drop down to a position symmetric with point 2; if the rotation still is not sufficient, a small backcut to point 9 can be made to achieve satisfactory rotation. A small triangular flap of tissue remains attached to the columella (Millard C flap), and this flap is later used to lengthen the shortened columella of the cleft side as well as to construct the medial aspect of the nasal sill. Final delineation of point 6 is now possible and is determined after adequate downward rotation of point 4. If additional height is needed, point 6 can be adjusted slightly into the nasal vestibule (avoid nasal vibrissae hairs) or point 5 can be moved 1 to 2 mm lateral toward the oral commissure.
The medial and lateral lip flaps are freed by sharp dissection from the underlying maxilla in a supraperiosteal plane to allow for a tensionless closure. Laterally, this is performed with a high gingivobuccal sulcus incision. Dissection is completed subcutaneously around the nasal ala, intercartilaginous region, and piriform aperture, as needed, to release tension and to allow for the nasal ala to be positioned independently of the lip.

Primary nasal reconstruction (if desired) is initiated by undermining the skin overlying the columella, nasal dome, and lower lateral cartilages. The skin lining the vestibule is elevated off the lateral crus of the lower lateral cartilage. This allows it to be actively repositioned within the skin pocket.
Depending on the individual case, the C flap can be advanced on itself, thus lengthening the cleft side of the columella or used for the reconstruction of the medial portion of the nasal sill. In many cases, it is used for construction of both columella and nasal sill.
The orbicularis oris muscles are dissected about 1 to 2 mm from their attachment to skin and mucosa, and then are approximated with interrupted 4.0 Vicryl sutures. After placement of each stitch, overall symmetry and rotation of the lip is evaluated. With inadequate rotation or

insufficient length of the lateral segment, adjustments need to be made.
The primary nasal reconstruction follows the muscular closure. The lower lateral cartilage is repositioned and fixed into place with through-and-through 4.0 nylon sutures tied over Teflon pledgets securing the dome of the cartilage to the contralateral side and to the upper lateral cartilages. The lip skin and mucosa are closed with 7.0 nylon or 6.0 chromic sutures, matching the vermilional cutaneous junction precisely. Final adjustment of the vermilion is completed to create a tubercle, and any tendency toward vermilion notching is corrected by creating a Z-plasty, with transposition of a mucosal flap from the fuller side to the more deficient side to balance the lip. Nylon sutures are removed at 5 to 7 days on an outpatient basis with sedation. Nasal bolsters can remain is place for 10 to 14 days.