**5. Preoperative tissue mobilization**

*"Success depends on preparation, and without preparation, there is failure."*

—Confucius

The goal of preoperative tissue mobilization is to lessen the soft tissue and bony cleft and accompanying deformities prior to definitive surgical treatment. Preoperative improvement facilitates surgical repair and results in better outcomes.

#### **5.1. Adhesive tape**

Pool and Farnworth advocated the use of adhesive tape for soft tissue mobilization prior to surgical repair of unilateral and bilateral clefts Long strips were applied from cheek to cheek for 6 weeks prior to surgery (**Figure 4**). They found a 53% average reduction in alveolar gaps, and lip segment narrowing from 40% to complete apposition [9].

**Figure 4.** A child with a complete unilateral cleft lip, with adhesive tape therapy in place. This is the same child in **Figure 1B**. Note the mobilization of soft tissue.

#### **5.2. Nasoalveolar molding**

The goals of unilateral cleft lip repair are both functional and aesthetic. In order to address these goals, one must understand the anatomical characteristics of unilateral cleft lip. Aesthetically the goals of surgical intervention include formation of lip continuity, establishing symmetry of the cupid's bow and the nose in a manner that places scars in less discernable areas. Recreation of the orbicularis muscle to circumferentially surround the opening of the oral cavity is impor‐ tant for long‐lasting cosmetic outcomes and lip and mouth function. Patients with isolated cleft lip rarely have feeding problems, unlike those with cleft palate. However, enrolling the child in a multidisciplinary clinic is advised to address the needs of each patient and family.

*"Success depends on preparation, and without preparation, there is failure."*

The goal of preoperative tissue mobilization is to lessen the soft tissue and bony cleft and accompanying deformities prior to definitive surgical treatment. Preoperative improvement

Pool and Farnworth advocated the use of adhesive tape for soft tissue mobilization prior to surgical repair of unilateral and bilateral clefts Long strips were applied from cheek to cheek for 6 weeks prior to surgery (**Figure 4**). They found a 53% average reduction in alveolar gaps,

**Figure 4.** A child with a complete unilateral cleft lip, with adhesive tape therapy in place. This is the same child in

—Confucius

**5. Preoperative tissue mobilization**

78 Designing Strategies for Cleft Lip and Palate Care

**5.1. Adhesive tape**

**Figure 1B**. Note the mobilization of soft tissue.

facilitates surgical repair and results in better outcomes.

and lip segment narrowing from 40% to complete apposition [9].

Alveolar molding is performed with an intraoral appliance to align the maxillary alveolar segments and narrow the cleft. Latham developed an active orthopedic device consisting of methyl methacrylate bases attached to the palatine bone with metal pins, and connected by a screw [10, 11]. Turning of the screw exerts an anterior force on the cleft‐side segment, narrowing the gap.

Grayson and the NYU group employ presurgical molding, using the nasoalveolar mold‐ ing (NAM), a passive orthodontic appliance [12, 13]. An acrylic orthodontic plate is fitted to cover the entire maxillary arch, with two buttons placed at 45° angle to the occlusal plane. Circular elastics are attached from the buttons and to steristrips on the face bilat‐ erally (**Figure 5**). Every 1–2 weeks the orthodontist adjusts the device small amounts by removing and adding acrylic. Once the alveolar gap measures less than 5 mm, a nasal stent is added to the appliance by wire extending from the plate. The stent is positioned under the soft triangle, and periodically augmented by adding soft acrylic. This tissue‐ expansion effect molds the alar cartilage and lengthens the columella with the goal of increasing tip projection.

**Figure 5.** A child with a complete bilateral cleft lip, with an NAM device in place.

#### **5.3. Surgical lip adhesion**

Lip adhesion is a first surgical stage in a two‐stage reconstruction developed by Randall [14]. A lip after adhesion not only molds the alveolar segments, but also improves nasal contour and vertical lip height of both medial and lateral segments. The disadvantages of a two‐stage surgical repair include an additional procedure and scarring, possibly making dissection more difficult during the second, definitive surgery. Randall made incisions on the vermillion of the medial and lateral lip elements. On the lateral lip element, supraperiosteal dissection is per‐ formed through a buccal incision. Subcutaneous dissection is performed on the medial segment to the nasal tip, allowing for mobilization of the cleft‐side lower lateral cartilage independent from rest of the nose. Mattress sutures are passed through the medial cleft margin incision, through the orbicularis oris and buccal mucosa. The mucosal flaps are then closed in layered fashion.
