**6. Surgical techniques of unilateral cleft lip repair**

*"Things done well, and with a care, exempt themselves from fear."*

—William Shakespeare

In unilateral cleft repairs, regardless of the name assigned, except for straight‐line techniques, have an oblique medial incision to correct the nasal malposition and drop the cupid's bow into a horizontal posture [15]. If the lateral segment is contoured to interpolate a congruent tissue flap, the repair can be conceptualized as a Z‐plasty. We have categorized lip repairs in this chapter by the level at which in the tissue is interpolated.

#### **6.1. Straight‐line repairs**

#### *6.1.1. Early repairs [16, 17]*

Ambroise Paré described a straight‐line repair for cleft lip in 1575. He excised the skin margins of the cleft with a razor, freeing the lip elements from the upper jaw and joining them together by transfixing the edges of the cleft with a needle and securing the needle with thread in a figure of eight pattern. In 1570 Gaspar Tagliacozzi of Bologna described excoriating the cleft edges and using interrupted sutures to close the cleft.

#### *6.1.2. Rose-Thompson (et al.) principle*

Some of the earliest changes in cleft lip repair were based on modifications to the straight line repair to increase the vertical length of the lip. In 1879, William Rose developed a design for cleft lip closure using curved incisions mutually concave from nostril to vermilion at a 60° angle [18]. This method was significant as it lengthened the union of the two cleft margins (**Figure 6**).

Later, James E. Thompson who aspired to reproduce a natural cupid's bow designed his paring procedure in a shape of a diamond excision. He emphasized the need for accurate markings for precise matching of the cleft sides when brought together [19]. In addition, when the vermilion thickness varied, Thompson altered the angle of his incisions to balance the vermilion closure [20]. Victor Veau performed a modified straight‐line closure, where on the noncleft side he excised the mucosa just distal to the mucocutaneous junction line to achieve a normal length [1]. He was successful in approximation of the muscular elements but rarely achieved a symmetric cupid's bow. The British surgeon Thomas Kilner described a technique of straight‐line closure combining methods used by Rose, Thompson, and Veau. Kilner's technique, known for its simplicity, lengthened the lip, and reapproximated the muscle. Kilner believed that a superior cosmetic result could be achieved by secondary surgery to perfect the initial repair. Nakajima and others utilized curved incisions on the noncleft side and but straight incisions on the cleft side to equalize the length and allow a straight line repair [21].

Straight‐line repairs have grouped together as the "Rose‐Thompson principle." While these techniques have the advantage of simplicity and speed, they often result in an asymmetric cupid's bow, a prominent scar and retrusion of the maxilla.

**Figure 6.** (A) Schematic representation of the incisions for a Rose repair. (B) Schematic representation of the closure of a Rose repair.

#### **6.2. Upper lip flaps**

**5.3. Surgical lip adhesion**

80 Designing Strategies for Cleft Lip and Palate Care

**6.1. Straight‐line repairs** *6.1.1. Early repairs [16, 17]*

fashion.

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

*"Things done well, and with a care, exempt themselves from fear."*

In unilateral cleft repairs, regardless of the name assigned, except for straight‐line techniques, have an oblique medial incision to correct the nasal malposition and drop the cupid's bow into a horizontal posture [15]. If the lateral segment is contoured to interpolate a congruent tissue flap, the repair can be conceptualized as a Z‐plasty. We have categorized lip repairs in

Ambroise Paré described a straight‐line repair for cleft lip in 1575. He excised the skin margins of the cleft with a razor, freeing the lip elements from the upper jaw and joining them together by transfixing the edges of the cleft with a needle and securing the needle with thread in a figure of eight pattern. In 1570 Gaspar Tagliacozzi of Bologna described excoriating the cleft

Some of the earliest changes in cleft lip repair were based on modifications to the straight line repair to increase the vertical length of the lip. In 1879, William Rose developed a design for cleft lip closure using curved incisions mutually concave from nostril to vermilion at a 60° angle [18]. This method was significant as it lengthened the union of the two cleft margins (**Figure 6**).

Later, James E. Thompson who aspired to reproduce a natural cupid's bow designed his paring procedure in a shape of a diamond excision. He emphasized the need for accurate markings for precise matching of the cleft sides when brought together [19]. In addition, when the vermilion thickness varied, Thompson altered the angle of his incisions to balance

—William Shakespeare

**6. Surgical techniques of unilateral cleft lip repair**

this chapter by the level at which in the tissue is interpolated.

edges and using interrupted sutures to close the cleft.

*6.1.2. Rose-Thompson (et al.) principle*

#### *6.2.1. Millard technique*

Millard conceptualized his rotation‐advancement technique while serving in Korea and first published in 1957 [22]. His technique is the most widely used by cleft surgeons, but has been modified since its inception. Its principles serve as the foundation of many unilateral repairs today.

Millard preserved anatomical landmarks: the cupid's bow and the philtral column. Downward rotation of the medial lip element restores vertical lip height and advancement of the lateral lip element repositions the alar base.

Millard marked the nadir and peaks of cupid's bow on both the lateral and medial lip with methylene blue. The distance from the alar base and the point selected for cupid's peak on the lateral segment should equal that of the noncleft side. His medial segment incision extends from the lateral cupid's peak of the medial element through the columellar‐labial junction to the philtral column of the noncleft side. The lateral advancement flap extends from the nasal sill around the alar base. The medial segment with cupid's bow is rotated downward, and the lateral segment flap is advanced into the defect created.

Millard felt that markings served as a guide only, with the actual repair being "cut‐as‐you‐go" individualized surgery (**Figure 7**).

**Figure 7.** (A) Schematic representation of the incisions for a Millard repair. (B) Schematic representation of the closure of a Millard repair.

#### *6.2.2. Salyer's modification*

Salyer modified the rotation advancement with many improvements, most notably by mak‐ ing the transverse incision of the lateral segment B‐flap not below the alar rim, but instead intranasally [23].

#### *6.2.3. Mohler technique*

Whereas the scar runs obliquely across the philtral column in Millard's repair, Mohler modi‐ fied the technique to create a "mirror image" of the philtral column on the noncleft side [24]. He accomplished a straight‐line closure of the lip by moving the rotation flap up into the columella. His technique used a back‐cut that terminated at the midpoint of the philtral depression. The defect created by the downward rotation was filled by tissue from the lateral element.

#### *6.2.4. Cutting technique ("Extended Mohler")*

Millard preserved anatomical landmarks: the cupid's bow and the philtral column. Downward rotation of the medial lip element restores vertical lip height and advancement of the lateral

Millard marked the nadir and peaks of cupid's bow on both the lateral and medial lip with methylene blue. The distance from the alar base and the point selected for cupid's peak on the lateral segment should equal that of the noncleft side. His medial segment incision extends from the lateral cupid's peak of the medial element through the columellar‐labial junction to the philtral column of the noncleft side. The lateral advancement flap extends from the nasal sill around the alar base. The medial segment with cupid's bow is rotated downward, and the

Millard felt that markings served as a guide only, with the actual repair being "cut‐as‐you‐go"

Salyer modified the rotation advancement with many improvements, most notably by mak‐ ing the transverse incision of the lateral segment B‐flap not below the alar rim, but instead

**Figure 7.** (A) Schematic representation of the incisions for a Millard repair. (B) Schematic representation of the closure

Whereas the scar runs obliquely across the philtral column in Millard's repair, Mohler modi‐ fied the technique to create a "mirror image" of the philtral column on the noncleft side [24]. He accomplished a straight‐line closure of the lip by moving the rotation flap up into the

lip element repositions the alar base.

82 Designing Strategies for Cleft Lip and Palate Care

individualized surgery (**Figure 7**).

*6.2.2. Salyer's modification*

intranasally [23].

of a Millard repair.

*6.2.3. Mohler technique*

lateral segment flap is advanced into the defect created.

Mohler's technique was modified by Cutting who moved the upper end of the incision to just beyond the midline of the columella (about 4/7th of the width on the noncleft side), and extended the back‐cut down to the noncleft philtral column [25]. This left a enough columellar tissue to fill in the defect created by downward rotation. A straight‐line closure symmetric to the noncleft side philtral ridge is the result. There is then abundant lateral segment tissue that may be used to provide nasal lining, as shown in **Figure 8A** and **B**.

**Figure 8.** (A) Schematic representation of the incisions for a Cutting repair. (B) Schematic representation of the closure of a Cutting repair.

#### **6.3. Middle lip flaps**

#### *6.3.1. LeMesurier technique*

In the LeMesurier technique, a quadrilateral shape flap is created on the lateral side of the cleft lip which is rotated to the medial side where a notch is formed by a back cut, as shown in **Figure 9A** and **B** [26].

In addition to creating fullness in the lower lip, an advantage of this technique includes the placement of the suture line down the center of the lip. Thus, the cupid's bow can be made symmetrical. The scar that develops from the LeMesurier technique is a "step line" scar which is unlike most scars associated with cleft lip repair. This may overcome the characteris‐ tic appearance of a cleft lip repair and can look like an accidental wound to the observer [27].

**Figure 9.** (A) Schematic representation of the incisions for a LeMesurier repair. (B) Schematic representation of the closure of a LeMesurier repair.

#### *6.3.2. Pool repair*

Pool placed the transverse limb of his Z‐plasty repair of the lip approximately 3–4 mm below the alar bases [28]. He found that positioning the incision of the medial segment allowed for complete caudal rotation and proper horizontal positioning of the cupid's bow without the need for back‐cuts or secondary flaps, see **Figure 10A** and **B**. He also found that this

**Figure 10.** (A) Schematic representation of the incisions for a Pool repair. The blue dotted line represents a horizontal approximately 3 mm below the alar bases for planning the Z‐plasty. (B) Schematic representation of the closure of a Pool repair.

technique allowed a better contour of the lip, especially the curve of the columellar‐labial juncture, which may be distorted by the transverse scar in higher rotation advancement tech‐ niques. The incisions also allow a "cut as you go" adjustment to the alar base for symmetry.

#### **6.4. Lower lip flaps**

*6.3.2. Pool repair*

Pool repair.

closure of a LeMesurier repair.

84 Designing Strategies for Cleft Lip and Palate Care

Pool placed the transverse limb of his Z‐plasty repair of the lip approximately 3–4 mm below the alar bases [28]. He found that positioning the incision of the medial segment allowed for complete caudal rotation and proper horizontal positioning of the cupid's bow without the need for back‐cuts or secondary flaps, see **Figure 10A** and **B**. He also found that this

**Figure 10.** (A) Schematic representation of the incisions for a Pool repair. The blue dotted line represents a horizontal approximately 3 mm below the alar bases for planning the Z‐plasty. (B) Schematic representation of the closure of a

**Figure 9.** (A) Schematic representation of the incisions for a LeMesurier repair. (B) Schematic representation of the

#### *6.4.1. Tennison-Randall repair*

In 1952, Charles Tennison proposed a repair based on the Z‐plasty principle to gain vertical lip length [29]. His technique, in particular, has proven to be advantageous in wide complete clefts. Peter Randall devised a mathematical system for designing the lip operation [30].

The base of the isosceles triangle of the lateral element is determined by the difference in lengths between the noncleft cupid's peak to the alar base and to the base of the columella. The isosceles triangle side length should equal the length of the 90° back cut of the medial element, as shown in **Figure 11A** and **B**.

**Figure 11.** (A) Schematic representation of the incisions for a Tennison‐Randall repair. (B) Schematic representation of the closure of a Tennison‐Randall repair.

#### *6.4.2. Fisher "anatomic subunit" repair*

Fisher designed a repair utilizing the Rose‐Thompson principle with close attention to the bor‐ ders of aesthetic subunits of the lip, as well as a small lower lip triangular interpolation flap [31]. Many have found that this technique yields esthetic scars and achieves a natural contour of the upper lip (**Figure 12**).

**Figure 12.** (A) Schematic representation of the incisions for a Fisher repair. (B) Schematic representation of the closure of a Fisher repair.

#### **6.5. Vermilion flaps**

#### *6.5.1. Noordhoff technique*

The Noordhoff technique utilizes a lateral lip triangular flap to reconstruct the dry vermilion [32]. A triangular flap is made on the lateral side of the cleft, where the vermilion height is the greatest, just before the red line converges to meet the white roll at the cleft edge (Noordhoff's point). The vermilion tissue medial to this triangular marking is used to augment the deficient vermilion underneath the cupid's bow. A straight cut is made on the medial side of the cleft to fit the inset of the lateral triangular flap (**Figure 13**).

**Figure 13.** (A) Schematic representation of the incisions for a Noordhoff flap. (B) Schematic representation of the closure of a Noordhoff flap.

#### *6.5.2. Powar technique*

The Powar Technique for unilateral cleft lip repair is a modification of the Noordhoff's lateral vermilion flap. The Powar technique not only maintains the parallel relationship of the muco‐ vermillion "red line" with the white roll but also more accurately matches the vermilion on the noncleft side [33]. In Power's modification, the vermilion deficiency is measured on the medial cleft segment and a custom matching triangular flap is created above the muco‐ver‐ milion junction on the lateral slide (**Figure 14**). This avoids the mucosal bulge that often is the result of the Noordhoff triangular flap inset.

**Figure 14.** (A) Schematic representation of the incisions for a Powar flap. (B) Schematic representation of the closure of a Powar flap.

#### **6.6. Adjuntive flaps**

**6.5. Vermilion flaps**

of a Fisher repair.

of a Noordhoff flap.

*6.5.1. Noordhoff technique*

86 Designing Strategies for Cleft Lip and Palate Care

The Noordhoff technique utilizes a lateral lip triangular flap to reconstruct the dry vermilion [32]. A triangular flap is made on the lateral side of the cleft, where the vermilion height is the greatest, just before the red line converges to meet the white roll at the cleft edge (Noordhoff's point). The vermilion tissue medial to this triangular marking is used to augment the deficient vermilion underneath the cupid's bow. A straight cut is made on the

**Figure 13.** (A) Schematic representation of the incisions for a Noordhoff flap. (B) Schematic representation of the closure

**Figure 12.** (A) Schematic representation of the incisions for a Fisher repair. (B) Schematic representation of the closure

medial side of the cleft to fit the inset of the lateral triangular flap (**Figure 13**).

Creation of the cupid's bow is a critical aesthetic concern in cleft lip surgery and has two major elements: continuity of the white roll and sufficient caudal rotation. It is tempting for the surgeon, when faced with a wide cleft, to preserve as much tissue width as possible. However, preserving lip tissue with attenuated or absent white roll yields unsatisfactory outcomes. The vast majority of patients who present for a revision of cleft lip scar benefit from excision of scar to an accurately determined Noordhoff's point and meticulous suture approximation of the white roll.

A cleft lip repair may be unacceptable if the cupid's bow is not horizontal due to insuf‐ ficient caudal rotation of the lip. A great advantage in the Pool technique is that it easily provides sufficient caudal rotation. In the case of insufficient rotation, enlarging the Z‐plasty flaps, a flap "back cut," or a second Z‐plasty may bring cupid's bow horizontal. A second smaller Z‐plasty just above the white roll is a very useful tool: the tightness caused by the Z‐plasty enhances the prominence of the white roll, and small flaps also break up a long linear scar (**Figure 15**). The Tennison and Fisher techniques employ this principle as part of their initial design.

**Figure 15.** (A) Schematic representation of closure of a cleft repair with the cupid's bow under‐rotated. The incisions for a second, smaller Z‐plasty above the white roll are planned. (B) Schematic representation of the closure of Z‐plasty.

#### **6.7. Hard palate repair at the time of lip repair**

Sommerlad advocates the Oslo Protocol for closure of the hard palate: a single‐layer mucop‐ erichondral flap of the vomarine septum simultaneous with primary cleft lip repair [34]. While the lip is incised and retracted, tissue exposure is optimal to the anterior palate. This tech‐ nique seems not to have unfavorable outcome on maxillofacial growth [35].

#### **6.8. Primary nasal repair**

Early nasal reconstruction is important for the patient's self‐esteem from a young age, and eliminates the need for correction of worsening nasal deformities as one matures and grows. The reparative success of cleft nasal deformity is dependent on dissection that frees the alar cartilage and its translocation into normal position.

#### *6.8.1. McComb's technique*

McComb's technique lifts the alar cartilage with its vestibular lining to shorten the cleft‐side nose [36]. Dissection in a subcutaneous plane is performed from the upper buccal sulcus and also through the columella to release the medial and lateral crura. The dissection then is extended from the nostril rim to the tip, dorsum, and nasion. The alar lift is achieved with either one or two mattress sutures through the nasal lining at the intercrural angle, raising the cleft side lower lateral alar cartilages to a symmetrical position.

#### *6.8.2. Anderl's technique*

The Anderl technique utilizes the incisions made for cleft lip repair and wide undermining of the nasal skin. The Anderl technique has extensive mobilization by undermining of the nasal dorsum, supraperiosteal dissection on the surface of maxilla from the vestibule to the infraorbital rim and from the piriform aperture to the maxillary tuberosity [37]. This maneuver allows for greater medial excursion of the lateral element during repair of the lip and nose. The cartilaginous septum is also released from its base attachment to the hard palate, straightened and sutured to the anterior nasal spine.

#### *6.8.3. Salyer's technique*

Salyer also uses extensive subcutaneous freeing of all elements and floating them above an abnormal skeletal base. He uses two intranasal‐transdermal sutures to create the genu of the ala [38]. In the completion of the lip and nasal repair, additional sutures may be used to contour the alar base.
