**8. Author's experience**

*"It is life's tragedy that we get old too soon and wise too late"*

#### —Benjamin Franklin

The senior author (DL) was trained in plastic surgery residency, as many were, to repair unilateral cleft lips with the Millard rotation‐advancement technique. Later, while on sur‐ gical missions to developing world countries, I had the opportunity and honor to work with Dr. Robert Pool, and learn his midlip Z‐plasty technique of lip repair. Moreover, I also observed his meticulous surgical technique and attention to detail that brought the children on whom he operated such excellent results. When I began practice with the Vermont State Cleft/Craniofacial Center, I used the Pool technique.

Still later in my practice, I was quite intrigued by the extended Mohler technique advocated by Dr. Court Cutting. While in New York City attending Dr. Barry Grayson's excellent workshop on nasoalveolar molding, Dr. Cutting graciously invited me to observe him operating on an infant with unilateral cleft lip. I observe his similar scrupulous attention to detail and excel‐ lent technique. I then began using this technique for a period of time. For reasons discussed below, I have returned to a midlip Z‐plasty technique for surgical reconstruction of children with unilateral cleft lip.

In my experience, the upper lip techniques of lip reconstruction have the disadvantage of a transverse scar across the columellar‐labial junction. The columellar‐labial junction naturally has a gentle curved shape, but a transverse scar across this curve will frequently result in a tight, noncurved junction.

Linear scars the entire height of the lip often results in scar hypertrophy (**Figure 16**). The linear Cutting/Mohler surgical linear scar line mimics a natural philtral ridge, however may result in a hypertrophic scar of the vertical limb.

**Figure 16.** A child 5 months after cleft lip repair by the Cutting "Extended Mohler" technique and Powar vermillion flap. This is the child from **Figure 1B** and **Figure 4**. Note the somewhat hypertrophied straight‐line vertical limb of the scar.

Continuity of orbicularis oris is the critical functional concern of cleft lip surgery. Midlip surgical techniques have a great advantage in that the incisions are made over the abnormal muscle bundles, and flap transposition redirects those muscle bundles with less extensive dissection (**Figure 17**).

infant with unilateral cleft lip. I observe his similar scrupulous attention to detail and excel‐ lent technique. I then began using this technique for a period of time. For reasons discussed below, I have returned to a midlip Z‐plasty technique for surgical reconstruction of children

In my experience, the upper lip techniques of lip reconstruction have the disadvantage of a transverse scar across the columellar‐labial junction. The columellar‐labial junction naturally has a gentle curved shape, but a transverse scar across this curve will frequently result in a

Linear scars the entire height of the lip often results in scar hypertrophy (**Figure 16**). The linear Cutting/Mohler surgical linear scar line mimics a natural philtral ridge, however may

Continuity of orbicularis oris is the critical functional concern of cleft lip surgery. Midlip surgical techniques have a great advantage in that the incisions are made over the abnormal muscle bundles, and flap transposition redirects those muscle bundles with less extensive

**Figure 16.** A child 5 months after cleft lip repair by the Cutting "Extended Mohler" technique and Powar vermillion flap. This is the child from **Figure 1B** and **Figure 4**. Note the somewhat hypertrophied straight‐line vertical limb of the scar.

with unilateral cleft lip.

90 Designing Strategies for Cleft Lip and Palate Care

tight, noncurved junction.

dissection (**Figure 17**).

result in a hypertrophic scar of the vertical limb.

**Figure 17.** (A) An infant with a complete unilateral cleft lip. (B) The infant in the operating room with markings for a Pool midlip Z‐plasty and Noordhoff vermillion flap repair. (C) The infant in the operating room with dissection completed. Because the Z‐plasty design and muscles are freed from their abnormal insertions without as much undermining of the skin. (D) The infant in the operating room with surgical repair completed. (E) This child at 3 years of age.

In my opinion, this technique yields very satisfactory results (**Figure 18**).

**Figure 18.** (A) An infant with a wide, yet incomplete unilateral cleft lip. Note the narrow Simonart's band. (B) The infant after a Pool midlip Z‐plasty and Powar vermillion flap repair. (C) The same child at 5 years of age.

At Vermont State Cleft/Craniofacial Center, we perform formal NAM presurgical orthopedics only on children with bilateral clefts who have premaxillary protrusion (**Figure 5**). Unfortunately, we have found that the frequent visits and lack of insurance coverage for NAM result in a high burden of care for families in Vermont. Because of this, we have not adopted this modality for children with unilateral clefts. We have found presurgical taping (**Figure 4**) to be an efficacious yet inex‐ pensive modality and it offers an opportunity for parents to play an active role in their child's care.

Thoughtful selection of a surgical method and careful attention to detail in the execution of surgical technique will yield the best results. We hope that this chapter will help surgeons in the care of children with cleft lip.
