cme correction of secondary cleft lip deformities€¦ · cme correction of secondary cleft lip...

CME

Correction of Secondary Cleft Lip DeformitiesSamuel Stal, M.D., and Larry Hollier, M.D.Houston, Texas

Learning Objectives: After studying this article, the practitioner should be able to (1) describe the common secondarydeformities of the cleft lip, (2) determine the appropriate timing for surgical intervention to correct the deformities, and(3) determine the best method of addressing each of the individual secondary deformities of the cleft lip.

Secondary deformities are common in children bornwith a cleft lip and palate. Patients with cleft lip deformitywill undergo multiple surgical procedures early in life, soit is imperative to prioritize treatment of their secondarydeformities and minimize the number of interventionsneeded. Of the many approaches used to correct theseproblems, surprisingly few work well consistently. As withall plastic surgery, the timing and procedure should bepredicated on the severity of the deformity. (Plast. Re-constr. Surg. 109: 1672, 2002.)

Secondary deformities of the cleft lip are therule rather than the exception. As the patientwith a cleft lip deformity will undergo multiplesurgical procedures throughout the course ofhis or her early life, it is imperative to prioritizetreatment of the secondary deformities andtherefore minimize the number of interven-tions necessary. A myriad of approaches havebeen used to correct these problems, but sur-prisingly few work well consistently. As with allplastic surgery, timing and the surgical treat-ment should be predicated on the severity ofthe deformity.

Essentially all patients with primary cleft lipdeformities are operated on within the firstyear of life. After this, there is a long period ofdramatic growth. Although this early surgery ismandatory to minimize secondary functionalproblems, the powerful variable of growth mayultimately distort the immediate surgical re-sult. Consequently, the correction of these sec-ondary deformities is an integral part of thecare of these patients. Indeed, these secondaryprocedures are frequently more complex thanthe initial surgery. The problems are so widelyvaried that the choice of an appropriate tech-

nique to correct them is challenging. Anotherextremely important variable is that of appro-priate timing of surgery. Determining the ageto surgically intervene is an important compo-nent of a successful outcome. As will be dis-cussed, this must be determined in large parton the basis of the severity of the deformityinasmuch as it relates to normal growth anddevelopment.

EVALUATION

Before embarking on secondary surgery forthe cleft deformity, one must accurately diag-nose all problems associated with the lip andnose. With respect to the lip, one must care-fully examine the lip scar, the status of theorbicularis muscle, the orientation of the ver-milion and white roll, the Cupid’s bow, and themucosa. The nasal deformity must be docu-mented and examined for symmetry of the alarbases and nostril shape, length of the colu-mella, and any deformations or deficiencies ofthe nasal lining. It is imperative that all of theseelements be related to the underlying skeletaldeformity on which they are based. Skeletalimbalance from maxillary hypoplasia or malpo-sition contributes significantly to the secondaryproblems commonly seen after initial liprepair.1

Once the deformity has been accurately di-agnosed, one must make every effort to deter-mine the underlying cause. Although hypopla-sia and distortion occur as a result of themalformation and set the stage for many of thecommonly seen secondary deformities, poorpreoperative design of the primary operation

Received for publication October 4, 2000; revised September 21, 2001.

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contributes as well. For example, a short lipmay be caused by something as simple as atight contracted scar. On the other hand, un-der-rotation of the initial lip repair may be thesource of the problem, as may be failure toanatomically reunite the underlying orbicu-laris. The design of the secondary surgeryshould be focused to correct the specific prob-lem. The solution must take into account thesoft tissue, muscle, and the underlying skele-ton. Addressing all short lips with the sameoperation is not sufficient. Numerous classifi-cation schemes have been devised to simplifythe evaluation of secondary cleft lip and nasaldeformities. However, they tend to be verycumbersome and do very little to facilitate thediagnosis and its underlying cause.2,3

Timing

There is no absolute rule for delineating theprecise timing of surgery for secondary defor-mities. Although Millard’s admonition that sur-gery may result in exaggerated scar formationin patients aged 8 to 18 years must be consid-ered, many patients will absolutely require sur-gical revision during this time period.4 Theseverity of the individual patient’s deformityand its effect on the child from a psychosocialor functional standpoint is also a critical factorto be considered. Secondary procedures to im-prove functional problems, such as speech,breathing, or eating, are frequently indicatedand need to be aggressively addressed regard-less of age. Perhaps the most common age forrevisional soft-tissue surgery in our clinic is inthe preschool period from 4 to 5 years of age.Peer interactions begin to develop at this time,and the child is extremely impressionable andvulnerable. Another common period for surgi-cal correction is during early adolescence. Thenature of peer interaction is frequently chang-ing at this time, and teenagers often becomeextremely self-conscious. In addition, teenagepatients usually express their opinions morevocally regarding their appearance and shouldbe involved in the decision-making process re-garding secondary surgery.

The cessation of facial growth is anothercritical landmark in the timing of secondaryoperations. However, it must be rememberedthat different components of the face ceasegrowing at different ages. Whereas mandibulargrowth may not be complete until age 16 orolder, nasal growth in girls has been conclu-sively shown to stop at approximately 11 to 12

years of age and in boys at approximately 13 to14 years of age.5

Cleft Lip

Normal lip anatomy. The anatomy of the up-per lip and its relation to the lower lip is re-markably constant between individuals. Thecentral defining structure of the upper lip is theCupid’s bow. The gentle curve of this structurebetween the Cupid’s bow peaks, and its rela-tionship to the white roll is important to recon-struct. In the 3-month-old child, the Cupid’sbow is generally less than or equal to 5 to 6 mm.As one ascends the philtrum above this, thephiltral columns on either side gradually nar-row as the columella is approached, where theyare generally 10 to 11 mm apart. These areimportant measurements in the repair of thecleft lip deformity, because the reconstructedphiltrum has a tendency to stretch significantlyover time. This is particularly true with the bi-lateral cleft lip deformity, in which the orbicu-laris muscle is usually sutured together, or toeither side of the prolabium. This causes thenew philtrum to stretch. As such, the width ofa Cupid’s bow should be designed no greaterthan 4 to 5 mm at the time of primary surgeryto avoid the commonly seen wide philtrum.

Another important component to upper lipanatomy is the length of the upper lip. At rest,the upper lip normally projects 2 to 3 mmanterior to the lower lip. The upper and lowerlips rest together in the relaxed state. A com-petent seal is easily created with light pressure.Failure to achieve adequate upper lip length atthe time of primary surgeries results in a fore-shortened tight-lip appearance. In the widecleft, this is sometimes inevitable, becausethere is a primary deficiency of tissue. How-ever, inappropriate design of the lip rotationmay also limit potential lip length.

Finally, the vermilion border, the distinctconvex white roll, and the precise relation be-tween these two structures are absolutely criti-cal in lip repair. The white roll is a structurethat cannot be duplicated surgically. In second-ary surgery, incisions should be carefully de-signed, preserving and aligning the white rollprecisely, because a malalignment of morethan 1 mm is clearly noticeable at a conversa-tional distance. Any intervening scar, whetherhypopigmented or hyperpigmented, interrupt-ing the continuous anatomic line is very notice-able. This is also true for the line of demarca-tion between the wet and dry vermilion. The

Vol. 109, No. 5 / SECONDARY CLEFT LIP DEFORMITIES 1673

vermilion lip line is normally straight, with anincreased fullness in the midline tubercle. Anydeviation from this with a notch or convexity isabnormal.

Prevention of Secondary Cleft Lip Deformities

The ideal time to address secondary defor-mities is at the time of the initial operation,when every effort should be made to preventthem. We have recently seen a shift in philos-ophy from staged, delayed procedures to anearly aggressive repair of clefts to minimizedeformities early.5–14 As such, it is importanteven before the surgery to use the techniquesof surgical orthopedics to align the cleft mar-gins, minimizing the tension on the repair andimproving the bony platform for the nasal cor-rection. In the past, many devices have beendescribed that allow either passive or activemanipulation of the cleft segment into a moreanatomic relationship.15,16 The passive platemaintains the transverse width of the maxillarysegments using external forces to retract thepremaxilla or malpositioned segment using ad-hesive tape and elastic bands. This technique ismost successful when there is adequate spacefor the premaxilla or maxillary segments.There is also some benefit from the device as afeeding appliance. The Latham device is a cus-tom-made appliance that is pinned to the max-illary segments. A ratcheted screw in the deviceexpands the segments, and elastic tractionhelps in retracting the protruding premaxilla.Typically, it takes about 6 weeks to align theexpanded segments to effect closure of thealveolar clefts. Many orthodontists think thatpremaxillary orthopedics has no real long-termadvantage in the management of the cleft pa-tient and may even have some deleterious ef-fects.17–19 Nevertheless, whatever the ultimateoutcome of the midfacial position, the signifi-cant advantages of presurgical alignment in-clude (1) allowing approximation of alveolarsegments, (2) facilitating nasal repair, and (3)decreasing tension on lip repair.7

In our experience, the most successfulmethod of presurgical treatment has been theuse of the passive appliance as described byGrayson and colleagues.12,20 As in standardtechniques, this procedure uses an intraoralprosthesis made of acrylic that is shaped to thecleft margins. It is gradually reduced in size toguide the cleft margins to a more anatomicorientation. In addition, a nasal extension onthe anterior portion of the device fits the nasal

vestibule. This is thought to gradually reshapethe collapsed ala by changing the shape of thelower lateral cartilage, which under the effectof maternal estrogen is still relatively mallea-ble.13 By better aligning the cleft margins, notonly is the lip and nasal repair facilitated, butalso primary approximation of the alveolus(gingivoperiosteoplasty) may be possible insome cases. Studies evaluating this techniquehave found bony continuity frequently reestab-lished across the alveolar segments, eliminat-ing the need for secondary bone graftprocedures.21

The primary drawback to this technique is itslabor-intensive nature. These children must beevaluated every 1 to 2 weeks for reshaping ofthe appliance. Furthermore, the parents mustparticipate actively in the care by cleaning, re-placing, and retaping the appliance in positiondaily. Many clinics are not equipped to providethis level of care, and there is a learning curveto successfully use this technique.

At the time of lip repair, one of the mostcritical steps is precisely marking the lip. Onemust take care to make all markings for theflaps indelible by applying methylene blue inkwith either a 25-gauge needle or a Beaver bladeto prevent the markings from being washed offduring the surgical preparation or distortedsecondary to local infiltration. Skin incisionsshould be beveled slightly to allow for eversionof the margins during closure. In addition, alltissue should be handled using skin hooks toavoid pressure necrosis, which can compro-mise the final result. Specific attention must begiven at the time of closure to the orbicularismuscle. Accurate release and anatomic approx-imation of both the superficial and deep com-ponents is imperative to both the appearanceand the function of the lip postoperatively.

This meticulous attention to detail shouldextend to reconstruction of the floor of thenose. Although this has very little effect on theappearance of the repair, it allows for usingtissue for the nasal sill and helps to better closethe anterior fistula seen in so many postoper-ative cleft lip patients. The exposure affordedby the primary lip operation is frequently neverachieved again, and a secondary operation forthis is consequently much more difficult.

In the bilateral lip, the universal stigma asso-ciated with staged repairs was so consistent andunacceptable that a change of thinking advo-cated by Mulliken, Cutting, McComb, and oth-ers led to a new era of prevention of bilateral

1674 PLASTIC AND RECONSTRUCTIVE SURGERY, April 15, 2002

deformities and a dramatic improvement inresults (Fig. 1).5–11,22 The new priorities for asuccessful repair include (1) symmetry, (2)muscular continuity, (3) appropriate philtralsize and shape, (4) formation of a mediantubercle from lateral labial elements, and (5)primary positioning of alar cartilages. Thesesurgical maxims, coupled with premaxillary or-thopedics, show great promise.

Deformities of the Vermilion Border

The vermilion border at the level of the cleftrepair may be malaligned or appear peakedbecause of a short vertical dimension to the lip.Mild deformities of the vermilion are com-monly seen early after the rotation advance-ment repair.23 This is thought to be somewhatattributable to a degree of superficial scar con-tracture, which usually resolves with matura-tion of that scar. We think it is beneficial tohave the parents participate in active massageof the scar to facilitate resolution of this prob-lem. However, if the problem persists beyond 1year postoperatively, we consider correction. Incases in which the lip is short by only 1 to 2mm, we prefer a diamond-shaped excision ofthe scar and closure, which increases thelength of the scar and brings the vermilionborder down. It is also possible to design asmall Z-plasty along the affected column; how-ever, we do not use this technique because itplaces additional scars on the lip that do notfall along anatomic landmarks.

In more severe cases (3-mm or greater dis-crepancy), the problem is most likely becauseof inadequate rotation of the lip. In thesecases, the repair should be taken down andrepeat rotation and advancement performedusing available adjacent tissue to achieve agreater length. This represents a problem withthe design of the initial operation. Any tech-nique short of this will not achieve adequatelengthening.

Malalignment of the vermilion or the whiteroll by as little as 1 mm is noticeable (Fig. 2). Ashas been pointed out previously, indelibly tat-tooing the border at the time of the initial liprepair is mandatory. If the problem requirescorrection, a simple Z-plasty designed alongthe border is usually successful in correctingthe malalignment (Figs. 3 and 4). This proce-dure also follows the principle that only vermil-ion should be used to reconstruct vermilion,and it allows for recreation of the vermilionwhite-roll transition.

Deficient Vermilion

The treatment of vermilion deficiencies isquite different in unilateral and bilateral defor-mities. The problem may be somewhat pre-vented at the time of the initial lip operation byback-cutting the mucosa in the gingivobuccalsulcus along the medial lip element, where thedeficiency is most common, and advancing itinferiorly. The resulting defect in the sulcusmay be filled using local tissue flaps (half Z-plasties). Placing skin hooks on the inferiorborder of the vermilion and then pulling downhelps in estimating the amount of vermilionadvancement that is necessary.

Once the problem becomes established, it

FIG. 2. Vermilion/white-roll mismatch caused by inaccu-rate alignment at the time of lip repair.

FIG. 1. Stigmata of the bilateral cleft deformity: paucity ofmidline vermilion with excess on lateral lip elements, widephiltrum with straight lateral borders, and flared alae.


most frequently presents as a “whistle” defor-mity or notch (Fig. 5). When the problem isvery mild, particularly when the lateral lip ele-ment appears to have a relative excess of ver-milion bulk, we perform a horizontal linearexcision on the inner aspect of the adjacent lipto diminish the discrepancy. To augment thedeficiency, however, local tissue rearrange-ment is usually sufficient. This frequently takesthe form of a V-Y advancement. Great caremust be taken to design the flap wide enoughto adequately fill the defect. As with any similarsituation, the defect should be created beforedesigning any flap.

Vermilion augmentation with a graft is alsoan option. In the past, we have used dermal fatgrafts with some success. These grafts havebeen harvested from the groin and placed intopockets created within the area of a deficiency.In approximately 50 percent of our patients,the appearance has been improved, but thefirmness and lumpiness of the lip that devel-oped was unacceptable to the patient. As hasbeen demonstrated by Coleman, it may bemost beneficial to minimize the amount of fat

that is placed along any one area of the recip-ient bed to maximize vascularity and grafttake.24 As such, fat harvested from the perium-bilical area may be centrifuged and injectedwith a needle with multiple passes along thearea of deficiency. We have used this techniquefor mild-to-moderate problems in 25 patientswith mixed success (Fig. 6). Clearly, this type ofprocedure is best for relatively mild deformi-ties. Deep, tight scarring prevents adequate ex-pansion of the lip where it is most needed andprovides a poor bed to revascularize the graft.Severe notching of the unilateral lip accompa-nied by scarring is often not amenable to localtissue rearrangement. Although this is rela-tively rare, such severe deficiencies need freshtissue. Even in the unilateral deformity, wethink the Abbé flap is the best choice to correctthe problem.

Vermilion deficiencies found in bilateralcleft lip are much more common than unilat-eral deformities and are frequently more se-vere. This should be expected, because thevermilion from the lateral lip element is rou-tinely used to replace the hypoplastic vermilionof the prolabial segment. Horizontal stretchingof the prolabial segment with time and growthmay also contribute to the problem.

Mild irregularities may be treated with tech-niques described above, such as V-Y advance-ments, double or single Z-plasty, or mucosalgrafts. The technique of deepithelialized, me-dially based submucosal flaps tunneled acrossthe midline to augment the defects is also par-ticularly effective, and we have used this withsuccess.7 A common problem in even a well-planned bilateral lip is a relative excess of mu-cosa in the adjacent lateral lip elements, whichshould be treated with conservative excision atthe time of any midline augmentation. Defini-tive lip touch-ups are often best delayed untilthe permanent central incisors have eruptedand after the premaxilla is in the correct ana-tomic position to more accurately judge appro-priate lip position.7

Severe bilateral cleft lip vermilion deficien-cies require Abbé cross-lip flap transfer. In ad-dition to augmenting the upper lip vermilion,this helps restore a balance by removing therelative excess vermilion from the lower lip.The technique of Abbé flap transfer is quitestraightforward; however, several points meritdiscussion. The flap should be designedsmaller than the actual defect to facilitate clo-sure of the lower lip and to allow for stretching

FIG. 3. Diagram illustrating Z-plasty rearrangement ofwhite-roll vermilion border to correct malalignment and scarcontracture (limited to white roll).


of the flap once in position. Great care must betaken to tattoo the vermilion borders and whiteroll of both the upper and lower lips beforebeginning this procedure, much as in a pri-mary lip repair. The location of the labial ar-tery on the pedicle side can be gauged usingthe cut side as a guide. Tissue from the dis-carded philtrum, if of good color and consis-tency, may be used to augment the floor of thenose and the columella only if absolutely nec-essary. Postoperatively, a nasal trumpet can beused to improve the airway. The flap may befurther protected from disruption by using Ivyloops for fixation, tying the loop loose enoughso that patients can insert food, spoons, andstraws in their mouth but not wide enough tooverstretch the flap. This is particularly usefulin the immediate postoperative period duringemergence from anesthesia, when the patientis not capable of protecting the flap (Fig. 7).

Cupid’s Bow Deformity

The Cupid’s bow itself is a difficult structureto recreate surgically. The problem usuallyarises at the level of the Cupid’s bow peakbecause of either malalignment of the vermil-ion and white roll or a short lip scar. In thesesituations, the problem should be addressed byeither a Z-plasty or a repeat lip rotation aspreviously described. Although direct recre-ation of the bow by skin excision and vermilion

advancement has been described, this is gen-erally an unacceptable procedure because ofthe artificial appearance that is created and thescar that the procedure induces.25 In our opin-ion, it is much better to simply focus on reset-ting the proper height for symmetry of theCupid’s bow and tolerate the scar. In severedeformities, use of the Abbé flap is the bestoption.

Mucosal Deficiencies

Sulcus deformities most frequently presentfor treatment around the time of initiation oforthodontic care in anticipation of a bonegraft. They are more commonly seen in thebilateral deformity. The prolabial vermilionused to recreate the sulcus is most often inad-equate. Although local flaps as described abovemay be useful, most frequently opening thearea of scarring and grafting the resulting de-fect is the most direct solution. Although skinmay be used, we think buccal mucosa is a bet-ter option, given the match to the surroundingtissue and the innocuous nature of the donorsite. It is always necessary to stent the graft siteto promote take, and we have found dentalamalgam useful for this purpose. Althoughthere is some secondary graft contracture thatcan be expected, prolonged stenting as hasbeen advocated by some authors is impracticalin most patients.1

FIG. 4. Diagram illustrating Z-plasty rearrangement of white-roll vermilion border to correct malalignmentand scar contracture (limited to scar).


Short LipA lip is considered short when the philtral

column on the cleft side is at least 3 mmshorter than the contralateral noncleft phil-trum. In very minor cases, the cause may beactive underlying scar contracture that im-proves over time (6 to 8 months). More severecases are usually caused by inadequate rotationof the lip at the time of the primary operationand are most often seen with an improperlydesigned rotation advancement repair. As pre-viously described, a diamond-shaped excisionof the scar and closure may augment the lip asmuch as 2 mm. A Z-plasty transfer along theline of the previous scar, although introducingnew scars on the lip, may be beneficial for asmuch as 3 mm of advancement. In the mostsevere cases, the entire lip repair must be takendown as before and repeat rotation advance-ment performed.

When evaluating these patients, consider-ation must be given to the status of the orbic-ularis muscle, which may not have been re-paired anatomically at the time of the primarylip surgery. This may contribute to shorteningof the lip. Preoperatively, this may be diag-nosed by asking the patient to purse the lips.With this maneuver, the orbicularis will notice-ably bulge on either side when it has not beenunited. When this is the case, the lip must betaken down and the muscle fully released fromits abnormal vertical insertions and reunitedwith sutures. Dissection of the orbicularis onthe medial lip should proceed no further thanhalf the width of the philtrum to preserve theintegrity and depth of the philtral dimple.

Long Lip

Very rarely does the rotation advancementlip repair produce a long lip. Long lip was

FIG. 5. Vermilion deficiency or notching in cleft lip deformity treated with local rearrangement of tissue.(Above) Unilateral; (below) bilateral.


more frequently seen with the Tennison re-pair, which is still a useful technique but not aspopular as the rotation advancement repair.26

In treating the long lip, there is a temptation tosimply superficially excise tissue from the alarbase and elevate the lip on the cleft side. How-ever, this frequently is insufficient and any re-duction in length achieved short lasting. Wethink it is necessary to excise tissue in all di-mensions to correct this deformity. The entirerepair should be taken down and the lip re-duced both vertically and transversely. We havefound permanent suspension sutures to theperiosteum helpful in maintaining theelevation.

Tight Lip

The tight lip may be seen in unilateral orbilateral cases, although more frequently in thebilateral deformity. In unilateral cases, thecause is usually a wide cleft not treated withpresurgical orthopedics. When a significant de-ficiency in tissue is present in the lip, the only

acceptable option is to bring in additional tis-sue in the form of a cross-lip transfer. Again,although used most frequently for the bilateraldeformity, severe deficiencies in the unilateralpatient may also be treated with the Abbé flap.However, this problem is being seen with de-creasing frequency because of presurgicaltreatment of wide clefts, which helps correctthe underlying skeletal imbalance before sur-gery is performed.

Wide Lip

The wide lip deformity is almost exclusivelyseen in the bilateral cleft lip patient and isalways caused by designing the new philtrumtoo widely at the time of the initial lip repair. Atthe age most lips are first repaired (3 to 6months), no more than 4 to 5 mm of pro-labium should be used to create the philtrum.Because the orbicularis is most frequently ap-proximated to the lateral border of the pro-labium, there is a great tendency for this tostretch over time (Fig. 8).

FIG. 6. Fat injection used to correct upper lip deficiencies after repair. (Left) Preoperative and(right) postoperative appearance.

FIG. 7. Abbé flap correction of a bilateral notch deformity. (Left) Preoperative and (right)postoperative appearance.


To correct this problem, the excess philtrumshould be excised along the previous lip scar.Just as in the primary operation, the philtrumshould be designed slightly narrower than theultimate desired width in anticipation ofstretching. In the past, consideration was al-ways given to using scar tissue or nostril sill withreasonable color and consistency rather thandiscarding it (forked-flap technique of Mill-ard).27 This tissue often became part of the newcolumella and nostril sill. We strongly believethat labial skin (often hair-bearing and thick)should not be used to reconstruct the colu-mella. The forked flap technique causes its

own deformities, introducing severe scarsacross the central columellar-labial junction,and the circumferential philtral scar producesa contracted bulge rather than a dimple.7

CONCLUSIONS

Secondary deformities are common in chil-dren born with a cleft lip and palate. They areboth intrinsic to the malformation and iatro-genic.7 The planning and procedures for anewborn with cleft lip and palate should bedone only by an experienced team of profes-sionals using the latest techniques to minimizethe problems and number of operations and toenhance normal growth and development.When a secondary deformity is observed, treat-ment should based on the degree of the defor-mity and the severity of the impact on thenormal functions and growth of a child.

Samuel Stal, M.D.1102 Bates #330MC 3-2314Houston, Texas [email protected]

REFERENCES

1. Bardach, J., and Salyer, K. E. Correction of secondaryunilateral cleft lip deformities. In J. Bardach and K. E.Salyer (Eds.), Surgical Techniques in Cleft Lip and Palate.Chicago: Yearbook Medical Publishers, 1987.

2. Williams, H. B. A method of assessing cleft lip repairs:Comparison of Le Mesurier and Millard techniques.Plast. Reconstr. Surg. 41: 103, 1968.

3. Assuncao, G. The VLS classification for secondary de-formities in the unilateral cleft lip: Clinical applica-tion. Br. J. Plast. Surg. 45: 288, 1992.

4. Millard, D. R., Jr. Cleft Craft: The Unilateral Deformity, Vol.1. Boston: Little, Brown, 1976.

5. Akguner, M., Barutcu, A., and Karaca, C. Adolescentgrowth patterns of the bony and cartilaginous frame-work of the nose: A cephalometric study. Ann. Plast.Surg. 41: 66, 1998.

6. Mulliken, J. B. Correction of the bilateral cleft lip nasaldeformity: Evolution of a surgical concept. Cleft PalateCraniofac. J. 29: 540, 1992.

7. Mulliken, J. B. Repair of bilateral complete cleft lip andnasal deformity: State of the art. Cleft Palate Craniofac.J. 37: 342, 2000.

8. Cutting, C., and Grayson, B. The prolabial unwindingflap method for one-stage repair of bilateral cleft lip,nose, and alveolus. Plast. Reconstr. Surg. 91: 37, 1993.

9. Cutting, C. B. Primary bilateral cleft lip and nose repair.In S. Aston, R. Beasley, and C. H. M. Thorne (Eds.),Plastic Surgery, Philadelphia: Lippincott-Raven, 1997.P. 257.

10. Cutting, C., Grayson, B., Brecht, L., Santiago, P., Wood,R., and Kwon, S. Presurgical columellar elongationand primary retrograde nasal reconstruction in one-stage bilateral cleft lip and nose repair. Plast. Reconstr.Surg. 101: 630, 1998.

11. Cutting, C., Grayson, B., and Brecht, L. Columellar

FIG. 8. The philtrum should be created from a prolabialsegment no larger than 4 to 6 mm at the time of primary liprepair. (Above) Philtral appearance in the early postoperativeperiod. (Below) Postoperative result several years laterdemonstrates significant stretching of the reconstructedphiltrum.


elongation in bilateral cleft lip (Letter). Plast. Reconstr.Surg. 102: 1761, 1998.

12. Grayson, B. H., Santiago, P. E., Brecht, L. E., and Cutting,C. B. Presurgical nasoalveolar molding in infantswith cleft lip and palate. Cleft Palate Craniofac. J. 36:486, 1999.

13. Maull, D. J., Grayson, B. H., Cutting, C. B., et al. Long-term affects of nasoalveolar molding on three-dimen-sional nasal shape in unilateral clefts. Cleft PalateCraniofac. J. 36: 391, 1999.

14. Grayson, B. H., Santiago, P. E., Brecht, L. E., et al. Pre-surgical nasoalveolar molding in infants with cleft lipand palate. Cleft Palate Craniofac. J. 36: 486, 1999.

15. Latham, R. A., Kusy, R. P., and Georgiade, N. G. Anextraorally activated expansion appliance for cleft pal-ate infants. Cleft Palate J. 13: 253, 1976.

16. Georgiade, N. G., and Latham, R. A. Maxillary archalignment in the bilateral cleft lip and palate infant,using pinned coaxial screw appliance. Plast. Reconstr.Surg. 56: 52, 1975.

17. Ross, R. B., and MacNamera, M. C. Effect of presurgicalinfant orthopedics on facial esthetics in complete bi-lateral cleft lip and palate. Cleft Palate Craniofac. J. 31:68, 1994.

18. Berkowitz, S. A comparison of treatment results in com-plete bilateral cleft lip and palate using a conservativeapproach versus Millard-Latham PSOT procedure. Se-min. Orthod. 2: 169, 1996.

19. Henkel, K. O., and Gundlach, K. K. Analysis of primarygingivoperiosteoplasty in alveolar cleft repair: Part I.Facial growth. J. Craniomaxillofac. Surg. 25: 266, 1997.

20. Nakajima, T., Yoshimura, Y., Nakanishi, Y., Kuwahara, M.,and Oka, T. Comprehensive treatment of bilateralcleft lip by a multidisciplinary team approach. Br. J.Plast. Surg. 44: 486, 1991.

21. Santiago, P. E., Grayson, B. H., Cutting, C. B., et al.Reduced need for alveolar bone grafting by pre-sur-gical orthopedics in primary gingivoperiosteoplasty.Cleft Palate Craniofac. J. 35: 77, 1998.

22. McComb, H. Primary repair of the bilateral cleft lipnose: A four-year review. Plast. Reconstr. Surg. 94: 37,1994.

23. Millard, D. R. Extensions of the rotation-advancementprincipal for wide unilateral cleft lips. Plast. Reconstr.Surg. 42: 535, 1968.

24. Coleman, S. R. Facial recontouring with lipostructure.Clin. Plast. Surg. 24: 347, 1997.

25. Gillies, H., and Kilner, T. P. Harelip: Operations for thecorrection of secondary deformities. Lancet 2: 1369,1932.

26. Stal, S., Klebuc, M., Taylor, T. D., et al. Algorithms forthe treatment of cleft lip and palate. Clin. Plast. Surg.25: 493, 1998.

27. Millard, D. R., Jr. Closure of bilateral cleft lip and elon-gation of columella by two operations in infancy. Plast.Reconstr. Surg. 147: 324, 1971.

Self-Assessment Examination follows onthe next page.


Self-Assessment Examination

Correction of Secondary Cleft Lip Deformitiesby Samuel Stal, M.D., and Larry Hollier, M.D.

1. ALL OF THE FOLLOWING ARE TRUE ABOUT PALATAL FISTULAS EXCEPT:A) Nasoalveolar fistula most frequently represents a residual cleft not addressed at the time of initial repair.B) Posterior fistula is secondary to a breakdown in closure.C) There is no such thing as a fistula that is simple to close.D) All fistulas should be immediately repaired regardless of symptoms.E) Bone grafting should only be considered if a good lining closure is present.

2. WHICH OF THE FOLLOWING SEEM TO CONTRIBUTE TO A POSITIVE OUTCOME IN CLEFT SURGERY?A) Premaxillary orthopedicsB) Nasoalveolar moldingC) Careful dissection and handling of tissuesD) Lip scar massageE) All of the above

3. ALL OF THE FOLLOWING ARE TRUE ABOUT AN ABBÉ FLAP EXCEPT:A) The lower lip has a philtrum, white roll, and Cupid’s bow.B) Local tissue rearrangement works in most cases of vermilion deficiencies, with the Abbé flap reserved for severe defects.C) An Abbé flap also improves lip balance by removing relative excess vermilion from the lower lip.D) An Abbé flap should be larger by 25 percent than the proposed new philtrum to compensate for contracture.E) The location of the labial artery can be anatomically gauged by using the cut side as a guide.

4. WHICH OF THE FOLLOWING SECONDARY DEFORMITIES IS MOST LIKELY TO BE CAUSED BY FAILURETO UNITE THE ORBICULARIS ORIS MUSCLE?A) A short lipB) Vermilion border malalignmentC) Vermilion notchingD) A long lipE) Mucosal deficiency

5. A SIGNIFICANTLY SHORT LIP FOLLOWING PRIMARY CLEFT REPAIR USUALLY REQUIRES WHICH OF THEFOLLOWING PROCEDURES?A) Diamond-shaped excision and closureB) Abbé flap transferC) Z-plasty rearrangementD) Takedown of the repair and repeat rotation

6. THE LONG LIP DEFORMITY CAN MOST FREQUENTLY BE CORRECTED BY EXCISING SKIN FROM THEALAR BASE AND SUTURE SUSPENDING THE LIP CEPHALAD.A) TrueB) False

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