36

Cleft Lip and Palate

Travis T. Tollefson

INTRODUCTION
Comprehensive management of the patient with a cleft lip and palate requires a collaborative multidisciplinary
team of specialists, typically including facial plastic or general plastic surgeons, otologists, speech and language
pathologists, nurses, geneticists, orthodontists, dentists, oral surgeons, audiologists, pediatricians, and social
workers. Orofacial clefting is the most common craniofacial birth defect; surgical management of this issue
requires meticulous soft tissue technique, in which mere millimeters of error in infancy may result in permanent
cleft stigmata. Producing a satisfactory aesthetic result depends upon careful attention to the skin and soft
tissue, nasal cartilages, teeth, and skeletal components, which must be addressed sequentially during the child's
growth and development. Concomitantly, speech and swallowing function are rehabilitated through painstaking
restoration of dental and palatal structures.
An orofacial cleft represents failure of fusion of the lip, nasal sill, alveolus, or palate, which may occur in a
spectrum of combinations of unilateral or bilateral deformities. The etiology of orofacial clefting is not well
understood, but the condition results from an interruption in the complex craniofacial developmental pathway.
Clefts may develop as complete or incomplete lip defects, complete or incomplete palate defects, or a
combination that may span all the way from the nasal sill to the uvula (Fig. 36.1). Lesser manifestations of
orofacial clefting are termed “microform,” “occult,” “minor,” or “forme fruste” (aborted form).
A variety of classification schemes have been suggested, the first in 1938 when Veau described his system:
group A includes defects of the soft palate l only; group B includes defects of the hard and soft palate not
extending anterior to the incisive foramen; group C includes defects extending through the entire palate and the
alveolar ridge; and group D includes complete bilateral cleft lip. This general framework may be useful in
discussion; however, further understanding of the developmental pathways that lead to orofacial clefting has
simplified classification of the palatal cleft based on whether the primary palate (structures anterior to the incisive
foramen, including the lip, premaxilla, and anterior septum) or the secondary palate (structures posterior to the
incisive foramen, including the lateral palatine shelves, soft palate, and uvula) is involved.
A comprehensive classification scheme should identify involvement of the primary and secondary palates as well
as lip and nasal deformities so that these areas may be addressed specifically during management. I prefer to
determine initially whether the cleft is typical or atypical. The atypical craniofacial clefts were described in the
landmark 1976 article by Tessier, who outlined a classification scheme for orofacial clefts that present with
atypical orientations, such as the number 7, macrostomia due to a cleft at the commissure of the lip (Fig. 36.2).
Extension of these clefts through the soft tissues may involve the maxilla, orbit, and skull base. For example, a
bilateral Tessier number 4 cleft extends from the upper lip through the nasolacrimal duct and into the lower eyelid
at the medial canthus (Fig. 36.3).
Typical orofacial clefts are described by laterality of the lip cleft (unilateral or bilateral) and its degree. The cleft
lip may be complete (through the lip and nasal sill), incomplete (orbicularis oris and skin are intact for at least
three-fourths of the length of the lip), or microform (characterized by a philtral skin
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groove, minor nasal deformity, orbicularis oris discontinuity, and a notched vermilion-cutaneous junction with
disruption extending to no more than one-fourth of the labial height, as measured from the normal peak of the
Cupid's bow to the nasal sill) (Fig. 36.4). The cleft alveolus may be complete or notched. Independent of the cleft
lip type, the cleft palate is described as unilateral (one palatal shelf is attached to the nasal septum) or bilateral.

FIGURE 36.1 The spectrum of incomplete cleft palate includes defects ranging from isolated uvular bifidity to
palatal clefting as anterior as the incisive foramen: (A) intraoral view of an incomplete soft palate cleft shows
extension just to the hard palate; (B) another child's unrepaired cleft palate extends through the hard palate. The
adenoid pad is seen between the two sides of the cleft uvula.

FIGURE 36.2 Atypical orofacial cleft, Tessier No. 7, demonstrating macrostomia (A) preoperatively, (B) after soft
tissue repair, and (C) left lower eyelid coloboma and ocular dermoids prior to removal.
FIGURE 36.3 Photograph of a child with bilateral Tessier No. 4 orofacial clefts (A) preoperatively and (B) after
subunit repair to recreate lower eyelids and continuity of the mouth; maxillary clefting will require future bone
grafting.

FIGURE 36.4 The features of a typical right microform unilateral cleft lip shown in (A) frontal view and (B) base
view, including notched mucosa, elevated Cupid's bow peak, furrowing of the philtral column, thinning of the dry
vermilion medially, widening of the nasal base, hypoplasia of the orbicularis oris muscle, and asymmetry of the
nostril.

In this chapter, I will outline the following: multidisciplinary management of cleft lip and palate, physical
examination findings, and potential associated syndromic and nonsyndromic comorbidities. Preoperative
planning will be reviewed, along with presurgical nasoalveolar molding (PNAM), and the indications and
contraindications for repair of the surgical cleft. Preferred techniques for unilateral and bilateral cleft lip repair
and palatoplasty will be described. Postoperative management will be reviewed with emphasis on prevention of
complications.

HISTORY
The role of a multidisciplinary team is to address the conditions that coexist with orofacial clefts, ranging from
difficulties with speech and swallowing to Eustachian tube dysfunction and audiologic issues to orthodontic,
dental, and orthognathic problems. Care of the child born with a cleft lip and/or palate begins with a consultation
soon after birth, during which the multidisciplinary team focuses on teaching the mothers effective feeding
techniques and emphasizes the importance of appropriate weight gain. In each patient, a comprehensive history
is obtained that includes familial, prenatal, and delivery events. Attention is dedicated to the presence of
additional physical findings as well as the possibility of a syndromic or sequence event. Consultations with
neonatal intensivists, geneticists, and additional specialists are made on a case-by-case basis. With each
patient, specialized care commonly continues through the teenage years and into early adulthood, involving
regular team meetings and sequential intervention, both operative and nonoperative.

PHYSICAL EXAMINATION
The presence of an orofacial cleft may be identified on routine prenatal ultrasound at 18 to 20 weeks of
gestation. Three-dimensional ultrasound technology has increased the detection rate of cleft lip, but not
isolated cleft palate. Because of this, expectant parents with a positive ultrasound are now presenting for
prenatal facial plastic surgery consultation. Preparation for and understanding of the surgical repairs
through educational consultation may help allay parental concerns. Prenatal consultation also allows the
surgeon to begin assessment for preoperative therapies, such as PNAM, which requires frequent clinic
visits and significant parental commitment.
The neonate is examined for cleft lip and cleft palate immediately after birth. Identification of the subtle
microform cleft lip or submucous cleft palate is facilitated with training and experience in identifying muscle
abnormalities that lack obvious epithelial defects. A thorough examination of the head and neck begins with
assessment and palpation of the continuity of the upper lip and nares. The maxillary alveolus is palpated for
a notch or cleft.
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FIGURE 36.5 Lower lip pitting seen in Van der Woude's syndrome.
Improved visualization of the soft palate may be achieved by placing the child supine in the parent's lap and
carefully extending the neck. The neonate often opens his or her mouth and spontaneously protrudes the
tongue, giving a good view. A tongue depressor and light should also be used to assess the palate and
uvula. A bifid uvula or zona pellucida in the soft palate should prompt palpation for a hard palate notch. The
lower lips are inspected for nodular lip pits as seen in Van der Woude's syndrome (Fig. 36.5). The oral
commissure and cheeks are evaluated for atypical clefting or auricular remnants found in
oculoauriculovertebral spectrum (Fig. 36.6). The shapes and positions of the ears are inspected, looking for
microtia or other features of hemifacial microsomia. The eyelids may also demonstrate colobomata or
notches.

INDICATIONS
The typical indications for proceeding with repair of the cleft lip are difficulty feeding, poor weight gain, and
airway obstruction. Although poor weight gain may indicate feeding difficulty, the surgeon and pediatrician
must also consider cardiac or other defects leading to failure to thrive. Breastfeeding is encouraged, though
formula supplementation is common. Postnatal weight loss of up to 10% of birth weight is normal, but
should be regained in 2 weeks. Thereafter, at least 1 ounce of weight gain per day indicates adequate
feeding. Nasogastric tube feeding is seldom required if a feeding nurse specialist can counsel the mother
effectively. Neonates with cleft palate have difficulty creating suction; they should be positioned upright to
limit nasal regurgitation. Specialized nipples, such as the Haberman nipple (Fig. 36.7), control the flow rate
from a bottle and may limit the infant's fatigue while feeding.

FIGURE 36.6 Oculoauriculovertebral spectrum, demonstrating hemifacial microsomia, left anotia, and (A) a
repaired unilateral complete cleft lip and palate, (B) 3-D CT scan showing the left unrepaired alveolar cleft
and left mandibular ramus reconstruction with rib grafting.

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 FIGURE 36.7 Infant with a bilateral cleft lip and palate feeding with a Haberman nipple, while the PNAM
appliance is in place. The cylindrical nipple on the bottle may be squeezed to control flow.

CONTRAINDICATIONS
Repair of an orofacial cleft may be contraindicated until airway obstruction is addressed. Airway obstruction
due to the tongue is seen in a small proportion of infants with orofacial clefts, with Pierre Robin sequence
being the most common cause (Fig. 36.8). Initial treatment includes prone positioning, nasopharyngeal
trumpet, nasal continuous positive airway pressure, or endotracheal intubation. Definitive surgical
intervention may include tracheostomy, mandibular distraction osteogenesis, or tongue-lip adhesion.

PREOPERATIVE PLANNING
The typical timeline for each of the discrete steps of orofacial cleft management is shown in Figure 36.9. Cleft lip
repair is often performed at 3 to 5 months of age. For infants with cleft palate, bilateral myringotomy and
tympanostomy tube placement is followed by behavioral audiometry prior to the cleft palate repair, performed
between 10 and 14 months of age. Speech and language pathology assessment and therapy are initiated after
vocabulary develops (3 to 5 years old) with emphasis on identifying velopharyngeal dysfunction. A secondary
speech surgery may be required to address hypernasality at this time. Superiorly based flap pharyngoplasty,
sphincter pharyngoplasty, and Furlow double-opposing Z-palatoplasty are procedures frequently used to limit
nasal air escape; when employing these techniques, the surgeon must be aware of the potential to produce
obstructive sleep apnea from excessive nasal obstruction.
In the presence of a typical unilateral or bilateral cleft lip and palate, dental and orthodontic care should be
initiated early. Prior to the eruption of the maxillary canines at around 7 to 10 years of age, an orthodontist will
begin dental preparation for the alveolar bone graft. The bone graft is often harvested from the iliac crest at
approximately 10 years of age. Orthognathic surgery for correction of dentofacial malocclusion is delayed
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until skeletal growth is complete, which occurs earlier in females than in males. Subsequently, definitive cleft
septorhinoplasty will address the nasal deformity in the teenage years.

FIGURE 36.8 Infant with Pierre Robin sequence demonstrating microgenia, glossoptosis, and cleft palate with
external mandibular distraction device.
FIGURE 36.9 Timeline for comprehensive management of cleft lip and palate showing surgical procedures on
the bottom and nonsurgical treatment above, from birth to adulthood.

Cleft Lip Repair

During the initial consultation, weight gain and feeding are assessed. The upcoming surgical procedures and
future multidisciplinary management are discussed. Wide cleft lips may require one of several presurgical
preparations including: lip taping, oral appliance use (Latham device), PNAM, 2-staged repair with a primary lip
adhesion, or delayed repair to allow tissue growth. Daily lip taping may affect soft tissue expansion. Standard
protocols use an adhesive strip or tape to appose the lip edges. The cheeks are protected with a skin barrier that
requires routine replacement due to lip wetting from feeding (Fig. 36.10). The Latham appliance actively
repositions the premaxilla but is not used frequently. Concerns with potential maxillary growth inhibition continue
to fuel the debate regarding the appropriate use of presurgical premaxillary positioning.
FIGURE 36.10 Infant with bilateral cleft lip and palate shown (A) preoperatively, (B) during lip taping, and (C) 1
week after surgical repair, with silicone nasal stents taped in place.

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FIGURE 36.11 Intraoral impression of the maxilla of an infant with a bilateral cleft lip and palate shown before
(left) and after (right) nasoalveolar molding repositioned the premaxilla posteriorly.

Presurgical Nasoalveolar Molding

Greyson and Cutting introduced and developed the principles of PNAM, including the addition of nasal prongs to
the traditional intraoral alveolar molding device. Alveolar molding will bring the maxillary alveolar segment or
segments into contact with the premaxilla in both unilateral and bilateral cleft lip and palate. Further objectives of
the PNAM technique are to bring the cleft lip segments closer together, expand the columellar mucosa and skin,
and improve symmetry of the nasal tip. Parental compliance should be assessed before initiating a PNAM
treatment program, which should begin within the first several weeks after birth.
In cases of a wide unilateral or bilateral cleft lip, alveolus and palate, presurgical orthodontic treatment with
PNAM is started at the second office visit (Fig. 36.11). A specialized orthodontist fabricates the PNAM appliance;
a maxillary impression is taken around the third postnatal week, after which, the mold is used to create an acrylic
nasoalveolar molding appliance. The orthodontist adjusts the appliance every week by removing hard acrylic and
adding soft acrylic (Permasoft denture liner, Dentsply International, Chicago, IL). Nasal prongs may be added to
the appliance and positioned just under the soft tissue triangle of the nostril (Fig. 36.12). The stents are adjusted
by adding soft acrylic to help create a tissue-expanding effect on the columellar skin, simultaneously reorienting
the nasal tip. The orthodontist adapts the appliance over the next several months to reposition the alveolar
arches, delaying the definitive cleft lip repair until approximately 4 to 5 months of age. The alveolar segments
may be repositioned to come in contact prior to lip closure, potentially allowing closure of the alveolar cleft with a
gingivoperiosteoplasty.
FIGURE 36.12 Infant with a right complete unilateral cleft lip and palate (A) preoperatively and (B) during PNAM
with the appliance and nostril prong in place; (C) another infant with bilateral cleft lip and palate shown
preoperatively, (D) with PNAM appliance, and (E) after repair in a frontal view showing the enhanced medial lip
tubercle and (F) profile view showing the effect of primary rhinoplasty on the nasolabial relation.

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Staged Repair
In the severely wide cleft lip, some surgeons choose to use a lip adhesion technique to bring the mucosa and lip
skin together without dissection of orbicularis oris muscle. The second-stage definitive cleft lip repair is then
delayed for several months until the orthopedic forces created by the lip adhesion move the lip and alveolar
segment into closer proximity. Another way to stage repair of the bilateral cleft lip deformity is to address each
side individually. The main drawbacks to this approach are the increased potential for asymmetry and difficulty in
reconstituting an intact orbicularis oris sphincter over the premaxilla.

SURGICAL TECHNIQUE
Unilateral Complete Cleft Lip
After induction of general endotracheal anesthesia, the tube is taped to the midline of the chin to avoid distortion
of the upper lip and nasal tip, and the eyes are protected with occlusive dressings. Local anesthetic (1%
lidocaine with 1:100,000 epinephrine) is infiltrated under the upper lip, into the supraperiosteal planes of the
maxilla, in order to block the infraorbital nerves. The oral commissures and midline buccal sulcus are injected,
taking care to avoid edema at the lip edges. Low volume injection into the plane between the lower lateral
cartilages and skin-soft tissue envelope (SSTE) of the nasal tip is performed through standard marginal injection
sites.

Lip Markings and Flap Design

Initial markings are placed at the subnasale and lateral alar base, by tattooing with a 30-gauge needle and
methylene blue (Fig. 36.13). The junction of the columella and the upper lip is marked, followed by the midline
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philtral column at the vermilion-cutaneous (v-c) junction. Approximately 2 to 3 mm lateral to this, the Cupid's bow
peaks on the cleft and noncleft sides are marked.

FIGURE 36.13 Cleft lip markings for the unilateral cleft lip repair using a modified Mohler rotation-advancement
technique. The five flaps are visualized as the rotation, the advancement, the columellar, the medial mucosal,
and the lateral mucosal flaps. The wet-dry (w-d) junction is where the wet vermilion and dry vermilion meet. The
triangle flap of the left lateral lip is marked just below point 8 to add dry vermilion mucosa to the medial lip. The
numbered points include the following: point 1 is center of Cupid bow, with point 2 the Cupid peak on the
noncleft side and point 3 the Cupid peak on the cleft side. The subnasale is the junction of the upper lip and
columella. Point 5 is chosen 2 to 3 mm above and away from the subnasale in the highest point of the rotation
flap. Points 3 to 5 are lengthened with a back-cut made to point (see inset). Points 6 and 7 are the commissures
of the lip. Points 4 and 9 are the junction of the ala to the columella in the nasal sill. Points 8 and 9 make up the
advancement flap height, which should equal line 3-5-x. Inset: The columellar flap (C) is elevated deep to the
dermis and rotated into the donor site of the rotation flap (A).

The modified Mohler rotation-advancement markings place the rotation flap incision up onto the columella,
approximately 1 to 1.5 mm above the subnasale and toward the noncleft side, approximately two-thirds to three-
fifths of the width of the columella away from the cleft side. This additional length of skin on the columella adds to
the rotational component of the rotation-advancement closure, and a back-cut may be added to extend the
rotational flap length. Attention is then directed to the columellar (“c” flap) markings, which follow the lateral cleft
edge of the prolabium at the junction of the cutaneous component of the columella and medial oral mucosa.
Great care should be taken to not include any mucosa in the “c” flap to ensure that mucosal edges are not
involved in the skin closure.
The most important consideration when restoring cutaneous lip height is proper marking and adjustment of the
position of the lateral advancement flap. This is necessary to create lip length symmetry between the cleft and
noncleft sides. Using a caliper, the first measurement is taken from the subnasale to the Cupid's bow peak on the
noncleft side. This measurement is recorded in a simple “tic-tac-toe” chart, which includes left and right on the
vertical columns and lip and nose on the horizontal rows (Fig. 36.14). The distance from the subnasale to the
Cupid's bow peak on the cleft side is then measured. The design of the flaps permits lengthening of the cleft side
to equal the height of the noncleft side. The difference in lip height between the cleft and noncleft sides may be
reduced by rotation-advancement and/or a small triangle flap from the lateral lip segment inserted into the
inferior-most medial lip v-c junction.
Using the noncleft side lip height as a guideline, the lateral lip advancement flap is drawn. Starting where the
triangular-shaped dry lip mucosa begins to taper, the length of the advancement flap should be designed to
equal the noncleft side lip length. This flap occasionally extends too far inferior and lateral toward the
commissure and may sacrifice excessive lateral lip. One key step is to look at the wet-dry lip junction on both the
lateral lip segment and the noncleft side. If the dry vermilion height on the cleft side is more than 1 mm deficient
compared to the noncleft side, then a triangle flap may be created on the dry vermilion from the lateral lip
segment and inset into the medial lip dry vermilion.
If the cleft side rotation flap height is insufficient, the advancement flap may be modified with a triangle flap
placed just above the cutaneous roll. Using this lateral lip triangle to add additional length to the advancement
flap side is similar to the Fisher subunit principle for cleft lip repair. The lateral triangle will be inserted into a
back-cut on the medial lip, resulting in an additional 1.5 to 3 mm of lip height. A triangle greater than 3 mm is not
recommended, as abnormal scarring outside of the lip subunits may result. Examples of advancement flap
markings on a very short lateral lip segment are shown in Figure 36.13.

Skin Incisions and Flap Creation

The lip segments are grasped with the thumb and index finger, and a #11 blade is used to incise the red lip's
lateral mucosal “l” flap. A #15C blade is then used to incise the cutaneous aspect of the lateral lip segment with a
minimal back-cut. The “l” flap mucosal edge is incised down to the buccal sulcus. This buccal sulcus incision
allows for a supraperiosteal dissection over the maxilla using gentle dissection with a cotton-tipped applicator or
gauze-covered fingertip. The “l” flap, which has been elevated off the edges of the orbicularis oris, is retracted
inferiorly so that dissection may extend to the piriform aperture. This permits the alar base to be released sharply
from the underlying, aberrant attachments. The mobilized alar base may then be repositioned superomedially.
The orbicularis oris muscle is dissected free from the overlying dermis and the underlying mucosa. Retraction
using a double-prong hook and Adson-Brown forceps provides countertension during sharp undermining, but
only to the extent necessary for closure. A wider cleft will require dissection for up to 5 to 7 mm, while a narrower
cleft may only require 3 to 4 mm of subcutaneous dissection of the advancement flap.
The rotation flap incision is facilitated using a double-prong hook under the nostrils to pull cephalad, while
downward finger tension is applied during incision from the columella down to the Cupid's bow peak on the cleft
side. The perpendicular dry vermilion incision at the distal end of the “m” flap is made with a #11 blade. The “m”
flap is dissected free from the underlying orbicularis oris muscle, and then the buccal sulcus and frenulum are
incised and separated from the premaxilla, releasing the orbicularis oris fibers from the nasal spine region
bluntly. The back-cut at the base of the columella is made with a #11 blade. The “c”
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flap is then incised and separated from the orbicularis oris fibers. A pair of round-tipped scissors is used to
dissect between the medial crural footplates of the lower cartilages and the subcutaneous soft tissue envelope.
The dissection of the SSTE off the lower lateral cartilages and nasal tip is performed just deep to the columella
and extended laterally. The dissection pocket is created as atraumatically as possible, extending over the upper
lateral cartilages.

FIGURE 36.14 Measurements are recorded to establish the advancement flap height using the noncleft side lip
height, the distance from subnasale to the Cupid's bow peak. The nasal base width is measured from the
subnasale (sn) to the alare (al) on the left and right.

To reconstruct the floor of the nose, an incision through the mucosa extends the “c” flap posteriorly along the
inferior aspect of the nasal septum. The septal mucosal edge is bluntly dissected and rotated laterally to contact
the lateral lip and nasal base. The nasal floor is closed with 5-0 chromic gut sutures, using the columella and
nasal ala junction on the noncleft side as a guide. The alar base “cinching” suture is passed through the cleft
side alar base and suspended to the level of the nasal spine and caudal septum with a 3-0 polyglactin suture. If
the alar base appears inferiorly malpositioned, cephalad placement of the suture may reposition the alar base
more symmetrically with respect to the contralateral side. Calipers are used to achieve symmetry in this
maneuver by measuring from subnasale to the alar base tattooed marking points. Meticulous closure of the floor
of the nose is essential in order to prevent nasolabial fistula formation. In a wide, unilateral cleft lip and palate,
the “l” flap may be transferred to the prolabium and secured to the “m” flap in a side-to-side fashion to add
additional mucosal closure or may be passed into the buccal sulcus. However, the skin edges of this flap leave
epithelialized lining in the buccal sulcus, and this is rarely needed.
The inner lining of the lip mucosa is approximated between the cleft and noncleft sides using 5-0 chromic gut
suture. Closure of the lateral lip mucosa to the premaxillary mucosa is performed, but undone if it distorts the
cutaneous lip closure. Usually, one 5-0 chromic gut suture is used to advance the lateral lip segment to the
premaxilla differentially, leaving the lateral-most aspect of the buccal sulcus incision without sutures. To create
symmetric fullness in the red lip, the orbicularis oris flap from the rotation side is sutured to the advancement side
in a horizontal mattress fashion using buried, 4-0 polyglactin or polydioxanone suture. The inferior-most aspect of
the orbicularis oris is reconstructed using a vertical mattress suture to evert the tubercle region. Additionally, 3 to
4 sutures in the orbicularis oris are usually required.

Primary Rhinoplasty
Previously, the subcutaneous soft tissue envelope was released from the lower nasal cartilages in preparation
for cartilage repositioning. The neonatal period provides a unique opportunity to reorient the lower lateral
cartilages surgically. Circulating maternal hormones responsible for softening cartilage are theorized to create
plasticity in the neonate's nasal cartilage, potentially permitting reshaping in the early neonatal period. Two
approaches should be considered: a transcutaneous plication approach and an intercartilaginous approach. A
transcutaneous suture may be used to reorient the cleft side dome of the lower lateral cartilage in a cephalic
direction. While cephalically positioning the cleft side nasal dome, full-thickness triangular fixation sutures may
be placed with the knot in the nose, using absorbable suture. Alternatively, through an intercartilaginous incision,
a 5-0 polydioxanone suture may be used to grasp the cephalic border of the cleft side lower lateral cartilage,
reorienting it more cephalically and medially to the upper lateral cartilage and dorsal septum, similar to Skoog's
description.

Lip Closure
Skin closure requires attention to the key area of the v-c junction, with the white roll first being reapproximated
using 5-0 polydioxanone suture on a P-2 needle, allowing precise matching of dermal height on either side of the
wound. If a lateral lip triangular flap was designed, insertion is completed in a back-cut mirroring the vertical
position of the inferior-most base of the triangle flap, usually just above the cutaneous roll. Subcuticular closure
continues superiorly. The “c” flap is rotated into the defect of the columella rotation flap site with deep 5-0
polydioxanone and 6-0 fast-absorbing gut. The distal tip of the “c” flap may be trimmed to improve contour and
symmetry. The lateral lip segments may require an additional fast-absorbing gut suture to ensure exact dermal
height matching of the skin edges. Mucosal reconstruction will begin with buried 5-0 polydioxanone suture to
approximate the dry vermilion triangle flap from the lateral lip segment into a back-cut on the medial lip segment,
and 5-0 chromic gut is used to reapproximate the mucosal edges, with care taken to maintain the symmetry of
the wet-dry junction. The skin edges are closed with surgical glue.
Once the mucosal closure is completed, and the dermal glue has been applied, a silicone elastomer nasal stent
is placed into the nostrils and secured with 4-0 silk for 7 days (Fig. 36.15). When the stent is removed, it is
cleaned and taped into position to maintain the nostril's shape for up to 6 weeks postoperatively.

Bilateral Cleft Lip

A modified Mulliken bilateral cleft lip and nasal deformity repair consists of concentric orbicularis oris
reconstruction, midline tubercle reconstruction, alar base narrowing, and primary rhinoplasty (Fig. 36.16).
Markings and presurgical planning are of the utmost importance. Precise lip markings, after local anesthetic has
been infiltrated, are possible only if the injections are performed in the deep mucosal layers, under the lip and up
to the infraorbital nerves, thereby avoiding distortion of the soft tissues.
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FIGURE 36.15 Infant with a left complete unilateral cleft lip and palate (A) preoperatively, showing the simplified
markings, which demonstrate that the left blue line needs to be elongated to the length of the yellow line, (B) 1
week after repair; and (C) nasal silicone conformers are taped either to the cheeks or nasal tip for up to 6 weeks
after repair.
Lip Markings and Flap Design
Landmarks are temporarily tattooed with methylene blue, using a 30-gauge needle and a cotton-tipped applicator
for hemostatic compression. Initial markings include the midline of the subnasale (Sn, the junction of the lip and
the columella) and the lateral-most aspects of both nasal alae (al). The alar base width (al-al) and each distance
from subnasale to alar base are recorded. The v-c junction in the midline of the philtrum is also marked.
The new philtral column will take the shape of a necktie. As suggested by Mulliken, the width of this in most 3- to
5-month-old infants should be no more than 3 to 4 mm at the Cupid's bow peaks. At the base of the nose,
however, the philtral flap may be as narrow as 2 mm. Creating a narrow philtrum accounts for widening
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that inevitably occurs during the healing process. Differential growth patterns of the lip and nose must also be
considered during flap design in order to produce a more normal appearance. At this stage, the goal should be to
attain philtral column lengths in the range of 6 to 8 mm.

FIGURE 36.16 Illustration of a bilateral cleft lip repair using a modified Mulliken technique. Labels are the same
as in Figure 36.13 except that the lowest point of the midphiltrum makes up a necktie shape to account for
wound tension and growth of the philtral column. The inferior-most philtral triangle has two points ( 2 and 3),
which are 2 to 3 mm lateral to the center. The lateral segments of the prolabium are de-epithelialized ( shaded
purple). The nasal marginal incisions provide access for the primary rhinoplasty.

Choosing the appropriate design for the advancement flaps from the lateral lip segments is the most difficult
consideration in preoperative marking, as several factors are involved. First and foremost, the v-c junction
separates the dry red lip and the cutaneous lip. The white roll is directly above this v-c junction. The wet-dry
junction of the vermilion lip is identified and marked where the dry lip mucosa begins to narrow as it extends into
the upper cleft. The height of the advancement flaps should be equal to or slightly longer than the length of the
philtral column, roughly 8 mm, which has been marked on the prolabium. If necessary, a triangular portion of the
superior margin of the advancement flap lip skin may be excised during the final lip closure. However, in most
cases, the priority is to create enough lip length by drawing this advancement flap incision inferiorly to where the
v-c junction and dry lip mucosa widths are symmetric between both sides. The midline lip tubercle will be created
with the lateral lip dry mucosa. The “l” flap incisions are started 2 to 3 mm proximal to the distal advancement
flap height (Fig. 36.16).
Restoration of the alar base requires anatomic reconstruction of the nasal sill through identification of the point at
which the columella extends down onto the premaxilla. Making these markings symmetric preoperatively
preserves the soft tissue of the nasal sill and alar base, preventing future nostril stenosis.

Lip Incisions and Flap Mobilization

The lateral lip segment incisions and release are performed first because of their dependent positions, so that
any bleeding from prolabium incisions will not compromise visualization. Using a #15C blade, the advancement
flaps are incised from the alar base down to the cutaneous roll. The incision across the dry mucosa is made
approximately 2 to 3 mm proximal to the distal-most point of the advancement flap incision. This allows the dry
vermilion mucosa to be rotated outward as it comes in contact with the prolabium, facilitating creation of a
tubercle. The incision results in a classic “l” flap, or lateral mucosal-type flap, which then is extended along the
buccal sulcus under the lip to allow for release of the orbicularis oris muscle attachments from the alar base.
Supraperiosteal dissection extends laterally onto the maxilla, with the amount of dissection being dependent on
lip width. To account for the increased wound tension in a wider cleft lip repair, more dissection along the face of
the maxilla will be required. The lateral lip soft tissue is released from the piriform aperture, extending to the level
of the inferior turbinate. Using cautery for this component may be helpful because of the vascularity of turbinate
tissue.
The contralateral segment is addressed in the same fashion, with care to make only a minimal alotomy. The
length of alotomy required is dependent on the width of the cleft, but in the vast majority of cases, the alotomy
does not extend to the lateral aspect of the ala. In general, alotomy incisions are avoided because suture track
marks may become prominent and difficult to conceal with growth, and the desired nasal architecture generally
may be achieved without them.
The prolabial incisions are then made. Using a downward cutting motion with a #15C blade, the philtral column is
incised just through the dermis in a pie-shaped fashion, thus creating the triangle tip at the distal edge of the
prolabial skin but not extending onto the mucosa. This flap may be narrow at the columella as the lateral
prolabial segments maintain their strong vascularity. The skin overlying the lateral-most prolabium will be de-
epithelialized. Markings for de-epithelialization are made along the margin of the v-c junction. Incisions are made
down to the soft tissues just superficial to the periosteum of the premaxilla. The periosteum is an easy plane for
blunt dissection with a cotton-tipped applicator and allows preservation of columellar vessels. The superior-most
horizontal nasal sill incisions are made lateral to the columella-lip junction, extending 90 degrees laterally to help
restore the nasal floor. These incisions are made just deep to the dermis so that vascularity is maintained in the
prolabium.
To prevent future adherence of the new prolabial lip segment to the premaxilla, the mucosa from the prolabium is
trimmed to size; usually, approximately 50% is removed in a horizontal fashion, and then 5-0 chromic gut suture
is used to tack the prolabial mucosa down to the periosteum of the premaxilla, thus creating a sulcus across
which the orbicularis oris reconstruction will be able to slide (Fig. 36.17).

Primary Rhinoplasty
The primary rhinoplasty technique is modified depending on the severity of the cleft lip nasal deformity. For a
severe bilateral deformity, the philtral incisions are extended into marginal incisions just anterior to the
caudalmost aspect of the lower lateral cartilages. This allows dissection over the dysmorphic lower lateral
cartilages in a plane just deep to the superficial musculoaponeurotic system. Circumferential incisions are
contraindicated due to the potential for causing nasal stenosis. Intradomal fat may be repositioned cephalically,
but removal is not recommended. The lower lateral cartilages are apposed to the upper lateral cartilages with 5-0
polydioxanone suture, using Skoog's technique. Intradomal suturing increases tip projection as the domes are
created from the lateral crura. The SSTE must be manipulated atraumatically to prevent scarring or pigmentation
changes. Careful marginal incision closure and excision of nasal rim soft tissue hooding is performed later in the
procedure.
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FIGURE 36.17 Sequence of steps for repair of this bilateral cleft lip and palate shown in (A) base view with wet-
dry junction of the vermilion (long arrow), cutaneous roll (short arrow), and prolabium just superior to the
premaxilla; (B) operative view, (C) lip incisions markings, (D) incision for the left lateral flap, and (E) elevation of
the skin from the underlying orbicularis oris; (F) the prolabial incisions are made and the philtrum created by
removing lateral epithelium; (G) the alar base suture is tightened to near 25 mm in width; (H) the orbicularis oris
muscle edges are sutured in the midline, and (I) the philtrum is secured into position with the lip mucosa everted
to accentuate the tubercle.
Muscle Dissection
Orbicularis oris dissection from the overlying dermis of the lateral lip segments is then performed with traction
and countertraction applied to the overlying skin. Careful soft tissue handling includes avoidance of skin edge
pinching. Using a small double-prong hook, the skin edge is rolled outward and the dermis is elevated with a #15
blade. Release from the orbicularis oris is performed for approximately 3 to 4 mm laterally, while the muscle is
grasped with Adson-Brown forceps to provide countertraction. In the case of a wide cleft, the dissection should
extend further, to a maximum of approximately 1 cm. To preserve orbicularis oris pars marginalis a 90-degree
change in plane is made at the vermilion as the double-prong hook is applied to the vermilion and retracted
upward. The orbicularis oris is released from the lip mucosa in the plane of the minor salivary glands. This allows
a rectangular orbicularis oris flap to be dissected free from the skin and mucosal linings. The flap is then
advanced over the prolabium to secure it to the contralateral side after the exact same dissection is performed on
the contralateral lip segment.
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Lip Closure
The key initial suture “sets” the alar base width with the use of a 3-0 or larger polyglactin suture. After placing
the suture symmetrically through the alar bases and passing under the new philtral column, calipers are used to
set the width at around 25 mm. Suture tension is adjusted accordingly. The previously recorded sn-al distances
are used for reference. Difficulty may arise in cases with an asymmetric or very wide bilateral cleft as one may
encounter preoperative alar base widths up to 45 mm.
Although a 25-mm alar base may seem narrow during closure, this intraoperative width accounts for tension on
the alar base and widening during wound healing. Avoidance of an unsightly, wide alar base is paramount to
preventing the stigmata of the bilateral cleft lip nasal deformity. After the alar base width has been set, a
concentric orbicularis oris is reconstructed. The muscles are brought together with a 3-0 or 4-0 polydioxanone
suture placed just under the v-c junction. The needle is placed orthogonal to the muscle fibers to orient the two
lateral segments symmetrically. After the sutures are placed in three equally divided spaces of the lip length, a
vertical mattress suture is placed to promote eversion of the orbicularis oris in the tubercle and orient the pars
marginalis to help restore volume under the cutaneous roll.
To define the nasolabial angle, a suture is applied to the superior-most aspect of the orbicularis oris and secured
to the periosteum of the nasal spine. Attention is then directed to restoration of the philtral column between the
lateral skin segments using a 6-0 absorbable monofilament suture on a small needle. The knot is buried to
prevent dermal suture granulomas. Meticulous approximation of the cutaneous aspects of the philtrum to the
area just above the cutaneous roll allows the triangular inferior aspect of the philtrum to be suspended within the
mucosa of the tubercle. The dry mucosa edges are sutured with vertical mattress 5-0 chromic gut suture to
create the midline tubercle. Reapproximation of the superior-most lateral lip segments to the philtral column may
require triangular skin excisions to form the nasal sills.
After subcuticular closure of the lip, any irregularities in epithelial heights are repaired with 6-0 fast-absorbing gut
suture. Surgical glue is applied in two thin layers to the skin edges, to avoiding causing track marks.
Alternatively, skin closure may be performed with 7-0 nylon sutures, but this requires a brief sedation for suture
removal in 5 to 7 days.
The closure of the rhinoplasty component requires meticulous attention to reapproximation of the marginal
incisions using 5-0 or 6-0 chromic gut. Potential excess hooding of the medial-most soft tissue triangle skin may
be trimmed using a Tajima “inverted-U” approach. The alar rims are symmetrically positioned when the marginal
incisions are closed with 6-0 chromic gut sutures. Nasal stents are placed, using either preformed silicone
elastomer stents or trimmed red Robinson catheters. These are sewn into place with 4-0 silk suture and left in
position for 7 days with attentive cleansing using saline droplets to maintain patency, as infant patients are
obligate nasal breathers.

Palatoplasty
The 2-flap palatoplasty is useful for most cases of unilateral or bilateral complete cleft palate (Fig. 36.18). The
vomer flap is opened like a book to reconstruct the nasal lining for the latter, while a unilateral septal flap is used
for the former. Overall goals include establishing adequate mobilization for a tension-free closure in three layers,
posterior lengthening of the soft palate with levator muscle release and repair,
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and closure of the anterior nasal floor, if possible. After induction of general endotracheal anesthesia, a shoulder
roll is placed and the eyes are protected with occlusive dressings. Preoperative cefazolin and dexamethasone
are given.

FIGURE 36.18 Two-flap palatoplasty technique. A: Unilateral cleft palate repair with flaps based on the greater
palatine artery are used. The levator veli palatini is released from the palatal bones and from the oral and nasal
flaps. If the muscle is moved posteriorly (intravelar veloplasty), the levator sling is created. B: After.

A Dingman retractor is used to expose the palate, and a repeating 20-minute timer is set to prompt regular
release of the tongue, thereby decreasing postoperative edema. Using a 27-gauge needle, 1% lidocaine with
1:100,000 epinephrine is injected around the greater palatine vessels and incisive foramen. The medial uvular
mucosa is excised with tenotomy scissors to address uvular bifidity. A #15 blade is used to incise the periosteum
of the medial cleft margin from the uvula to the border of the posterior palatal shelf, leaving a 2-mm mucosal
edge for closure. The incision extends to the posterior premaxilla and medially along the alveolar cleft. If this was
not previously addressed during cleft lip repair, the incision is then extended medial to the tooth-bearing maxilla
from the posterior maxillary tubercle. Scoring of the periosteum facilitates flap elevation. A Beaver blade may be
used to make the anterior horizontal incision, completing the U-shaped flap.
A Hurd elevator is used to mobilize the flap posteriorly up to the greater palatine vessels, working in a
subperiosteal plane. Elevation medial to the vessels reveals the posterior extent of the palatal shelf. The
aberrant levator veli palatini aponeurosis is released from the posterior palatal shelf, allowing medialization for
future closure. Blunt dissection with a Freer elevator is performed lateral to the greater palatine neurovascular
bundle until the space of Ernst is entered behind the vessels. Gentle, controlled upward traction releases the
pedicle. Occasionally, periosteal release is required for adequate mobilization. The tensor veli palatini is either
released from the hamulus or gentle infracture of the bone may be performed in those cases where excess flap
tension is noted. The flap edges are gently cauterized, and Surgicel (Ethicon, Somerville, NJ) is applied for
hemostasis. A Woodson elevator is used to release the nasal mucosa from the undersurface of the palatal shelf
along the entire extent of the bony margin.
The soft palate dissection is completed with the release of the levator veli palatini from the nasal layer, thereby
eliminating traction between the oral and nasal layers. Intravelar veloplasty is performed by some authors, but I
feel that it may diminish vascularity and increase scarring as a result of additional dissection. In a unilateral cleft
palate, any septal mucosa on the vomer is incised where the oral mucosa and septum converge. The
submucoperichondrial flap is elevated for adequate mobilization but minimized in order to respect the potential
septal cartilage growth centers. The nasal layers are closed with buried 5-0 chromic gut sutures. Uvular
reconstruction is completed with a traction suture placed at the apex, allowing the uvula to be pulled forward
while the posterior surface is sutured. Fine 6-0 polyglactin sutures are used to reorient the uvular muscle during
closure. The two sides of the levator muscle sling are approximated in the midline with 4-0 polyglactin sutures,
taking care to avoid sawing of the sutures through the friable mucosal edges. The oral layer is then closed using
a combination of vertical mattress and simple interrupted 4-0 polyglactin sutures. Three tacking sutures are
applied between the oral and nasal layers to minimize dead space. The anterior and lateral flap margins are then
apposed to the maxillary mucosa with 3-0 polyglactin sutures. Cautery and digital pressure provide hemostasis
prior to the patient's emergence from anesthesia.

Other Techniques
Incomplete and submucous cleft palate may be addressed using similar approaches, but varying the incisions
and flap design. The von Langenbeck palatoplasty is a variant of the 2-flap technique in which the anterior-most
flap is left attached to the posterior maxillary arch. Transposing these two bipedicled flaps to the midline closes
the cleft. The Furlow double-opposing Z-plasty is a useful technique for closing the incomplete cleft palate or for
subsequent lengthening of the palate. The majority of the levator veli palatini muscle is included in the posteriorly
based flaps. When the limbs of the Z-plasty are completed for the nasal and oral flaps, the amount of palatal
lengthening is determined by the angle of the flap design (Fig. 36.19).

POSTOPERATIVE MANAGEMENT
Cleft Lip Repair
The goals of postoperative care are to provide analgesia, promote early feeding, and protect the repair from
infection or trauma. The use of intermittent soft arm restraints for up to 2 weeks postoperatively should be
considered when the patient is not under direct observation. Feeding with a catheter-tipped syringe for the first 3
to 7 days will minimize orbicularis oris motion and tension on the skin sutures. However, in my experience in
international work where breast-feeding may be the only available option, I have found that breast-feeding does
not result in a higher rate of wound complications.
A nasal Merocel (Medtronic, Mystic, CT) maybe used to maintain a dry postoperative wound and can be placed
in the cleft side nostril instead of the silicone conformers. A light coating of bacitracin ointment over the mucosal
closure and nostrils may also be applied. Of note, the ointment should not contact the surgical glue as it may
cause premature degradation of the adhesive.
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FIGURE 36.19 Furlow palatoplasty (double-opposing Z-plasty) technique. A: The posteriorly based oral
myomucosal layer on the right is rotated posteriorly, whereas the left nasal mucosal layer is rotated anteriorly. B:
Conversely, opposing flaps are oriented to avoid suture lines that are directly over one another. C: The Z-plasty
increases palatal length and creates a levator sling. D: Nasal mucosal flaps are closed first maintaining the
myomucosal flap posteriorly.

Pain management usually requires acetaminophen, with or without codeine, and may be augmented with
bupivacaine nerve blocks at the conclusion of surgery. The use of intravenous antibiotics (cefazolin, 25 mg/kg)
and steroids (dexamethasone 0.5 mg/kg) is limited to a single preoperative dose and then two postoperative
doses.
On postoperative day 6 or 7, the silicone nostril conformers are removed and washed. The surgical glue is
released with petroleum jelly and the wound cleansed with saline. The silicone nasal conformers are taped into
the nostrils, and either silicone gel sheeting or paper tape covers the incision for the next 3 to 4 weeks.

Cleft Palate Repair

Although a tongue suture may assist with airway maintenance, this is rarely needed. Positioning the patient in
the lateral decubitus position allows secretions to drain from the mouth and opens the airway. Perioperative
antibiotics include one preoperative and two postoperative doses. Analgesia is achieved with acetaminophen
and codeine, quickly transitioning to acetaminophen alone when possible. Ibuprofen is allowed 48 hours after
surgery.
The initial postoperative period requires oxygen saturation monitoring and parent teaching for feeding with a
catheter-tipped syringe. For 2 weeks after cleft palate repair, no bottles or nipples should be introduced into the
mouth, and soft foods served with a spoon should be allowed only with proper parent counseling on preventing
the child from placing fingers or foreign bodies into the mouth.
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COMPLICATIONS
Cleft Lip Repair
With appropriate preoperative planning, few complications should arise after cleft lip repair. Inadequate
weight gain and nutrition may lead to a prolonged hospital course, possible anesthesia difficulties, or wound
healing impairment. Aesthetic outcomes after cleft lip and palate repair are difficult to measure objectively.
When unsatisfactory results are seen after cleft lip repair, the deformity is categorized as the following:
Cupid's bow peak “creeping” into the cutaneous lip height
Vermilion deficiency or excess
Orbicularis oris discontinuity
Subtle minor deformities may be addressed at the time of planned operations in the future, but major
revisions should be performed before the child enters school.
Decreased lip height may result when the medial cleft lip is inadequately rotated. This may be rectified
using a revision rotation-advancement and/or a laterally based triangle flap. A vermilion mismatch
between the two sides of the cleft lip may be addressed with a triangle flap Z-plasty and redistribution of
mucosal volume. More sophisticated revision techniques are employed in areas of deficiency, such as
reorientation of buried flaps or application of free dermal grafts to the lip.
Dynamic lip examination may reveal that the orbicularis oris was inadequately released or repaired.
Repairing this defect requires complete division of the lip, removal of any central scar, dissection of
functional muscle, and creation of a concentric orbicularis oris sphincter. A common site for this problem
is the nasal sill, which may also be the site of a fistula due to inadequate nasal floor reconstruction.
Although direct access through the nostril may be effective, closure of the nasal floor and fistula is often
better approached through complete division of the lip repair and thorough revision closure.
Lip dehiscence, though rare, occurs more frequently in the setting of patient-centered problems (e.g.,
poor nutrition or infection) or surgeon error (e.g., excessive wound tension or a lack of layered closure).
Delaying a cleft lip repair for weeks or months may allow maxillary repositioning or soft tissue taping, as
well as improvement in nutritional status.
The risk of an undiagnosed cardiac defect is also higher in patients with cleft lip and palate. Delaying
surgical repair permits additional time to identify associated comorbidities that may affect the patient's
recovery.
Palatoplasty
Complications following palatoplasty may present both in the immediate postoperative period and in a more
delayed fashion.

Common Immediate Complications

Hemorrhage
Airway obstruction related to anatomic compression (e.g., Pierre Robin sequence)
Narcosis: Oxygen saturation monitoring and careful attention to the patient's level of consciousness
are imperative.
 Late Complications
Palatal dehiscence
Palatal fistula
Tooth bud injury
Midface growth inhibition
Palatal fistulas may be repaired primarily, with a tongue flap or with a facial artery myomucosal flap.
Even with proper palatal reconstruction, approximately 10% of patients will have velopharyngeal
insufficiency despite speech therapy. These patients will require a thorough multidisciplinary speech
evaluation and treatment program including consistent and carefully directed speech therapy,
nasopharyngeal fiberoptic endoscopic examination, and possible nasometry or lateral fluoroscopic
videography. The latter has lost favor due to the radiation exposure required for the study. Surgical
correction may include double-opposing Z-plasty, sphincter pharyngoplasty, or superiorly based flap
pharyngoplasty.

RESULTS
While it is nearly impossible to erase completely the stigmata of orofacial clefting, the well-executed repair
should achieve middle and lower facial symmetry with a normal lip contour, adequate nasal tip projection,
and
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minimal scarring. Velopharyngeal reconstruction should permit normal phonation and minimize
nasopharyngeal reflux, without causing upper airway obstruction. Examples of cleft lip and palate repairs
are illustrated in Figures 36.20, 36.21, 36.22 and 36.23.
 FIGURE 36.20 Patient with an incomplete unilateral cleft lip preoperatively (A) and 3 years after surgery
(B).

PEARLS
Management of cleft lip with or without cleft palate is best accomplished by a multidisciplinary team.
The nasal deformity seen in both unilateral and bilateral orofacial clefts should be addressed with the primary
lip repair.

Unilateral Cleft Lip

Creation of adequate medial lip height with either a rotation flap or inset of a triangle flap is imperative.
Orbicularis oris undermining from the cutaneous lip dermis is limited on the medial side in order to produce a
philtral dimple.
The nasal floor is created from septal mucosal dissection and lateral nasal mucosa divided from the piriform
aperture.
FIGURE 36.21 Patient with a complete unilateral cleft lip and palate preoperatively (A), 6 months postoperatively
(B), and at 4 years (C) after surgery.

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FIGURE 36.22 Patient with an asymmetric bilateral cleft lip and palate preoperatively (A) and 4 years
postoperatively (B).
FIGURE 36.23 Patient with incomplete bilateral cleft lip and palate. Imaging during the first week of life (A), of the
PNAM molding (B), with the application of the PNAM molding (C), 7 months after PNAM molding (D and E), and
3 years after surgical correction (F).

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Bilateral Cleft Lip
Presurgical molding and lip taping may help prepare the lip for tension-free repair.
The use of primary rhinoplasty and PNAM may obviate the need for secondary columellar skin lengthening.
The philtral column should be made necktie shaped and as narrow as 4 mm at the Cupid's bow peak.
The narrow philtrum will survive due to vascularity from the de-epithelialized prolabium.
Suturing the superior-most orbicularis oris to the nasal spine may help emphasize the nasolabial angle.

Palatoplasty
Complete dissection and release of the palatoplasty flaps allows tension-free apposition and three-layered
closure.
The greater palatine neurovascular bundle may be released bluntly from the periosteum to maximize mobility
of the flaps.

PITFALLS
Poor soft tissue handling techniques compromise tissue viability and lead to scarring, hyperpigmentation,
tears, and compromise of the end aesthetic outcome.
Unilateral Cleft Lip
Daily lip taping may affect soft tissue expansion.
Nasal alotomy is not necessary with modern cheiloplasty techniques.

Bilateral Cleft Lip

Under correction of the alar base width is common. One should set made as narrowly as possible, around 25
mm.
Wound healing forces will widen a philtral column flap making it excessively wide.

Palatoplasty
Incomplete dissection and release of the palatoplasty flaps leads to a greater incidence of palatal dehiscence
and fistula formation.
Failure to close the anterior-most nasal flaps can lead to a nasolabial fistula.

INSTRUMENTS TO HAVE AVAILABLE

Cleft lip and palate set
Standard plastics set
Dingman retractor
Hurd elevator
Woodson elevator

ACKNOWLEDGMENT
The author would like to recognize Maj. Marc H. Hohman, MD, for his exceptional contributions to the writing of
this chapter. His work in the writing, editing, and figure creation of this chapter is greatly appreciated, without
which this chapter would not have been possible.

SUGGESTED READING
Fisher DM. Unilateral cleft lip repair: an anatomical subunit approximation technique. Plast Reconstr Surg
2005;116:61-71.

Grayson B, Cutting C. Presurgical nasoalveolar orthopedic molding in primary correction of the nose, lip, and
alveolus of infants born with unilateral and bilateral clefts. Cleft Palate Craniofac J 2001;35:193-198.

Mulliken JB. Primary repair of bilateral cleft lip and nasal deformity. Plast Reconstr Surg 2001;108:181-194.

Skoog T. A design for the repair of unilateral cleft lips. Am J Surg 1958;95:223-226.

Tessier P. Anatomical classification facial, cranio-facial and latero-facial clefts. J Maxillofac Surg 1976;4:69-
92.
 37
Cleft Lip Rhinoplasty
Jonathan M. Sykes

INTRODUCTION
All patients with a cleft lip deformity have an associated deformity of the nose. The surgical repair of the cleft
nasal defect is performed at the time of the primary cleft lip operation at approximately 10 weeks of age. The goal
of the primary rhinoplasty is to lessen the secondary deformity and to allow the nose to grow in a symmetric
fashion. A secondary rhinoplasty is sometimes required, and is preferably performed in late adolescence, after
facial skeletal growth is complete. Successful cleft rhinoplasty requires a structural approach that rebuilds the
nasal infrastructure. The deformity associated with congenital clefting of the lip and nose requires restoration
and repositioning of multiple layers of tissue. The nose must be reconstructed on a stable foundation to achieve
symmetry, to preserve function, and to correct facial deformity.
In order to properly treat the cleft lip nasal deformity, one must understand the characteristic defects of the nose
associated with a unilateral or bilateral cleft lip. This chapter describes the nasal abnormalities associated with
cleft lip and outlines the operative techniques and timing of the surgery to correct the cleft nasal deformity.

HISTORY
Ultrasound techniques and advances in perinatal medicine allow many children with a cleft lip and nasal
deformity to be diagnosed in utero. Early detection of facial irregularities helps the surgeon counsel the child's
parents and plan for surgical treatment. It is important for families to understand prenatal and hereditary risk
factors that may have resulted in the cleft deformity. A geneticist can elicit a family history of any craniofacial
abnormalities or syndromes, evaluate genetic risk factors, and provide counseling to families.
Upon learning that their child has a cleft lip and nasal deformities, many parents are anxious to expedite
reconstructive surgery. Prenatal, birth, and postnatal histories are of considerable importance in the evaluation of
a patient who may undergo future surgical interventions. Further, ensuring adequate growth and weight gain
before surgery is paramount. The goal weight prior to surgery is 10 pounds. Cleft lip and cleft nasal deformity are
often associated with a cleft palate, which may cause difficulties with nursing. Specialized feeding techniques
using bottles with customized nipples, such as the McGovern nipple, facilitates nursing and subsequent
improvement in nutrition and weight gain. Nurses especially trained in working with cleft lip and palate patients
are a good resource for parents and the surgeon.

PHYSICAL EXAMINATION
The physical examination of a patient with a cleft lip nasal deformity should include an assessment of the
severity of the cleft lip along with any other associated defects, such as the presence of an associated cleft
palate or cleft alveolus. Additionally, it is important in any child with a congenital cleft malformation involving
the lip,
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nose, or palate to examine the patient for any associated syndromes, abnormalities, or deformities. Patients
who have syndromic clefting should be carefully examined by a knowledgeable pediatric geneticist to
identify any potential systemic anomalies.
FIGURE 37.1 Unilateral cleft lip nasal deformity. An infant is shown with a complete left cleft lip, cleft palate,
and cleft nasal deformity. The left nostril is displaced inferiorly, laterally, and posteriorly; the nasal tip is
flattened, asymmetric, and poorly defined; the floor of the nose is absent.

Patients who have undergone primary surgical treatment for clefting of the lip with an associated nasal
deformity may require a secondary nasal surgery, usually in late adolescence. The nature of the secondary
cleft rhinoplasty operation depends on the identification of nasal deformities that have persisted following
the original repair. Several nasal features must be noted in the physical exam, including alar position,
columellar height, tip definition, symmetry, nasal tip projection, and the position of the nasal septum.
Unilateral Cleft Lip Nasal Deformity
A unilateral cleft lip nasal deformity results from a lack of bony support for the nasal base. Depending on the
severity of the defect, a cleft nasal deformity can include a common cavity from the nasal floor into the
mouth, depression and widening of the ala on the cleft side, flattening of the nasal dome, underprojection of
the nasal tip on the cleft side, and deficient bone in the alveolus and maxilla (Fig. 37.1). The features of a
unilateral cleft lip nasal deformity are summarized in Table 37.1.
Bilateral Cleft Lip Nasal Deformity
Patients with a bilateral cleft lip deformity have a range of severity in their oral and nasal defects. The
common sequelae of a bilateral cleft lip nasal deformity are a shortening of the columella; a wide, flattened
appearance of the nasal tip; and a substantial loss of nasal tip support (Fig. 37.2). Clefting and bone loss in
the maxillary eminence and bilateral alveolar ridges are important to note. Dentition and alignment of the
incisor and canine teeth can be significantly impacted by clefting of the alveolus. Stunted midfacial growth
can occur in patients with bilateral cleft lip deformities. Nasal symmetry is often present if the severity of the
bilateral cleft lip deformity is equal on both sides. The features of the bilateral cleft lip nasal deformity are
summarized in Table 37.2.
Secondary Nasal Deformity
Although the original nasal deformity associated with congenital cleft lips are characteristic, secondary cleft
nasal deformities exhibit more variability. Secondary cleft nasal deformities are related to three factors: (1)
the original congenital malformation, (2) any repositioning and surgical scarring resulting from prior surgical
intervention, and (3) alterations of the nose related to growth. At the time of evaluation for secondary
rhinoplasty,
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the septum has not typically been corrected with a previous procedure and has characteristics associated
with either the unilateral or bilateral cleft lip deformity. In the unilateral cleft lip nasal deformities, the septum
is caudally deviated to the noncleft side and posteriorly deviated to the cleft side. In symmetric bilateral cleft
lip nasal deformities, the septum is often wide but is relatively in the midline.

TABLE 37.1 Physical Examination Findings of the Unilateral Cleft Lip Nasal Deformity

Nasal tip Medial crus of lower lateral cartilage is shortened on cleft side
Lateral crus of lower lateral cartilage is lengthened on cleft side
Total length of the lower lateral cartilage on the cleft side equal to the
noncleft side
The nasal tip on the cleft side has a flattened appearance and is displaced
laterally

Columella Appears shortened on the cleft side

Columellar base is deflected to noncleft side (from orbicularis oris muscle
contraction)

Nostril Has widened, flattened, horizontal appearance

Floor of the Occasionally absent

nose

Nasal septum Deviated caudally to the noncleft side and posteriorly to the cleft side
Deviation typically does not cause nasal airway obstruction

Alar base Displaced laterally, inferiorly, and posteriorly

FIGURE 37.2 Bilateral cleft lip nasal deformity. A: A male infant is shown with a congenital bilateral
symmetric cleft lip in addition to clefting of the secondary palate. He has a mild nasal deformity associated
with his bilateral cleft lip deformity and a notched alveolus. B: A male infant with a complete bilateral cleft lip
and cleft in the anterior palate is shown. The patient has a more severe nasal deformity than the patient
shown in (A) and suffers from a shortened columella, absent nasal floor bilaterally, and an overly protruding
premaxilla.

Secondary deformities of the septum and nasal tip can be addressed during definitive septorhinoplasty. In a
unilateral cleft lip patient, the nasal tip is underprojected on the cleft side. In bilateral cleft lip nasal
deformities, the tip is underprojected bilaterally. The underprojection of the nasal tip is often associated with
a deficiency of internal and external skin. Because the underlying deformity is deficient bony skeleton on the
cleft side, there is typically inadequate support to the alar base (Fig. 37.3).

INDICATIONS
Patients with a cleft lip will often require surgery to correct associated deformities of the nose that are not
addressed primarily with the initial cleft lip repair. The goal of initial repair is to create symmetry and improve
nasal tip projection, in addition to closing connections between the floor of the nose and the mouth.
Secondary cleft lip rhinoplasty is performed to correct aesthetic and functional problems of the nose.
Indications for revision surgery include a widened nasal base, persistent columellar shortening, poor tip
definition, a flattened nasal dorsum, alar asymmetry, and the desire for scar revision. Timing for secondary
rhinoplasty is preferably when a patient's facial growth is complete. Performing an intermediate rhinoplasty
before the completion of facial growth may be warranted in school-age children or adolescents with severe
nasal deformities that are socially hindering and a source of ridicule.

CONTRAINDICATIONS
Infants who are underweight or malnourished or who suffer from global illness or syndromic sequelae may
not be good candidates for any elective primary surgery on a cleft lip nasal deformity. Secondary definitive
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rhinoplasty, including major revisions, should be avoided in children and young adolescents who are
expected to have further facial growth. Operating on the nose too early in children and adolescents may
damage growth plates and create problematic scarring, stunting midfacial growth or nasal growth. If Class III
malocclusion is present in patients who have a cleft lip and nasal deformity (Fig. 37.4), orthognathic surgery
for malocclusion should precede their planned definitive secondary cleft rhinoplasty.

TABLE 37.2 Physical Examination Findings of the Bilateral Cleft Lip Nasal Deformity

Nasal tip The medial crura portion of the lower lateral cartilage is shortened bilaterally
The lateral crura portion of the lower lateral cartilage is shortened bilaterally
The lateral crura are caudally displaced
The domes are widened, leading to a flat tip with poor definition

Columella Short
Wide columellar base

Nostril Horizontal shape bilaterally

Floor of Usually absent bilaterally

the nose

Nasal The septum is midline if the severity of the bilateral cleft lip is equal; if one side is
septum more severe, the septum deviates to the less affected side

Alar base Widened with excess show of internal nasal lining

FIGURE 37.3 Skeletal changes in a unilateral cleft deformity. The septum is deviated caudally to the
noncleft side and posteriorly to the cleft side. The nasal floor is absent, and there is a common cavity
between the mouth and the nose.
PREOPERATIVE PLANNING
Patients with a cleft lip nasal deformity may also have a cleft palate, middle ear effusion and hearing loss,
speech delay, and significant dental, orthodontic, and orthognathic issues. A team approach to patients who
suffer from any craniofacial abnormality is important. Any planned procedure on a patient with multiple surgical
concerns should be coordinated with all involved team members. Patients with a cleft nasal deformity in addition
to a cleft lip and palate are expected to undergo a sequence of procedures at different ages (Table 37.3).
Before any surgery is performed, patients with a unilateral cleft lip and nasal deformity may benefit from the use
of nasal alveolar molding (NAM). NAM is a nonsurgical technique that uses a custom-fit prosthesis to guide and
reshape nasoalveolar segments of tissue (Fig. 37.5A and B). The alteration of tissue using NAM can shorten a
wide cleft, improve nasal tip symmetry, and lengthen the columella in a bilateral cleft deformity.

FIGURE 37.4 Class III malocclusion treated with Le Fort I osteotomy and maxillary distraction. The teenage
patient shown has undergone a bilateral cleft lip repair and palate repair when she was a child. She
subsequently developed maxillary hypoplasia and Class III malocclusion. A preoperative photograph is shown on
the left, prior to any maxillary distraction (A). The central photograph (B) shows the titanium halo and maxillary
distraction device in place following a Le Fort I osteotomy. The postoperative result after plate fixation of the
distracted maxillary segment is shown on the right (C).

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TABLE 37.3 Surgical Interventions for Cleft Lip, Cleft Palate, and Cleft Nasal Deformity

Primary cleft lip repair and cleft rhinoplasty, 10 wk of age

bilateral myringotomy tubes

Palatoplasty (repair of cleft palate) ˜1 y of age

Alveolar bone grafting Between ages 9 and 11 year old

Secondary cleft rhinoplasty Completion of facial growth; 15 year old in

males and 17 year old in females
FIGURE 37.5 A: Nasal alveolar molding (NAM). By placing a malleable synthetic material into the unilateral cleft
lip and palate defect of a patient, a custom NAM has been made. The custom mold is shown in the lower part of
the image. From the custom mold, a firm prosthesis can be made for nasoalveolar molding. The final NAM device
is shown in the superior aspect of the photograph. B: Preoperative use of NAM prior to primary unilateral cleft lip
repair and cleft rhinoplasty. Upper left: A nasoalveolar molding device is taped in place. Upper right: The device
has been removed after extended preoperative use, and the patient is intubated for a primary cleft lip repair and
cleft rhinoplasty. Lower left: The skin markings for a Millard advancement rotation unilateral cleft lip repair are
made. Lower right: The immediate postoperative result following cleft lip repair and cleft rhinoplasty is shown.

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Surgical planning for primary cleft lip rhinoplasty includes performing a careful three-dimensional assessment of
the cleft nasal deformity and the confluent cleft lip. Anticipated challenges, such a wide cleft, should be included
in the operative plan. Proper instruments and materials must be available for the procedure, such as Silastic
nasal conformers and arm restraints to prevent manipulation of the wound in the postoperative period.
Consistent and thorough communication with the parents of an infant undergoing surgery helps to manage
expectations in the postoperative period.
Patients undergoing secondary cleft rhinoplasty may require auricular or costal cartilage for nasal reconstruction.
Contingency plans for graft material should be considered, including the possibility of cartilage and tissue
harvest from multiple sites or the use of alloplastic materials. Preoperative photography helps the surgeon to
analyze the nasal deformity and communicate the surgical plan with the patient.

SURGICAL TECHNIQUE
Unilateral Cleft Lip Rhinoplasty
At 10 weeks of age, infants with a unilateral cleft lip deformity may undergo a repair of the cleft lip and associated
nasal deformity. A primary cleft rhinoplasty is performed at the same time as the lip repair with no extra incisions.
Patients are placed under general anesthesia and incubated with an oral RAE endotracheal tube. The operating
room table is turned 180 degrees. The eyes are protected with Tegaderm. The gingivolabial sulcus, periphery of
the cleft lip, and nasal sill are injected with Xylocaine 1% with 1:100,000 epinephrine. Care is taken to avoid
distortion of the tissues with the injection of local anesthetic. The landmarks of the cleft lip are marked for
planned incisions using a 1-cc syringe filled with a small amount of methylene blue and a 30-gauge needle. The
most critical marks made on the skin help to guide the reapproximation of cupid's bow on the noncleft and cleft
side. The patient's face is then painted with Betadine and draped. The planned incisions for a Millard rotation
advancement flap for a unilateral cleft repair are marked using methylene blue on the skin (Fig. 37.6).
Incisions made for a primary cleft lip repair provide access for primary cleft rhinoplasty. Once the incisions for a
Millard rotation advancement flap have been made, the lower lateral cartilage on the cleft side is
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mobilized by performing a subcutaneous dissection of the medial and lateral crura. Scissors are introduced
caudally beneath the columellar skin to access and free the medial crura and to release the dome of the cleft
side of the nose (Fig. 37.7A). In a similar fashion, the lateral crura on the cleft side is accessed through an
existing incision and released from the overlying skin (Fig. 37.7A). Dissection takes place superficial to the lower
lateral cartilage on the cleft side and beneath the skin (Fig. 37.7B).
FIGURE 37.6 Skin markings and landmarks for a Millard advancement-rotation flap repair of a unilateral cleft lip.
M, medial mucosal flap; L, lateral mucosal flap; C, central cutaneous flap. (From Hopper RA, Cutting C, Grayson
B. Cleft lip and palate. In: Thorne C, ed. Grabb and Smith's plastic surgery. Philadelphia, PA: Lippincott Williams
& Wilkins, 2007:201-225.)
FIGURE 37.7 A: Approach to the lower lateral cartilage on the cleft side during primary cleft rhinoplasty.
Dissection superficial to the lateral (left) and medial (right) crura is shown. Access to the lower lateral cartilage is
achieved through the cleft lip incisions. Dissection takes place superficial to the cartilage and beneath the nasal
skin envelope. B: Intraoperative dissection of the lower lateral cartilage on the cleft side. Incisions for a left-sided
unilateral cleft lip repair have been made. Left: Scissors are inserted deep to the skin and superficial to the
lateral crura. Right: In a similar fashion, the medial crura are dissected to enable tip refinement in this primary
cleft rhinoplasty.

Following dissection of the lower lateral cartilage on the cleft side of the nose, sutures are placed full thickness
through the skin and nasal lining. The nasal sutures placed during a primary cleft rhinoplasty are intended to
raise the nasal tip on the cleft side, narrow the tip, and improve nasal symmetry. Nasal sutures are tied externally
over a bolster made of a cut laparotomy sponge tape. Soft Silastic nasal conformers are then placed in both
nostrils (Fig. 37.8). The nasal conformers are secured with a through and through 4-0 nylon suture through the
nasal septum. Arm restraints (“No-Nos”) are placed to prevent the patient from manipulating the surgical site.

Bilateral Cleft Lip Rhinoplasty

The bilateral cleft is usually symmetric. In isolated cases, a bilateral cleft deformity can be asymmetric (Fig. 37.9).
In most instances where asymmetry is not significant, the goal of the primary rhinoplasty is to increase nasal tip
projection and to improve columellar length. Improvement in tip symmetry as well as tip projection is the goal
when asymmetry is severe. In cases of severe asymmetric bilateral cleft asymmetry,
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patients should be treated similarly to a unilateral cleft deformity. The operative goals are then to close the nasal
floor, create a normal nasal sill on each side, reposition the alar base, and increase nasal tip projection.

FIGURE 37.8 Nasal bolsters and Silastic nasal conformers following unilateral cleft rhinoplasty. A: A
preoperative photograph is shown of a left unilateral incomplete cleft lip with an associated nasal deformity. B:
The patient with the incomplete left cleft lip has undergone a primary repair, including a cleft rhinoplasty and the
placement of nasal bolsters and sutures. C: A patient with a right complete cleft lip has undergone primary cleft
lip repair and rhinoplasty, with nasal bolsters and conformers shown in place. D: A postoperative photograph
showing nasal conformers taped in place.

In the bilateral (symmetric) deformity, the operative goals are to reconstruct the nasal floor and nasal sill, to
reposition the alar base into a more normal position, and to increase nasal tip symmetry bilaterally (Fig. 37.10).
Repositioning the nasal base is accomplished by freeing up the alar base from its attachments to the maxilla.
This is done by releasing the soft tissue fibers from the pyriform aperture that attach the alar base to the deeper
soft tissue structures and bony skeleton. After these soft tissue attachments are divided with a curved tenotomy
scissor, the alar base can be repositioned by recreating the muscular sling at the superior aspect of the lip.
Reapproximation of the muscle is accomplished with a 4-0 clear monofilament long-acting absorbable suture.
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Reapproximation of the muscular sling at the base of the nose provides volume to the superior aspect of the lip
and support to the floor of the nose and nasal sill. Reapproximation of the muscle must be performed in a
symmetric fashion so that reconstruction of the nasal sill does not differ from one side to another. Because of the
absence of muscle in the central prolabium in the bilateral cleft lip deformity, the muscle provided to the base of
the nose must come from the lateral lip segments. Therefore, muscle dissection in the lateral lip segments is
performed to advance the orbicularis oris muscle across the midline of the lip. The muscular reapproximation
should be performed throughout the entire height of the lip. It is crucial to advance the upper portion of the
muscular sphincter of the lip to provide sufficient volume to the central lip segment while recreating the muscular
sling that supports the base of the nose.
FIGURE 37.9 Asymmetric bilateral cleft lip deformity. A patient is shown with an asymmetric bilateral cleft lip in
which the right side is more severely affected than the left.
FIGURE 37.10 Primary bilateral cleft lip repair with tip rhinoplasty. A: A patient with an incomplete symmetric
bilateral cleft lip deformity is shown. B: Skin markings are made in preparation for cleft lip repair and primary cleft
rhinoplasty. C and D: Flaps are dissected, and mucosal closure is planned. E: Excess skin is removed. F: The
immediate postoperative result is shown, including narrowing of the nasal base. The nasal base was narrowed
by placing sutures through the deep alar tissue bilaterally during the lip repair dissection.

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The standard bilateral upper lip incisions are used to gain access to the nasal tip. Dissection between the lower
lateral cartilages and skin of the nasal tip is performed in a blind fashion. The external skin is carefully freed from
the lower lateral cartilage, centrally over the medial crus and laterally over both lateral crura. After the skin is
freed from the lower lateral cartilages, the lip is closed in a standard layered fashion. This is performed by first
closing the mucosal layer, then the muscular layer (as mentioned above), and finally the external skin in a
bilateral fashion. After lip closure, sutures are placed within the nasal domes to achieve more definition and
projection of the nasal tip. The new domes are refined with bolsters and sutures. Medial advancement of the
lateral crura is used to obtain improved medial crural projection. Two to four domal bolster sutures are placed
lateral to the preexisting dome. At the conclusion of this procedure, Silastic nasal conformers are sutured into
position with 4-0 monofilament nylon suture.

Secondary Rhinoplasty
The operation performed during a secondary cleft rhinoplasty is completely dependent on the functional and
aesthetic needs of the patient. The surgery is ideally delayed until a patient has undergone full facial growth.
Goals of the operation may be to improve airway function, define the nasal tip, achieve nasal symmetry, increase
nasal projection, lengthen the columella, and narrow the nasal base (Fig. 37.11). Principles of secondary
rhinoplasty combine the known underlying tissue defects present in a cleft nasal deformity with the structural and
grafting techniques of revision rhinoplasty (Fig. 37.12A and B).

FIGURE 37.11 Secondary cleft rhinoplasty. A: A preoperative base view is shown of a patient with a left
unilateral cleft lip and associated nasal deformity. B: A sagittal view of the same patient reveals a flattened and
underprojected nasal tip. C: A postoperative base view is shown following secondary rhinoplasty and lip revision.
The tip has more definition, and there is improved projection and symmetry. D: The immediate postoperative
sagittal photograph, demonstrating improved projection, rotation, and definition of the nasal tip.

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The surgery is performed with the patient under general anesthesia intubated with an endotracheal oral RAE
tube secured to the midline lower lip and chin. The table is turned 90 or 180 degrees, and the nasal septum and
nasal dorsum are injected with Xylocaine 1%, 1:100,000 epinephrine. It is of critical importance to perform a
careful and thorough injection with local anesthetic to minimize bleeding. An open approach is frequently used
when extensive tip work and grafting is expected. For an open approach, standard columellar and marginal
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incisions are used. Any donor graft site is injected with local anesthetic, prepped, and draped. Grafting material
used in secondary cleft rhinoplasty includes the nasal septal cartilage, auricular cartilage, costal cartilage,
temporalis fascia, costal perichondrium (harvested simultaneously with cartilage), or alloplastic. A summary of
operative techniques to address the cleft nasal deformity in secondary rhinoplasty is presented in Table 37.4.

FIGURE 37.12 A: Bilateral cleft lip definitive rhinoplasty. Upper left: A photograph of patient with a bilateral cleft
lip nasal deformity is shown. Definitive secondary rhinoplasty is planned to correct a low dorsum, to lengthen the
nose, and to increase tip projection. An intraoperative lateral view of the nose is shown prior to any surgical
intervention. Upper right: The nasal tip skin envelope has been elevated with standard marginal and columellar
incisions and an open approach. To increase nasal length and projection, a caudal septal extension graft is
used. The graft consists of PDS foil (blue) secured with 5-0 PDS suture to a thin carved rib cartilage graft. Lower
left: A lateral view of the caudal septal extension graft is shown. Lower right: An oblique view of the nasal tip
shows the caudal septal extension graft in place and secured to the short caudal native septum and placed
between the medial crura. The graft is then trimmed, and the medial crura are secured to the caudal septal
extension graft in a tongue-and-groove fashion. B: Top: Following the placement of a caudal septal extension
graft (A), dorsal augmentation is planned in a patient with a bilateral cleft lip nasal deformity. Temporalis fascia is
secured in a tubular fashion with interrupted 5-0 chromic suture around a 1-cc syringe after the Luer-Lok tip is
cut off. The syringe is then filled with diced rib cartilage. The native syringe plunger is then used to gently fill the
tubed temporalis fascia with the diced cartilage while gently pulling the fascia off of the syringe. Middle: The
temporalis fascia filled with diced cartilage is held above the nasal dorsum and will be used for dorsal
augmentation. Bottom: Immediate postoperative photograph following the placement of diced cartilage-filled
temporalis fascia for dorsal augmentation, in addition to the placement of a caudal septal extension graft.

TABLE 37.4 Problem-Based Operative Techniques in Secondary Cleft Rhinoplasty

Functional nasal Septoplasty

obstruction Correction of vestibular or nasal scarring/stenosis

Poorly defined nasal Columellar strut for projection and stabilization

tip Tip-defining suture techniques
Cartilage tip or shield graft

Middle third Spreader grafts to internal nasal valve

deficiency/collapse Onlay grafts
Flaring sutures

Nasal tip asymmetry For unilateral cleft patients: lateral crural steal on the cleft side with
interdomal sutures
Possible vertical dome division

Shortened columella For unilateral cleft rhinoplasty patients, consider V-Y lip skin
advancement
Columellar strut graft
For bilateral cleft rhinoplasty, consider central V-Y skin advancement or
bilateral “forked flaps” a

Widened alar base Alar base reductions

Malpositioned ala Excision of concave lower lateral cartilage and replacing it in convex
fashiona

aSykes JM, Jang YJ. Cleft lip rhinoplasty. Facial Plast Surg Clin North Am 2009;17:133-144.

POSTOPERATIVE MANAGEMENT
Following primary cleft rhinoplasty, infants and children are typically kept in the hospital for 1 or 2 days to ensure
adequate oral intake and pain control. The patient's arms are restrained to avoid manipulation of the wound. Soft
Silastic nasal conformers are kept in place with a nylon suture, and the suture is removed at 1 week
postoperatively. The conformers are then kept in for 6 weeks postoperatively to help stent the nostrils open and
support the ala and tip on the cleft side. The Silastic conformers can be secured to the nose with tape, if needed.
Nasal suture bolsters are removed at 7 to 10 days postoperatively.
Secondary rhinoplasty patients often require wound care from the donor site used in cartilage grafting in addition
to nasal incisions. All incisions are kept clean and antibiotic ointment is applied three times a day for the first
postoperative week. The avoidance of vigorous activity for 3 weeks and contact sports for up to 6 months can
help prevent trauma to the healing nose.

COMPLICATIONS
Wound dehiscence and infection are potential complications in the early postoperative period following a
cleft lip repair and primary cleft rhinoplasty. Long-term and unsightly scarring may occur as a result of poor
wound healing. In patients who lack a nasal floor on the cleft side, an oronasal fistula may persist after
attempted surgical repair. Overaggressive narrowing of the nostril on the cleft side during primary cleft
rhinoplasty can cause vestibular and nasal stenosis. Secondary rhinoplasty patients have preexisting scar
that may persist or worsen after surgery.

RESULTS
All patients with a cleft nasal deformity and associated cleft lip or palate are expected to have a sequence of
operations to address underlying functional and aesthetic problems. Patients with an isolated cleft lip and
nasal deformity may achieve acceptable symmetry and cosmesis with a primary surgery. Patient's families
are always counseled, however, that major or minor interventions may be necessary in the future,
depending on the needs of the patient and the desires of the parents. It is important to temper the
expectations of the patient and their families. The goal of performing major secondary interventions after full
facial growth has been achieved and following any orthodontic or orthognathic interventions should be
communicated.

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PEARLS
A team approach is necessary in the treatment of patients with craniofacial abnormalities.
Parent and family compliance is critical for the success of primary cleft rhinoplasty.
Avoid making the nostril too small during primary cleft rhinoplasty; it is easier to narrow the nose at a later
stage than to correct a nasal stenosis.
Secondary rhinoplasty should take place after orthodontic and orthognathic issues have been addressed.

PITFALLS
A wound dehiscence or infection in the early postoperative period can lead to long-term scarring of the lip and
nose.
Aggressive intermediate rhinoplasty may impede nasal growth in children and young adolescents.

INSTRUMENTS TO HAVE AVAILABLE

Basic rhinoplasty set
 Basic plastic soft tissue set
Soft Silastic nasal conformers
Nasoalveolar molding device

ACKNOWLEDGMENTS
The author would like to thank Drs. Christina K. Magill and Gregory C. Park for their contributions in the writing
of this chapter. Their work in the writing, editing, and figure creation for this chapter is greatly appreciated,
without which this chapter would not have been possible.

SUGGESTED READING
Grayson BH, Santiago PE, Brecht LE, et al. Presurgical nasoalveolar molding in infants with cleft lip and
palate. Cleft Palate Craniofac J 1999;36(6):486-498.

Hopper RA, Cutting C, Grayson B. Cleft lip and palate. In: Thorne C, ed. Grabb and Smith's plastic surgery.
Philadelphia, PA: Lippincott Williams & Wilkins, 2007:201-225.

Sykes JM, Jang YJ. Cleft lip rhinoplasty. Facial Plast Surg Clin North Am 2009;17:133-144.

Sykes JM, Senders CW. Surgery of the cleft lip and nasal deformity. Oper Tech Otolaryngol Head Neck Surg
1990;1:219-224.