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Saudi Journal of Oral Sciences

SHORT COMMUNICATION

The True Triangle in cleft lip repair: A novel

technique
Abdullah I. Al Atel
Department of Oral Maxillofacial Surgery, Prince Mohammed Bin Abdualziz City, Riyadh, Saudi Arabia

Abstract

The aim of this short communication is to describe the True Triangle (TT) technique for the repair of unilateral cleft lip (CL). A total
of 309 patients were operated using the TT technique. The final cleft lip repair results showed positive outcomes. Conclusion:
This technique may overcome some of the drawbacks of the previously described surgical techniques used for CL repair.
Key words: Cleft lip, repair technique, true triangle

Given the complex nature of cleft lip (CL) and the esthetic
and functional characteristics associated with its repair,
new surgical techniques may bring small changes in the
CL repair.[1] This short communication describes the use
of a true triangle for the surgical repair of CL.
This technique practiced in the last 6 years in the Oral
and Maxillofacial Surgery Department at Prince Sultan
Military Medical City, Riyadh, Saudi Arabia. A total of
309 patients were operated using the True Triangle (TT)
technique (Al- Atel Technique) to repair the CL; the final
cleft lip repair results showed positive outcomes.

(Point 1) base of columella

(Point 2) at lip-collumella crease
(Point 3) at lip-collumella crease to mirror (point 2)
relation to (point 1)
(Point 4) at mid of philtrum (tubercle), near the
vermillion cutaneous junction
(Point 5) at peak of cupids bow
(Point 6) at peak of cupids bow, mirror point 5
relation to point 4 and 1 mm above the vermillion
cutaneous junction
(Point 7) is 2 mm superior to (Point 6) and forms the
base of triangle at non-cleft side

The True Triangle Cleft Lip Repair

Technique (Al Atel Technique)
Surgical markings

The technique uses 24 unique surgical points and in

keeping with other techniques these points are marked
on the patient using methylene blue [Figure 1]. The
points can be described as those on the medial lip (noncleft side). Nasal floor, and medial lip (non-cleft side)
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Figure 1: Surgical anatomical points of the flap design for the TT technique
Address for correspondence:
Dr. Abdullah I. Al Atel, Department of Oral Maxillofacial Surgery,
Prince Mohammed Bin Abdualziz City, Riyadh, Saudi Arabia.
E-mail: dratel.a@gmail.com

DOI:
10.4103/1658-6816.138487

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Abdullah I. Al Atel: True triangle technique in cleft lip repair

(Point 8) is the apex of the triangle as points 6, 7,

and 8 form a triangle with 2 mm base
(Point 9) is 1 mm below the vermillion cutaneous
junction and forms the base of triangle with point 11
Points 6 and 9 form a line perpendicular to the
vermillion cutaneous junction and pass through the
peaks of the cupids bow
(Point 10) at mid of vermillion form apex of triangle
with points 9 and 11
(Point 11) at the vermillion mucus junction
(Point 12) commissure of non cleft side
Nasal floor (Non-cleft side)

(Point 13) at sub alare medial side

(Point 14) at sub alare lateral side, on the curve of
the alar-lip junction
Lateral lip (Cleft side)

(Point 15) at sub-alare lateral side, on the curve of

alar-lip junction
(Point 16) at sub-alare medial side
The distance between points 2 and 13 (nasal sell at
non-cleft side) equal the distance between points
3 and 16 (nasal sell at cleft side)
(Point 17) medial tip of advancement flap
(Point 18) peak of cupids bow at cleft side (1 mm
above the white roll )
(Point 19) is 2 mm superior to point 18 and forms
with point 18 the base of the triangle
(Point 20) apex of the triangle
(Point 21) is 1 mm below vermillion cutaneous
junction
(Point 22) midpoint of vermillion forming the apex
of the triangle, base is formed by points 21, 23
(Point 23) vermillion mucus junction
(Point 24) commissure cleft side

Surgical technique

While a detailed description of the surgical technique is

beyond the scope of this short communication the technique
utilizes marking skin and subcutaneous incisions, incision
of the orbicularis oris muscle, tip rhinoplasty, closure of the
nasal layer of the alveolar cleft, and location of the nasal
floors followed by closure of the orbicularis oris muscle and
skin closure. This is then followed by mucosal closure and
finally active placement of the alar base and placement of
the nasal sell. The repair diagrams for the rectangular shape
of philtrum [Figure 2a] and shield type of philtrum [Figure2b]
are shown in this communication. At the time of preparation
of this communication, 309 patients had been operated on
using this technique. The pre and post-operative pictures
are shown below [Figure3a-f]. The detailed outcome as
well as patient and parent satisfaction from the technique
are beyond the scope of this communication.

Discussion
This technique is a combination of Millard[2] or Mohler[3]
technique, depending on the philtrum shape of the
non-affected side of the cleft, in addition to creating a
modified true triangle used by Noordhoff.[4]
The purpose of using the rotation flap is to get the
lengthening effect. The back cut is used to get the
lengthening effect advocated by Mohler[3], and it is used
in rectangular-shape philtrums. The back cut and its
associated lengthening effect has also been previously
used by Randall.[5]
The two true triangles drawn at medial and lateral side of
the cleft are placed 1 mm above the vermillion border to

The distance between points 5 and 12 (peak of cupids

bow and commissure at non-cleft side) equals the
distance between points 24 and 18 (peak of cupids bow
and commissure at cleft side).

Figure 2: (a) The True Triangle lip repair diagramming in the case of rectangular
shape of philtrum where the cutback (the arrow) is used. (b) The True Triangle
lip repair diagramming in the case of Shield type of philtrum where the
rotation part (the arrow) is used

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Figure 3: (a) Right CL pre-operative. (b) Same patient one month post
operative CL repair with TT CL repair technique. (c) Same patient Three
months post operative. (d) Six months post operative, CL repair with TT CL
repair technique. (e) One year post operative. (f) One year post operatively,
notice the nostril near symmetrical result

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Abdullah I. Al Atel: True triangle technique in cleft lip repair

avoid the resultant irregular white roll which could result

when the triangle is placed at the vermillion border. The
triangle at the medial side of the cleft where the triangle
base is 2 mm or less to avoid the obvious notching
or discrepancy effect noted in Millards technique[2]
corrected by Thompson[6] and Fisher.[7] The triangle is
directed toward the collemella, unlike Fisher (2005) where
the triangle is directed medially in a horizontal direction.[7]
This technique may overcome some of the drawbacks of the
previously described surgical techniques used for CL repair.

2.

3.
4.

5.
6.
7.

References
1.

Cite this article as: Al Atel AI. The "True Triangle" in cleft lip repair: A
novel technique. Saudi J Oral Sci 2014;1:114-6.
Source of Support: Nil, Conflict of Interest: None declared.

Atack NE, Hathorn IS, Semb G, Dowell T, Sandy JR. A new index for
assessing surgical outcome in unilateral cleft lip and palate subjects

S J Oral Sci Vol 1 No 2

aged five: Reproducibility and validity. Cleft Palate Craniofac J

1997;34:242-6.
Millard DR Jr. A primary camouflage in the unilateral harelook. In
Transactions of the International Congress of Plastic Surgeons. Baltimore,
MD, Williams & Wilkins; 1957. p. 160.
Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg 1987;80:511-5.
Noordhoff MS, Chen YR, Chen KT, et al. The surgical technique for
the complete unilateral cleft lip-nasal deformity. Operat Tech Plast
ReconstrSurg 1995;2:167-74.
Randall P. A triangular flap operation for the primary repair of unilateral
clefts of the lip. Plast Reconstr Surg Transplant Bull 1959;23:331-47.
Thomson HG. Unilateral cleft lip repair. Oper Tech Plast Reconstr Surg
1995;2:175-81.
Fisher DM. Unilateral cleft lip repair: An anatomical subunit approximation
technique. Plast Reconstr Surg 2005;116:61-71.

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