Treatment of Complete Bilateral Cleft

Lip-Nasal Deformity
Philip Kuo-Ting Chen, M.D.,1 M. Samuel Noordhoff, M.D., F.A.C.S.,2
and Eric J.W. Liou, M.S., D.D.S.3

ABSTRACT

The modern technique of presurgical orthopedics and nasoalveolar molding

produces a better skeletal foundation and nasal shape for the repair of the bilateral cleft
lip-nasal deformity. The general principles are as follows: (1) preserve the presurgical

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columellar length; (2) keep the width of the central lip segment narrow without
compromising the blood supply; (3) advance the columella prolabium complex superiorly
to allow reconstruction of the orbicularis oris muscle behind the prolabium; (4) release the
alar cartilage attachment from the pyriform rim and provide additional coverage of this soft
tissue deficiency with the use of inferior turbinate flaps; (5) release and reposition the lower
lateral cartilage; (6) adequately dissect above the maxillary periosteum; (7) reconstruct
the nasal floor by local mucosal flaps; (8) reconstruct the prolabial buccal sulcus with tissue
from the prolabium; (9) reconstruct the orbicularis muscle sphincter and attach it to the
anterior nasal spine; (10) reconstruct a new Cupid’s bow, central vermilion, and lip tubercle
with tissue from the lateral lips; (11) balance the height of both lateral lips without any
incision around the ala; and (12) maintain the presurgical nasolabial angle. The residual
nasal deformity remains a problem that needs further improvement. The long-term result
in Chang Gung Craniofacial Center suggests overcorrection of columella height before,
during, and after lip repair.

KEYWORDS: Bilateral cleft lip, nasoalveolar molding, long-term result

T he objective for surgical correction of the bi-
lateral cleft lip is to reconstruct a symmetrically balanced
lip and nose with good columellar length. The most
common approach is a two-stage correction with col-
umella elongation as a secondary procedure at the age of
1 to 5 years.1–10 Noordhoff,11 in 1989, reported a one-
stage reconstruction with microscopic dissection of the
prolabium as an island pedicle flap and interdigitation of
the two-forked flap between the columella and pro-
labium for primary elongation. It was abandoned be-
cause it was technically too complicated. Mulliken12,13
trimmed the forked flap and reconstructed the nose with
intranasal and nasal tip incisions that allowed approx-
imation of the splayed lower lateral cartilages for accen-
tuation of the columella. Trott and Mohan14 advocated
an open rhinoplasty approach raising the nasal tip with
the prolabial flap for approximation of the alar domes.
Cutting et al15 used presurgical nasoalveolar molding to
stretch the columella to achieve a more satisfactory one-
stage repair. Millard et al5 advocated aggressive, active
presurgical orthopedics, gingivoperiosteoplasty, and lip
adhesion along with a forked flap elongation of the

Cleft Lip Repair: Trends and Techniques; Editor in Chief, Saleh M. Shenaq, M.D.; Guest Editor, Joseph K. Williams, M.D., F.A.C.S., F.A.A.P.;
Seminars in Plastic Surgery, Volume 19, Number 4, 2005. Address for correspondence and reprint requests: Philip Kuo-Ting Chen, M.D.,
Craniofacial Center, Chang Gung Memorial Hospital, 5, Fu-Hsin Street, Kwei-Shan, Taoyuan, Taiwan. 1Department of Plastic & Reconstructive
Surgery, 2Superintendent Emeritus, 3Department of Orthodontic and Craniofacial Dentistry, Chang Gung Memorial Hospital, Taipei, Taiwan.
Copyright # 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 1535-2188,
p;2005,19,04,329,342,ftx,en;sps00184x.
329
330 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005
Figure 1 The double-Y numbered classification. The numbers 1
to 9 represent the right side of the cleft and the numbers 11 to 19
represent the left side of the cleft. The number 10 represents a
submucous cleft palate. It more accurately defines the nature of
the clefts on either or both sides of the primary palate, 1 to 9 (or
11–19) as well as either or both sides of the secondary palate, 16
to 19 (6–9) or any combination.
columella. Most of the recent techniques that achieve a
better result use the technique of presurgical orthopedics
or nasoalveolar molding to stretch the columella pre-
surgically and try to maintain or further lengthen it
surgically.
RECORDING OF PATHOLOGY
There are many possible variations of the bilateral cleft
lip. The morphology can vary from being complete on
both sides to asymmetric with a complete cleft on one
Figure 2 A patient with a diagnosis of bilateral median facial dysplasia. (A) The patient has a relatively small premaxilla and prolabium,
very deficient columella, and septal cartilage along with wide alveolar clefts. The premaxilla usually has one central incisor and a weak
premaxilla-vomerine suture. (B) There is no lip frenulum.
side and incomplete on the other. Kernahan’s ‘‘striped Y’’
method16 cannot fully illustrate the range and diversity
of the asymmetric cleft. The double-Y numbered classi-
fication, reported by Noordhoff in 1990,17 is a more
accurate method for recording as well as a more suitable
system for computer database documentation (Fig. 1).
For patients with a complete cleft of primary and
secondary palate on one side and a complete cleft of
the secondary palate on the other side, this classification
can record the pathology in a more accurate way than the
single striped Y classification.
EVALUATION OF PATHOLOGY
There is a wide variation in the quality and amount of
tissue in the prolabium, premaxilla, nasal cartilages,
vomer, and lateral lip elements.18–22 All bilateral clefts
have some amount of asymmetry in their horizontal or
vertical dimensions.23 All cleft patients have a certain
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amount of tissue deficiencies. These deficits are most
severe in bilateral medial facial dysplasia patients24
(Fig. 2), who, therefore, have a less than optimal out-
come after lip and nose repair. They always have a
significant growth disturbance and require orthognathic
surgery when they reach skeletal maturity. It is impor-
tant to document these deformities or any preexisting
asymmetry, or both, prior to surgery to assess the post-
operative results more accurately.
GENERAL PLAN OF MANAGEMENT
Presurgical orthopedics, nasoalveolar molding, is started
on the first visit. The aim of this molding process is to
centralize the premaxilla, narrow the alveolar gaps,
match the alar cartilages, and elongate the columella.
This process usually takes 3 to 4 months to achieve an
optimal outcome. The initial surgery is usually per-
formed at 3 to 4 months of age, depending on the result
of the molding process. The palate is repaired at about
 TREATMENT OF COMPLETE BILATERAL CLEFT LIP-NASAL DEFORMITY/CHEN ET AL
12 months of age together with the insertion of grommet
tubes. Speech assessment is started at 2.5 years. If the
patient requires speech therapy, it starts at 3.5 years.
Velopharyngeal insufficiency is diagnosed by nasoendo-
scopy at 4 years old and corrective surgery for velophar-
yngeal insufficiency is performed as soon as the diagnosis
is made. Residual alveolar clefts are closed before the
eruption of canine teeth, usually when the child is 9 to
11 years old. If the patient has any psychological prob-
lems related to any residual lip or nasal deformity, a
revision surgery is usually done before the child enters
primary school.17
PRESURGICAL ORTHOPEDICS/
NASOALVEOLAR MOLDING
The purpose of presurgical orthopedics or nasoalveolar
molding is to restore a more normal nasal shape and a
balanced skeletal base. The following techniques have all
been used in Chang Gung Craniofacial Center for the
past 20 years.
Presurgical Orthopedics
The protruding premaxilla may be gradually pushed
back by applying micropore tapes across the lip with or
without traction rubber bands.25 It is suggested that the
patient sleep in either the prone or side-lying position
to increase pressure on the cheeks. The movement of
the alveolar segments is controlled by an acrylic plate.
This simple technique is effective in expanding the
prolabial tissue and places the premaxilla in a better
position.26
Nasoalveolar Molding
SILICONE NASAL CONFORMER
A silicone nasal conformer can be used as a tool for
presurgical nasal molding when the patient has an
incomplete cleft lip.27 The height of the conformer can
be adjusted by gradually adding some soft resin or flat
silicone sheets on the domes (Fig. 3).
GRAYSON’S TECHNIQUE
A passive-type orthopedic appliance is used together
with taping of the lip for premaxilla and alveolar mold-
ing. The protruding premaxilla is molded first into a
proper position. When the alveolar gap is approximated
and the arch is aligned, a nasal molding device is added
to the orthopedic appliance to increase the columellar
length as well as to reshape the alar dome. A nonsurgical
lip adhesion is performed by placing tape across the
upper lip. The tape aids in the closure of the clefts,
decreases the width of the base of the nose, and helps to
approximate the lip.28
331
Figure 3 A method to increase the columellar height gradually
by adding silicone sheets to the domes of the nasal stent. It can
be used for presurgical elongation of the columella in incomplete
clefts or postoperative maintenance of the nostril configuration in
an overcorrected position of the columella.
FIGUEROA’S TECHNIQUE
Alveolar molding and nasal molding are performed
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simultaneously using an acrylic plate with rigid acrylic
nasal extension. Rubber bands are connected to the
acrylic plate for gentle retraction of the premaxilla back-
ward. A soft resin ball attaching to the acrylic plate
across the prolabium is sometimes used to maintain the
nasolabial angle29 (Fig. 4).
LIOU’S TECHNIQUE
The nasoalveolar molding device is composed of a dental
plate, two nasal components for nasal molding, and
several micropore tapes for premaxillary retraction. Den-
ture adhesive (Poligrip, Australia) keeps the dental plate
on the maxillary lateral segments. The nasal components
are made up of 0.028-inch stainless steel wire projecting
forward and upward bilaterally from the anterior part of
the dental plate. The top portion contains a soft resin
molding bulb that fits underneath the nasal cartilages for
nasal molding. Micropore tapes are placed across the
cleft lips and prolabium to minimize the alveolar cleft
and retract the premaxilla. At the same time, they pull
both alar bases medially. Retraction of the premaxilla
and lengthening of the columella are performed at the
same time. The columella is lengthened and stretched by
pulling on the premaxilla backward. The nasal tip is kept
at the same height while the premaxilla is pulled back.
Rather than pushing forward, the soft resin molding
bulbs basically support the nasal cartilages and nasal tip30
(Fig. 5).
The key point of nasal molding in bilateral clefts
is to push the alar domes forward in a sagittal direction
for columellar lengthening instead of pushing the domes
upward in a cephalic direction into a turned-up nasal tip.
Nasoalveolar molding techniques require regular patient
follow-up with an interval of 1 to 2 weeks. Grayson’s
technique approximates the alveolar cleft before the
nasal molding. Both Figueroa’s and Liou’s method
achieve nasal and alveolar molding at the same time.
332 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4
GENERAL SURGICAL PRINCIPLES
There are several surgical principles that need to be
stressed. They are as follows: (1) preserve the presurgical
columellar length; (2) keep the width of the central lip
segment narrow without compromising the blood sup-
ply; (3) advance the columella prolabium complex supe-
riorly to allow reconstruction of the orbicularis oris
muscle behind the prolabium; (4) release the alar carti-
lage attachment from the pyriform rim and provide
additional coverage of this soft tissue deficiency with
the use of inferior turbinate flaps; (5) release and repo-
sition the lower lateral cartilage; (6) adequately dissect
above the maxillary periosteum; (7) reconstruct the nasal
floor by local mucosal flaps; (8) reconstruct the prolabial
Figure 5 (A) Liou’s device. The nasal molding device is connected to the intraoral acrylic plate with wires. (B) The nasolabial angle is
maintained by tapes across the lip.
2005
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Figure 4 (A) Figueroa’s device with rigid nasal extension for nasal
molding: The alar domes are pushed upward and the columella
lengthened by the device. (B, C) The nasolabial angle is maintained
by a soft resin ball attached to the molding device.
buccal sulcus with tissue from the prolabium; (9) recon-
struct the orbicularis muscle sphincter and attach it to
the anterior nasal spine; (10) reconstruct a new Cupid’s
bow, central vermilion, and lip tubercle with tissue from
lateral lips; (11) balance the height of both lateral lips
without an incision around the ala; and (12) maintain the
presurgical nasolabial angle.25,31
SURGICAL PROCEDURE
Markings and Measurements
The landmarks of the lip are marked out on the pro-
labium and both lateral segments. The various vertical
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Figure 6 The markings and incision lines on the prolabium. The point IS is the center of the prolabium. The points CPHR and CPHR’ are
the proposed peak of the Cupid’s bow on the right side, and the points CPHL and CPHL’ are the peak of the Cupid’s bow on the left side.
A Trott incision is shown on the right side of the insert. The incision extends through the membranous septum in front of the medial
crura of the lower lateral cartilages into an open rhinoplasty incision. The incision on the left side of the insert is an infracartilaginous
incision. The incisions on the prolabial mucosa divide the prolabial mucosa and vermilion into three flaps. The medial one is used for
lining the raw surface of the premaxilla. The two lateral flaps (the PM flaps) are used for reconstruction of the nasal floor as shown in
Figure 8. The insert also shows the incision line on the lateral lip.

and horizontal measurements are evaluated for any
asymmetry. The width between CPHL and CPHR is
usually maintained at 5 to 6 mm. The central segment is
gradually narrowed toward the columellar base and main-
tained at 4 mm in width at the level of the columellar base.
Traction applied to the alae is usually needed to identify
the nasolabial junction. The incision lines are kept
straight, not curvilinear. The proposed peak of the Cupid’s
bow on the lateral lips (CPHR’ and CPHL’) is marked at
the point where the vermilion first becomes widest and
usually would be 13 to 15 mm from the commissure or 3 to
4 mm lateral to the converging junction of the red line and
white skin roll (WSR)(Fig. 6).
behind the columella up into the membranous septum
and continuing up along the skin-mucosa junction to the
dome area, then along the lower border of the lower
lateral cartilages (LLCs) as a gull wing open rhinoplasty
incision or outside the alar rim as a Trott incision (Fig. 6,
insert). The central segment, the forked flap, and the
columella are raised as a unit to expose the cartilaginous
framework. The central part of the vermilion and mu-
cosa of the prolabium is used for the lining of the raw
surface on the premaxilla. The lateral parts of the
prolabial mucosa flaps (PM flaps) are used for nasal floor
reconstruction (Figs. 7 and 8).

Central Segment
A double hook is used to retract the columella up, and a
small single hook is used to stretch the prolabium. The
central segment is developed by laying a number 11 blade
on the incision line of the prolabium to give a straight
cut. The two forked flaps are developed with lateral
incisions on the skin-vermilion junction extending
Lateral Segments
The incision is made from the proposed peak of Cupid’s
bow along the cleft edge to the edge of the alveolar cleft.
The incision is right above the WSR to develop a WSR–
vermilion–free border flap. This flap will be used for
reconstruction of the central Cupid’s bow. An L-mu-
cosal flap is raised along the cleft edge. The incision is
then turned upward along the pyriform rim and then
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Figure 7 The orbicularis marginalis white skin roll and vermilion flap on the lateral lip (OM) is incised as a lateral advancing flap for
reconstruction of the Cupid’s bow beneath the prolabium. The orbicularis peripheralis (OP) muscle is released in a subdermal plane from
the overlying skin and alar base. A mucosal flap (L) based on the alveolar margin and an inferior turbinate flap (T) are raised for lining the
pyriform aperture and for reconstruction of the nasal floor. The insert shows the fibrofatty tissue of the nasal tip dissected from the
lower lateral cartilages. Both lower lateral cartilages are clearly visible for assessing the pathology and symmetry.

around the inferior turbinate to be incorporated with the
inferior turbinate flap. The dissection is carried above
the periosteum on the maxilla. The abnormal muscle
insertion on the lateral segment is released adequately
until the lateral segment can be brought medially to
touch the medial segment without tension. The cleft
edge is then opened to develop the WSR–vermilion–free
border flap. The dissection on the mucosal side is limited
to 2 mm, and the dissection on the skin side is quite
extensive to separate the abnormal muscle insertion from
the skin. The dissection is carried below the alar base to
release the abnormal muscle component that inserts to
the alar base (Fig. 7).
Nasal Floor and Muscle Reconstruction
The inferior turbinate flap is used to fill in the defect
on the pyriform area after the LLCs are advanced.

Figure 8 The separated lower lateral cartilages are approxi-

mated by either absorbable sutures, 5-0 polydioxanone, or non-
absorbable sutures, 5-0 polypropylene. The premaxilla is covered
by the superior part of the residual central vermilion-mucosa flap
of the prolabium (plmf). The pm flaps above the plmf flap
attached to the premaxilla are brought laterally for reconstruction
of the nasal floor and sulcus.
 TREATMENT OF COMPLETE BILATERAL CLEFT LIP-NASAL DEFORMITY/CHEN ET AL 335

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Figure 9 After releasing the attachments of the lateral crura to the pyriform rim, the LLC is reattached in a superior position to the
ULC. The remaining raw surface of the pyriform area is closed by rotating the inferior turbinate flap into the pyriform area and suturing
it to the rim of the maxilla (upper illustration). The free edges of the L flap and T flaps are sutured to each other and the tip attached to
the membranous septum and upper premaxilla. The outer pm flap on the premaxilla is extended laterally and attached to the
maxilla, following which the free edges of the pm and L flaps are approximated. The vestibular skin is rotated medially and sutured to the
leading edges of the T flap and L flap and the membranous septum, thus achieving good nasal floor closure. The vestibular skin
is advanced as far as needed to the membranous septum to achieve good symmetry, rotation of the ala inward, and appropriate
nostril size.

The turbinate and L flaps are sutured together, brought

across the cleft, and sutured to the septal incision to
reconstruct the nasal floor. Special attention must be
focused on the width of the nostril. The PM flap is
sutured below the L-flap for lining. The orbicularis
muscles are approximated with 4-0 polyglactin sutures
with the upper edge sutured to the anterior nasal spine
(Figs. 9 and 10).

Nasal Reconstruction and Cupid’s Bow

Reconstruction
The separated LLCs are approximated by absorbable
sutures, 5-0 polydioxanone, or nonabsorbable sutures,
5-0 polypropylene, depending on the surgeon’s prefer-
ence (Fig. 8). The fibrofatty tissue on the nasal tip is
brought to the top of the approximated nasal tip. The
skin flap of the central segment is then sutured to the Figure 10 The advancing vestibular skin is shown attached to
lateral lip. Through-and-through alar transfixion sutures the membranous septum to form the nasal floor. Final adjust-
ments are made between the membranous septum and vestib-
are placed on the alar-facial groove to provide further ular skin to achieve symmetry, turning in of the ala, and
support to the LLCs (Fig. 11, insert). The excessive appropriate nostril size. The orbicularis peripheralis (OP) muscles
tissue on the nasal floor is adequately trimmed and the are approximated centrally with interrupter absorbable sutures.
336 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005
Figure 11 After approximating the OP muscle, the upper edge of the OP muscle is sutured to the anterior nasal spine or nasal septum
to maintain the height of the lip. The insert shows the final appearance after redraping of the nasal tip and approximation of the prolabial
flap to the lateral lip. The central lip Cupid’s bow is reconstructed by advancing the WSR-vermilion flaps (OM) from the lateral lip. The
LLCs are further supported by alar transfixion sutures (ATSs).
floor is closed. The full-thickness WSR, vermilion, and
free border flap are brought together below the central
segment to reconstruct the central lip. Excessive orbicu-
laris marginalis muscle on the tip of the WSR–vermi-
lion–free border flaps is preserved for augmentation of
the lip tubercle (Fig. 11).
POSTOPERATIVE CARE
The wounds on lip and nose are covered by antibiotic
ointment without any dressing. The sutures are removed
5 to 7 days after surgery at the outpatient clinic. The lip
scar is supported by micropore tapes as well as silicone
sheets for 6 months. A silicone nasal splint is needed for
6 to 9 months. Throughout this period, the height of the
splint is gradually increased by adding silicone sheets to
the domes of the splint. The central prolabial portion of
the lip will gradually widen and lengthen by the age of
3 years. The nasal width will also increase, similar to the
central prolabial portion of the lip width. The columella
length will shorten slightly after the primary lip repair
and then remain stable without further growth, while the
rest of the nose will grow significantly in both height and
width. This results in a relative relapse appearance of the
columella.30 Figure 12 shows a series of photographs
demonstrating the effect of presurgical nasoalveolar
molding and the postoperative changes of the nasal
shape.
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DISCUSSION
Comparison of the Molding Techniques
The different techniques of alveolar or nasoalveolar
molding are used in Chang Gung Craniofacial Center.
Grayson’s technique, with emphasis on approximating
the alveolar clefts before nasal molding, achieves the best
preoperative nasal shape symmetry and skeletal base
balance. However, it is also the most expensive and
time-consuming method. Figueroa’s and Liou’s techni-
ques of performing alveolar and nasal molding at the
same time are simpler and less expensive methods. A
study32 comparing the three techniques in unilateral
clefts showed that the latter two techniques tend to
result in a larger diameter in the cleft side nostril post-
operatively.
GINGIVOPERIOSTEOPLASTY
Millard, Mulliken, and Cutting5,12,13,15,33 all advocated
the importance of primary gingivoperiosteoplasty. The
long-term result from Cutting and Grayson’s report34
showed that 60% of the patients who received primary
gingivoperiosteoplasty do not need alveolar bone graft-
ing later on. However, it is very difficult to perform a
primary gingivoperiosteoplasty unless the alveolar gap is
around 1 to 2 mm. Figueroa’s and Liou’s techniques
tends to leave the alveolar gap larger, 3 to 4 mm, which
limits the possibility of a primary gingivoperiosteoplasty.
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Figure 12 (A, B) Frontal and mental views of a patient at 3 weeks, first visit at 2 weeks. Liou’s technique was used for nasoalveolar
molding. (C, D) Views at 4 months after nasoalveolar molding at time of surgical repair. (E, F) The postoperative appearance of the boy at
1 year of age. (G, H) Frontal and mental views of the boy at 5 years.
338 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005
CENTRAL SEGMENT HEIGHT AND WIDTH
There is a significant difference in the outcome of the
shape of the central lip in the bilateral cheiloplasty with
or without muscle approximation. In the technique
without muscle approximation, the central lip tends to
become wider and remains short. With muscle approx-
imation, the central lip segment has less widening but
more lengthening. Mulliken12,13 advocated narrowing
the central lip width down to 2 to 3 mm for a better
long-term result. Noordhoff,11 in attempting a primary
elongation of the columella by interdigitating the forked
flaps into a transverse incision in the columella, found
two vessels running from the columella to the prolabium.
A central segment that is 2 mm wide at the columellar
base may injure the vessels. A 4-mm-wide base of the
prolabium includes both columellar vessels, providing a
good blood supply to the prolabium. The long-term
result shows a tendency of widening as well as length-
ening of the central segment. A wide central segment
in primary lip repair, although maintaining a good
blood supply, may result in an unnaturally wide Cupid’s
bow.
Regarding the vertical height of the central lip,
Lee35 advocated that the vertical height of the central lip
in a 3-month-old baby should be around 7 mm. How-
ever, the height is somewhat predetermined by the size
of the prolabium. A prolabium shorter than 7 mm
should not be lengthened on the operating table, as it
will always lengthen vertically with muscle approxima-
tion and have a satisfactory appearance. A relatively
longer prolabium can provide additional tissue for the
columella and make it easier to achieve a better nose.
The critical problem in determining the vertical height
of the lip occurs when there is a marked discrepancy
between the vertical height of the central lip and the
lateral lips. In this situation, the surgeon should verti-
cally shorten the lateral lip to match the vertical height
of the central prolabial portion of the lip. Otherwise,
the nasal tip will be pulled downward because of the
tension in the central segment. Even a short vertical
length of 4 to 5 mm will elongate adequately with muscle
repositioning.
FORKED FLAP
Millard suggested preserving the prolabial tissue lateral
to the central segment as forked flaps that are banked on
the nasal floor. These banked forked flaps are used for
columellar lengthening in secondary revisions. The ex-
perience in Chang Gung Craniofacial Center does not
support his concept in Oriental patients. Pigott36 studied
the ratio between dome component and columellar
component in Caucasians of varying ages. The dome
columellar ratio is much greater in Orientals than in
their Caucasian peers. A nose with a disproportionately
long columella often results after a columellar elongation
procedure using the banked forked flaps. The banked
forked flaps also end up with unsightly scarring on the
nasal floor. The authors do not bank these forked flaps.
They are trimmed to an adequate size and sutured
backward to the septum to improve the nasolabial angle.
The report from Nakajima et al suggested a similar
approach.37
SEPTAL INCISION – IN FRONT OR BEHIND THE LLC’S
Cutting et al15 raised the central segment tissue behind
the medial crura of LLCs and reported that it has a safer
blood supply to the prolabium. Trott and Mohan14 used
a technique of raising the central segment in front of the
LLCs. The Chang Gung experience comparing the two
techniques shows that there is no difference in terms of
blood supply to the central prolabium between these two
techniques. Cutting and Noordhoff believe that the
medial crura need to be elevated superiorly on the septal
cartilage, and Trott and Mulliken leave the LLCs
attached to the septum. In the authors’ experience, the
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two techniques offer a similar early result. Technically,
the retrograde dissection and approximation as advo-
cated by Cutting is more difficult compared with the
technique of approximation of cartilages under direct
vision as advocated by Trott.
NASOLABIAL ANGLE
In his anatomical dissection around the nasolabial
angle, Wu38 showed that the angle is maintained by
a ligament from the subcutaneous tissue to the anterior
nasal spine. Whenever the columella-prolabium com-
plex is raised, the nasolabial angle tends to be flattened
after operation. However, this procedure is definitely
necessary as the separated orbicularis muscles need to
be approximated under the prolabium to achieve an
anatomical repair. The technique with the placement
of the incision behind the medial crura tends to main-
tain a better nasolabial angle postoperatively than the
technique with the incision located in front of the
medial crura. Restoration of the ligament by a tuck-
down suture from skin to anterior nasal spine may
jeopardize the blood supply to the prolabium. Suturing
the tips of the forked flaps backward to the septum
may be more helpful in maintaining the nasolabial
angle.37
OPEN VERSUS CLOSED RHINOPLASTY
The approximation of the LLCs can be achieved
through either an open or closed rhinoplasty. The
authors’ experience shows a similar result with the two
techniques. Technically, a closed rhinoplasty with two
rim incisions or bilateral Tajima39 incisions is simpler
than the open rhinoplasty through a gull wing or Trott
incision. However, an open gull wing incision, approx-
imating the LLCs through direct vision with nonab-
sorbable sutures, is the author’s preferred method. This
allows the surgeon better visualization for accurate
 TREATMENT OF COMPLETE BILATERAL CLEFT LIP-NASAL DEFORMITY/CHEN ET AL
approximation of the LLCs. The open technique also
provides a better approach for redraping or redistributing
the central segment tissue.
POSTOPERATIVE NASAL SHAPE MAINTENANCE
Friede et al40 used a postoperative acrylic molding splint
to improve nasal configuration. Other reports used a
similar concept for postoperative maintenance.27,41–45 In
Chang Gung Craniofacial Center, a silicone conformer
is routinely used after surgery and proved its efficacy in
maintaining the postoperative nasal shape in unilateral
clefts46 as well as in bilateral clefts. It is necessary to use
the splint for at least 6 months postoperatively while
waiting for scar maturation.
MUSCLE DISSECTION
Delaire47 suggested wide subperiosteal dissection on the
maxilla to achieve a functional closure. There is still
controversy about whether a subperiosteal or supraper-
iosteal muscle dissection is better in terms of function or
subsequent facial growth. There are no scientific data
supporting the concept that a subperiosteal dissection
results in less scarring or better facial growth. A muscle
dissection above the periosteum seems to offer a better
release of the abnormal muscle insertion around the alar
base from both the skin side and periosteal side. The
technique presented here keeps the extent of muscle
dissection as minimal as possible but still adequate for
muscle approximation at the center. This should create
minimal scarring or muscle tension in front of the
maxilla.
MUSCLE RECONSTRUCTION
Manchester48,49 felt that the orbicularis muscle should
not be reconstructed as it would cause too much tension
and growth disturbance. Nagase et al50 showed that
there was no significant growth disturbance after
muscle reconstruction. There is a definite difference
in the appearance of the bilateral lip repair with or
without muscle reconstruction. Muscle reconstruction
produces a much better result both functionally and
aesthetically.
CUPID’S BOW AND LIP TUBERCLE
The techniques leaving the prolabial WSR and vermi-
lion on the prolabium to reconstruct the Cupid’s bow
result in a Cupid’s bow with abnormal peaking, indis-
tinct prolabial WSR, and irregular vermilion with a
depressed scar at the central lip. The quality of the
WSR from the lateral lips is much better compared
with the WSR of the prolabium. The reconstruction of
the central lip by advancing the WSR–vermilion–orbi-
cularis marginalis flaps from the lateral lip beneath the
prolabial segment gives a continuous WSR, underlying
vermilion, parallel red , and a full central prolabial
tubercle without notching.31,51,52
339
HORIZONTAL INCISION ON LATERAL LIPS
From the experience in unilateral cleft lip repair,53 the
horizontal incision below the nasal floor is usually un-
necessary. Nevertheless, the alar-facial groove has a
better appearance if the skin is kept intact. The surgeon
needs only to approximate the orbicularis muscles. How-
ever, in the presence of a vertical discrepancy between
the central lip and lateral lips, a horizontal incision below
the nasal floor may be needed. The lateral incision is
used for shortening of the longer lateral lip.
LONG-TERM RESULTS
The long-term results in nasal reconstruction usually
give an impression of relapse of the nasal shape. How-
ever, studies of long-term results for both unilateral and
bilateral clefts by photometric measurements with 1:1
photographs show that there is a tendency of increase of
the nostril width even when the nostril height is main-
Downloaded by: University of Queensland. Copyrighted material.
tained postoperatively. This condition gives an impres-
sion of relapse.30,54 These studies show the importance
of overcorrection of the nostril height and nostril width
during surgery and the need to maintain the nostril
shape in an overcorrected position postoperatively.
There are no scientific data suggesting the amount of
overcorrection during surgery. The postoperative main-
tenance can be achieved by gradually adding silicone
sheets or soft resin to the nasal splint to increase the
nostril height.
CONCLUSION
Presurgical orthopedics and nasoalveolar molding pro-
vide the surgeon with a much better skeletal foundation
for reconstruction of the bilateral cleft lip. The goal is to
restore all the displaced tissue, reconstruct the dynamic
sphincter, reconstruct the Cupid’s bow with tissue from
the lateral lips, overcorrect the nasal width, maintain and
further elongate the columella during surgery, and main-
tain the columellar height postoperatively. Reconstruc-
tion of the bilateral cleft lip-nasal deformity remains a
challenging task. The results vary with any technique as
there is a wide range of tissue deficiencies that are also
factors in achieving a successful result.
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