Unilateral Cleft Lip—Approach

and Technique
Kenneth E. Salyer, M.D.,1 Shai M. Rozen, M.D.,1 Edward R. Genecov, D.D.S.,2
and David G. Genecov, M.D.1

ABSTRACT

This article presents the philosophy, technique, and personal and team approach
for treating children with unilateral cleft lip-nose deformities based on the senior author’s
36 years of experience. The treatment of unilateral cleft lip almost without exception must
involve correction of the nasal deformity. To obtain excellent results, the surgeon must
integrate technique, teamwork, and timing based on multidisciplinary protocols developed
over the years. Technique must involve broad dissection of the nasal and lip elements off
the abnormal skeletal base and delicate but wide dissection of the nasal cartilage to achieve
contour and tip projection. The team must include and assimilate surgical, orthodontic,
speech, and when necessary orthognathic viewpoints to achieve the optimal result. The
final goal is to bring the child to normal facial appearance at conversational distance. It is
important to realize that the treatment of the unilateral cleft is rarely one procedure at one
time but rather a culmination of several interventions precisely timed in the growing phase
of the child from infancy to adulthood.

KEYWORDS: Unilateral cleft lip, cleft lip, cleft lip and nose deformity, cleft
orthognathics, cleft orthodontics

T he term unilateral cleft lip is almost a misno-
mer because nearly always the nose is an integral part of
the problem that must be addressed to obtain an im-
proved result. Based on more than three decades of
experience, this article presents the philosophy and the
global approach to the treatment of the child with the
unilateral cleft lip. There are several key elements that
must be considered to obtain the desired result. First, the
nasal involvement is almost ubiquitous and therefore
must be addressed primarily at the time of lip surgery.
Second, the treatment should always be multidiscipli-
nary, involving the cleft surgeon, orthodontist, and
speech pathologist when the palate is involved. Third,
the problem confronted is dynamic over the time of the
child’s development, and therefore protocols spanning a
time period (Tables 1 and 2) rather than one-time ‘‘home
run’’ solutions are the rule rather than the exception.
The long-term protocols have evolved gradually
over the years and consistently produce good to excellent
results. Passive perisurgical orthopedics is applied at
2 weeks of age. Other than the use of the passive device,
the abnormal skeletal base is mainly ignored at this stage
and emphasis is put on the soft tissue repair of the cleft
lip/nose complex. This is the most important surgical
stage in primary cleft lip/nose repair. When the palate is
involved, two-flap palatoplasty is performed at 8 months
of age. Approximately 35% of the authors’ patients need
minor secondary correction of the lip and/or nose,
generally performed at preschool age, around 5 years
old. Definitive rhinoplasty is performed in most cases at

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: Kenneth E. Salyer, M.D., International
Craniofacial Institute, Cleft Lip and Palate Treatment Center, 7777 Forest Lane, Suite C-717, Dallas, TX 75230. 1International Craniofacial
Institute, Cleft Lip and Palate Treatment Center, 2Private Practice, Dallas, Texas. Copyright # 2005 by Thieme Medical Publishers, Inc., 333
Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 1535-2188,p;2005,19,04,313,328,ftx,en;sps00183x.
313
314 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005

Table 1 Surgical Protocol and palate. Despite reluctance of some surgeons to

Patient Age/Stage perform early nasal surgery, simultaneous lip-nose re-
of Development Treatment construction avoids the need for subsequent major nasal
surgery with more severe nasal deformity and less pliable
3 months Primary cleft lip and nose
cartilaginous framework. This technique can be learned
6–9 months Two-flap palatoplasty
by any dedicated cleft surgeon. It is important to
5 years 35% Secondary minor lip surgery
remember that while developing treatment protocols
7–9 years 100% Cancellous iliac bone graft to
over time, they should be based on ongoing experience,
alveolar cleft
continuous critique, and an adoptive attitude to im-
7 years to full growth Distraction osteogenesis in selected
provements.
severe cases
Full growth 25–30% Orthognathic surgery
12–18 years Rhinoplasty—other soft tissue
UNILATERAL CLEFT LIP-NOSE REPAIR
The field of cleft surgery has seen major advances over
or after completion of growth. Palatal expansion is the past 30 years.1–3 Normal function and normal to
performed at 5.5 years of age, followed by cancellous near-normal appearance are a realistic goal and can be
iliac bone grafting when one third to two thirds of the achieved.4 To obtain excellent results, a dedicated team
tooth’s root has developed but prior to its eruption into approach following a surgical–orthodontic–speech-
the cleft void. In our experience, bone grafting at this oriented protocol based on long-term experience is
stage provides enough bone for the orthodontist in 95% essential.
of the cases to achieve orthodontic restoration. An open The most important stage in treating cleft pa-
airway promotes normal facial growth; therefore, limited tients is the primary cleft lip-nose repair. It has become
septoplasty and turbinectomy are performed as needed the standard of care in the United States and in several
from the early age of 4 to 5 throughout the completion of other countries to treat the nasal deformity concomi-
the case. Between the ages of 5 and 15, if sagittal growth tantly with the lip deformity. Many different surgeons
of the maxilla is delayed because of the cleft dysmorpho- have reported consistently good results when performing
genesis, we perform one of two procedures. In cases primary nose repair at the time of lip repair (H. Anderl,
where there is up to 4 mm retrusion of the maxilla at the personal communications, 1986). 5–10 Despite the grow-
occlusal plane, a Delaire face mask traction is used ing acceptance of the timing of primary nose repair,
(Great Lakes Orthodontics, Tonawanda, New York). severe secondary deformities are not uncommonly seen
With a retrusion of 12 mm or more we perform (Fig. 1). The reason is experience. Because of the
distraction. complexity of both primary and secondary cleft proce-
After orthodontic alignment and leveling of the dures, only the experienced or well-trained surgeon
teeth upon completion of growth, orthognathic surgery should perform these operations. The correlation of
is performed in about 35% of the patients to achieve experience and results has been well depicted by the
optimal facial balance and aesthetics. A key tenet in Clinical Standards and Advisory Group study.11 Even
removing cleft stigmata is creating a full, convex, pro- more emphasis should be put on meticulous follow-up
jecting facial skeleton. and self-critical analysis of the results to obtain improved
The senior author has developed and refined these results over time.
protocols over 36 years of practice treating these difficult The technique for primary lip and nose repair has
facial deformities. Early nasal reconstruction is key for been extensively described by the senior author over the
enhancing the patients self-esteem from an early age. years. Based on close analysis of the patients followed
This has become the senior author’s standard of care in over the years, certain modifications and improvements
the treatment of patients with unilateral cleft lip-nose have been incorporated in the authors’ original techni-
ques to obtain more consistent results in terms of
Table 2 Orthodontic Protocol decreased scarring and improved symmetry, balance,
Patient Age/Stage and aesthetics. These modifications are described in
of Development Treatment this article.
2 weeks Passive infant appliance
5.5–8.5 years Palate expansion
NECESSARY OR NOT NECESSARY?
7–9 years Preparation for bone graft
5–10 years Face mask
Nasal Deformity
Mixed dentition Routine orthodontics
Correction of the nasal cleft deformity is necessary
14–16 years (25–30%) Final treatment, perisurgical
during the primary surgery as discussed previously. The
orthodontics
abnormal anatomy of the cleft nose includes several
 UNILATERAL CLEFT LIP—APPROACH AND TECHNIQUE/SALYER ET AL 315

Figure 1 (A, B) Frontal and lateral views of secondary deformity due to inadequate dissection and release of lip and nasal components
referred to our institution for correction. Note the short lip and the left alar bucking. (C, D) Postoperative frontal and lateral views after
correction of secondary defect with appropriate release of all components

components. The alar base, the medial and lateral crus of
the alar cartilage, the nasal dome, the columella, and the
nasal septum—all are affected by the skeletal base,
consisting of the alveolus, maxillary segments, and pal-
ate. The severity of the primary nasal deformity is
intimately related to the degree of displacement, abnor-
mality, and hypoplasia of the maxillary segments. Con-
tinued hypoplasia and displacement of the maxillary
segments, particularly the lesser segment, result in vary-
ing degrees of maxillary deficiency in the unilateral cleft
lip and nose deformity. Subsequent growth and the final
degree of deformity and outcome depend on the cleft
dysmorphogenesis and the selection of surgical proce-
dures and sequencing. Rehabilitation must address the
three-dimensionality and growth over time to obtain the
desired result.
In the base of the primary deformity of the nose is
the displacement of the lower lateral cartilage laterally
316 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005
and inferiorly on the cleft side. The nasal dome is
flattened and slumped in a downward position. The
alar cartilage on the cleft side is flat and gives it a false
appearance of lengthening when compared with the
noncleft side, which is abnormally displaced to the other
side. The relationship of the lower lateral cartilage to the
septum is normal, but the septum itself is tilted because
of the cleft deformity, thereby tilting the base of the nose
toward the noncleft side and the tip of the nose toward
the cleft side. The question that arises in our experience
is whether the septum should also be translocated or
moved surgically. Anderl believes so; we feel it is not
necessary. But the answer is in long-term analysis of
results, which we are currently conducting. The key to
correction of the cleft nasal deformity is dissecting free
and translocating the alar cartilage with its attached
vestibular lining into a normal position, thereby estab-
lishing the normal vault and shape of the cartilage.5,6,8
At this stage, the major deformity of the nose is
corrected. When combined with complete freeing of
the soft tissue envelope of the nose and correction of
the alar bases and floor of the nose, consistently good
results may be achieved at the time of primary correction.
Lip Adhesion
Lip adhesion may contribute to unnecessary additional
scarring and abnormal tethering of the lip or nasal
elements and therefore is an unnecessary procedure.
The current author evaluated early cases of 50 patients
in a double-blind randomized fashion comparing those
performed with and those without lip adhesions; im-
proved aesthetics in the group that did not undergo lip
adhesion brought the author to abandon this technique.
Still, many experienced cleft surgeons continue to use
the lip adhesion12 with the purpose of treating the
abnormal skeletal base, making it easier for the surgeon
to close the lip at the expense of the overall aesthetic
result for the lip and nose. Others have reported benefits
in using nonsurgical lip adhesion with tape.13 Lip
adhesion may actually cause fixation or scarring of the
alar base or associated adjacent structures in an abnormal
position, making it more difficult to obtain a definitive
normal contour of the nose.
THE ABNORMAL SKELETAL BASE AND
PREOPERATIVE ORTHOPEDICS
Passive Perisurgical Orthopedics
Obtaining symmetry of the skeletal base is one of the
main long-term goals for complete correction of the cleft
deformity. The attempt to achieve skeletal symmetry at
infancy by active perisurgical orthopedics in cases of
unilateral deformities is misguided treatment in the
senior author’s opinion. Early periosteoplasty abnor-
mally locks the segments, producing additional scarring,
and does not consistently produce enough bone to
support the teeth in the cleft defect to allow excellent
orthodontic restoration. Close to half these patients need
future bone grafting. In the senior author’s opinion, it is
key to ignore the skeletal abnormality at the early stage
and reconstruct the soft tissue components consisting of
skin, cartilage, and muscle.
For these reasons, the current authors’ team
approach for the past 29 years, for all complete clefts
involving the alveolus and maxillary segments, is to use
passive perisurgical orthopedics. In the first few days of
the child’s life an impression is made on which the
orthopedic passive appliance is fabricated. This acrylic
device initially prevents collapse of the maxillary seg-
ments and aids in feeding. The primary objective of the
appliance is to control the segments once the lip is
closed. It functions as a guide to the maxillary segments
and locks them into position after cheiloplasty and
before palatoplasty. They also aid or improve the nasal
airway by providing a temporary midline closure and
nasal septum after closure of the lip, thereby probably
also contributing to more normal growth of the nasal
airway.
There is no scientific proof that passive orthope-
dics provide improved results—it is our empirical ap-
proach based on team member interaction and influence.
Based on clinical observation, the senior orthodontist
believes that the appliance improves horizontal and
vertical skeletal deficiency by stimulating bone produc-
tion before and after lip closure; however this hypothesis
remains to be proved.14 Cases in which the midline is
shifted more than 2 mm require moving the entire
maxilla using a Le Fort I maxillary osteotomy. It is easier
to perform this in infants treated with a passive perisur-
gical orthopedic appliance for midline and maxillary
deficiencies. The current authors believe that this con-
tributes to better symmetry of the alar bases on the
deficient cleft side and improves septal deviation by
guiding the maxillary segments into a more normal
anatomic relationship. No effort is directed at shifting
the deviated septum or changing the skeletal base
actively with this technique. The passive appliance
allows better control of the maxillary segments before
the time of palatoplasty and is worn from infancy to the
time of the two-flap palatoplasty at the age of 8 months.
After palatoplasty, this method may decrease the
amount of maxillary collapse by locking in the maxillary
segments.
Active Presurgical Orthopedics
Millard and Latham are credited with popularizing
active presurgical orthopedics.15,16 This represents an
opposite philosophy to the senior author’s in that active
orthopedics with active force is used to alter the skeletal
 UNILATERAL CLEFT LIP—APPROACH AND TECHNIQUE/SALYER ET AL
base prior to cleft lip nasal repair. Some advocates of this
philosophy have added a primary gingivoperiosteoplasty
to close the cleft alveolus. One report states that 60% of
these patients do not need bone grafting later.17 Essen-
tially, this means that 40% of the patients eventually
need a second procedure for bone grafting. In the senior
author’s hands, primary bone grafting yields a 96%
success rate. Therefore, a procedure that yields only
60% success and necessitates a second procedure is
both unnecessary and detrimental to midfacial growth
and outcome.18 For these reasons, periosteoplasty has
been abandoned by some centers.19 Performing early
distraction and completing early orthodontic treatment
in infants are, in the current authors’ opinion, detrimen-
tal to growth and development.20 Anterior cross bite and
anterior open bite are frequent; therefore, premature
surgery due to insufficient amount of bone to support
the teeth is detrimental.
As previously mentioned, the authors’ approach
of ignoring the abnormal skeletal base at the time of
primary surgery has resulted in near-normal growth in
nearly 70% of the patients. With this approach of passive
orthopedics, palatal expansion at the average age of 5.5,
and bone grafting of the cleft deficiency at the time of
tooth development, these patients do not require or-
thognathic surgery. Bone grafting at the age of 7 to 9 at
the time of cuspid or lateral incisor development using
immobilization at the time of grafting produces a 96%
success rate in the authors’ experience.21,22
Presurgical Nasoalveolar Molding
Nasoalveolar molding has been used and advocated
in both unilateral and bilateral cleft cases.23 Through
expansion it probably creates more columellar tissue,
which is needed in bilateral cleft deformities. In the
most common cases of unilateral cleft lip the nasal and
lip elements are present; therefore, the senior author
does not believe nasoalveolar molding is needed in most
unilateral deformities. In the rare Tessier facial cleft,
there may be missing elements, in which cases tissue
expansion is warranted. Nasoalveolar molding is quite
labor intensive, requiring weekly adjustments by an
experienced and dedicated orthodontist or surgeon.
More so, full compliance is needed from the parents of
the infant and there are multiple frequent visits. Most
often this technique is used in combination with active
presurgical orthopedics, which the senior author thinks
is detrimental to growth. The unilateral cases presented
here do not warrant this technique. Because of the
complexity and labor intensiveness of this technique,
it is not practical nor available in most places in the
world. The New York group23 has provided this modal-
ity and has shown excellent results in bilateral cases,
but the use in most unilateral cases is in our opinion
unnecessary.
317
PROTRACTION AND DISTRACTION
OSTEOGENESIS
The proportional effect of surgical scarring versus the
severity of the primary cleft dysmorphology on abnormal
growth seen in patients with cleft deformities is not
completely clear. Although there is literature stating that
in some third world countries certain untreated cleft
cases have shown near-normal facial development,24 we
think even those untreated cases do not have normal
development of the small segment, especially in the
severe cases. There is no conclusive evidence that scar-
ring from surgery is the sole reason for abnormal facial
growth, although we consider it a major factor. We
believe that the degree of tissue absence and cleft
dysmorphogenesis most probably correlates with the
degree of facial growth abnormality when careful surgery
is performed with minimal scarring. Compensation for
this abnormal growth may be performed in certain
patients in the age group of 5 to 15 years by either facial
protraction with a mask or distraction osteogenesis,
depending on the amount of retrusion.
Facial Protraction
In cases with maxillary retrusion of 4 mm or less, the
Delaire facial protraction mask (Great Lake Orthodon-
tics, Tonawanda, NY) is used. At the senior author’s
center, new bone production has been demonstrated
with advancement of the anterior nasal spine using
protraction in cleft patients. The posterior nasal spine
is retracted in our palatal flaps, probably due to the use of
posterior vomer flaps.25
Distraction Osteogenesis
After 13 years of evaluating distraction in about 250
patients, it is our opinion that distraction, in its current
state of art, should be used in major deformities or
retrusion of the maxilla of 12 mm or more. Distraction
offers balancing of the facial skeleton during growth,
allowing improvement in appearance, speech, and
occlusion—all of which improve self-esteem.
Although a majority of these patients require
additional definitive skeletal surgery, distraction provides
ongoing normalization of jaw relationships during growth
and development, offering a major advance in cleft care. It
is important to note that definitive orthodontic surgery is
more difficult after distraction. Osteotomies should avoid
any teeth or tooth buds. We need more data to evolve a
more definitive protocol for distraction.
COMMONLY SEEN SURGICAL ERRORS
AND PITFALLS
Achieving good consistent results in primary repair of
cleft patients depends on in-depth understanding of the
318 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005
cleft lip-nose deformity. Suboptimal outcome or secon-
dary deformities may result from poor operative plan-
ning, operative error, or postoperative scar contraction.
Most secondary deformities that are encountered by the
senior author are from inadequate understanding of the
biology of the cleft deformity or of the described tech-
nique. This probably results from inadequate technical
appreciation of how to release, reshape, and reconstruct
the lip and nose adequately while minimizing a detri-
mental scar.
One of the most common mistakes seen in
secondary cases is inadequate release of the abnormally
attached lower lateral cartilage to the pyriform rim in
unilateral and bilateral cases. Release above the inferior
turbinate is crucial for advancement of the abnormally
displaced alar cartilage to achieve tip projection or nasal
symmetry. An inadequate release of the abnormally
tethered alar base is often encountered in these secon-
dary cases. Another common and related mistake is
inadequate release and mobilization of the nasal lining,
achieved by extending the incision cephalad to the
inferior turbinate to allow proper mobilization of the
alar cartilage and lining. Many authors incorrectly think,
in the senior author’s opinion, that this mobilization
necessitates the addition of tissue as a mucosa or turbi-
nate flap. The additional scarring formed by this method
may actually tether the alar cartilage instead of enabling
mobilization of all the nasal elements. Creating cartilage
lining flaps is unnecessary. The sentinel concept is
sufficient dissection for adequate mobilization of the
cartilage.
The basic tenet of tension-free closure applies
without exception to the lip closure. If lip closure is
performed under tension, more scarring will result.
Similarly, careful technique is important to min-
imize scarring associated with surgery and a probable
contributor to abnormal growth.26 The senior author
believes that raising mucoperiosteal flaps in cases of cleft
palate repair does not in itself cause significant sagittal
growth abnormalities; it does cause alveolar collapse.
Any excessive dissection in the space of Ernst may cause
severe scarring in the pterygomaxillary region, causing
potential growth restriction.
The team approach is important. The use of
a multidisciplinary team, particularly integration of
the surgical and orthodontic care, is key for achieving
the best results. Primary surgery without close and
continuous orthodontic follow-up and intervention
during growth will consistently produce poor results.
Mission surgery without developing a local team is a
flawed concept for delivery of the best possible result.
Optimal results cannot be expected during and after
completion of growth by surgery alone. Multidis-
ciplinary management of the cleft deformity is vital in
all patients who have complete cleft of the lip and
palate.1
SURGICAL TECHNIQUE
As noted before, the final result is a product of two
factors. The first, which we have no control over, is the
degree of primary dysmorphology. The second, which is
scarring, is at least partially dependent on respect for the
tissue and technique. The following procedure descrip-
tions are the latest modifications the senior author has
added to his technique in the repair of unilateral cleft lip
and nose deformity, in the quest to achieve consistent
symmetry and balance of the nose and lip at the time of
the primary repair.
A balanced face that is attractive reflecting ‘‘no’’
deformity is the goal. This can now be achieved in most
cases in our experience.
Lip
There is a large variety of ways to obtain lip closure with
excellent results, each one with advantages and disad-
vantages. Many techniques today put an emphasis on
exact preoperative markings on the skin, which commit
the surgeon to some extent to incisions that may not
always be optimal after full dissection of the muscle and
release of the lip and nose from the abnormal skeletal
base. After identification of the peak of the Cupid’s bow
on the cleft side of the median segment, a near-vertical
incision the length of the noncleft philtral column is
made attempting to mirror the noncleft philtral column.
A transverse incision on the lateral lip segment is
performed through and through on the vermilion-cuta-
neous junction laterally until encountering a normal
white roll, thus creating a vermilion flap. There is little
resemblance to the initial Millard procedure.2 The
method the senior author uses is fluid and allows
improvisation and artistry by the surgeon as well as
good access to the nose during the primary repair. The
final skin design is decided after the muscle and alar
symmetry is obtained.
Muscle
Alignment of the muscle is an important basis for lip
reconstruction.27 Medial and especially lateral preper-
iosteal dissection releases the abnormally positioned
muscle from the skeletal base, which is key to accom-
plishing symmetry of the alar bases. When releasing the
muscle within the lip, a small sliver of muscle should be
left attached to the vermilion to provide an orbicularis
marginalis. Dissection of the muscle from the lip should
not be extended for more than 4 to 5 mm laterally and
should avoid crossing the midline of the philtrum
medially to avoid effacing the natural philtral pit. Those
who believe that a major dissection subcutaneously or
subperiosteally is necessary to achieve a good result are
probably mistaken. Unnecessary dissection causes un-
necessary scarring, which is detrimental to growth.
 UNILATERAL CLEFT LIP—APPROACH AND TECHNIQUE/SALYER ET AL 319

Figure 2 Design of lip repair with the authors’ modification of

the rotation-advancement procedure. The peak of the Cupid’s
bow on the noncleft side is marked at an equal distance from the
Figure 3 The incision on the medial lip segment is performed
midline of the columella-lip junction. The incision lines on the cleft
with a number 67 Beaver blade. The incision on the lateral lip
side continue from the vermilion-skin border into the nasal cavity
segment is carried through and through with a number 65 Beaver
and on to the lateral nasal wall, above the inferior turbinate. This
blade on the vermilion-cutaneous junction, dissecting a vermilion
incision will free the displaced and abnormally attached soft
flap. The incision is carried intranasally and cephalically above the
tissue from the underlying bone.
inferior turbinate.

In the midline, muscle fibers may be slightly bunched performed, as used earlier by the senior author while
together to provide fullness to the midlip. developing the technique29 (Fig. 3).
The medial lip incision toward the columella is
performed with a number 67 Beaver blade. The lateral
Combined Correction of the Lip and Nose lip element is incised at the vermilion-cutaneous junc-
The peak of the Cupid’s bow on the cleft side is marked tion with a number 65 Beaver blade with attention to
on the vermilion cutaneous border (the white roll) at an including a piece of orbicularis muscle in the vermilion
equal distance from the midline to that of the noncleft flap to create the orbicularis marginalis. Now the lateral
side (Fig. 2). To facilitate the symmetric design of the dermal skin element is undermined and dissected off the
philtrum, a single arm skin hook may be placed in the muscle for a distance of 2 to 4 mm with careful hemo-
middle of the prolabium, retracting the prolabium to the stasis (Fig. 4). At this stage the medial lip element is
midline and then marking. Another important factor is
preincision marking of the wet line on the vermilion of
each side of the lip, which is critical for a good color
match of both sides of the lip and improved aesthetic
result as observed by Noordhoff.28 Also, when perform-
ing the transverse incision on the lateral lip a sliver of
orbicularis should be left on the new vermilion to provide
a full vermilion with orbicularis marginalis. As seen in
Figure 2, the incision on the lateral segment follows the
dotted line cephalically above the inferior turbinate. This
allows full access to the lower lateral cartilage to perform
its release from the skin envelope and partially from the
nasal lining. If more access is needed, the incision may be
extended further within the nose. Despite the extensive
freeing of the cartilage, the cartilage itself is not exposed.
The incision around the base of the ala on the lateral
rotation advancement flap is no longer performed. This
eliminates the scarring around the alar base but still
allows appropriate release of the alar cartilage. The Figure 4 The orbicularis oris muscle is pulled with pick-ups, and
the skin of the lateral lip segment is undermined from the
rotation incision on the medial lip may extend along underlying muscle at a distance of 2 to 4 mm. The medial lip
the base of the columella to provide additional length, segment is rotated downward and pulled with a hook until its
but no back cut or extension into the columella is height matches that of the lip segment on the cleft side.
320 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005
Figure 5 The medial lip segment is pulled down to match
the length of the lip segment on the cleft side. The skin on the
medial lip segment is undermined from the orbicularis oris
muscle.
rotated downward with a hook, comparing the height to
the height of the noncleft lip. If the cleft lip height is still
short, extension of the incision through the skin, muscle,
or underlying mucosa is performed to achieve adequate
length (Fig. 5). Undermining of the skin medially in
general should not pass the midphiltrum if the philtral
dimple is to be preserved. The incision from the alar base
is extended intranasally above the inferior turbinate
(Fig. 6). The extension of this incision is determined
by the degree of nasal deformity. Through this incision
the skin envelope may be dissected and the underlying
nasal cartilage released, thus allowing repositioning of
the alar cartilage into a more symmetric and correct
anatomical position. The alar cartilage is at the same
Figure 6 The intranasal incision from the base of the ala is
extended above the inferior turbinate. The extent of the incision
is determined by the degree of nasal deformity. Through this
incision, the soft tissue is dissected from the underlying abnor-
mal skeletal base. The incision allows symmetric repositioning of
the nasal components.
Figure 7 The scissors are inserted through the incision at the
base of the ala on the cleft side to dissect the skin from the lateral
crus of the lower lateral cartilage. The nasal mucosa is dissected
from the lateral cartilage, except for the area at the dome.
Complete mobilization of the lower lateral cartilages must be
achieved before the alar cartilages can be repositioned with stent
sutures.
time dissected from the lining, leaving the cartilage
attached at the dome near the genu (Fig. 7). The
abnormally attached foot plate of the medial crus is
released using tenotomy scissors. Through this inci-
sion, the abnormally attached muscles of the lip and
nose are freed, and access to the nasal dome is gained
(Fig. 8).
The importance of meticulous dissection and
freeing of all elements of the lip and nose cannot be
overemphasized. This must be completed prior to sutur-
ing the muscle if symmetry is the goal. If needed, further
dissection should be performed. Dissection over the alar
dome is carried to the noncleft side to reposition the
abnormally positioned alar cartilage on both the cleft and
the noncleft side. Once all elements are free, two straight
Figure 8 Dissection of the skin over the lateral cartilage on the
noncleft side.
 UNILATERAL CLEFT LIP—APPROACH AND TECHNIQUE/SALYER ET AL
Figure 9 Straight Keith needles with Dacron pledgets are
inserted intranasally through the nasal mucosa, lower lateral
cartilage, and skin in the dome area. When tied, this suture shifts
the alar dome to project the nasal tip.
Keith needles (Richard Allen Scientific, Chicago, IL) on
Prolene sutures driven through Dacron pledgets are used
to transpose the alar cartilage and shape it. The goal is
correct cartilage placement and relationship with the
adjacent skin and vestibular lining. It may be necessary to
reinsert the suture until optimal position is achieved.
This allows recruiting of the alar cartilage to the dome at
the genu to achieve projection of the nasal tip (Fig. 9).
The stent stitch is pulled upward without tying it down
while the second key suture is placed in the orbicularis
oris muscle of the lip to achieve lip and nasal symmetry.
Sometimes the domal stitch may need to be reinserted
Figure 10 The nasal mucosa and orbicularis oris muscles are
sutured. A stent suture with two pledgets—one placed inside the
nasal cavity in the dome area and one in the skin—is pulled
upward and medially to correct the position of the lower lateral
cartilage. A transverse cut is extended only minimally into the sill
if needed.
321
Figure 11 Stent sutures are in place, positioning the lower
lateral cartilage on the cleft side symmetric to the one on the
opposite side. The floor of the nose, lip, and vermilion are
repaired. In most cases, this procedure results in a well-balanced
lip and nose.
after the muscle suture is done due to further shift in
tissue. In most cases, symmetry is achieved.
Often, a buried alar base stitch from the cleft side
to the noncleft side helps achieve more nasal base
symmetry. Once the muscle closure is completed, an
additional lateral alar stent suture is placed to adapt the
nasal lining and the overlying skin with the cartilage at
the alar base. Alternatively, a buried stitch may be used,
but the senior author believes that in his hands better
cartilage molding and contour can be obtained with a
stent stitch. No tissue is excised in the floor of the nose;
any excess skin or lining is sutured and allowed to fall in
the nasal floor deficiency.
The transverse lateral element incision is brought
into the floor of the nose to create the sill (M.S.
Noordhoff, personal communication, 1992).10 The in-
cision length is according to the position of soft tissue
elements of the lip and alar base (Fig. 10). To get the
best vermilion match, the vermilion is matched both at
the cutaneous-vermilion junction and at the wet-dry
mucosa line (Fig. 11). Rarely, a small triangular flap
above the white role is performed to achieve better
positioning of the vermilion. The senior author prefers
to delete this procedure if possible. How the skin and
lining are used in closure is case dependent and depends
on how they lie when the nose is positioned into the
proper projection. The skin of the columella C flap is
closed according to how it wants to lie, without tension
in the nostril or nose when the ala is pulled up with the
stent sutures. The subdermis is closed with interrupted
6-0 PDS (Ethicon, Somerset, NJ). Mucosal closure is
performed with a 4-0 chromic, and a 6-0 nylon is used
for skin. This procedure produces a consistently good
322 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4
Figure 12 (A, C, E) Frontal preoperative views at age 2 months and postoperative views at ages 5 and 14. (B, D, F) Submental vertex
views respectively.
result in the hands of an experienced surgeon, who may
make modifications or alterations in each step of the
operation as needed.
Finally, it is probably better to delay primary
nasal surgery if the technique consistently causes scarr-
ing, vestibular stenosis, a small nostril, or any other
deformity.
RESULTS
Results are depicted in Figures 12 and 13.
2005
DISCUSSION
At the time of inception of this technique, early nasal
surgical intervention was considered detrimental to the
growth of the young infant’s nose. The results and
techniques at that time gave poor results. The prevalent
belief was to allow uninterrupted completion of growth
prior to surgical intervention. After 36 years of perform-
ing this procedure on over 750 patients with long-term
follow-up, the senior author believes that most cleft
lip-nose deformities can and should be repaired at
the primary operation. The alar repositioning, sill
 UNILATERAL CLEFT LIP—APPROACH AND TECHNIQUE/SALYER ET AL 323

Figure 13 (A) Preoperative frontal view at age 3 months. (B) Postoperative frontal view at age 5.
(C) Postoperative frontal view at age 16. (D, E) Postoperative left and right lateral views at age 16.

reconstruction, and tip projection can be achieved at the
time of the primary procedure. Of course, in many cases
changes occur with growth that necessitate further
secondary revisions. These changes are usually related
to the septum and skeletal base. Using the described
treatment protocol, the results the senior author achieves
at the primary repair of the soft tissue remain consistent
with subsequent growth. Failure to achieve satisfactory
results should be apparent to the surgeon at the time of
completion of the primary repair.
Alignment of the skeletal base is not necessary at
the time of primary repair. Passive devices may initially
direct the segments toward each other after cheiloplasty
and subsequently help prevent palatal collapse after
palatoplasty. Active preoperative surgical orthopedics is
currently popular and assists the surgeon in closure of the
soft tissue by approximating the skeleton, but the au-
thors believe that this causes abnormal locking position
of the maxillary segments, causing damage to the growth
of the face, resulting in a more severe deformity when
growth is completed. Late results have demonstrated
this assumption.30 The use of periosteal flaps to close the
bony cleft early results in 40% of the patients needing
additional bone grafting.
The authors’ technique attempts to eliminate the
early stigmata of primary cleft lip-nose in young chil-
dren. It eliminates the alar buckling, a consistent finding
of cleft nasal deformities prior to primary repair. When
performed by an experienced surgeon, the primary
procedure may create a near-normal external nose.
324 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005
Figure 14 (A) Preoperative frontal vertex view at age 1 month. (B) Postoperative
frontal view at age 8 months. (C) Postoperative frontal view at age 3 years.
When surgery is done, continued multidisciplinary treat-
ment is continued based on a long-standing protocol,
and secondary procedures are performed, the result can
be a normal, attractive child with minimally noticed
deformity. This technique allows mobilization and
repositioning of the alar cartilage and creation of a
near-normal nasal tip projection and alar base symmetry.
If the desired lip and nose shapes are not achieved, minor
secondary procedures can be done, either before school
age or when final surgical correction is performed.
It must be understood that subsequent treatment is
needed in all the patients.
Over the years, with gained experience, this
procedure has been changed to give consistently im-
proved and more predictable results. When the senior
author published his first 15 years of experience with this
technique, it showed that buckling of the alar cartilage
and flattening of the nose were consistently eliminated
on the cleft side as opposed to patients who had only lip
repair without treating the nose. Thus far, in the senior
author’s series to date, there are no severe residual cleft
nasal deformities. However, the perfect nose without
deformity is unusual. Patients who have excessive scar-
ring of the nose and lip frequently have poor results.
Patients with compliant parents generally have good
nasal contour throughout their growth after primary
surgery and may require only minimal surgery at a later
stage. With a critical eye on the results, the senior author
reports that about 35% of the patients require early
minor secondary procedures, generally performed before
the child begins school. Definitive repair after comple-
tion of growth is considered more of an aesthetic
correction to obtain optimal facial balance and harmony
rather than a major deformity correction. Almost all
unilateral cases need septoplasty and turbinectomy dur-
ing the course of care. The authors’ goal for these
children is to achieve facial harmony and balance, normal
speech, full dentition with normal occlusion, and a
beautiful smile, resulting in an attractive face with no
stigmata of clefting at a conversational distance.
 UNILATERAL CLEFT LIP—APPROACH AND TECHNIQUE/SALYER ET AL 325

Figure 15 (A, C, E, G) Frontal views of the patient in Figure 14 at the ages of 5, 9, 16, and 17. (B, D, F, H) Occlusion in same ages
respectively (note orthodontic work over the years).
326 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005
Figure 16 (A–E) Stacked lateral views
at the ages of 2, 5, 9, 16, and 17. Note
orthognathic surgery (Le Fort 1) per-
formed between parts D and E
With the described technique, the senior author
achieves good to excellent results after primary repair.
No external scars or exposure of the cartilage is
needed.31,32 Minor positioning and sculpting of the
alar cartilages during the teenage years to achieve im-
proved aesthetic balance is all that is necessary. Most of
these patients have rhinorrhea and some degree of nasal
obstruction. The authors have obtained good results by
doing early inferior turbinectomy or limited submucosal
resection at the age of 5 to 10 and definitive submucosal
resection or inferior turbinectomy after growth is com-
plete. Early elimination of nasal obstruction has im-
proved the authors’ results.
The key to achieving consistently good results
with this early repair technique is total release and
mobilization of all the elements, including the skin
envelope, the nasal cartilage, the underlying muscula-
ture, the vestibular lining, and the oral mucosa. Once
complete mobility is achieved, what remains is reposi-
tioning the lip and nasal components in the appropriate
anatomical position to obtain normal contour and sym-
metry with the normal side. This procedure can be
consistently performed in these patients and maintained
using nasal stent sutures or sutures without stents. Early
primary repair of the deformity contributes to more
normal growth and development of the nose, and more
important, it corrects the deformity early, promoting
better psychosocial development and good self-image
before adverse psychosocial effects of the deformity cause
damage.
An emphasis on the intranasal incision is impor-
tant. The incision is placed at the level of the inferior
turbinate, extending into the nose far enough to achieve
complete mobility of all nasal and lip elements without
distortion when repositioned. By this approach, com-
plete mobilization of the abnormally based alar base is
performed. Bardach and Salyer1 previously emphasized
no dissection over the maxilla. The senior author finds it
necessary to perform extensive preperiosteal dissection
over the maxilla to free the abnormally attached lip and
nasal musculature. The authors do not believe this
interferes with subsequent growth, which has been
demonstrated in their own patients.33
The current authors do not fell it necessary to
close the area of the incision along the inferior turbinate
with the use of a turbinate mucosa flap or an L or M
flap.2 In the senior author’s opinion, such flaps may cause
distortion of the tissue, interfering with obtaining the
desired result. Total mobilization of all the displaced
elements and proper repositioning are key for successful
reconstruction. Whether the surgeon uses a triangular
flap or rotational advancement flaps for the skin incision
itself is of secondary importance. The alar base incision
in the lateral advancement flap design is now eliminated,
thus avoiding the scar in the nostril floor.
The senior author advocates the use of nasal stents
postoperatively. The current authors insert these at the
time of primary suture removal 1 week postoperatively.
This technique splints the nostril with silicone con-
formers to limit the effects of scarring and wound
contracture. The splints are worn for 3 months, and
the authors believe they improve scarring and vestibular
stenosis in primary cases. The splint used is a Koken
stent (Silimed, Porex Surgical, Newnan, GA) in primary
 UNILATERAL CLEFT LIP—APPROACH AND TECHNIQUE/SALYER ET AL 327

Figure 17 (A–C) Lateral cephalograms of the same patient (Figs. 14–16) at ages 9, 16,
and 17.

and secondary cases. The senior author believes that
individually designed silicone nostril stents may further
improve this technique. Preoperative nostril expansion
using tissue expansion is unnecessary in patients with
unilateral cleft lip-nose defects because it is time con-
suming and labor intensive.
The authors are evaluating speech results, facial
balance, and dental occlusion in 50 random completed
cases.34 Their findings revealed that velopharyngeal
closure could be obtained in 92% of patients treated
with two-flap palatoplasty at 8 months of age. Good to
excellent facial aesthetic balance of the face, lip, and nose
could be achieved in all compliant patients receiving
complete treatment. Excellent dental occlusion was
achieved with orthodontic treatment and orthognathic
surgery when required.
328 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005
SUMMARY
Good to excellent results have consistently been achieved
by the authors in primary unilateral cleft lip-nose repair.
Over the years, modification and improvements have led
to improved symmetry and balance with less scarring.
When used by experienced surgeons, this technique
yields consistent, predictable, and reproducible results
for all patients with unilateral cleft lip and nose. The goal
is normal appearance and function at conversational
distance. The achievement of excellent soft tissue and
bone restoration while optimizing the patients’ facial
growth as they grow depends on a surgical-orthodontic-
speech-oriented treatment plan. Cleft surgery is not a
one-person, one-time reconstructive process. As evi-
denced in the last patient presented, to obtain excellent
results using this primary technique, a multidisciplinary
team approach based on a long-term treatment protocol
is essential (Figs. 14–17).
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