Ideas and Innovations

The Essential Anatomical Subunit

Approximation Unilateral Cleft Lip Repair
David K. Chong, F.R.A.C.S.
Jordan W. Swanson, M.D.,
M.Sc.
Melbourne, Victoria, Australia; and
Los Angeles, Calif.
Summary: The anatomical subunit approximation cleft lip repair advanta-
geously achieves a balanced lip contour, with the line of repair hidden along
seams of aesthetic subunits. Dr. David Fisher's original description of the
repair reflects the considerable thought that went into the evolution of his
design. As his technique has gained acceptance in the intervening 10 years,
the authors note several key principles embodied in it that represent a shift
in the cleft lip repair paradigm. The authors believe understanding these
principles is important to mastery of the anatomical subunit technique, and
facilitate its teaching. First, design a plan that adheres to anatomical sub-
units and perform measurements precisely. Second, identify and adequately
release each cleft tissue layer from the lip and nose to enable restoration
of balance. Third, drive surgical approximation through inset of the lateral
muscle into the superiorly backcut medial orbicularis muscle, followed by
skin closure with inferior triangle interposition above the white roll. In this
article, the authors present essential components of the technique, and iden-
tify several principles that enable its successful execution.  (Plast. ­Reconstr.
Surg. 138: 91e, 2016.)

T
ranscendent in the anatomical subunit
approximation cleft lip repair1 is the abil-
ity to place the repair line at the seams of
aesthetic subunits and achieve robust lip length
and symmetry. Dr. Fisher explains that the tech-
nique originated from combining the best of
competing repair methods he learned in train-
ing,2 particularly Dr. Thomson’s modification3 of
the Randall-Tennison inferior triangle repair4,5
and Dr. Noordhoff’s modification6 of Millard’s
rotation-advancement technique.7,8 The extensive
markings laid out in Dr. Fisher’s original article
10 years ago reflect the considerable thought
that he put into creating a balanced lip and the
evolution of his design.1 In the interim, as his
technique has been adopted and adapted by sub-
sequent surgeons, we have observed that several
specific markings and maneuvers appear to be
especially important in the success of the repair.
Furthermore, we have identified several princi-
ples that, although not necessarily original to the
anatomical subunit repair, in our opinion are par-
ticularly important to its successful execution. In
this article, we briefly introduce these modifica-
tions and principles.
Markings and maneuvers
The essential medial lip markings identify key
anatomical landmarks and allow the discrepancy
between cleft and noncleft philtral height to be
calculated using calipers (Fig.  1). The rationale
for these points is explained well by Fisher.1
We then proceed to simplify the extensive
nasal markings by dynamically repositioning the
lateral nasal base before marking the lateral side.
This requires first mobilizing the lateral lip ele-
ments by incising the lateral oral mucosa along
Disclosure: The authors have no relevant financial
interests related to this article.

From the Division of Plastic Surgery, Royal Children’s Hos-
pital; and the Division of Plastic Surgery, University of
Southern California and the Shriner’s Hospital for Chil-
dren.
Received for publication June 21, 2015; accepted February
19, 2016.
Copyright © 2016 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000002257
Supplemental digital content is available for
this article. Direct URL citations appear in the
text; simply type the URL address into any Web
browser to access this content. Clickable links
to the material are provided in the HTML text
of this article on the Journal’s Web site (www.
PRSJournal.com).

www.PRSJournal.com 91e
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 Plastic and Reconstructive Surgery • July 2016

Fig. 1. Marking of the medial lip (yellow) and columellar base (purple) anatomi-
cal landmarks enables measurement of the noncleft philtral height (a) and the
cleft philtral height (b). A backcut (c) is marked to bisect the two limbs on the
medial side, with length according to the equation a – b – 1 mm = c. Lateral lip
(pink) markings are driven by the Noordhoff point. Finally, dynamic nasal repo-
sitioning is performed after supraperiosteal dissection of the lateral lip tissues
off of the maxilla, to identify the lateral nasal sill point that corresponds to the
medial nasal sill (blue markings). Callipers are used to best fit the three incision
lines (corresponding to the nasal rim, philtral column b, and equilateral interposi-
tional triangle with side c) between the nasal sill and the Noordhoff points. Note
how the planned incisions sharply angulate toward the cleft as they descend
from the white roll into the mucosa on each side, which enables lengthening to
be achieved by straight-line closure of a diamond-shaped deformity (the Rose-
Thompson effect). In the equation, 1 mm is subtracted from the difference in phil-
tral heights to account for the approximate 1-mm gain from this effect.

the gingivobuccal sulcus and performing a supra-
periosteal dissection and muscle dissection as
needed. With the lateral nose repositioned using
a forceps, retractor, and digital manipulation, a
lateral nasal sill point is marked to correspond to
the medial nasal sill point. The Noordhoff point
is then identified at the lateral white roll, and
cutaneous and vermillion interposition triangles
are designed based on the extent of medial defi-
ciency.9 Importantly, the planned incisions angu-
late sharply toward the cleft and cross the white
roll at right angles into the mucosa on each side;
this enables lengthening to be achieved through
the Rose-Thompson effect.10,11
Each of three tissue elements is aberrantly
retracted in a cleft deformity—skin, orbicularis
muscle, and mucosa—and each must be suffi-
ciently released to enable repositioning during
repair (Fig. 2). Medial incisions and dissection are
carried out first. Release of the skin is achieved
through incision design, and by incising subder-
mally to free it from the orbicularis muscle slightly.
Similarly, the orbicularis oris muscle must be dis-
sected transversely from its aberrant attachment to
the anterior nasal spine, so that it can be rotated
laterally and inferiorly. Finally, the mucosa must
be released transversely, in most cases across the
midline frenum, to prevent the repaired lip from
being tethered intraorally. With gentle downward
traction on the vermillion, we ensure that the dis-
section has sufficiently untethered the medial tis-
sues to the level of Cupid’s bow before incising
the lateral lip elements. This allows the size of the
skin triangle to be modified should there be a mis-
calculation from measurements before the lateral
element dissection.
Lateral skin incisions and dissection are per-
formed. To mobilize the muscle in a complete
cleft lip, this includes dissecting the lateral lip
muscle from the alar base transversely approxi-
mately 2  cm, and creates the anatomical “empty
triangle” beneath the ala.
Thorough closure of the nasal floor during
primary lip repair is essential to prevent subse-
quent nasolabial fistula and facilitate later ante-
rior palatal repair in complete clefts. We typically
use the extended lateral nasal wall flap12 or a
vomer flap. Primary nasal repair is performed by

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 Volume 138, Number 1 • Essential Subunit Cleft Lip Repair

Fig. 2. Each of the three medial and lateral lip tissue layers—skin, orbicularis oris muscle,
and oral mucosa—must be identified, then released perpendicular to their line of ten-
sion to enable mobilization for advancement. In particular, the orbicularis muscle must
be sufficiently released from the anterior nasal spine medially to enable interposition
of the lateral segment, and laterally from the ala to enable creation of the anatomical
“empty triangle” beneath it.

dissecting nasal skin off of the lower lateral car- Principles

tilage, and repositioning the nasal septum ante- Several key principles are reinforced in a suc-
riorly and affixing to the anterior nasal spine as cessful anatomical subunit approximation repair.
needed.13,14 First, a precisely measured plan adhering to ana-
Having released each cleft tissue layer, tomical subunits is made and followed to pre-
advancement and closure follow. The orbi- serve key landmarks. The most distinct junctions
cularis muscle facilitates adequate “rotation”
and constitutes the layer of strength. While an
assistant uses skin hooks with inferior tension
in both the medial and lateral lip elements to
balance them, the superolateral muscle is inset
into the backcut of the medial muscle with
4-0 suture, which drives medial lip lengthening
(Fig.  3). This initial stitch sets the foundation
of the repair. Muscle approximation proceeds
superiorly to inferiorly with gradually decreasing
tension, which facilitates anterior projection of
the pars marginalis and conveys pout to the lip.
Furthermore, the premeasured interpositional
skin triangle “snaps in” to the backcut above
the white roll during approximation, creating a
pout to the white roll and hiding itself within
the shadow of the lip. The final step—the only
“cut as you go”—occurs at the nasal sill, where Fig. 3. To reconstruct the normal upper lip contour, which pro­
some fine tuning ensures the right diameter and jects forward at the level of the pars marginalis when viewed
shape to the nostril opening, and best matches laterally, the upper lateral orbicularis is inset into the superior
incision placement to the contralateral nostril backcut of the medial orbicularis. Unlike rotation-advancement
sill contour. Alar shaping stitches and lower lat- techniques in which skin and muscle move en bloc, the rotation-
eral hitching stitches are placed to shape the advancement derived from this technique is in a different plane
nose and nasal stents are fitted. than approximation of the overlying skin incision.

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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

between these subunits include the paired phil-
tral columns, the white roll along the vermillion
border, and the decussation of the nasal sill at the
columellar base; an ideal line of repair adheres
to these seams. As a tailor always premeasures a
pattern before cutting fabric into a suit, we also
believe that pattern design specific to the anatom-
ical presentation of the unrepaired cleft is essen-
tial before incision. Identifying key landmarks
facilitates a symmetrical nose, correct alar base
position, and a balanced Cupid’s bow. Length-
matched incisions and angles enable a prede-
termined interpositional triangle to snap into
position.
Second, each cleft tissue layer must be iden-
tified and released from both the lip (skin, orbi-
cularis oris muscle, and oral mucosa) and nose
to enable restoration of anatomical position.
Because the skin markings are determined before
incision, cutting as you go to compensate for inad-
equate rotation is not an option. Because the skin
incision is limited to subunit junctions, the tech-
nique relies on conceptually spreading the “rota-
tion” (and thus release) across all tissue layers and
not just the skin.
Third, accurate muscle reapproximation fun-
damentally drives the repair. Advancement borne
primarily of the muscle layer creates an overall
eversion and projection of the lip and, coupled
with angulated incisions to maximize the Rose-
Thompson effect, helps explain why the inter-
posed skin triangle is often much smaller than in
the Tennison-Randall repair.4,5,15 As a result, robust
lengthening can occur beneath an incision limited
to subunit junctions. [See Figure, Supplemental
Digital Content 1, which shows preoperative (left)
and immediate postoperative (right) photographs
of a patient with left unilateral cleft lip repair per-
formed using the described method at 6 months
of age, http://links.lww.com/PRS/B760. See Figure,
Supplemental Digital Content 2, which shows fol-
low-up at 3 years of age of the same patient, http://
links.lww.com/PRS/B761.]
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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • July 2016
David K. Chong, F.R.A.C.S.
Division of Plastic Surgery
Royal Children’s Hospital
50 Flemington Road
Melbourne, Victoria, Australia
davidkchong@gmail.com
acknowledgment
We gratefully acknowledge our illustrator, Bill Reid.
references
1. Fisher DM. Unilateral cleft lip repair: An anatomical
subunit approximation technique. Plast Reconstr Surg.
2005;116:61–71.
2. Fisher DM. Unilateral cleft lip repair: Anatomic subunit
approximation technique. In: Losee J, Kirschner RE, eds.
Comprehensive Cleft Care. 2nd ed. New York: CRC Press; 2015.
3. Thomson HG. Unilateral cleft lip repair. Oper Tech Plast
Reconstr Surg. 1995;2:175–181.
4. Tennison CW. The repair of the unilateral cleft lip by the
stencil method. Plast Reconstr Surg (1946) 1952;9:115–120.
5. Randall P. A triangular flap operation for the primary repair
of unilateral clefts of the lip. Plast Reconstr Surg Transplant
Bull. 1959;23:331–347.
6. Noordhoff MS. The Surgical Technique for the Unilateral Cleft Lip-
Nasal Deformity. Taipei: Noordhoff Craniofacial Foundation;
1997.
7. Millard DR Jr. Complete unilateral clefts of the lip. Plast
Reconstr Surg Transplant Bull. 1960;25:595–605.
8. Millard DR. Extensions of the rotation-advancement
principle for wide unilateral cleft lips. Plast Reconstr Surg.
1968;42:535–544.
9. Noordhoff MS. Reconstruction of vermilion in unilateral
and bilateral cleft lips. Plast Reconstr Surg. 1984;73:52–61.
10. Rose W. On Harelip and Cleft Palate. London: HK Lewis; 1891.
11. Thompson JE. An artistic and mathematically accurate
method of repairing the defect in cases of harelip. Surg
Gynecol Obstet. 1912;14:498–505.
12. Khosla RK, McGregor J, Kelley PK, Gruss JS. Contemporary
concepts for the bilateral cleft lip and nasal repair. Semin
Plast Surg. 2012;26:156–163.
13. McComb H. Primary repair of the bilateral cleft lip nose: A
10-year review. Plast Reconstr Surg. 1986;77:701–716.
14. Salyer KE. Primary correction of the unilateral cleft lip nose:
A 15-year experience. Plast Reconstr Surg. 1986;77:558–568.
15. Tse R, Lien S. Unilateral cleft lip repair using the anatomical sub-
unit approximation: Modifications and analysis of early results
in 100 consecutive cases. Plast Reconstr Surg. 2015;136:119–130.