Unilateral Cleft Lip Repair: An Anatomical
Subunit Approximation Technique
David M. Fisher, F.R.C.S.C., F.A.C.S.
Toronto, Ontario, Canada
Background: A technique of unilateral
cleft lip repair is described. The repair
draws from a variety of previously described
repairs and adheres to a concept of ana-
tomical subunits of the lip. Cases from
within the spectrum of the deformity have
been chosen from a series of 144 consec-
utive cases to demonstrate the applicability
of the technique in all forms of unilateral
cleft lip.
Methods: Incisions cross the lip perpendic-
ular to the cutaneous roll at the cleft side
peak of Cupid’s bow of the medial lip and
at the base of the philtral column of the
lateral lip. Above this level, incisions ascend
the lip to allow for approximation along a
line symmetrical with the non– cleft-side
philtral column. Incisions then ascend su-
perolaterally bordering the lip columellar
crease to the point of closure in the nostril
sill. A Rose-Thompson lengthening effect
occurs just above the level of the cutaneous
roll. If necessary, a small triangle positioned
just above the cutaneous roll is often used.
Any central vermilion deficiency is aug-
mented by a laterally based triangular ver-
milion flap from the lateral lip element.
Results: Since January of 2000, this tech-
nique has been used in 144 consecutive
unilateral cleft lip repairs. The inferior tri-
angle is small (average, 1.24 mm; range, 0
to 2 mm). The technique can be applied to
all degrees of unilateral cleft lip.
From the Division of Plastic Surgery, The Hospital for Sick Children, and the Department of Surgery, University of Toronto. Received for
publication April 9, 2004; revised August 23, 2004.
Presented at the American Cleft Palate–Craniofacial Association meeting, in Chicago, Illinois, March 19, 2004, and at the Canadian Society
of Plastic Surgeons/Société Canadienne des Chirurgiens Plasticiens meeting, in Hamilton, Ontario, Canada, June 3, 2004.
DOI: 10.1097/01.PRS.0000169693.87591.9B
61
Conclusions: A technique of unilateral
cleft lip repair is described. The repair al-
lows for a repair line that ascends the lip at
the seams of anatomical subunits. (Plast.
Reconstr. Surg. 116: 61, 2005.)
SURGICAL TECHNIQUE
After satisfactory induction of anesthesia and
placement of a conformed oral endotracheal
tube fixed on the chin in the midline, the
patient is placed in the supine position with the
neck slightly extended using a small shoulder
roll. The operating table is tilted into a slight
reverse Trendelenburg position. Presurgical
photographs and measurements are obtained.
The face is prepared and draped.
Markings
Medial lip. The midline and height of the
non– cleft-side philtral column are marked at
the lip-columellar crease (points 1 and 2) (Fig.
1). Point 3, the height of the cleft side philtral
column, is marked on the lip-columellar crease
to mirror point 2 relative to point 1. The upper
lip midline and peaks of Cupid’s bow are
marked at the vermilion-cutaneous junction
(points 4, 5, and 6). Along lines perpendicular
to the vermilion-cutaneous junction and pass-
ing through the peaks of Cupid’s bow, points 7
and 8 are marked just above the cutaneous roll
(at the junction between the cutaneous roll and
the “flat” portion of the upper lip). Line 3– 8
should mirror the non– cleft-side philtral col-
umn (line 2–7) in its upper part. The opening
62
FIG. 1. (Above and center) Key landmarks and surgical
plan outlined with pen and gentian violent ink. See text
(Surgical Technique) for description. (Below) Immediate
postoperative appearance.
cut on the medial lip skin is marked above the
cutaneous roll along a line initiated at point 8,
running perpendicular to the philtral column
(line 3– 8) and terminating at point 9 before the
midline of the philtrum. The “red line” is
marked at three points (10, 11, and 12) below
the midline and below the peaks of Cupid’s
bow. Points 8, 6, and 12 should form a straight
line running perpendicular to the free margin
of the lip. Line 10 –12 represents the opening
PLASTIC AND RECONSTRUCTIVE SURGERY, July 2005
incision in the red lip that will accept a laterally
based vermilion flap from the lateral lip
element.
The markings on the medial lip vary little
from case to case. The position of point 3 and
therefore of the slope of line 3– 8 will vary
between cases to exactly mirror the position
and slope of the non– cleft-side philtral col-
umn. For minor clefts, the degree of downward
rotation of the cleft-side peak of Cupid’s bow
may be minimal, and therefore an inferior tri-
angle may not be necessary. In such cases, the
required lengthening (of 1 mm or less) can be
achieved by a Rose-Thompson type effect
alone.
Nasal floor. Right and left subalare (the most
inferior point on the curve of the alar-lip junc-
tion) are marked (points 13 and 14). Because
the cleft-side ala is laterally rotated into a more
vertical position (more so in complete clefts),
the cleft-side subalare is marked after rotating
the alar insertion with digital pressure predict-
ing the final position of the lip and ala after lip
repair. Point 16 represents the height of the lip
at the site of proposed closure in the nostril sill.
It is drawn at a point along the lip-columellar
crease symmetric with point 15. These latter two
marks are somewhat arbitrary, and one needs to
consider the amount of skin lateral to the cleft-
side columellar base and medial to the cleft-side
alar insertion. If there is a deficiency of lateral
lip element tissue medial to the alar insertion,
point 16 needs to be positioned more laterally
to avoid a constricted naris. If there is ample
lateral lip element tissue medial to the alar in-
sertion, point 16 can be, and ideally should be,
more medially placed at the base of the
columella.
Measurements and Calculations
Measurements are taken from the heights of
the philtral columns at the lip-columellar
crease to the points marked above the peaks of
Cupid’s bow above the cutaneous roll; line 2–7
represents the total lip height, line 3– 8 repre-
sents the greater lip height. The total lip height is
measured with the lip at rest. The greater lip
height is measured with gentle downward trac-
tion on the lip to unfurl the medial lip and
predict the tension on the lip after repair. The
lesser lip height (base width of the small inferior
triangle) is equal to the total lip height minus
the greater lip height and minus 1 mm (Fig. 2):
Vol. 116, No. 1 / UNILATERAL CLEFT LIP REPAIR
FIG. 2. The base width of the inferior triangle (c) is cal-
culated. The total height (a) and greater height (b) are mea-
sured from points just above the cutaneous roll above the
peaks of Cupid’s bow to the height of the philtral column in
the lip-columellar crease. Approximately 1 mm of lengthen-
ing occurs by a Rose-Thompson type effect, thereby reducing
the required size of the inferior triangle. a ⫺ b ⫺ 1 mm ⫽ c.
Lesser lip height
⫽ 共total lip height兲 ⫺ 共 greater lip height兲 ⫺ 1 mm
⫽ base width of the small inferior triangle
(1)
With the opening of the opening incision (line
8 –9), the cleft side peak of Cupid’s bow is
rotated caudally. There is additional length
gained, approximately 1mm, as the angle
formed by line 3– 8 and line 6 – 8 opens fully to
180 degrees. The lesser lip height is usually
between 1 and 1.5mm and should be kept less
than 2mm. For minor clefts, an inferior trian-
gle may not be necessary.
Lateral lip. The markings of the lateral lip
require adjustment for the vertical height of the
lateral lip. Having said this, one should not
compromise on the base of the philtral column
or on the point of proposed closure in the nos-
tril sill. As described by Noordhoff,1 it is best to
use vermilion height to determine the point on
the lateral lip that will form the base of the
philtral column and meet point 6 at the cleft
63
side peek of Cupid’s bow. Point 17 is positioned
along the vermilion-cutaneous junction at the
point where the cutaneous roll and red line
(vermilion-mucosal junction) begin to con-
verge medially. At this point, there will be ad-
equate vermilion height and the remaining lat-
eral cutaneous roll will be of optimal quality.
Moving this point medially will result in central
vermilion deficiency and will leave a cutaneous
roll of poor quality. If this point is moved lat-
erally, lateral lip transverse length, which is
most often deficient, will be further compro-
mised. Furthermore, there is a natural antero-
superior convexity of the cutaneous roll that
can be preserved if point 17 is placed according
to Noordhoff’s recommendations and will pro-
vide for a more natural appearing lip. Along a
line perpendicular to the vermilion-cutaneous
junction and passing through point 17, point 18
is marked just above the cutaneous roll. Lines
6 – 8 and 17–18 will meet and therefore should
be of equal length. The point of proposed clo-
sure in the nostril sill (point 19) is then posi-
tioned as far medial and superior from point 14
as point 15 is from point 13. Ultimately, the
position of point 19 should be positioned rel-
ative to point 16 such that when they are ap-
proximated, the cleft-side nostril circumfer-
ence will equal that of the non– cleft-side and
such that the alar bases will lie in the same
vertical level. The distance between points 18
and 19 will then dictate the pattern of the re-
maining markings on the skin of the lateral lip.
Using calipers, points 20 and 21 are then placed
between points 18 and 19. Point 22 is positioned
relative to points 18 and 20 to complete an
isosceles triangle; lines 18 –22 and 20 –22 are
equal to line 8 –9 and the base width of the
triangle equals the lesser lip height. If the lateral
lip is short (Fig. 3), point 20 can be positioned
lateral to the sagittal plane passing through
point 18 and segment 20 –22 can be coincident
with the lower portion of line 21–20. The re-
quired length will be gained as the angle 21–
20 –22 opens from 0 to 90 degrees. If the lateral
lip is vertically long (Fig. 3), point 20 should be
positioned along a straight line joining points
18 and 21. If the lip is still too long (Fig. 3), a
medially based wedge excision of upper lip can
be performed below point 19. The upper limb
of this wedge excision should be positioned
within the medial extent of the alar crease and
its lateral extreme; the lateral apex of this wedge
excision should never extend laterally beyond
subalare (point 14). A lateral rhinotomy inci-
64 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2005

FIG. 3. The vertical limb (greater height) of the repair will vary in slope to mirror the non– cleft-side philtral
column. With minor clefts, the inferior triangle above the cutaneous roll may not be required. Lateral lip markings
will vary depending on the vertical height of the lateral lip element. The positions of the point of closure in the
nostril sill and of “Noordhoff’s point” should not be compromised.

sion along the alar crease is never used. It is
unnecessary and leaves an unsightly scar. Alter-
ing the vertical level of point 19 to accommo-
date the vertical length of the lateral lip is dis-
couraged. Any adjustment will compromise the
final vertical position of the alar insertion. Point
21 is placed between points 19 and 20 so that
lengths 21–19 and 21–20 equal lengths 3–16
and 3– 8, respectively, and such that angle 19 –
21–20 approximates angle 16 –3– 8. Point 23 is
marked along the red line below point 17. The
lateral vermilion flap is then marked. Along a
line joining points 17 and 23, point 24 is marked
such that the length of line 17–24 equals that of
line 6 –12. Lengths 23–25 and 24 –25 are equal
to the length of the opening incision along the
red line of the medial lip (line 10 –12), and
the base width of the triangle should equal the
amount of vermilion augmentation required
(the length of line 5–11 minus the length of line
6 –12).
Incomplete clefts. Above points 16 and 19 (or
19'), a wedge excision of nostril sill is per-
formed. The distance between points 16 and 19
(or 19') should be 1 mm less than the difference
in the circumference of the cleft-side and non–
cleft-side nares (1 mm less to avoid a constricted
cleft-side naris). To determine this, I size the
nares with Hegar cervical dilators. These dila-
tors are numbered according to their diameter.
Multiplying the difference in diameter by 3 (ap-
proximately ␲) will equal the maximum amount
of allowable excision of nostril sill. Mucosa of the
cleft margins is removed by wedge excision, with
the peak above the level of the cleft. Occasionally,
a short lateral upper buccal sulcus advancement
incision is helpful.
Complete clefts. The upper aspect of the pos-
terior closure is accomplished using a medial
flap from the medial segment, a modified lat-
eral flap from the lateral segment, and an in-
ferior turbinate flap (Fig. 4). A broadly based
medial flap extends from point 16 to the upper
extent of the mucosal incision. It generally
needs to be only 1 to 2 mm in length, enough
to receive sutures. Above point 19 (or 19'), a
Vol. 116, No. 1 / UNILATERAL CLEFT LIP REPAIR
FIG. 4. With complete clefts, an inferior turbinate flap (t),
medial flap (m), and modified lateral flap (l) are used for the
posterior lamella of closure. The turbinate flap is unified with
the lateral flap along their adjacent borders. The turbinate
flap resurfaces the raw area produced by anterior reposition-
ing of the cleft-side alar base and its distal margin crosses the
alveolar cleft above the level of the gingiva. This distal margin
will approximate with the medially advanced upper buccal
sulcus incision margin of the lateral lip element. The lateral
flap will be trimmed of distal mucosa and will meet with the
medial flap.
65
rectangular lateral flap is marked. In contrast to
Millard’s lateral flap, it is superolaterally based
at the level alar vestibular skin. Its base extends
from point 19 (or 19') to just below the antero-
lateral extreme of the inferior turbinate. The
distal margin of the flap is initially the upper
portion of the vertical mucosal incision; how-
ever, it is generally trimmed of distal mucosa
and is then composed of skin only. From the
upper limit of the mucosal incision and extend-
ing only as much as necessary, a lateral upper
buccal sulcus advancement incision with or
without a back-cut is made. If there is significant
anteroposterior distance between the greater
and lesser maxillary segments, an anteriorly
based inferior turbinate flap1 is used. It will
rotate caudally and anteriorly and will be uni-
fied with the lateral flap. It will be used to cover
the mucosal defect created by the anteromedial
advancement of the lateral lip, and its distal
margin will span the alveolar cleft above the
level of the gingiva.
Maneuvers
Sterile tapes are placed over the closed eye-
lids. Key landmarks are tattooed with gentian
violet dye and a 25-gauge needle. Bilateral in-
fraorbital nerve blocks are performed, and the
cleft-side alar base, piriform rim, and inferior
turbinate are infiltrated with 1% lidocaine with
epinephrine 1:200,000 (maximum dose, 0.5
ml/kg). No infiltration of the lip is performed.
After placement of a moist mouth pack, dissec-
tion begins on the medial lip. Incisions are
made with scalpel and completed with scissors.
The opening incision above the cutaneous roll
is through skin and subcutaneous tissue and
not through muscle. Cleft marginal tissue is
discarded. Dissection frees the muscle from the
overlying skin and vermilion and from the un-
derlying mucosa. Dissection between skin and
muscle is limited to 1 mm from the cut edge to
preserve the philtral dimple. The orbicularis is
freed from its upturned insertion in the region
of the columellar base and upper alveolar cleft
margin. The lip and columellar base are posi-
tioned to predict the final position, and an
appropriate downward rotation of the cleft
side peak of Cupid’s bow is verified. Lateral lip
markings can then be altered if necessary.
Dissection continues with the lateral lip. In-
cisions are made with scalpel and completed
with scissors. For complete clefts, it is helpful to
start with the mucosal incisions, as this will
release the tether of the lip from the region of
66 PLASTIC AND RECONSTRUCTIVE SURGERY, July 2005
the upper alveolar cleft margin and lower piri-
form rim. Cleft marginal tissue is discarded.
Dissection frees the muscle from the overlying
skin and vermilion and from the underlying
mucosa. On the lateral lip element, dissection
between skin and muscle is more extensive,
extending laterally as far as the alar base to
relieve the orbicularis muscle bulge. Orbicu-
laris is freed from its upturned insertion in the
region of the alar base and upper alveolar cleft
margin. Dissection deep to muscle and in an
extraperiosteal plane frees the alar base from
the underlying maxilla. The vestibular web,
formed by the caudal margin of the lower lat-
eral cartilage’s lateral crus, the accessory carti-
lages, and investing perichondrium, is released
from its posterolateral attachment to the piri-
form rim (Fig. 5). When this release from the
piriform rim is sufficient, the alar base can now
be advanced anteromedially without accentu-
ating the buckling of the alar rim and of the
lateral alar flare. If there is significant antero-
posterior distance between the greater and
lesser maxillary segments, anteromedial ad-
vancement of the alar base will leave a large
raw periosteal surface at the upper alveolus
and lower piriform margin that is best covered
with an inferior turbinate flap. The inferior
turbinate flap is elevated and rotated inferiorly
and then anteriorly. The turbinate flap donor FIG. 6. Minor unilateral cleft. Surgical markings (above)
site is cauterized. Adjacent margins of the lat- and postoperative result at 7 days (below). Note that for minor
eral flap and inferior turbinate flap are sutured clefts, an inferior triangle above the cutaneous roll may not
together. The originally medial margin and be required. A vermilion flap from the lateral lip element is
usually required.
now posterior margin of the turbinate flap is
then sewn to the free margin of the upper
alveolar and lower piriform area incision (Fig.
4). The distal margin of the lateral flap is ro-
tated across the cleft and sutured to the medial
flap. The upper buccal sulcus incision is su-
tured closed. The distal margin of the turbi-
nate flap will be sutured to the upper edge of
the lateral lip mucosa in the interval of the
alveolar cleft. Closure continues caudally with
approximation of the medial and lateral lip
element mucosa. From within the nasal vesti-
bule, forceps are used to reposition the cleft-
side dome anteromedially and to grasp the
caudal margin of the upper lateral cartilage.
One or two internal nasal valve plication su-
tures are placed to maintain the anteromedial
advancement of the lateral crus and to create
FIG. 5. In this incomplete cleft, the cleft-side dome is re- the normal overlap of the lower lateral carti-
tracted anteromedially, placing the vestibular web under ten-
sion. The vestibular web formed by the lower lateral cartilage lage and the upper lateral cartilage. With a
accessory cartilage complex and investing perichondrium is Ragnell retractor, the cleft-side dome is re-
released from its attachment to the piriform margin. tracted anteromedially, and alar transfixion su-
Vol. 116, No. 1 / UNILATERAL CLEFT LIP REPAIR 67
approximation, internal nasal valve pexy su-
tures, alar transfixion sutures, and deep dermis
approximation; 7-0 Prolene for skin, and 7-0
Vicryl for vermilion. Despite avoiding infiltra-
tion of the lip, bleeding is not excessive and is
easily controlled with direct pressure on the lip
and electrocautery. Infants can breast or bottle
feed already in the recovery room. Lip sutures
are removed at 5 to 7 days from the
cheiloplasty.

RESULTS
One hundred forty-four consecutive unilat-
eral cleft repairs (73 incomplete and 71 com-
plete) form the present series. Example cases
are shown (Figs. 6 through 15). In 50 patients
aged 3 to 6 months treated consecutively dur-
ing the latter half of this experience, the mean
discrepancy in vertical height (measured from
subnasale to the peak of Cupid’s bow) was 2.41
mm (range, 0.5 to 3.5 mm) and the mean base
width of the inferior triangle was 1.24 mm
(range, 0 to 2 mm).

FIG. 7. Halfway incomplete unilateral cleft. Surgical

markings (above) and postoperative result at 7 days (below).

tures are placed to obliterate any dead space

created by the release of the vestibular web
from the piriform rim and to maintain antero-
medial advancement of the lateral crus. The
columellar base and cleft-side alar base are
approximated with an “alar cinch stitch.” Care-
ful placement of this suture will allow the alar
bases and columellar base to be positioned in
the appropriate horizontal plane. Muscle ap-
proximation is performed. Skin is approxi-
mated with deep dermal and then simple in-
terrupted sutures. The lateral vermilion flap is
debulked of underlying muscle, trimmed to
size, and inset into the opening incision along
the red line of the medial lip. Antibiotic oint-
ment is applied to the suture line. The throat
pack and eyelid tapes are removed. Elbow
splints are placed and maintained for 2 weeks.
The patient is awakened from general anesthe-
sia and extubated.
Presently, I use 5-0 and 6-0 chromic catgut
suture for the mucosa; 4-0 polydioxanone for FIG. 8. Complete unilateral cleft. Surgical markings
the alar cinch stitch; 5-0 Monocryl for muscle (above) and postoperative result at 7 days (below).
68
FIG. 9. Complete unilateral cleft. Surgical markings
(above) and postoperative result at 7 days (below).
DISCUSSION
When we consider the challenge of cleft lip
repair, the ultimate goal should be a lip and
nose of normal form and function. Regardless
of how close we may come to achieving this
goal, we still must accept a cutaneous scar that
may heal less predictably than we may wish and
that is permanent. Various techniques of lip
repair have been described, each of which po-
sition the cutaneous scar uniquely. Applying
the principle of anatomic subunits2 to cleft lip
repair, the “ideal line of repair” should be one
that ascends the lip from the cleft-side peak of
Cupid’s bow to the base of the nose along a
line exactly mirroring the non– cleft-side phil-
tral column and that then continues superolat-
erally bordering the lip-columellar crease to
the point of closure in the nostril sill. This is
possible with minor clefts; however, with most
overt clefts, the medial lip is deficient in verti-
cal height. In the mid 1800s, Mirault3 intro-
duced a technique of cleft lip repair that rep-
resented a significant advance over previous
PLASTIC AND RECONSTRUCTIVE SURGERY, July 2005
FIG. 10. Minor unilateral cleft. Preoperative appearance
(above) and postoperative result at age 3 years (below).
straight-line repairs. He augmented medial lip
deficiency with tissue from the lateral lip ele-
ment. This principle has been preserved in
subsequently devised repairs.
Realizing that the rotation incision alone was
often inadequate, Millard modified his original
repair4 by introducing a back-cut in the upper
lip beginning at the extreme of the rotation
incision.5 Noordhoff1 modified Millard’s rota-
tion advancement by adding a small triangle
that he pared off the lateral lip just above the
cutaneous roll and that was then inset into an
opening incision in the medial lip, again posi-
tioned just above the cutaneous roll. This
achieved the necessary rotation and avoided
the increase of scar at the base of the nose that
accompanies the back-cut. I was impressed by
how ineffective the rotation incision can be
and how frequently Noordhoff used his little
triangle above the cutaneous roll. I was also
impressed by the effect of this triangle; it pro-
vides a small amount of tension just above the
cutaneous roll that accentuates the pout of the
Vol. 116, No. 1 / UNILATERAL CLEFT LIP REPAIR 69

FIG. 11. Halfway incomplete unilateral cleft. Preoperative FIG. 12. Complete unilateral cleft. Preoperative appear-
appearance (above) and postoperative result at age 3.5 years ance (above) and postoperative result at age 14 months
(below). (below).

FIG. 13. Complete unilateral cleft. Appearance before presurgical orthodontics (left) and postop-
erative result at age 12 months (right).
70
FIG. 14. Complete unilateral cleft. Appearance before
presurgical orthodontics (above) and postoperative result at
age 9 months (below).
lip. Thomson6 modified the inferior triangle
techniques of Tennison7 and Randall8 to limit
the base width of the inferior triangle to only 2
mm. After training with Noordhoff and
Thompson, I questioned whether it would be
possible to plan on a small triangle just above
the cutaneous roll at the outset and then avoid
the rotation incision altogether to place the
majority of the scar along the “ideal line of
repair.” This formed the basis of the described
repair.
The described technique is reliable because
it is based on previously described repairs and
principles. A Rose-Thompson lengthening9,10
occurs as the sloped incisions crossing the cu-
taneous roll of the medial and lateral lip ele-
ments approximate in the vertical. This allows
for a smaller triangle than would be required
by a classic inferior triangle technique. The
inferior triangle is positioned according to
Noordhoff’s description, above the cutaneous
roll, to allow for better continuity of the roll
PLASTIC AND RECONSTRUCTIVE SURGERY, July 2005
FIG. 15. Complete unilateral cleft. Appearance before
presurgical orthodontics (above) and postoperative result at
age 12 months (below).
and to optimally position the tension of the lip
repair. The required length having been
achieved, the incision lines can then be placed
to allow for approximation along the seams of
anatomical subunits.
In designing a rotation-advancement repair
when the lateral lip element is short in vertical
height, it may be necessary to compromise the
position of the base of the philtral column on
the cleft side (by moving it laterally) and in
doing so compromise lateral lip transverse
length to achieve vertical height. This is rarely
if ever necessary with this repair (as in the
classic inferior triangle repairs) because appro-
priate triangulation with calipers can almost
always accommodate the available height of
the lateral lip. Underrotation is rare using this
technique despite using such a small triangle.
Common to all inferior triangle repairs, there
is some tendency to flatten Cupid’s bow. This
seems a reasonable compromise because a
shallow Cupid’s bow is seen also in the noncleft
Vol. 116, No. 1 / UNILATERAL CLEFT LIP REPAIR
population and is not itself a stigma of clefting.
The cutaneous scar on the nose is minimized
and is essentially limited to the cleft-side nostril
sill. Primary rhinoplasty is performed with the
intent of improvement and the realization that
complete correction of the nasal deformity de-
pends on augmentation of the alar base and
piriform margin skeletal deficiencies, which
may have to wait to be addressed at the time of
alveolar bone grafting. The achievable goals of
this primary rhinoplasty then are (1) central-
ization of the columellar base, (2) symmetrical
alar base repositioning in the craniocaudal
plane, (3) nostril margins of equal circumfer-
ence, (4) release of the attachments of the
lower lateral cartilage–accessory cartilage com-
plex from the lateral piriform rim to allow for
some anterior repositioning of the alar base
without accentuation of the nostril rim buckle
and lateral alar flare, and (5) anteromedial
advancement of the cleft-side lateral crus and
dome concurrent with (6) creation of the nor-
mal overlap of the caudal margin of the upper
lateral cartilage by the cranial margin of the
lateral crus. Dissection is not performed in the
tip of the nose. Dome approximation and def-
inition, and correction of the nasal septal and
pyramid deviations, will await formal secondary
open septorhinoplasty. The examples shown
will have had various combinations of the fol-
lowing as indicated by severity of the primary
deformity: presurgical nasoalveolar molding,11
alar base release, lateral piriform release, infe-
rior turbinate flap, internal nasal valve plica-
tion sutures, alar transfixion sutures, columellar
base–alar base cinch stitch, and postoperative
nasal stenting.
71
CONCLUSION
A technique of unilateral cleft lip repair is
described that allows for approximation of the
medial and lateral lip elements almost entirely
along the seams of anatomical subunits of the
lip and nose.
David M. Fisher, F.R.C.S.C., F.A.C.S.
555 University Avenue
The Hospital for Sick Children
Toronto, Ontario M5G 1X8, Canada
david.fisher@utoronto.ca
REFERENCES
1. Noordhoff, M. S. The Surgical Technique for the Unilateral
Cleft Lip-Nasal Deformity. Taipei: Noordhoff Craniofa-
cial Foundation, 1997.
2. Burget, G. C., and Menick, F. J. The subunit principle
in nasal reconstruction. Plast. Reconstr. Surg. 76: 239,
1985.
3. Blair, V. P., and Brown, J. B. Mirault operation for single
harelip. Surg. Gynaecol. Obstet. 15: 81, 1930.
4. Millard, D. R. Complete unilateral clefts of the lip. Plast.
Reconstr. Surg. 25: 595, 1960.
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