Cleft Lip and Palate Surgery

Atlas of Non-Desirable
Outcomes in Cleft Lip

and Palate Surgery
A Case-Based Guide
to Preventing and Managing
Complications
Percy Rossell-Perry
Editor
123
Atlas of Non-Desirable Outcomes in Cleft Lip
and Palate Surgery
Percy Rossell-Perry
Editor
Atlas of Non-Desirable
Outcomes in Cleft Lip
and Palate Surgery
A Case-Based Guide to Preventing
and Managing Complications
Editor
Percy Rossell-Perry
San Martin de Porres University of Lima
Lima, Peru
ISBN 978-3-030-98399-4 ISBN 978-3-030-98400-7 (eBook)

https://doi.org/10.1007/978-3-030-98400-7
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
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I wish to dedicate this book to my Lord Jesus
Christ who guides all my works.
To my supportive wife Patti and my parents
Blanca and Percy.
To my friend, Dr. William Carter, in gratitude
to his generous help as surgeon and
professor, giving their best for the benefit of
poor children of Peru.
To my professors, Drs. Daniel and Claudio
Kirschbaum, who made possible my
professional development in plastic surgery.
Finally, this book is dedicated to all my
patients and their parents who have taught
me a lot about love for others.
Foreword
Three types of surgeons exist who boast never having poor results or
complications:
1. Surgeons who do not operate
2. Practitioners who do not follow their patients
3. Frank liars
I pity this unfortunate group because they forsake a great opportunity to learn
and better treat future patients.
A book devoted to unfavorable results and complications as Dr. Rossell-Perry
has compiled contains a wealth of material related to the treatment of patients born
with clefts of the oral structures. Starting with anesthesia to the final treatment of
skeletal growth deficiencies, he covers the entire gamut of obstacles to ideal
outcomes.
Although no one welcomes poor results, I have always found the challenge of
correcting adverse unwelcomed outcomes an intellectual learning experience. They
stimulate thinking outside the box to devise and formulate a solution. By sharing his
vast experience, Dr. Rossell-Perry provides the reader an excellent platform to find
a solution.
More book on adverse outcomes need be written. The reader and mostly the
patients will be richly rewarded. My congratulation to Dr. Rossell-Perry for sharing
his enormous experience with us.
Henry K. Kawamoto Jr.

Clinical Professor, Emeritus
U.C.L.A. Division of Plastic Surgery
Los Angeles, CA, USA
vii
Preface
The Atlas of Non-desirable Outcomes in Cleft Lip and Palate Repair is my eighth
book and represents a lifetime dedication to this field supported by 25 years of expe-
rience and more than 3000 operated patients.
This book based on illustrative images of cleft lip and palate sequels after pri-
mary repair is a useful educational tool for any resident or surgeon with interest in
cleft surgery. Sequel prevention and used surgical techniques for secondary correc-
tion are well described and presented with long-term outcomes.
The evaluation of an operated patient with complication or bad outcome must
consider a careful identification of the etiology and associated events. Better under-
standing of the secondary deformity has resulted in an increase of successful repair
of these problems. At this point, I would refer to the words of Victor Veau, one of
the greatest contributors to cleft lip and palate surgery, who said: “I feel in a way,
inclined to brag about my mistakes, because if I am more advanced than my col-
leagues in something I owe it almost entirely to my failures.” Niels Bohr, Danish
scientist and Nobel laureate, defined an expert as “A person that has made every
possible mistake within his or her field.”
The election of a proper strategy (surgical technique) to address the cleft lip and
palate secondary deformities and surgeon’s skills and experience are equally impor-
tant. Appropriate supportive treatment must consider an interdisciplinary manage-
ment including orthodontic and speech therapy. Teamwork will achieve a more
consistent and satisfactory result.
The management of bad results and complications associated to the cleft lip and
palate surgery has evolved over a period of 25 years. Different surgical techniques
have been developed during this time. The double unilimb Z plasty for unilateral
whistler deformity and the conversion method for bilateral whistler deformity repair
are good examples. Their utility and efficacy have been evaluated and demonstrated
through different scientific researches developed by the author and published in
high-impact indexed journals. This book presents our work, based on the experience
of a group of experts in the management of complications and poor results observed
in operated cleft lip and palate patients.
ix
x Preface
I feel grateful for the life-changing experience I had during my international fel-
lowship at the Institute of Reconstructive Plastic Surgery at the New York University
and University of California Los Angeles under the direction of Dr. Joseph Mc
Carthy and Dr. Henry Kawamoto Jr., respectively.
I owe a special thanks to William Carter, MD, for his lessons during my first
years sharing surgical campaigns in Peru, and I am deeply grateful to my brother
Luis Rossell-Perry who did the beautiful illustrations in this book.
Lima, Peru Percy Rossell-Perry

Acknowledgments
I would like to express my gratitude to my brother Luis Rossell-Perry for his contri-
bution to the excellent illustrations in this book.
xi
Contents
1 Generalities�� 1
Percy Rossell-Perry
2 Anesthetic Complications�� 11
Percy Rossell-Perry and Mision Noriega-Ambulodegui
3 Cleft Lip Surgery Complications�� 27
Percy Rossell-Perry
4 Cleft Palate Surgery Complications �� 51
Percy Rossell-Perry
5 Other Complications�� 67
Percy Rossell-Perry
6 Bad Results in Unilateral Cleft Lip Surgery �� 85
Percy Rossell-Perry
7 Bad Results in Bilateral Cleft Lip Surgery�� 137
Percy Rossell-Perry
8 Bad Results in Cleft Palate Surgery �� 193
Percy Rossell-Perry
9 Dental Skeletal Bad Results in Cleft Lip and Palate Surgery�� 267
Carlos Estrada Vitorino, Rossell-Perry Percy,
and Omar Cotrina Rabanal
Index�� 307
xiii
Editors and Contributors
About the Editor
Percy Rossell-Perry, MD, PhD, FACS Born in

Lima, Perú, he studied human medicine at San Marcos
University of Lima, completing in 1993. Then, he
underwent plastic surgery training at Kirschbaum
Institute between 1993 and 1996 and at Militar Central
Hospital between 1996 and 1999 supported by San
Marcos University of Lima. He completed his visiting
scholar fellowship at Emori University in Atlanta in
2004 and at UCLA and New York University in 2006
(under Drs. Henry Kawamoto and Joseph Mc Carthy)
as winner of the Plastic Surgery Education Foundation
Scholarship 2005.
His teaching experience began in 1987 in the
Department of Human Anatomy, School of Human
Medicine, University of San Marcos, which continued
up to the year 2000. He has taught specialty courses at
the Universities of San Marcos and Cayetano Heredia
and through the Peruvian Society of Plastic Surgery.
Actually, he is a professor of postgraduate studies in
the Faculty of Human Medicine at San Martin de
Porres University in Lima, Peru.
Although involved in many aspects of plastic sur-
gery, his main activity now is centered around surgery
for patients with cleft lip and palate. Since 2016, Dr.
Percy Rossell-Perry has been assistant plastic surgeon
at Edgardo Rebagliatti Martins Hospital of ESSALUD
where he performs pediatric reconstructive plastic sur-
gery. He was a consultant plastic surgeon at the
xv
xvi Editors and Contributors
Casimiro Ulloa Hospital (2004–2008) and Cayetano

Heredia Hospital (2009). In addition, during the last
years, he has worked as a consultant plastic surgeon in
other hospitals of Lima, Peru, such as San Bartolome
Hospital of Lima, Alberto Sabogal and Guillermo
Almenara Hospitals of ESSALUD, and Naval Hospital
of Peru. In 2011, he obtained a master’s degree in
teaching university and a doctorate (PhD) in human
medicine from San Marcos University of Lima in
2014. He has also a diploma in clinical research from
Harvard University, USA.
Throughout his professional career, Dr. Percy
Rossell-Perry has been awarded many times. In 2002,
he was awarded with the KAELIN National Award for
scientific research from ESSALUD. Later, he received
the Humanitarian Award from the Interplast
Foundation, USA, in 2003. Then, in 2005, he won the
Plastic Surgery Educational Foundation Scholarship
granted by the Pierr Foundation of the USA. In Perú,
he received three times the Hipolito Unanue National
Award for the Best Scientific Edition in 2010, 2013,
and 2019 for the books Treatment of the Cleft Lip and
Palate, Basic management of chronic cutaneous
lesions based on scientific evidence, and Bad results
and complications in cleft lip and palate surgery.
He has written many books and scientific articles.
Dr. Percy Rossell-Perry is the main author of the fol-
lowing books: Cleft Lip and Palate Treatment (2009),
Unilateral Cleft Lip Surgery (2011), Basic manage-
ment of chronic cutaneous lesions based on scientific
evidence (2012), Bilateral Cleft Lip Surgery (2013),
Cleft Palate Surgery (2015), Bad Results and
Complications in Cleft Lip and Palate Surgery (2018),
and Atlas of Operative Techniques in Primary Cleft
Lip and Palate Repair (2020).
He has authored the following chapters: “Principles
of Cleft Palate repair in Global Cleft Care in Low-
Resource Settings” (Editors: David Low and Jordan
Swanson) and “Mucoperiosteal Necrosis after
Palatoplasty” in Surgical Atlas of Cleft Palate and
Palatal Fistulae textbook (Editor: Ghulam Fayyaz).
Since 2006, he has authored more than 50 scientific
articles published in indexed journals.
Dr. Percy Rossell-Perry is editorial board member
of the journal Plastic Reconstructive Surgery GO and
Journal of Craniofacial Surgery.
Editors and Contributors xvii
He is reviewer of the most important plastic sur-

gery journals of the world (such as Plastic
Reconstructive Surgery Journal, Aesthetic Plastic
Surgery Journal, Journal of Plastic Surgery and Hand
Surgery, and Journal of Craniofacial Surgery).
He is a well-known international lecturer and has
presented his experiences in countries such as Chile,
Brazil, Mexico, and the USA and has been elected as
a member of the scientific committee of the IX and X
International Cleft Lip and Palate Foundation
Congress (CLEFT 2009 in Brazil) and (2013 in USA).
Likewise, he was chair the Symposium “Cleft Surgery
in developing countries” during CLEFT 2013 in
Orlando, USA. He is a member of the Task Force for
the CLEFT 2022 in Edinburgh.
Dr. Percy Rossell-Perry was president of the Latin
American Craniofacial Association (LATICFA) dur-
ing 2018–2020. He is a fellow of American College of
Surgeons, and a member of the American Society of
Plastic Surgery and other international medical
associations.
Dr. Percy Rossell-Perry was medical director of the
Outreach Surgical Center Program Lima, a cleft pro-
gram supported by ReSurge International and Smile
Train foundations from the USA, which has been
attended by more than 3000 patients with clefts in
Peru and other countries for more than 25 years
since 1994.
Actually, he is scientific director of the Smile Train
South American Medical Advisory Council (SAMAC)
and member of the Smile Train Global Research and
Innovation Advisory Council (STRIAC).
Contributors
Percy Rossell-Perry, MD PhD San Martin de Porres University of Lima,

Lima, Peru
Mision Noriega-Ambulodegui, MD Departament of Anesthesiology, Guillermo
Almenara Irigoyen Hospital ESSALUD, Lima, Peru
Omar Cotrina Rabanal, DDS Department of Dental, ARMONIZAR Foundation,
Lima, Peru
Carlos Estrada Vitorino, DDS OMFS CIRMAX Institute, Lima, Perú
Chapter 1
Generalities
Percy Rossell-Perry
1.1 Introduction
The expected results of a surgical intervention cannot be guaranteed 100%. The

multifactorial nature of the human body’s response and related perioperative events
make it difficult to predict with certainty the evolution that a surgical act will follow.
From the surgical point of view, the most important factors associated with the qual-
ity of the outcomes are the surgeon, the surgical technique, and the characteristics
of the cleft lip and palate.
The surgeon is considered by different studies [1] as the most important factor
associated with quality of the surgical outcome. His performance depends on the
choice of an appropriate strategy to treat the problem (surgical technique) and its
proper execution. This is supported by his manual skill, training, and surgical expe-
rience (number of cases operated through his professional practice). His perfor-
mance is its lack of uniformity because the surgeon as a human being bases his
performance on his physical and mental condition, which is variable.
The surgical technique is defined as the selected strategy used to correct the
problem, and it is varied. Different surgical techniques have been described to treat
cleft lip and palate, and there is not a clear evidence of superiority of one over the
others. It can be assumed that the success of the method will depend on an adequate
choice and execution by the surgeon. There are few comparative studies of cheilo-
plasty techniques, and thus there is no consensus for one technique to be better than
another. In the author’s opinion, some techniques are more advantageous than oth-
ers [2]. Regarding cleft palate repair, there are many comparative studies (including
systematic reviews) which have not shown that one surgical protocol is better than
another today [3].
P. Rossell-Perry (*)
San Martin de Porres University of Lima, Lima, Peru
© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2022
P. Rossell-Perry (ed.), Atlas of Non-Desirable Outcomes in Cleft Lip and Palate
Surgery, https://doi.org/10.1007/978-3-030-98400-7_1
2 P. Rossell-Perry
The cleft lip and palate characteristics must be well considered in order to spec-
ify its severity and how it will be treated. A description of the severity of the defor-
mity is mandatory. Current cleft lip and palate classifications are many, and their use
lacks consensus. A frequent cause of bad outcomes is the use of a limited surgical
technique to correct a certain form or severity of the cleft. In addition, there are
additional factors as healing, nutritional status, immune response, and associated
pathologies. These may be responsible for poor results and complications even after
performing a surgical technique properly by a skilled surgeon.
Regarding complications, events or unexpected circumstances before, during, or
after the surgical act may affect the outcome. For example, during the surgery, one
of the most frequent events is the bleeding.
In relation to the anesthetic act, complications associated with the respiratory
system are the most important and most frequent to observe in patients with cleft lip
and palate [4]. Airway spasm is relatively common in children and may occur when
the patient is intubated or extubated as well as during the anesthesia. Accidents
related to the position of the endotracheal tube can be also observed, and it can suf-
fer torsions, compressions, or even involuntary extubation.
There are also the postoperative period complications. A deficient care of the oper-
ative wound, such as trauma due to handling the child or falls or bumps, is not uncom-
mon to be observed. Feeding-related events can be more serious. Aspiration of food
is the first cause of serious postoperative complication in this period, and it is associ-
ated with respiratory distress. According to the Smile Train database, postoperative
aspiration is the most frequent cause of “sentinel event” (serious complication).
1.2 Definitions
Bad results may be a consequence of complications (events that occur in the course
and evolution of a surgical and anesthetic act, different from the usual manifesta-
tions of this and associated with the injuries caused by it) [5]. Therefore, it may be
difficult to estimate whether an event is a complication or a bad result or if one is the
cause of the other. For example, the development of granulomas or hypertrophic
scars as a result of surgical incisions and stitches made during the cheiloplasty may
be estimated as a surgical complication.
At the same time, a problem can be a complication and bad result. Thus, dehis-
cence from cleft lip surgery is a complication when this is caused by an infection,
and it is also a bad result when it is produced by a lip closure under tension.
Sometimes, it is difficult to determine whether the non-desirable event is a compli-
cation or a bad outcome. For example, a hypertrophic scar contracture in the oper-
ated nose generating airway obstruction may be developed by a predisposition of
the patient to form it (complication); but it may be also due to a linear scar used by
the surgeon inside the nose. In this case, the event may be considered as a bad out-
come. Bad outcomes are usually observed as a result of a poor execution of the
1 Generalities 3
surgical technique or an inadequate postoperative care of the wound. The shortcom-

ings of the surgical technique or healing disorders of the patient’s tissues are limita-
tions that can lead to obtain bad outcomes despite an adequate execution of the
technique by the surgeon.
The bad result may be considered as the result of the following factors in the
formula:
Bad Outcome : Congenital Hypoplasia + Surgery + Growth Effect
In summary, the terms complication and bad outcome must be differentiated. So:
Complication
It is an event that occurs in the course of a surgical-anesthetic act different from the
usual manifestations of this and that is a consequence of the effects caused by it [5].
These events generally aggravate and lengthen postoperative recovery of the sur-
gery or may become a permanent sequelae or the death of the patient. They are not
very frequent but can occur despite the use of a surgical technique and appropriate
anesthetic.
Bad Outcome
It is an unwanted effect of an anesthetic surgical which does not achieve the objec-
tives set before surgery. Unlike the complication, it is often due to a deficiency in the
surgical-anesthetic procedure or to the inadequate performance by the professional
medical team. Factors attributable to the patient should not be the reason of a bad
outcome since the identification of patient’s condition before the procedure and
adequate planning can avoid such results.
At this time, differentiating what is considered a complication and what is a bad
outcome would seem like a byzantine discussion; however, clarifying this condition
becomes very important to determine the proper handling of the event.
Thus, non-desirable scarring generated by a predisposition of the patient to
develop it should be managed following a conservative protocol and would contra-
indicate surgery. Also a scar contracture developed by a bad positioned scar (bad
outcome) may require a surgical correction to improve the outcome.
This comes to be the most important application to consider to differentiate a
complication from a bad result. In addition, we have to consider this: the bad out-
come can be prevented but not all complications can be prevented.
1.3 Data
The author’s experience over 25 years is presented here describing a series of com-
plications and bad results observed in the treatment of cleft lip and palate surgery.
His first textbook published in 2009 [6] included 166 surgical and anesthetic com-
plications in 585 cleft lip patients (28.37%). The hypertrophic was the most fre-
quent surgical complication after cleft lip repair (44 patients). Regarding cleft palate
surgery, 95 surgical and anesthetic complications were observed (20.74%), the most
4 P. Rossell-Perry
common complication being vomiting in 19 patients and respiratory depression in

15 cases. Reoperative hemostasis was observed in six patients.
An observational study published by the author observed 5.54% of reoperative
hemostasis after primary cleft palate repair [7]. Another comparative study observed
a greater number of complications, and bad outcomes were observed in the patients
operated under the surgical mission model of care despite being operated on by the
same surgeon [8].
These outcomes may be explained by operating conditions such as weather, alti-
tude, technological issues, number of surgeries, and others [8].
In this study, 6.47% of cases of wound dehiscence were observed in cleft lip and
palate surgeries performed in a reference center. In addition, 1.5% of bleeding and
1.3% of wound infection were observed after cleft lip repair. Regarding cleft palate
repair, 2.3% of reoperative hemostasis was observed.
Other studies show similar outcomes with an increased rate of complications and
bad results associated with the surgical mission model of care [9, 10]. A study
developed by Schonmeyr et al. [11] in India observed that itinerant surgeons are a
risk factor for the development of postoperative complications.
In our performance as a reference center, the rate of unilateral cleft lip revision
was 10.1% and 21.6% for bilateral cleft lip. Regarding cleft palate surgery, we
observed 3.8% of palatal fistulas and 9.4% of velopharyngeal insufficiency [8].
The maxillary hypoplasia has been evaluated by our team through a randomized
clinical trial, and it was concluded that only 6.94% of patients had poor occlusion
(Atack’s 5-year scale grades 4 and 5) [12].
In a compilation of the primary surgeries performed by the author between 2001
and 2017 (including a total number of 1640 operated cases), the following bad out-
comes and complications were obtained (Figs. 1.1, 1.2, 1.3, 1.4, and 1.5).
Primary unilateral cleft lip nose repair major revisions: 45 (7.22%)
Primary bilateral cleft lip nose repair major revisions: 78 (19.40%)
Primary cleft palate repair revisions: 67 (10.89%)
1.4 Patient Evaluation
The first step in the interdisciplinary management of the cleft lip and palate second-
ary deformities is the physical exam and diagnosis of the sequel as well as the ade-
quate time for its correction. The involved area should be carefully examined both
in animation and at rest considering its anatomy in third dimension. Lip function
should be evaluated when asking the patient smiling and twitching the lips. The
palpation of the lip will allow to determine the characteristics of the lip scar.
Documentation of this information must be photographically recorded.
The most important aspects in lip evaluation to be considered are:
(a) Lip scar characteristics
(b) Symmetry of the upper lip
1 Generalities 5
250
200
150
100
50
0
Respiratory Airway Endotracheal Aspiration Anaphylaxis
depression spasm tube related syndrome 3 (0.12%)
155 (9.45%) 187 (11.4%) 216 (13.7%) 77 (4.69%)
Fig. 1.1 Anesthetic complications (n: 38/640 – 38.90%)
100
80
60
40
20
0
Postop Dehiscence Infection Hypertropic Queloid Granuloma
bleeding 5 (0.8%) 10 (1.60%) scar scar 21 (3.37%)
7 (1.12%) 93 (14.92%) 1 (0.16%)
Fig. 1.2 Bad results and complications in unilateral cleft lip repair (n: 183/623 – 29.37%)
6 P. Rossell-Perry
100
90
80
70
60
50
40
30
20
10
0
Postop Dehiscence Infection Hypertroph Granuloma Nasal Prolabial
bleeding 35 (10.43%) 5 (1.24%) scar 18 (4.47%) stenosis necrosis
10 (2.48%) 79 (19.65%) 29 (7.21%) 1 (0.24%)
Fig. 1.3 Bad results and complications in bilateral cleft lip repair (n: 207/402 – 51.49%)
100
90
80
70
60
50
40
30
20
10
0
Postop Dehiscence Infection Flap Fistulas VPI Maxillary
bleeding 21 (3.41%) 3 (0.48%) necrosis 22 (3.57%) 52 (8.45%) hypoplasia
28 (4.55%) 2 (0.32%) 45 (7.31%)
Fig. 1.4 Bad results and complications in cleft palate repair (n: 173/615 – 28.13%)
1 Generalities 7
800
700
600
500
400
300
200
100
0
Respiratory Hyperthermia Hypothermia Dingman Vomiting Diarrhea Acute Chronic Death
infection 723 (44.08%) 25 (1.52%) Open mouth 57 (3.47%) 10 (0.60%) Otitis Otitis 1 (0.06%)
315 (19.20%) related media media
310 (18.90%) 17 (1.03%) 322 (19.63%)
Fig. 1.5 Other complications associated with cleft lip and palate surgery (n: 1640)
(c) Labionasal muscle function

(d) Upper lip vermilion characteristics
(e) Shape of the cupid’s bow
(f) Symmetry of the philtral columns
(g) Continuity of the white and red roll
(h) Alterations of the labial sulcus
(i) Position of the premaxilla in bilateral cases
At the level of the reconstructed nose, it should be noted:
(a) Projection of the nasal tip
(b) Symmetry of the nose
(c) Nasal columella characteristics
(d) Symmetry and width of the nasal bases
(e) Vestibule of the nose characteristics
(f) Presence of scar contractures and synechiae
(g) Nasal septum characteristics
(h) Nasal valve function through nasometry
The palate evaluation must consider:
(a) Physical exam to evaluate the presence of fistulas and/or dehiscence
(b) Speech evaluation to determine velopharyngeal dysfunction and/or compensa-
tory articulations
(c) Complementary nasoendoscopy and fluoroscopy diagnostic evaluation
(d) Middle ear function evaluation
Dental skeletal evaluation should be estimated through the physical exam and
complementary studies as X-ray and 3D CT scan.
8 P. Rossell-Perry
The time at which the patient should be treated will depend on many factors such
as the age of the patient and severity of the sequel considering the aesthetic impact
and functional nature of this and its psychosocial implications.
Scar revision after the age of 5 is associated with increased rate of hypertrophic
scar, and any revision after this age should be carefully considered and discussed
with the parents.
It has already been established that it seeks to give aesthetic and functional at
early age allowing a comprehensive rehabilitation of the patient with emphasis on
their integration into the society. The diagnostic must be specified in degrees of
severity and diagrammed in the patient’s medical record so then can be used to esti-
mate the evolution of the treatment provided.
The time when the patient should be treated depends on the following factors:
(a) Impact of anesthesia
(b) Functional nature of the deformity
(c) Severity of the aesthetic deformity
(d) Psychological impact of the deformity and surgery
(e) Impact of the surgery on facial growth
(f) Potential complications associated with the secondary treatment
An individual assessment should be made in which the aesthetic consequences
should not be minimized compared to functional ones due to their psychologi-
cal impact.
I like to correct aesthetic and functional defects early to prevent psychological
problems, in special during school period. This is in contrast to traditional schemes
that recommend waiting for maturity of the patient to treat these sequels. Therefore,
there is not a consensus regarding an optimal age to correct these non-desirable
outcomes.
References
1. Ozawa T, Dutka J, Garib D, Lauris R, et al. Influence of surgical technique and timing of pri-
mary repair on interarch relationship in UCLP: a randomized clinical trial. Orthod Craniofac
Res. 2020;24(2):288–95.
2. Rossell-Perry P. A 20-year experience in unilateral cleft lip repair: from Millard to the triple
unilimb Z-plasty technique. Indian J Plast Surg. 2016;49(3):340–9.
3. Rossell-Perry P. New diagram for cleft lip and palate description: the clock diagram. Cleft
Palate Craniofac J. 2009;46(3):305–13.
4. Desalu I, Adeyemo W, Akintimoye M, Adepoju A. Airway and respiratory complication in
children undergoing cleft lip and palate repair. Ghana Med J. 2010;44(1):16–20.
5. Sokol DK, Wilson J. What is a surgical complication? World J Surg. 2008;32(6):942–4.
6. Rossell-Perry P, editor. Tratamiento de la fisura labio palatina. Lima: Universidad San
Marcos; 2009.
7. Rossell-Perry P, Schneider WJ, Gavino-Gutiérrez AM. A comparative study to evaluate a sim-
ple method for the management of postoperative bleeding following palatoplasty. Arch Plast
Surg. 2013;40(3):263–6.
1 Generalities 9
8. Rossell-Perry P, Segura E, Salas-Bustinza L, Cotrina-Rabanal O. Comparison of two models

of surgical care for patients with cleft lip and palate in resource challenged settings. World J
Surg. 2015;39(1):54.
9. Roldán J, Pape H, Koch H, Koller M. Ten year cleft surgery in Nepal: achievements and les-
sons learned for better cleft care abroad. Plast Reconstr Surg Glob Open. 2016;4(5):e711.
10. Maine RG, Hoffman WY, Palacios-Martínez JH, et al. Comparison of fistula rates after pala-
toplasty for international and local surgeons on surgical missions in Ecuador with rates at a
craniofacial center in the United States. Plast Reconstr Surg. 2012;129:319e–26e.
11. Schonmeyr B, Wendby L, Campbell A. Surgical complications in 1408 primary cleft pal-
ate repairs operated at a single center in Gwahati Assam India. Cleft Palate Craniofac
J. 2016;53(3):278–82.
12. Rossell-Perry P, Cotrina-Rabanal O, Figallo-Hudtwalcker O, Gonzalez-Vereau A. Effect of
relaxing incisions on the maxillary growth after primary unilateral cleft palate repair in mild and
moderate cases: a randomized clinical trial. Plast Reconstr Surg Glob Open. 2017;5(1):e1201.
Chapter 2
Anesthetic Complications
Percy Rossell-Perry and Mision Noriega-Ambulodegui
2.1 Introduction
Unexpected outcomes are associated with any surgical intervention even when a
surgery is performed successfully. A complication is considered as an unexpected
event that occurs in the course of a surgical act different from the usual manifesta-
tions of this and that is a consequence of the effects caused by it. A number of peri-
operative events cannot be totally prevented by the surgeon, and only an adequate
follow-up of the operated patients may guarantee their diagnostic and proper
management.
Common complications observed in association with cleft lip and palate surgery
are respiratory depression, airway obstruction, aspiration syndrome, respiratory
infections, wound infection, dehiscence and bleeding, hypertrophic scars, and oth-
ers. Early diagnostic and intervention is the key point for the successful handling of
these problems.
This chapter presents the most common complications associated with the cleft
lip and palate surgery and their diagnostic and interdisciplinary management.
Cleft lip and palate patients have a higher risk of anesthetic complications in
comparison with normal population [1, 2] due to the characteristics of the congeni-
tal airway deformity [3]. These patients have a special condition that must be taken
into account in the planning of the anesthetic act. In addition, the possible existence
of associated malformations (cardiac, neurological, and others) further complicates
M. Noriega-Ambulodegui
Departament of Anesthesiology, Guillermo Almenara Irigoyen Hospital ESSALUD,
Lima, Peru

Switzerland AG 2022
12 P. Rossell-Perry and M. Noriega-Ambulodegui
the scenario and requires a careful preoperative evaluation. Therefore, the preopera-
tive evaluation should consider:
• Previous surgeries and anesthesia: type, complications, etc.
• Recent respiratory infections and their treatment
• Chronic respiratory conditions, such as asthma or others, ruling out associated
congenital problems
• Child’s development measured through the growth curves
• Information about nutritional status and its possible disorders (acute or chronic
malnutrition)
• Associated conditions such as heart disease, allergies, etc.
• Family history of prolonged paralysis, sudden death, malignant hyperthermia,
genetic diseases, medical disorders, allergic reactions, and drug addiction
Airway problems in patients with cleft lip and palate are frequent and have been
described by different authors [3–5]. A study conducted in Nigeria observed respi-
ratory complications in about 40% of the studied patients [6]. McQueen in another
study reported 31% of these complications [7]. Other studies reported 4–8% of
major complications [8, 9].
The most common respiratory complications related to cleft lip and palate repair
anesthesia are endotracheal tube-related problems, respiratory depression, airway
spasm, and aspiration.
2.2 Endotracheal-Related Complications
Endotracheal intubation is difficult to be performed in cleft lip and palate intubation

and requires experience to achieve it successfully [3, 4]. The use of laryngeal mask
was also described although it seems to be more indicated in syndromic cases in
which intubation is extremely difficult (i.e., Robin sequence). However, Bordet [10]
described an increased rate of complications using laryngeal mask in cleft lip and
palate patients.
A study published by Arteu-Gauthier et al. concluded that the Robin sequence
has a higher risk of difficult intubation; in addition, it was observed that a history of
feeding problems and the width of the cleft palate are predictors of difficult intuba-
tion in these patients [11]. The Cormack-Lehane scale is used to evaluate the degree
of visibility of the larynx; thus, the lower laryngeal visibility (degrees III and IV of
this scale) and early age have a greater probability of having difficulty in intuba-
tion [12].
Fiber-optic support may be necessary to perform intubation under direct vision
[13, 14] (Fig. 2.1).
Complications such as failed intubation, disconnection, and accidental extuba-
tion of the endotracheal tube can be observed in a range of 2–10% [15–17]. These
complications seem to be more associated with cleft palate surgery because of the
use of instruments as the Dingman mouth opener [15, 18]. This instrument fre-
quently compresses the tubes with the tongue depressor (Fig. 2.2). Sometimes, it is
2 Anesthetic Complications 13
a b
Fig. 2.1 The use of fiber optics allows endotracheal intubation under direct vision of the patient
(a) Image view to illustrate intubation using scope support. (b) Image of the intubation under
direct vision
Fig. 2.2 The image shows

the site of compression of
the endotracheal tube
below the tongue depressor
necessary to fix the endotracheal tube laterally at the level of the oral commissure to
prevent this.
These anesthetic complications observed during palatal surgery can easily be
detected through vital function monitoring and capnography which allows its rapid
correction without further compromising the patient’s condition. The neck exten-
sion during cleft palate surgery can also cause displacement of the endotracheal tube.
The failed and repeated intubation attempt are associated with respiratory com-
plications as development of pneumonia or even pneumothorax [19].
Case 1
A 2-year-old patient with antecedent of unilateral cleft lip and palate scheduled for
palatal fistula closure in Huaraz, Peru. Preoperatory exams in normal ranges.
After monitoring with EKG, non-invasive blood pressure, and pulse oximetry,
the patient was induced with sevoflurane without neuromuscular relaxant and intu-
bated using number 4.5 endotracheal tube without cuff and positioned 12 cm from
the oral commissure.
After auscultation, the endotracheal tube was confirmed in good position.

Capnography was not available. All the time ventilation was spontaneous and
assisted with the Mapleson Reis system.
Forty-five minutes after the surgery started, the oxygen saturation drops from 98
to 91% (FiO2 100%). The vesicular murmur was good and a slight stridor was
heard. Bag movements of the ventilation system and bag-assisted chest movements
were suitable.
The surgeon observed an air leak and gurgling from the operative field; therefore,
the surgery stopped, and then the anesthesiologist decided to perform a direct laryn-
goscopy and evidenced that the endotracheal tube had been displaced outside the
glottis.
The tube was removed and the patient was re-intubated continuing with the sur-
gery and finishing it without inconvenience. The patient evolved without
complications.
Diagnostic: Endotracheal tube extubation.
Prevention: Constant review of the position of the endotracheal tube is recom-
mended during surgery since the surgeon’s movements and head position change
during surgery and can extubate the patient accidentally.
Case 2
A 5-month-old patient with unilateral cleft lip and palate scheduled for primary
cheiloplasty in Chimbote, Peru. Preoperatory exams in normal range.
There was not any contraindication for the anesthesya after preoperative evalua-
tion. Anesthetic act starts monitoring with EKG, non-invasive blood pressure, and
pulse oximetry, the patient then was induced with sevoflurane and propofol without
neuromuscular relaxant. The patient was intubated using a 4.0 endotracheal tube
without cuff and positioned 10 cm from the oral commissure. Auscultation of both
lung fields was uniform.
Ventilation was assisted with the Mapleson Reis system. Around 20 minutes
after the surgery started, the saturation drops to 89% with FiO2 100%. The anesthe-
siologist evidenced that the endotracheal tube was displaced 12 cm from the oral
commissure.
The tube was positioned correctly, and an alveolar recruitment was made using
the ventilation bag. The saturation improves to 91–92% and the surgery continued.
After the surgery, an X-ray showed left lung atelectasis.
The patient was admitted to the ICU unit and was discharged the next day in
good condition. Intraoperative atelectasis may be associated with endotracheal tube
cuff herniation, inadvertent endobronchial intubation, or significant obstruction
from secretions or blood in the endotracheal tube.
Diagnostic: Lung atelectasis associated with inadvertent endobronchial intuba-
tion during inhalatory general anesthesia procedure.
Prevention: Securing of the patient’s head and endotracheal tube position pre-
venting unwanted movements during surgery may prevent any displacement of the
tube position. A proper confirmation of the depth of the endotracheal tube is
mandatory.
2.3 Respiratory Depression
It can be estimated as the condition in which the oxygen saturation measured by

oximetry is below 80% [4]. In a study published by Wood in 39 patients, they
observed that 42% of studied patients had episodes of hypoxemia (less than 92% of
saturation) within 48 hours postoperatively. This observation may be explained by
the respiratory pattern of the cleft patients, which is predominantly oral unlike that
of non-cleft children in whom the pattern is nasal [20]. A study done by Hairfield
et al. [21] showed that 68% of the studied cleft patients had an oral respiratory pat-
tern. Hence, the cleft lip closure may generate some degree of respiratory difficulty,
a fact that has been described by some authors [22, 23]. This difficulty is associated
with the reduction of the airway when the lip is repaired. It is not severe and is cor-
rected spontaneously after a period of compensation.
Respiratory depression as a complication has another etiology and requires
urgent attention due to its severity and prognosis. This complication may occur in
any of the different stages of the anesthetic act: induction, intubation, extubation,
and recovery. Diagnosis is made through the physical exam and anesthetic monitor-
ing; the respiratory pattern can be decreased in frequency and amplitude. Increased
heart rate may be associated with compensatory mechanism; however, there may be
cardiac depression in severe cases.
The oxygen saturation value below 80% confirms the diagnosis. Respiratory
depression during the anesthetic act is usually diagnosed and effectively treated by
the anesthesiologist because the patient is under intubation and monitoring. This
complication is of higher risk when it occurs during the recovery process.
Thus, the proper implementation of the recovery room and a trained professional
team care is essential for the management of this complication. Some of the used
drugs during maintenance of anesthesia and analgesia (such as benzodiazepines and
opioids) may have this effect on the patient during the recovery time despite the
short duration of its effects.
Respiratory depression due to opioid use was observed in 3/97 patients by Fillies
et al. [19] with respiratory arrest in 1 case.
The management of the internal environment is also important due to the acido-
sis associated with hypoxemia. Anemia from significant blood loss during the sur-
gery is not a cause of respiratory depression, but it may worsen the evolution of this
complication.
In cleft palate surgeries with excessive bleeding, the use of blood transfusion
may be necessary to improve breathing condition.
The management of respiratory depression is based on the administration of oxy-
gen therapy and the identification of the etiology which is usually obstructive (air-
way spasm) or drug related (pharmacological). The use of EV bicarbonate is also
indicated to treat metabolic acidosis associated with hypoxemia.
Basic management to treat respiratory depression also consist of placing the
patient in lateral decubitus, as well as properly positioning of the head and jaw to
deliver oxygen through a Venturi mask. The lateral decubitus position during the
immediate postoperative period prevents aspiration of blood and gastric contents,

and access to opioid antagonist drugs, such as naloxone, should be considered as
part of the basic stock of drugs when opioid drugs have been used during postopera-
tive period.
There are reported cases of fatal outcome in patients treated with opioids as post-
operative analgesic due to respiratory depression. Similar effects may be observed
using benzodiazepines in the postoperative recovery period when there is not an
adequate postoperative monitoring.
Respiratory depression refractory to the basic treatment requires ventilatory
assistance in pediatric intensive care units; It is important to have an effective sys-
tem of access to this type of medical assistance in a timely manner.
Case 3
A 6-month-old patient operated on for cleft lip repair without incident during the
surgical act was received in PACU. Intraoperatively, the anesthesiologist used fen-
tanyl 15mcg and sevoflurane for induction and lysine clonixinate 80 mg for postop-
erative analgesia.
At the PACU, the pediatrician indicated 0.5 mg of midazolam. After 20 minutes,
the nurse communicates that the patient is cyanotic. The patient was returned to the
surgical room and was re-intubated for being depressed and hypoventilating; after
30 minutes, the patient recovered and went back to the recovery room.
After reviewing the medication given in PACU, it was verified that there were
10 cc ampoules of 50 mg of midazolam and 2.5 mg of midazolam was given by
mistake causing respiratory depression in the patient.
Incidents in which a wrong drug was administered involve ampoules and
syringes.
The most common error is giving the wrong drug from a correctly labelled
syringe as in the presented case. The main causes of error were similar appearance,
inattention, and haste.
Diagnostic: Postoperatory drug-associated respiratory depression.
Prevention: Proper team communication and rechecking of the syringe and drug
ampoule before administration of the drug may prevent this event. In addition, the
use of standardized drug storage and checking protocols are recommended.
Case 4
A 3-month-old patient was scheduled for cleft lip repair. Preoperative evaluation did
not observe any contraindication for surgery and anesthesia. Only sevoflurane was
used for induction and maintenance at 3%. The patient was intubated on first attempt
using 3.5 endotracheal tube without cuff. During surgery, the anesthesiologist admin-
istered fentanyl 15 mcg and finally metamizole (30 mg/kg) as postoperative analgesia.
The child is extubated awake and goes to recovery in good condition saturating
98%. Thirty minutes after, the nurse detects that the child is cyanotic, unresponsive
with the head flexed and there was no pulse. The team started pediatric advanced
resuscitation maneuvers. More than 100 compressions per minute were performed,
and the child was intubated in less than 10 seconds. A dose of epinephrine 0.01 mg/
kg was administered and continued with compressions; after 3 minutes, the patient
comes out of cardiac arrest and was received in the pediatric ICU.
The etiology of this complication remains unclear; however, it could be pre-
sumed that the cause of the cardiorespiratory arrest was the residual effect of opi-
oids and airway obstruction by the fall of the tongue in the flexed position of the
head in the care of the mother.
Diagnostic: Probably drug-associated respiratory depression.
Prevention: Postoperatory monitoring in PACU under staff supervision and well-
implemented devices is mandatory after the surgical anesthetic act to prevent any
fatal event that may occur.
2.4 Airway Obstruction
This anesthetic complication is mainly due to airway reactivity (spasm), a common

condition in children and in cleft lip and palate patients [3, 4].
Other causes of airway obstruction are aspiration of food, anaphylaxis, or pres-
ence of foreign body (gauze, secretions). The most common cause of airway
obstruction during anesthesia is laryngospasm. Most of them are self-limited, but if
they persist, they have a high morbidity and mortality; hence, its early detection and
treatment is of importance.
The incidence of laryngospasm and bronchospasm can represent up to 40% of
the complications in pediatric anesthesia [24, 25]. It is known that they are more
frequent in the post-induction and post-extubation period as well as are more associ-
ated with the use of inhalatory induction in comparison to intravenous induction due
to the irritating effect of anesthetic gases. The presence of respiratory infections
increases the reactivity of the airway and the possibility of spasm [26]. Patients with
mild or incipient respiratory processes who undergo general anesthesia with endo-
tracheal intubation have a higher chance of developing respiratory complications
compared to healthy children [27].
The treatment is symptomatic and based on ventilatory support with oxygen and
use of anti-inflammatory drugs. In addition, secretions should be removed and stim-
ulate the trigger point of interruption of the spasm (bimanual retroauricular pres-
sure) and endotracheal intubation. If this is not possible, the tracheostomy may be
considered.
A clinical trial done by Kundra et al. in 2008 concluded that wearing a laryngeal
mask decreased the possibility of laryngospasm compared to endotracheal intuba-
tion [28].
Case 5
A 6-month-old female patient scheduled for primary closure of bilateral cleft lip.
Preoperatory evaluation was completed without obvious alterations. After finishing
the surgery without problems, the patient was extubated asleep. One minute after,
the saturation progressively decreases to 80% with FiO2 100%, and expiratory stri-
dor is perceived.
Positive pressure ventilation was used which included vaporizer at 8%, and
10 mg of propofol was administered. Despite this, the saturation continues to drop,
and a cardiac arrest was developed. Epinephrine 0.01 mg/kg was administered,
chest compressions were started at 100 per minute, and positive pressure ventilation
was continued. On auscultation, there were a silent chest and few wheezing. A
direct laryngoscopy examination was performed, and a gauze dressing was observed.
The foreign body was removed using a Magill forceps.
All vital signs were normalized. Upon auscultation, the wheezing and rales dis-
appear, and the child went to the recovery room.
Diagnostic: Airway obstruction by a gauze and cardiac arrest.
Prevention: Proper team communication and checking protocols are recom-
mended. Registration of the “pack in” and “pack out” events by the circulant nurse
is important to prevent this common complication. A long visible stitch may be
applied to the gauze used inside the mouth avoiding its forgetfulness after surgery.
Case 6
A 17-year-old male patient scheduled for cleft lip revision. History of asthma, his
last episode 3 months ago. Use the inhaler occasionally.
During the anesthetic act, the induction was made with propofol 120 mg, fen-
tanyl 150 mcg, and distensil 50 mg. Monitoring with EKG, NIBP and pulse oxim-
etry was performed.
After intubation, lung fields are auscultated and no vesicular murmur can be
heard. Despite increasing positive pressure, the thoracic expansion was poor, and
this complication was diagnosed as severe bronchospasm. Therefore, hydrocorti-
sone 500 mg and dexamethasone 8 mg were administered, and the anesthetic level
was increased with sevoflurane. Then, 150 mg of aminophylline and an additional
dose of muscular relaxant (vecuronium) 4 mg plus a dose of ketamine 50 mg
were used.
Ventilation didn’t improve; the saturation drops to 85% with FiO2 100%. Under
this situation, adrenaline was administered. Forty minutes after, his breathing pat-
tern improves, and the team decided not to continue with the surgical intervention.
The patient went to the PACU and was discharged the next day.
Diagnostic: Airway obstruction due to severe bronchospasm associated
with asthma.
Prevention: Asthma is a frequent underdiagnosed condition with a higher preva-
lence and incidence in the population. The US National Asthma Education and
Prevention Program recommends that the level of asthma control, used medication
during the past 6 months, and pulmonary function be reviewed before surgery.
Uncontrolled asthma is considered to be the main risk factor for bronchoconstric-
tion during surgery [29].
2.5 Aspiration Syndrome
This complication represents the most common cause of sentinel event (serious
complication associated with the anesthetic-surgical act in patients with cleft lip and
palate) according to the Smile Train Foundation database [30]. Food aspiration
pneumonia has been reported in up to 35% [31]. This occurs mainly postoperatively
often related to aspiration or vomiting of food or gastric content. Therefore, the time
when feeding is provided and the form it is administered play an important role.
The patient can start oral feeding 2 to 3 hours after finished the anesthesia. This
rule is subject to individual considerations made by the anesthesiologist in relation
to the duration of the surgery and the doses of used drugs. I like to recommend the
use of teaspoon or a feeding bottle. Special care must be taken with the use of
syringes which can cause aspiration if they are not used properly. Breastfeeding is
another option; a published systematic review has shown no problems related to
breastfeeding [31]. The development of aspiration pneumonia with the use of iodin-
ated solutions has also been described in cleft palate surgery [32]. The diagnosis of
this complication is usually made through the associated hypoxemia and suspected
foreign body or presence of blood or gastric contents. Stridor, hissing, and crackles
to auscultation may be associated. The compromise of the basal area of the right
lung is suggestive; however, a veiling of both lung fields can be observed when
severe respiratory distress has been installed [33].
The management of this complication requires positioning the patient in lateral
decubitus, decreasing the rate of aspiration, suction of gastric contents and oral cav-
ity as well as ensuring that the airway is permeable and adequately hydration of the
patient parenterally until tolerate the oral route. Oxygen therapy is administered,
and corticosteroids are used to control the associated inflammatory condition and
laryngeal spasm. Complimentary antibiotic treatment is necessary because these
conditions are often complicated by pneumonia and pneumonitis [34].
Case 8
A 1-year and 8-month-old patient scheduled for primary cleft lip and palate repair.
After a surgical act without incidents, the patient was extubated and moved to
PACU. Thirty minutes later, the patient presented significant bleeding. After surgeon
evaluation, the patient is returned to the surgical room for reoperative hemostasis.
The child was intubated after three attempts due to poor visualization, and the
monitor shows 92% of saturation with FiO2 100%, NIBP 65/40 mmHg, and hear
rate 168 per minute. Disseminate rales and wheezing were evidenced after lung
auscultation.
After control of the bleeding, an X-ray reveals infiltrates in both lung fields com-
patible with aspiration. The patient is managed at the ICU and treated with antibiot-
ics and anti-inflammatory drugs and is discharged at the third day.
Diagnostic: Aspiration syndrome.
Prevention: Preoperatory patient’s evaluation is important in order to detect any
clotting disorder. A careful hemostasis during cleft palate repair is the most impor-
tant factor to be considered in the prevention of postoperative bleeding and potential
aspiration syndrome. Any aspiration of blood during surgery may be estimated by
the anesthesiologist in order to prevent related complications. Patients after cleft
palate surgery should not be discharged the same day of the surgery to monitor the
patient and promptly address complications like this.
2.6 Respiratory Infections
The factors that favor the development of respiratory infections are age, malnutri-
tion, bronchial hyper-responsiveness, and immunosuppression [35]. The most fre-
quent are the upper respiratory infections observed in 40% of the affected patients
followed by lower respiratory infections (25%) [35]. Another study observed 0.7%
of patients complicated with upper respiratory infection and 0.4% with broncho-
pneumonia [18].
These complications require hospital management and may be associated with
other complications as pneumothorax [35].
Respiratory infections associated with inhalatory general anesthesia are due to
handling of the upper airway, alteration of the physiological reflexes, hypothermia,
difficult intubation, and re-intubation inflammatory process generated by the surgi-
cal act and drugs. The use of prophylactic antibiotics is recommended in these cases
[36]. Special attention must be paid to the presence of acute respiratory infections
and the indication for surgical-anesthetic act. These disorders are frequent (it is
estimated that a normal child has three to eight episodes per year with a resolution
period of bronchial hyper-responsiveness of 6 to 8 weeks) [37].
Given the elective nature of cleft lip and palate surgery and the risk of potential
complications associated with the use of inhalatory general anesthesia, it is recom-
mended to postpone the operation.
2.7 Other Anesthetic Complications
There are other complications associated with the anesthetic act which are less fre-
quent to observe. These are:
Anaphylaxis. It can occur in response to any drug administered by the team dur-
ing the anesthetic-surgical procedure or in the postoperative time. Its occurrence has
been reported on 1 every 5000 to 10,000 anesthesia [38]. Around 60% of these
patients are allergic, and the observed mortality rate is 3–9% [39]. Symptomatic
management is required to stabilize and control the hypersensitive response of the
patient. Use of adrenaline and EV fluids as well as corticosteroids is
recommended.
Pneumothorax. It is another infrequent complication. Cases of pneumothorax
have been reported during general anesthesia in patients with acute respiratory
infections non-diagnosed before the surgery [35]. The accumulation of secretions
due to the inflammatory process can lead to the development of areas of atelectasis
with pneumothorax and severe respiratory failure. Mechanical ventilation may cre-
ate increased insufflation and barotrauma with the consequent rupture and air leak-
age generating the pneumothorax.
This usually occurs during the surgical act after intubation and is character-
ized with low oxygen saturation. During physical exam, there are absence of
breath sounds on the affected side and wheezing on the contralateral side. The
diagnostic is confirmed through the thoracic puncture, the appearance of bubbles,
and the improvement in oxygen saturation after treatment. Aspiration of the
secretions from the airway, and a chest drain with a water seal is recommended
as treatment.
An X-ray will determine the magnitude of the problem and as a reference for the
evolution of the complication.
Subcutaneous emphysema. It has been observed associated with cleft lip sur-
gery [40].
This is usually located on the face, neck, and upper thorax. On examination, this
is characterized by subcutaneous crepitus. The complication is produced by injury
of the respiratory or gastrointestinal tract associated with the endotracheal intuba-
tion or barotrauma generated by manual or mechanical ventilation.
When produced in small amount, it does not require treatment, and it is usually
reabsorbed during the first 48 hours. In severe cases, when there are discomfort and
respiratory distress, it is necessary to remove the air using catheters or surgical
incisions.
Cognitive disorders. This complication is characterized by affecting higher neu-
rological functions with long-term manifestations. Even though the scientific evi-
dence is not enough actually to establish an association between this complication
and the use of general anesthesia in children, it may be underdiagnosed.
Some preliminary studies are suggesting the appearance of long-term cognitive
disorders in children undergoing surgical procedures with general anesthesia
according to the study published by Ing et al. in Pediatrics in 2012 [41]. This study
suggests that the development of problems in receptive language (comprehension,
reasoning, and use of language) and cognition in children undergoing general anes-
thesia at an early age.
A recent cohort study published by Clausen et al. could not observe an associa-
tion between the application of general anesthesia in cleft lip and palate surgery and
the academic performance of patients in their adolescence [42].
At the moment, it is advisable in a preventive way to reduce surgical times and

the duration of anesthesia and surgeries.
Malignant hyperthermia. It is another rare complication that is due to a genetic
disorder of the chromosome 19, triggered by anesthesia, and characterized as a
hypermetabolism crisis.
Its incidence ranges from 1:10000 to 1:50000 anesthetic procedures [43].
The treatment is using dantrolene sodium which has reduced mortality by
80–90% [44]. This complication presents the following characteristics: muscle stiff-
ness, increased temperature after anesthesia (greater than 40 degrees), elevated lev-
els of CO2 (a sensitive sign), tachycardia, arrhythmia, lactic and respiratory acidosis,
hyperkalemia, and muscular pain [43]. Prevention is important identifying the
patient by family history.
A complementary treatment of the complication is the administration of anes-
thetics and hyperventilation of the patient. Then, cold solutions should be adminis-
tered by different ways to control temperature. Additionally, the treatment of the
electrolyte disorder and the metabolic acidosis is required [45].
Ramasamy et al. published a case of a 10-year-old boy who underwent general
anesthesia for alveolar bone graft who developed malignant hyperthermia [46], In
this case, the problem was diagnosed early, and dantrolene was used with a favor-
able evolution of the patient.
Dempsey et al. published another case in 1978. It was a 6-month-old boy with
cleft lip who had surgery with general anesthesia who developed this complication
and with timely management evolved favorably [47].
Pediatric emergence delirium. It is defined as the mental state of psychomotor
agitation characterized by altered consciousness and behavior during the postopera-
tive time after general anesthesia in children [48]. It is common and appears to
affect up to 70% of children who have received general anesthesia. The complica-
tion has been described in association with cleft palate surgery [49, 50].
This complication is manifested by confusion, psychomotor agitation, crying,
anxiety, irritability, inability to recognize the surrounding environment, uncoopera-
tive behavior, enuresis, and nightmares [51]. Described associated factors are inha-
latory anesthesia, rapid awakening, preoperative anxiety, and use of some drugs as
anticholinergics and naloxone [52]. For prevention or once the condition has been
triggered, the use of sedatives is indicated. Midazolam is one of the most used
(0.1 mg/kg) [53].
Complications associated with venous cannulation. It is relatively frequent to
observe in patients with certain characteristics, such as female, malnourished
patients, dehydration, premature, prolonged fasting, thick fat pad, and anatomical
variants of their peripheral venous system. This problem is related to a series of
another complications as follows: bruising, ecchymosis, phlebitis, cellulitis, and
suspension of the surgical act. Technology has provided useful instruments to han-
dle these situations which allows to visualize the location of venous vessels [54]
(Fig. 2.3).
Fig. 2.3 Use of

transillumination
technology for the
localization of peripheral
veins
References
1. Von Ungern-Sternberg B, Boda K, Chambers N, Rebmann C, et al. Risk assessment for

respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet.
2010;376:773–83.
2. Mamie C, Habre W, Delhumeau C, Argiroff C, Morabia A. Incidence and risk factors of peri-
operative respiratory adverse events in children undergoing elective surgery. Paediatr Anaesth.
2004;14:218–24.
3. Kulkarni KR, Patil MR, Shirke AM, Jadhav SB. Perioperative respiratory complications
in cleft lip and palate repairs: an audit of 1000 cases under «Smile Train Project». Indian J
Anaesth. 2013;57(6):562–8.
4. Law R, De Klerk C. Anesthesia for cleft lip and palate surgery. Updat Anesth. 2002;14:27–30.
5. Takemura H, Yasumoto K, Toi T, Hosoyamada A. Correlation of cleft type with incidence of
perioperative respiratory complications in infants with cleft lip and palate. Paediatr Anaesth.
2002;12:585–8.
6. Desalu I, Adeyemo W, Akintimoye M, Adepoju A. Airway and respiratory complications in
children undergoing cleft lip and palate repair. Ghana Med J. 2010;44(1):16–20.
7. McQueen K, Magee W, Crabtree T, Romano C, Burkle F. Application of outcome measures in
international humanitarian aid: comparing indices through retrospective analysis of corrective
surgical care cases. Prehosp Disaster Med. 2009;24:39–46.
8. Sandberg D, Magee W, Denk M. Neonatal cleft lip and cleft palate repair. AORN
J. 2002;75:490–8.
9. Adhikari M, Mukherjee P, Mukherjee P. Anesthetic management of cleft lip and palate. Indian
Pediatr. 1992;29(3):337–41.
10. Bordet F, Allaouchiche B, Lansiaux S, et al. Risk factors for airway complications during
general anaesthesia in paediatric patients. Pediatr Anesth. 2002;12:762–9.
11. Arteau-Gauthier I, Leclerc J, Godbout A. Can we predict a difficult intubation in cleft lip/pal-
ate patients? J Otolaryngol Head Neck Surg. 2011;40(5):413–9.
12. Gunawardana R. Difficult laryngoscopy in cleft lip and palate surgery. Br J Anaesth.
1996;76:757–9.
13. Griesdale D, Liu D, McKinney J, Choi P. Glidescope video laryngoscopy vs direct laryn-
goscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth.
2012;59(1):41–52.
14. Frei F, Wengen D, Rutishauser M, Ummenhofer W. The airway endoscopic mask: useful
device for fibreoptic evaluation and intubation of the paediatric airway. Paediatr Anaesth.
1995;5:319–24.
15. Xue FS, Zhang GH, Li P, et al. The clinical observation of difficult laryngoscopy and difficult
intubation in infants with cleft lip and palate. Pediatr Anesth. 2006;16:283–9.
16. Tay C, Tan G. Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in
Singapore. Pediatr Aesth. 2001;11:711–8.
17. Kwari DY, Chinda JY, Olasoji HO, Adeosun OO. Cleft lip and palate surgery in children:
Anaesthetic considerations. Afr J Paediatr Surg. 2010;7:174–7.
18. Kalpana R, Mohan R, Abasaheb M, Shivaji B. Perioperative respiratory complications in cleft
lip and palate repairs: an audit of 1 000 cases under Smile Train Project. Indian J Anaesth.
2013;57(6):562–8.
19. Fillies T, Homann C, Meyer U, Reich A, y col. Perioperative complications in infant cleft
repair. Head Face Med. 2007;3(9):1–5.
20. Wood F. Hypoxia: another issue to consider when timing cleft repair. Ann Plas Surg.
1994;32(1):15–9.
21. Hairfield M, Warren D, Seaton D. Prevalence of mouthbreathing in cleft lip and palate. Cleft
Palate J. 1988;25(2):135–8.
22. Murat I, Constant I, Maud’Huy H. Perioperative anaesthetic morbidity in children: a database
of 24 165 anaesthetics over a 30-month period. Pediatr Anesth. 2004;14:158–66.
23. Lees V, Pigott R. Early postoperative complications in primary Cleft lip and palate surgery. Br
J Plast Surg. 1992;45(3):232–4.
24. Jindal P, Khurana G, Gupta D, Sharma J. A retrospective analysis of anesthetic experience in
2 917 patients posted for cleft lip and palate repair. Anesth Essays Res. 2013;7(3):350–4.
25. Hatch D. Airway management in cleft lip and palate surgery. Anesth. 1996;76:755–6.
26. Kwari DY, Chinda JY, Olasoji HO, Adeosun OO. Cleft lip and palate surgery in children:
Anaesthetic considerations. Afr J Paediatr Surg. 2010;7(3):174.
27. Lee SH, Choi YW, Jeon SC, Park CKU, Ki. Aspiration pneumonia in patients with cleft palate.
J Korean Radiol Soc. 2013;48(3):289–93.
28. Kundra P, Supraja N, Agrawal K, Ravishankar M. Flexible laryngeal mask airway for cleft
palate surgery in children: a randomized clinical trial on efficacy and safety. Cleft Palate
Craniofac J. 2009;46(4):368–73.
29. Liccardi G, Salzillo A, De Blasio F, D'Amato G. Control of asthma for reducing the risk of
bronchospasm in asthmatics undergoing general anesthesia and/or intravascular administra-
tion of radiographic contrast media. Curr Med Res Opin. 2009;25:1621–30.
30. Patient safety guidelines and recommendations. The smile train anaesthesia guidelines. 2005.
Available from: http://www.medpro.smiletrain.org.
31. Duarte GA, Ramos RB, Cardoso AF. Feeding methods for children with cleft lip and/or palate:
a systematic review. Braz J Otorhinolaryngol. 2016;82(5):602–9.
32. Sukwha K, Hyo H, Seok E, Cheol J, Ji, Ung P, Hyun T, Choi. Aspiration pneumonia caused by
Povidone-iodine (betadine) in Cleft Palate patient. Arch Craniofac Surg. 2013;14(1):50–2.
33. Borland L, Sereika S, Woelfel S, Saitz E, y col. Pulmonary aspiration in pediatric patients dur-
ing general anesthesia: incidence and outcome. J Clin Anesth. 1998;10:95–102.
34. Marik P. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344(9):665–71.
35. Sheeja Rajan TM, Krishnakumar KS. Early postoperative complications and duration of hos-
pital stay after primary Palatoplasty. J Evid Based Med Healthc. 2014;1(2):36–40.
36. Joel Massari Rezende TSA, Silveira BR. Acute respiratory failure during pediatric anes-
thesia: Atelectasia and hypertensive pneumothorax. Case report. Rev Bras Anestesiol.
2012;62(1):80–7.
37. Módolo NSP-IVAS e anestesia: deve-se adiar a cirurgia? Atualização em Anestesiologia,
Volume VI. Editores Auler Junior JOC, Iwata NM, Pereira RIC-São Paulo. Office Editora,
2001, pp. 13–25.
38. Mertes PM, Tajima K, Regnier-Kimmoun MA, et al. Perioperative anaphylaxis. Med Clin
North Am. 2010;94:761–89, 2.
39. Simons FE, Ardusso LR, Bilò MB, et al. World Allergy Organization. 2012 update: World
Allergy Organization guidelines for the assessment and management of anaphylaxis. Curr
Opin Allergy Clin Immunol. 2012;12:389–99.
40. Vijayakumar B, Ganessan R, Anbalagan V. A case of severe subcutaneous emphysema in the
post-operative period following cleft lip surgery. Indian J Anaesth. 2010;54(2):163–5.
41. Ing C, DiMaggio C, Whitehouse A, Hegarty M, Brady J, et al. Long-term differences in language
and cognitive function after childhood exposure to anesthesia. Pediatrics. 2012;130(3):e476.
42. Clausen N, Pedersen D, Pedersen J, Møller S, Grosen D, et al. Oral Clefts and academic per-
formance in adolescence: the impact of anesthesia-related neurotoxicity, timing of surgery, and
type of oral clefts. Cleft Palate Craniofac J. 2017;54(4):371–80.
43. Miller R. Malignant hyperthermia. 4.ª ed. Harcourt Brace; 1996.
44. Kolb ME, Horne ML, Martz R. Dantrolene in human malignant hyperthermia. Anesthesiology.
1982;56(4):254–62.
45. Britt BA. A etiology and pathophysiology of malignant hyperthermia. In: Malignant hyper-
thermia. Springer U.S; 1987. p. 11–42.
46. Ramasamy S, Lee CY, Nabil S, Nazimi AJ, Nordin R, Ramli R. Malignant hyperthermia in a
cleft lip and palate patient: a case report. J Oral Maxillofac Surg Med Pathol. 2015;27(4):533–5.
47. Dempsey WC, Mayhew JF, Metz PS, Southern TE. Malignant hyperthermia during repair of a
cleft lip in a 6-month-old infant, with survival. Ann Plast Surg. 1978;1(3):315–8.
48. Silva L, Braz L, Mbdolo N. Emergence agitation in anesthesia; current features. J Pediatr.
2008;84:107–13.
49. Hao X, Xiao-Peng M, Li-Xian X. Cause analysis, prevention and treatment of postoperative
restlessness after general anesthesia in children with cleft palate. J Dent Anesth Pain Med.
2017;17(1):13–20.
50. Voepel-Lewis T, Malviya S, Tait A. A prospective cohort study of emergence agitation in the
pediatric postanesthesia care unit. Anesth Analg. 2003;96:1625–30.
51. Lu Y, Xu D, Zhou J, Ji F, Cao M. Risk factors analysis of emergence agitation in children after
general anesthesia and surgery. J Sun Yat Sen Univ. 2013;34:240–3.
52. Sikich N, Lerman J. Development and psychometric evaluation of the Pediatric Anesthesia
Emergence Delirium scale. Anesthesiology. 2004;100:1138–45.
53. Tang L. A small dose of midazolam for prevention of children’s emergence agitation during
postoperative recovery period. Contemp Med. 2011;17:6–8.
54. Shahzad A, Naufal M, Walter N, Saeed A, Meriaudeau F. A review on subcutaneous veins
localization using imaging techniques. Curr Med Imag. 2014;10(2):125–39.
Chapter 3
Cleft Lip Surgery Complications
Percy Rossell-Perry
3.1 Introduction
Complications related to its surgery are not frequent; however, they can be serious.
Studies published by Conway et al. and Fillies et al. [1, 2] observed a higher mortal-
ity in comparison with cleft palate surgeries. A study published by Paine et al. [3]
observed that most of the perioperative complications associated with cleft lip sur-
gery are respiratory in nature. Although there is a functional aspect, the cleft lip
repair is closely related to the aesthetic appearance observing psychological compli-
cations that affect patient’s social inclusion and development. The following are the
most common associated complications observed during our experience managing
cleft lip deformity.
3.2 Associated with Presurgical Orthopedic
The presurgical orthopedic is an alternative for cleft lip surgery management used
to position the alveolar segments and premaxilla and acquires great importance in
the management of severe bilateral cleft lip and palate.
One of the most currently used is the nasoalveolar molding (NAM) described by
Grayson [4] which consists of using rigid plates that allow molding the cleft seg-
ments and nose deformity. This method is not free from complications among which
the following have been reported.

Switzerland AG 2022
28 P. Rossell-Perry
3.2.1 Aspiration of Impression Material
This is one of the most serious complications although infrequent. When this proce-
dure is indicated, the parents must sign an informed consent where related compli-
cations (including death) are described. If this complication happens, the patient
requires urgent attention due to respiratory distress which is a serious condition for
a young child. This complication may require ventilatory support at ICU. Currently,
the oral impression is performed in the office, and there are no always effective
referral and support mechanisms for pediatric intensive care. The use of 3D technol-
ogy for the design of the plates may avoid this complication [5].
3.2.2 Skin Irritation and Pressure Sores
It is frequently associated (up to 36%) [6] using this technology. Cases of nasal
pressure sore and skin necrosis have also been reported by action of the nasal shaper
(Fig. 3.1). Skin irritation is associated with the concomitant use of tapes.
3.2.3 Nasal and Intraoral Bleeding
It is associated with pressure ulceration of the NAM plaque and nasal conformer.
3.2.4 Facial Growth Disturbance
Different studies (especially those published by Samuel Berkowitz) [7] have

observed the negative effect of long-term NAM orthopedics on the growth of the
maxilla.
Fig. 3.1 Patient undergoing treatment with NAM orthopedics for cleft lip and palate management.
A contact dermatitis generated by the use of tapes on the cheek may be appreciated
3 Cleft Lip Surgery Complications 29
The retroposition of the vomero-premaxillary junction caused by presurgical

orthopedics would be associated with disturbance of the anteroposterior develop-
ment of the maxilla due to vomero-premaxillary synostosis. This author states that
the ventroflexion observed using lip adhesion is less harmful than the effect devel-
oped by the NAM [7].
3.2.5 Associated Infections
Candidiasis and higher risk for dental caries development have been associated with
the use of the presurgical nasoalveolar molding appliance [8, 9].
3.2.6 Premature Eruption of the Maxillary Incisors
3.2.7 Children Pain, Stress, and Discomfort
These are associated with the complications mentioned above which leads to chil-
dren stress whose impact on their health has not been well estimated.
3.3 Postoperative Wound Bleeding
Postoperative bleeding is not an infrequent complication to observe after cleft lip

surgery due to the crying of the child. In our experience, we observed a rate of
1.12% in unilateral and 2.48% in bilateral cleft lips. The blood loss during surgery
may be associated with the surgeon’s experience, surgical technique, age, and gen-
der (increased in males).
Fillies [2] observed an average of 21 ml of blood loss in relation to cleft lip
surgery.
Doyle and Hudson [10] reported the requirement of blood transfusion in approxi-
mately 10% of the operated cleft lip patients, and Fillies reported 0.2% of cases [2].
In our experience, significant postoperative bleeding after cleft lip repair was
observed in 3 cases from 585 surgeries (0.51%) [11].
Some causes of postoperative bleeding after cleft lip repair are poor hemostasis,
excessive crying, coagulopathy, and infection and associated dehiscence of the
operative wound.
Uncontrolled postoperative pain is also a cause of increased bleeding. For this
reason, pain control is strongly recommended, and in persistent cases, sedation may
be recommended as an adjunct although this measure requires adequate monitoring
of the patient. Gentle compression of the operative wound is usually sufficient, and
required hemostasis in the operating room is rarely necessary.
30 P. Rossell-Perry
3.4 Postoperative Wound Infection
This complication is produced by a breakdown of the balance between the tissues

and the pathogen, as a result of decrease in the natural defenses of the tissues
(immunosuppression) and/or proliferation of the agent.
It is a rare complication, so in a review of more than 3000 cleft lip surgeries oper-
ated in India, it was found 1.1% of postoperative infection [12]. Another publication
made by Nagy in 2011 reported 2.6% of postoperative infection [13]. In our experi-
ence, this complication was observed in 1.6% of unilateral cleft lips and 1.24% of
bilateral cleft lips.
A common cause of immunosuppression is the malnutrition which predisposes
the patient to infection. Congenital immunosuppression may be observed in asso-
ciation with clefts.
A hematological disorder called cyclic neutropenia has been described in the
literature by Desai et al. [14] in association with cleft lip and palate.
Distant infectious foci must also be diagnosed and treated prior to the surgery as
they are a common cause of infection in the operative wound. Common sources in
these patients are respiratory, digestive, and urinary tracts and skin. Gram + germs
are more common [15, 16]. Staphylococcus aureus and B hemolytic streptococcus
have been found in swabs of the nose, throat, and ear of patients with cleft lip and
palate [17].
The care in the surgery is related to the handwashing (corner stone in preven-
tion), adequate aseptic conditions, and the proper sterilization of the surgical
material.
Patient short hospital stay prevents infections due to nosocomial germs.
These infections are usually caused by non-hospital-acquired germs that are sen-
sitive for first-line antibiotics. We have observed empirically a predisposition to
infection when the operative wound is covered with adhesive tapes. Apparently,
retention of secretions and bleeding may be the cause of this phenomenon although
there is no scientific evidence to support this claim. A published clinical trial con-
cluded that there are no differences between the two groups using a dressing that
covers the wound or not in operated cleft lip patients. Therefore, these coverages
seem not to be necessary [18].
The diagnosis is made by observing a local inflammatory reaction and edema
that begins after 3 to 4 days postoperatively which evolves with purulent drainage
and dehiscence of the operative wound (Fig. 3.2). Fever may be associated, while
the leukocyte count shows leukocytosis with left deviation characteristic of the
acute nature of the infection.
Treatment of infection involves management of the infected wound and use of
topical and systemic antibiotics [18]. The infected wound may be cleaned using
dilute antiseptics during 2 or 3 days and then saline solution is sufficient. The devi-
talized tissue should be debrided by physiological autolysis being more suitable for
pediatric patients. The use of topical antibiotics is indicated for short periods (4 to
5 days). Empirically, we use bacitracin or mupirocin ointment for this purpose.
Fig. 3.2 Patient with

bilateral cleft lip and nose
who had operative wound
infection during the
postoperative fourth day
and developed small
dehiscence
Regarding systemic antibiotic therapy, in recent years, it has been observed an

increase of community-acquired methicillin-resistant Staphylococcus aureus
(MRSA) infections [19].
Around 25–50% of skin infections are due to MRSA and methicillin-sensitive
Staphylococcus aureus (MSSA) infections [19].
Antibiograms should be recommended to select the type of systemic antibiotic;
however, in practice, it is not always possible to resort to the laboratory, and the
treatment starts empirically looking for the benefit of the patient.
We use oral amoxicillin or dicloxacillin for the initial treatment of the infection.
If the antibiogram reported infection for MRSA bacteria, a specific antibiotic treat-
ment should be initiated [19]. The parenteral route is reserved for patients with oral
intolerance.
Finally, another aspect to be considered within the infection is the antibiotic
prophylaxis. Different publications have shown the absence of scientific evidence
that demonstrate the efficacy of these preventive treatments [20].
Preoperative prophylaxis is not routinely used by us, and this is recommended in
cases such as difficult intubation, history of recurrent respiratory infections, and
other situations that predispose to infection. For this purpose, the UCLA pre-
incisional antibiotic protocol which considers one dose of first-generation cephalo-
sporin 1 hour before the operative incision and cefazolin is recommended (25 mg/
Kg), and in allergic patients, vancomycin is an alternative (15 mg/Kg).
The use of prophylactic antibiotics in the postoperative period is very wide-
spread; however, there is no scientific evidence to support this practice. The antimi-
crobial utilization review from the Greater Glasgow and Clyde Committee,
recommends the use of 5 days of postoperative antibiotics with amoxicillin
32 P. Rossell-Perry
clavulanic acid or clindamycin (in allergic patients) [21]. A recent literature review
and meta-analysis concluded that more studies are required to understand the utility
of antibiotic prophylaxis in plastic surgery [21–23].
3.5 Postoperative Cleft Lip Dehiscence
This is a more frequent complication associated with severe bilateral cleft lip and
palates. Different authors reported cleft lip dehiscence between 0.4 and 3.2%. In our
experience, this complication has been observed in 1.3% of cases [2, 24–26]
(Figs. 3.3 and 3.4).
This non-desirable event becomes a complication when it occurs as a result of
infection or trauma (fall, blow). A dehiscence may be considered as a bad outcome
when the dehiscence is the product of a closure under tension.
A preoperative assessment of the cleft’s severity is important to provide oppor-
tune management to the skeletal malposition reducing the tension of the surgical lip
closure. Thus, specially in severe bilateral cleft lip and palates, early diagnosis and
timely preoperative orthopedic management may prevent this complication.
The early attempt to close usually has poor outcomes since the tissues are
inflamed with a propensity to infection and a new dehiscence, although the surgeon
may accept this option under pressure from the parents who claim a prompt solu-
tion. A conservative management in which the wound is allowed to evolve to spon-
taneous closure is recommended in special when a wound infection is associated.
The functional and aesthetic sequels generated by this second intention closure will
be corrected later (no less than 6 months and ideally in 1 year). The main disadvan-
tage of this conservative method is that the tissue retracts as a result of the scarring
process making the secondary reconstruction more difficult.

bilateral cleft lip and palate
who underwent primary
cheiloplasty and suffered a
blunt trauma with the
consequent wound
dehiscence on the third
postoperative day. The
wound healed by
secondary intention with
soft tissue retraction

cheiloplasty and
progressed with partial
dehiscence of the operative
wound. The premaxilla is
positioned through the lip
dehiscence
3.6 Hypertrophic Scar
This is probably the most common postoperative complication after cleft lip surgery
[11, 26]. It is defined as excessive growth of scar tissue within the limits of the
operative wound and can be associated with symptoms such as redness, pain, or
itching [27]. This disorder is due to a failure in the healing period of proliferation
with fibroblastic hyperactivity and excessive production of collagen fibers and scar
tissue. They are usually raised, red, or pink lesions made up of type III collagen
fibers [28, 29] (Fig. 3.5).
The most common causes of hypertrophic scar are idiosyncratic reaction, opera-
tive wound infection, and wound closure under tension [28, 29]. The use of long-
term absorbable sutures is also a cause of hypertrophic reaction of the scar. The
recommendation is to use fast-absorbing sutures.
A prospective randomized study published by Holtmann in 1983 observed an
increased chance of developing hypertrophic scars after using linear closure tech-
niques (like Millard and Mohler of straight line method) [30] (Fig. 3.6). Another
study published by Soltani et al. [31] observed racial differences in relation to the
increased rate of hypertrophic scars. A higher incidence has been observed in Asians
(36.3%) compared with Caucasians (11.8%). A study developed by Wilson et al.
compared the use of tapes versus wound closure adhesive and concluded that no
differences were observed in relation to hypertrophic scar development after cleft
lip surgery [32].
34 P. Rossell-Perry

bilateral cleft lip who
developed
hypertrophic scar
Fig. 3.6 Long-term

hypertrophic scar
contracture associated with
rotation advancement
technique
Few or no evidence exist regarding the preventive effect of hypertrophic scar

development using wound closure adhesives like octyl cyanoacrylate, although we
have observed associated complications using these products (Fig. 3.7).
The prevention of hypertrophic scar formation is mainly based on avoiding ten-
sioned surgical closure and placing the surgical incisions through the lip tension
lines [27]. Linear scars (although they appear to be more aesthetic when located
Fig. 3.7 Long-term

postoperative scar
contracture associated with
the use of wound closure
adhesive
a b
Fig. 3.8 Patient with unilateral cleft lip who developed scar contracture at 2 months after primary
cheiloplasty being observed after 1 year the total remission of this retraction. (a) Postoperative
view after 3 months showing scar contracture and lip shortness. (b) Postoperative view after one
year showing improvement of the lip’s length
between aesthetic units of the lip) also seem to favor the development of hypertro-
phic scars [30]. A study published by Raposo-Amaral et al. observed a high fre-
quency of hypertrophic scars during the first three postoperative months. However,
total remission was observed using conservative treatment between 9 and 12 months
after surgery [33] (Fig. 3.8). It is important to note that their group of patients was
operated using a linear technique (Mohler).
An adequate surgical technique with non-traumatic tissue management seems to
favor the development of better scars. The early use of tapes or silicone gel or sheets
36 P. Rossell-Perry
has been widely described in the literature as a preventive method for hypertrophic
scar development [27, 28]. The scar final estimation after cleft lip repair must be
done after 1 year.
Treatment of this complication is usually conservative and should be started
when the scar is still immature. This is based on the following principles:
• Use of Silicone
This method is effective in the prevention and treatment of hypertrophic scars
and may be associated with corticosteroids in severe and refractory cases [34, 35].
Its effect would be related to the hydration of the scar more than to the
pressotherapy.
The procedure consists of the adhesive silicone (sheet or gel) application by peri-
ods of time until remission of the lesion; the treatment begins on the third postop-
erative week applying it once or twice a day until remission of the lesion (Fig. 3.9).
a b
Fig. 3.9 Patient with unilateral cleft lip operated using the Millard technique. Development of
hypertrophic scar has been observed at 3 months after surgery (a). The improvement of the scar
can be observed over the months (6 months (b) and 1 year (c)) in response to silicone gel treatment
One study compared the efficacy of sheet versus gel silicone and didn’t observe
differences. However, we have observed better outcomes using silicone gel [36].
During the second postoperative month, the response to this treatment should be
evaluated. If the scar does not improve or gets worse, infiltration with corticoste-
roids should be considered. Use of silicone is continued until the eighth or ninth
postoperative month, and if there is no evidence of hypertrophic reaction, the treat-
ment can be discontinued. The majority of labial scars progress satisfactorily around
9 months [33]. Finally, the use of moisturizing creams with gentle massage is rec-
ommended for the recovery of healing tissues until completing one postopera-
tive year.
• Use of Corticosteroids
This treatment reduces the inflammatory process while decreasing the collagen
formation [27]. Triamcinolone in solution for intradermal use is recommended for
this purpose in association or not with lidocaine. Although there are few random-
ized clinical trials, its use is quite widespread, and in our experience, this treatment
is limited to severe cases that do not improve using silicone (Fig. 3.10) [37].
A fine needle (number 26 or 30) is used, and the corticosteroid solution is applied
into the scar tissue observing the whitening of the scar. The entire scar should be
infiltrated avoiding healthy edges. We use a combination of lidocaine 2% and triam-
cinolone in a ratio of 1:1, and the volume depends on the size of the scar. The
response to this scheme is variable, but it is common that a single application may
be insufficient and it is recommended to repeat it and combine treatment methods.
Some side effects associated with this treatment are hypopigmentation, skin atro-
phy, and telangiectasia. Topical application of corticosteroids (patches, creams) is
not supported by scientific evidence [38].
• Surgical Resection of the Lesion
a b
Fig. 3.10 A 3-month-old patient with severe hypertrophic scar contracture after primary cleft lip
and nose repair (left) (a). The contracture was improved using local infiltration of steroids in com-
bination with silicone gel after 2 months (right) (b)
38 P. Rossell-Perry
If there are an important aesthetic and functional impairment due to the hypertro-
phic scar and no response to the conservative management after 1 year of postopera-
tive evolution, surgical scar resection should be considered.
The scar evaluation must be done after a period of 1 year since there may be
temporal hypertrophy and retraction during this time. Any surgical resection must
be considered after this time and not before. The scar is resected doing a dissection
of the edges in the subcutaneous plane, and a tension-free closure must be performed.
It is advisable to complement by infiltrating corticosteroids and/or silicone if
signs and symptoms of early hypertrophic reaction (redness, raised scar, and
itch) appear.
Care should be taken when resecting the scar, not to create a longer lip. The
curved incision made on the outside of the scar makes the lip height increase.
An increased rate of hypertrophic scar development has been observed by us in
patients after age of 5, and we do recommend to consider carefully any surgical scar
revision after this age.
3.7 Keloid Scar
This complication is defined as excessive growth of scar tissue outside the limits of
the initial surgical wound. It is usually accompanied by symptoms such as intense
pain and itching. Keloids are more common in African, Asian, or Hispanic
patients [27].
It is a very rare complication in cleft lip surgery. We have observed one case after
25 years of experience, and this is produced by failure during healing contraction
period [27].
The most common cause of keloid scars is the patient’s idiosyncratic reaction,
and their treatment of this condition is often refractory [29].
Treatments used for keloids are the same as for hypertrophic scars, but surgical
resection of the keloid must be reserved for special cases because it may generate a
worse condition [30]. Based on our experience, treatment may start with conserva-
tive management (combination of silicone and corticoids) during a 3 to 6 months’
period after which we may observe partial remission. It can be continued with
spaced periods of treatment until the reaction is completely controlled. It is recom-
mended to start the treatment early since a decreased response has been observed in
older keloids [28]. The prolonged use of corticosteroids should be limited avoiding
the appearance of side effects, and use of moisturizing creams is recommended also
to improve keloid symptoms.
Surgical resection of these lesions are limited to severe cases with great defor-
mity and refractory conservative treatment. We recommend the resection leaving a
thin keloid border (1–2 mm) to reduce the chance of keloid reaction and recurrence.
Then, the edges are dissected in the subcutaneous plane, and finally the wound is
closed without tension.
Other treatments have been described but require more scientific evidence to be
used in children. They are heparin, bleomycin, interferon alfa, 5-fluorouracil, laser,
pulsed light, botulinum toxin hyperbaric oxygen, cryotherapy, radiofrequency, and
radiotherapy.
3.8 Granuloma
This complication is generally associated with the use of surgical sutures.

It is characterized by a bleeding tumor at the level where the suture is located. By
definition, it is understood as a tumor composed of granulation tissue (collagen
fibers, fibroblasts, and blood vessels) which is usually produced in response to
infection or presence of foreign body [39]. The granuloma is characterized by a
bright red bleeding mass (Fig. 3.11).
Treatment is conservative since the granuloma disappears when the suture is
reabsorbed although on rare occasions it is necessary to remove the suture. Suture
removal will be necessary if the granuloma is associated with non-absorbable mate-
rials, such as nylon.
The use of silver nitrate bars may be useful to cauterize the granuloma by reduc-
ing the related symptoms such as bleeding until the granuloma resolves.
Fig. 3.11 A case of

granuloma after primary
cleft lip nose repair. The
lesion was developed
4 days after surgery and
associated with the use of
transcutaneous resorbable
stitches. The case resolved
spontaneously after stitch
reabsorption of the suture
(3 weeks)
40 P. Rossell-Perry
3.9 Complications Associated with Primary

Cleft Rhinoplasty
This procedure is not without complications and the most important are:
• Bleeding
The nose has a rich vascularity; hence, the bleeding is a frequent complication to
observe. The magnitude of this complication is in relation with the extension of the
nose surgery. It may be associated with other complications like hematomas, aspira-
tion, vomiting, and bruising. Hematoma is not frequent to observe after primary
nasal surgery, and when it does develop, it is small and completely reabsorbed.
Primary septoplasty (limited to the anterior portion of the septum) is described in
the literature, and its use may add a greater risk of bleeding after primary
rhinoplasty.
Any surgical technique using extended nose incisions may require nasal packing
to prevent postoperative bleeding.
• Hypertrophic Scar
The probability of developing hypertrophic scar after primary rhinoplasty
depends on the used technique and patient’s idiosyncratic reaction.
Techniques such as Mulliken’s and Tajima’s which employ nasal tip incisions
and skin resection have greater chance of developing this complication in compari-
son with conservative techniques [40, 41].
The use of subnasal incisions described by Millard is associated with this com-
plication, and they are very difficult to correct (Fig. 3.12).
Fig. 3.12 Unilateral cleft

lip and palate patient who
developed a hypertrophic
scar after primary cleft lip
repair using the
conventional Millard
technique. Note the
presence of subnasal
hypertrophic scar
Linear vestibular incisions tend to create hypertrophy and retraction; hence, it is

important to prevent its use. Scar retraction may generate a serious complication
such as nasal stenosis (Fig. 3.13). The development of nose keloids is quite rare in
these patients.
• Foreign Body
Given the characteristics of the anatomy of the nose, it is easy for a gauze to
remain in the nose after surgery and go unnoticed during some time. The operative
bleeding can mask the foreign body and would not be detected by the surgeon.
The introduction and removal of any pack must be verified by all the personnel
present in the operating room. It should be part of the pre- and postoperative
checklist.
When this complication occurs, it manifests with a bad smell through the nose
and may be associated with infection and bleeding. The diagnosis can be confirmed
using a rhinoscope. The treatment consists of the removal of the foreign body which
can be done easily when the diagnosis is made early. In the case of foreign bodies
that have been in place for longer time (more than a month), the removal would be
more difficult because of the surrounding tissue adhesion. The foreign body has
strong adherence to the tissues, and the removal is associated with important bleed-
ing. In this situation, it is recommended to perform foreign body removal in the
operating room under general anesthesia. Thus, the gauze can be removed, and any
associated bleeding can be controlled. Other associated complications are septal
perforations, synechiae, sinusitis, and toxic shock syndrome associated with nasal
packing, although they are not frequent [42–44].
The use of systemic antibiotics is necessary in these cases for 5 to 7 days.

lip patient who developed
severe scar contracture
after primary lip and nose
repair using rotation
advancement method and
nasal marginal incision
42 P. Rossell-Perry
Other types of foreign bodies are less frequent, as residues of material from
impressions and fixation wires [45].
• Infection
This complication is rare. Alef et al. observed 4.6% of infection after primary
rhinoplasty [46]. The event occurs 3 to 5 days after surgery and presents inflamma-
tion, odor, and pain (Fig. 3.14). Late infections can occur generally associated with
a foreign body as described before.
Treatment is carried out with systemic antibiotics evolving without sequels.
However, due to the abundant perinasal blood supply, this complication must be
managed with promptness since in severe cases it can be associated with serious
complications such as venous sinuses thrombosis, meningitis, and sepsis [47].
• Nasal Stenosis
This is a complication seen more frequently actually due to the increased popu-
larity of primary nasal surgery in cleft patients (Figs. 3.15 and 3.16).
The stenosis can occur at the vestibular level (affecting the nasal valves). Thus,
the main associated symptom is functional nasal obstruction with shortness of
breath. This complication is associated with scar disorders and the use of linear
vestibular incisions that, when retract, reduce the area of the nasal vestibule with
obstruction of the airway.
Early conservative treatment is indicated, but if the problem persists, surgery is
indicated. We use the V-Y-Z technique to release the retraction produced by the
scar [48].
The use of postoperative nasal conformers is indicated to prevent scar retraction
at this level [49].
Fig. 3.14 A 4-month-old patient with unilateral cleft lip who developed infection after primary lip
nose repair during the fifth postoperative day. Complication was resolved after 1 week of local and
systemic antibiotic treatment
a b
Fig. 3.15 Cleft lip and palate patient who developed vestibular scar contracture and synechia after
primary rhinoplasty (a). The contracture was released using the V-Y-Z method which required
postoperative nasal conformers during at least 6 months (b)
a b
Fig. 3.16 Another unilateral cleft lip with severe nasal synechia (a). The contracture was released
using the V-Y-Z technique, and nasal conformers were required during 6 months (b)
• Skin Necrosis
After primary rhinoplasty, there is a risk of ischemia and necrosis due to factors
as compression or aggressive surgical technique.
Some surgeons like to use adhesive tapes over the nasal tip and postoperative
nasal shapers. Those have been shown to be associated with ischemia and necrosis
of the skin.
Postoperative infection, in severe cases, may generate skin necrosis although it is
rare to observe. This complication is characterized by paleness of the affected area
and then darkening associated with the loss of viability of the skin segment. The
sequel is usually serious and leaves aesthetic and functional deformities.
44 P. Rossell-Perry
We recommend an initial conservative management with topical antibiotics (bac-

itracin, mupirocin, or nitrofurazone). Then, the size of the affected area is delimited
and reduced by scar contracture later.
Special attention requires the alar and columellar necrosis as these create an
obvious defect after healing.
• Complications Associated with the Use of Implants
Currently, the use of implants (silicone or filling materials) such as hyaluronic
acid has become popular because it simplifies reconstruction. Hyaluronic acid is a
biodegradable material with low percentage of complications and is being used in
the treatment of secondary deformities.
Different situation occurs using silicone implants, and there are different reports
about associated complications in the literature. They include infections, granulo-
mas, and extrusion [50–52].
Its use facilitates nasal reconstruction in cleft patients; however, long-term expe-
riences have shown an increased rate of complications, and their use is not recom-
mended (Fig. 3.17).
3.10 Prolabium Necrosis
This is a rare complication associated with bilateral cleft lip repair.

It could be considered more a bad outcome than a complication. Necrosis of this
cutaneous segment is related to inadequate surgical management. Some techniques
as Mulliken’s design a very small prolabium in combination with primary rhino-
plasty and may be associated with increased chance of necrosis [53]. Trott’s method
combines primary lip repair and open rhinoplasty, decreasing blood supply to the
distal segment of the flap (prolabium) [54].
Severe infection and inadequate surgical manipulation of the tissues are other
factors to be considered (Fig. 3.18).
Any severe form of bilateral cleft lip and palate should receive presurgical man-
agement or lip adhesion prior to primary repair in order to prevent this
complication.
Loss of this lip segment generates an obvious aesthetic deformity of the upper
lip, and the Abbe flap is one of the most used techniques for upper lip repair (see
Chap. 3).
3.11 Granuloma
This complication has been observed in association with the use of transcutaneous
stitches.
Its location is more frequent inside the nose and around the supra alar crease.
a b
c d
Fig. 3.17 A 23-year-old woman with unilateral cleft lip and palate who underwent a secondary
rhinoplasty when she was 18 (a, b). The surgeon used a piece of silicone to improve nasal tip. The
patient came to the office consulting for inflammation and pain as well as recurrent nasal defor-
mity. During tertiary rhinoplasty, the silicone implant was identified and removed (c, d). Nasal
deformity was finally corrected by elongation of the nasal vestibule (e)
46 P. Rossell-Perry

operated on for primary
bilateral cheiloplasty who
had loss of prolabium due
to poor manipulation and
postoperative infection
associated with tension of
the surgical closure
a b
Fig. 3.19 Two cases of granuloma both in bilateral cleft lip nose repair. The lesions were devel-
oped 3 days after surgery and associated with the use of transcutaneous resorbable stitches (a).
Both cases resolved spontaneously after stitch reabsorption of the suture (3–4 weeks) (b)
Treatment is conservative since the granuloma disappears when the suture is

reabsorbed although on rare occasions it is necessary to remove the suture
(Fig. 3.19).
Suture removal will be necessary if the granuloma is associated with non-
absorbable sutures or if the suture takes a long time to be reabsorbed or if there is an
associated infection since these conditions can develop hypertrophic reaction of the
lip scar.
References
1. Conway H, Bromberg B, Hoehn R, Hugo N. Causes of mortality in patients with cleft lip and
palate. Plas Recons Surg. 1966;37(1):51–61.
2. Fillies T, Homann C, Meyer U, Reich A, et al. Perioperative complications in infant cleft
3. Paine K, Tahiri Y, Wes A, Wink J, et al. An assessment of 30-day complications in primary cleft
lip repairs: a review of the 2012 ACS NSQIP pediatric. Cleft Palat Craniof J. 2016;53(3):283–9.
4. Grayson B, Santiago P, Brecht I, Cutting C. Presurgical nasoalveolar molding in infants with
cleft lip and palate. Cleft Palat Craniofac J. 1999;36(6):486–98.
5. Ahmed MK, Ahsanuddin S, Retrouvey JM, Koka KS, Qureshi H, Bui AH, Taub PJ. Fabrication
of Nasoalveolar molding devices for the treatment of cleft lip and palate, using stereolithog-
raphy additive manufacturing processes and computer-aided design manipulation software. J
Craniofac Surg. 2019;30(8):2604–8.
6. Levy-Bercowski D, Abreu A, DeLeon E, Looney S, Stockstill J, Weiler M, Santiago
P. Complications and solutions in Presurgical Nasoalveolar Molding therapy. Cleft Palate
Craniofac J. 2009;46(5):521–8.
7. Berkowitz S. Why hasn't Cutting and Grayson done a longitudinal study to show why
Nasoalveolar Molding should not be used? Cleft Palate Craniofac J. 2019;56(1):141.
8. Yilmaz HN, Hatipoglu S, Erdem B, Can B, Kadir T. Adherence frequency of candida albicans
on nasoalveolar molding appliances. J Stomat Oral Maxillofac Surg. 2020;121(5):473–7.
9. Hassani H, Chen J-W, Zhang W, Hamra W. Comparison of microbial activity among infants
with or without using Presurgical Nasoalveolar Molding appliance. Cleft Palate-Craniofac
J. 2020;57(6):762–9.
10. Doyle E, Hudson I. Anaesthesia for primary repair of cleft lip and cleft palate: a review of 244
procedures. Pediatr Anesth. 1992;2(2):139–45.
11. Rossell-Perry P. Tratamiento de la fisura labio palatina. Lima: Ed. San Marcos; 2009.
12. Gopalakrishna A, Agrawal K. A status report on management of cleft lip and palate in India.
Ind J Plas Surg. 2010;43(1):66–75.
13. Nagy K, Mommaerts M. Postoperative wound management after cleft lip surgery. Cleft Palate
Craniofac J. 2011;48(5):584–6.
14. Desai A, Gopalkrishnan K, Joshi V, Bhasker R. Cyclic neutropenia in a cleft lip and palate
patient: a case report. Cleft Palat Craniof J. 2011;48(6):776–8.
15. Costa B, Oliveira Lima J, Gomide M, Silva Rosa O. Clinical and microbiological evaluation
of the periodontal status of children with unilateral complete cleft lip and palate. Cleft Palate
Craniofac J. 2003;40(6):585–9.
16. Cocco J, Antonetti J, Burns J, Heggers J, Blackwell S. Characterization of the nasal, sublin-
gual, and oropharyngeal mucosa microbiota in cleft lip and palate individuals before and after
surgical repair. Cleft Palate Craniofac J. 2010;47(2):151–5.
17. Chuo C, Tommons M. The bacteriology of children before primary cleft lip and palate surgery.
Cleft Pal Craniofac J. 2005;42(3):272–6.
18. Olalere Omoyosola G, Stella Amiede O, Babatunde Babasola O. Randomized controlled trial
comparing dressing and no dressing of surgical wound after cleft lip repair. J Contemp Dental
Prac. 2015;16(7):554–8.
19. Stevens D, Bisno A, Chambers H, Patchen Dellinger E, et al. Practice guidelines for the diag-
nosis and management of skin and soft tissue infections: 2014 update by the infectious dis-
eases society of America. Clin Infect Dis. 2014;59(2):147–59.
20. Smyth A, Knepil G. Prophylaxis antibiotics and surgery for primary clefts. Br J Oral Maxillofac
Surg. 2008;46(2):107–9.
21. Mankowski P, Cherukupalli A, Slater K, Carr N. Antibiotic prophylaxis in plas-
tic surgery correlation between practice and evidence. Plastic Surg. 2021; https://doi.
org/10.1177/2292550321997005.
48 P. Rossell-Perry
22. Olawoye OA, Michael AI. Olusanya A perioperative antibiotic therapy in orofacial cleft sur-
gery. What is the consensus? Annals of Ibadan. Postgrad Med. 2020 Jun;18(1):S51–7.
23. Richardson C, Mattison G, Roring J. The optimal duration of antibiotic prophylaxis in plastic
surgery: a meta-analysis of 32 publications running head: optimal duration of antibiotics in
plastic surgery. Health Sci J. 2016;10(2):24–9.
24. Wilhelmsen H, Musgrave R. Complications of cleft lip surgery. Cleft Palate J. 1996;3:223–31.
25. Lees V, Pigott R. Early postoperative complications in primary cleft lip and palate surgery. Br
J Plast Surg. 1992;45(3):232–4.
Surg. 2015;39(1):54.
27. Rabello F, Souza C, Júnior J. Update on hypertrophic scar treatment. Clinics.
2014;69(8):565–73.
28. Yagmur C, Akaishi S, Ogawa R, Guneren E. Mechanical receptor-related mechanisms in scar
management: a review and hypothesis. Plas Recons Surg. 2010;126(2):426–34.
29. Bayat A, McGrouther D, Ferguson M. Skin scarring. BMJ. 2003;326:88–92.
30. Holtmann B, Wray C. A randomized comparison of triangular and rotation advancement uni-
lateral cleft lip repairs. Plas Recons Surg. 1983;71(2):172–8.
31. Soltani A, Francis C, Mohamed A, Kratsonyi A, et al. Hypertrophic scarring in cleft lip repair:
a comparison of incidence among ethnic groups. Clin Epidemiol. 2012;4:187–91.
32. Wilson A, Mercer N. Dermabond tissue adhesive vs Steri-Strips in unilateral cleft lip repair: an
audit of infection and hypertrophic scar rates. Cleft Palate Craniofac J. 2008;45(6):614–9.
33. Raposo-Amaral CE, Giancolli AP, Denadai R, Marques FF, Somensi RS, et al. Lip height
improvement during the first year of unilateral complete cleft lip repair using Cutting extended
Mohler technique. Plast Surg Int. 2012;2012:206481.
34. Tollefson T, Kamangar F, Aminpour S, Lee A. Comparison of effectiveness of silicone gel
sheeting with microporous paper tape in the prevention of hypertrophic scarring in a rabbit
model. Arch Facial Plas Surg. 2012;14(19:45–51.
35. Poston J. The use of silicone gel sheeting in the management of hypertrophic and keloid scars.
J Wound Care. 2000;9(1):10–6.
36. Berman B, Flores F. Comparison of a silicone gel filled cushion and silicone gel sheeting for
the treatment of hypertrophic or keloid scars. Dermatol Surg. 1999;25(6):484–6.
37. Koc E, Arca E, Surucu B, Kurumlu Z. An open, randomized, controlled, comparative study
of the combined effect of intralesional triamcinolone acetonide and onion extract gel and
intralesional triamcinolone acetonide alone in the treatment of hypertrophic scars and keloids.
Dermatol Surg. 2008;34(11):1507–14.
38. Zurada J, Kriegel D, Davis I. Topical treatments for hypertrophic scars. J Am Acad Dermat.
2006;55(6):1024–31.
39. Adams D. The granulomatous inflammatory response: a review. Amer J Pathol. 1976;84(1):164.
40. Tajima S, Maruyama M. Reverse U incision for secondary repair of cleft lip nose. Plas Recons
Surg. 1977;60:256.
41. Mulliken J. Principles and techniques of bilateral complete cleft lip repair. Plas Recons Surg.
1985;75(4):342–8.
42. Smith D, Afifi A, Jiang S, Ford M, y col. Nasal tip complications of primary cleft lip naso-
plasty. J Craniofac Surg. 2009;20(5):1327–33.
43. Hull H, Mann J, Sands C, Gregg S, Kaufman P. Toxic shock syndrome related to nasal pack-
ing. Arch Otolaryngol. 1983;109(9):624–6.
44. Chuang Y, Huang Y, Lin T. Toxic shock syndrome in children: epidemiology, pathogenesis and
management. Paediatr Drugs. 2005;7(1):11–25.
45. Kamat A, Taball A. Chronic foreign body of the nasal cavity and sphenoid sinus: surgical
complication. Cleft Palat Craniof J. 2012;49(1):114–7.
46. Alef M, Irwin C, Smith D, Losee J. Nasal tip complications of primary cleft lip nasoplasty. J
Craniofac Surg. 2009;20(5):1327–33.
47. Marshall D, Slattery P. Intracranial complications of rhinoplasty. Br J Plas Surg.

1983;36(3):342–4.
48. Rossell-Perry P. Primary unilateral cleft lip nasal deformity repair using V-Y-Z plasty: an
anthropometric study. Indian J Plast Surg. 2017;50(2):180–6.
49. Menger D, Lohuis P, Kerssemakers S, Trenite G. Postoperative management of nasal vestibule
stenosis: the custom-made vestibular device. Arch Fac Plas Surg. 2005;7(6):381–6.
50. Wai Pak M, Yin Chan E, Van Hasselt C. Late complications of nasal augmentation using sili-
cone implants. J Laryng Otol. 1998;112(11):1074–7.
51. Shirakabe Y, Shirakabe T, Kishimoto T. The classification of complications after augmentation
rhinoplasty. Aesthet Plast Surg. 1985;9(3):185–92.
52. Wong P, Nield D, Khoo C. The pathogenicity of coagulase negative Staphylococcus in the
presence of silicone rubber implants. Br J Plast Surg. 1987;40:94–6.
53. Mulliken JB. Primary repair of bilateral cleft lip and nasal deformity. Plas Recons Surg.
2001;108(1):181–96.
54. Trott JA, Mohan N. A preliminary report on one stage open tip rhinoplasty at the time
of lip repair in bilateral cleft lip and palate: the Alor Setar experience. Br J Plast Surg.
1993;46(3):215–22.
Chapter 4
Cleft Palate Surgery Complications
Percy Rossell-Perry
4.1 Introduction
Unlike cleft lip surgery, cleft palate repair requires different conditions in relation to
the magnitude of the operation and its complications. Although it is treated on an
outpatient model in some centers, it is recommended to provide a day care surgery
due to the possibility of bleeding, aspiration, or airway obstruction.
The most common complication is postoperative bleeding with 4.55% of cases
in our experience. Musgrave reported 2.2% in a study published in 1960 [1].
At this point, we have to differentiate the common postoperative bleeding
observed due to the crying and agitation of the child from the significant bleeding
after surgery that requires surgical intervention. Some bleeding may appear if the
child cries intensely and resolve after the agitation is under control. But if the
amount is significant and persistent, it requires urgent management and reoperative
hemostasis.
Other associated problems such as fistulas, dehiscence, or velopharyngeal insuf-
ficiency should be considered as bad results mostly.
The model of care becomes a factor risk for the development of complications
and bad results. In a study published by us, the surgical campaign model (widely
disseminated in low-income countries) has an increased number of complications
and bad results in comparison with patients operated in a referral center, despite
both groups being operated by the same surgeon [2].
The most frequent complications observed in our experience associated with
cleft palate surgery are presented below.

Switzerland AG 2022
52 P. Rossell-Perry
4.2 Related to the Use of the Mouth Opener
The mouth gag is an instrument of essential use for performing palatoplasties due to
the nature of this intervention. The most widely used and widespread type of mouth
opener is the Dingman’s. This instrument is associated with some of the complica-
tions related to the endotracheal tube mentioned in this book. In addition, this device
presents other complications as follows:
• Burns
Due to the metallic structure of this instrument, it is common to observe burns
around labial commissures because of the contact of the cautery with the lateral
branches for oral retraction. Sometimes, they can be serious, since they are elec-
trical burns (Fig. 4.1). It can be prevented by using a protector for the electrocau-
tery tip.
The management is quite conservative using mupirocin or bacitracin oint-
ment. Use of oral retractors to prevent scar contractures may be indicated for
severe cases [3]. Generally, this complication resolves without sequels (Fig. 4.2).
• Tooth loss or damage
The trauma generated by the anterior Dingman’s hooks on the maxillary arch
can cause loss or damage of teeth. This instrument should be carefully positioned
to prevent this complication.
• Endotracheal tube compression
As we mentioned in complications related to anesthesia, the presence of the
mouth gag and the action of the surgeon in the oral cavity may produce changes
to the endotracheal tube during the surgery. The tongue depressor may compress
or kink the tube when this is not preformed. In occasions, the tube must be later-
alized to allow airflow through the tube. Nasotracheal intubations are not fre-
quently used and lead with other complications as bleeding although this tube
position hampers the surgeon’s performance.
Fig. 4.1 Cleft lip and

palate patient after primary
palatoplasty who had burns
at the labial commissures
and lower lip edema by
compression of the tongue
depressor
4 Cleft Palate Surgery Complications 53
a b
Fig. 4.2 A 1-year-old patient after primary cleft palate repair suffered commissure burns due to
electrocautery (a) and evolved favorably without sequel after 1 week using conservative treatment
(topical antibiotics) (b)
Fig. 4.3 A 1-year-old

patient with incomplete
cleft palate who developed
tongue and lower lip
edema after primary repair
due to mouth gag
compression. The
complication revolved
spontaneously well
• Lip and tongue injury

It is not frequent to observe. This problem is developed by compression made
by the tongue depressor of the mouth opener on these tissues during palate
surgery.
The Trendelenburg position and hyperextension of the neck may contribute
also. It is surgical time dependent [4]. The compression generates venous con-
gestion and edema. The problem is detected at the end of the surgery or during
the recovery period (Fig. 4.3). If the problem is detected early, a delayed extuba-
tion after resolving tongue edema is recommended. In severe cases of tongue
edema, (massive tongue swelling), it requires fast handling and endotracheal
54 P. Rossell-Perry
n asopharyngeal intubation or tracheostomy to guarantee the patient’s airway [5,

6]. In non-severe cases, the swelling came down drastically by 72 h postopera-
tively with a conservative management and steroids. The use of injectable ste-
roids appears to be beneficial in the prevention of lingual edema associated with
cleft palate surgery [7].
• Temporomandibular joint luxation
This complication has not been reported before in the literature.
Sometimes, due to the excessive opening of the mouth opener, there is a luxa-
tion of this joint. It is evidenced by the permanence of oral opening after remov-
ing the mouth gag.
The harmful effect of this complication may depend on the surgical time.
The treatment is simple and consists of recuing manually the dislocation.
• Skin lesions on the chest
Relatively frequent. They occur due to the pressure generated on the skin by
the base of the tongue depressor. The device produces a pressure injury that
improves and resolves spontaneously. It should be prevented by using a soft pro-
tection over the chest.
4.3 Bleeding
Intra- and postoperative bleeding is a frequent complication in cleft palate repair.

Fillies [8] observed an average of 45 ml of bleeding during this surgery (10% of
blood volume). Blood loss during palatoplasty depends on surgeon’s experience,
surgical technique, age of the patient, and gender (more in males) [8, 9]. Doyle and
Hudson [10] have reported this complication in 16% of patients.
We have to differentiate the bleeding observed after surgery and associated with
the child agitation and crying from the continuous and more intense bleeding which
requires reoperative hemostasis. The first one is resolved spontaneously after child
agitation is controlled through pain medication.
Hemodynamic compromise and requirement for blood transfusion are infrequent.
In our experience of nearly 3000 palatoplasties, this requirement was exceptional
(5 cases, representing 0.16% of total) [11]. Similar findings have been reported by
Fillies (0.2%). The frequency of blood transfusion requirement in cleft palatoplasty
is 10% according to Adeyemo in a small sample of patients [12].
Severe bleeding associated with hypovolemic shock is rare to observe, and no
cases were found in the literature. However, due to the nature of the vascularization
of the palate, the postoperative bleeding may be considerable, and risk of hypovole-
mia, aspiration, and airway spasm require urgent attention.
Causes of postoperative bleeding are deficiencies of intraoperative bleeding con-
trol (more frequent and this is more a bad result than a complication), section of
vascular pedicles, rebound of hypotensive anesthesia, palatal flap necrosis, and
infection of the operative wound. Bleeding due to von Willebrand disease and con-
genital platelet disorder has been described in the literature by Pang [13].
Basic management for the treatment of this complication involves:

• Maintenance of IV route that allows the administration of fluids
• Lateral decubitus position to reduce risk of aspiration
• Manual compression of the operative wound with gauze until the patient can be
evaluated by the surgeon to determine the magnitude of bleeding
• Pain medication revision if necessary
Non-severe bleedings use to be controlled with this initial management. In the
case of severe bleeding, a reoperative hemostasis is necessary.
The experience of the PACU (post-anesthesia care unit) staff is important in dif-
ferentiating between severe and non-severe cases. Severe bleeding is not frequent,
and in our experience, only 6 of 458 palatoplasties required reoperative hemostasis
(1.31%) [11]. A recent study observed 5.54% of severe postoperative bleeding [9].
During reoperative hemostasis, the bleeding site is usually located at the level of
the palatine vessels or nasal mucosa (highly vascularized).
If the bleeding is persistent and the bleeding is coming from the nasal mucosa, it
is recommended to use a Foley catheter (number 8 or 10) and fill the balloon with
5 ml of air or water, leaving it at the level of nasopharynx (Fig. 4.4). The catheter is
fixed using adhesive tape at the nasal and frontal level. A small piece of gauze is
placed at the nostril rim level to prevent nasal injury. The device is later removed
when the bleeding is controlled. For this purpose, first deflating the balloon and
observe if the bleeding persists, later if there is no bleeding may be removed with
care. It is recommended not to exceed 12 h of use. A comparative study carried out
showed that the need for reoperation can be avoided [9].
Fig. 4.4 Anatomical

location of the Foley
catheter balloon used as
posterior nasal packing for
the control of bleeding
during cleft palate repair
56 P. Rossell-Perry
The use of synthetic hemostatic products such as cellulose polymer (poly anhidro
glucuronic acid) on raw areas of the operated palate in combination with vitamin K
is also useful in controlling bleeding although there is insufficient scientific evi-
dence [14].
The use of drugs that reduce bleeding such as aprotinin, aminocaproic acid, and
tranexamic acid has been evaluated. Favorable outcomes have been reported by
Durga [15]; however, more studies are necessary to estimate its utility. Another
study published by Arantes [16] found no differences with the use of tranexamic
acid during primary palatoplasties. These drugs may be indicated when the bleeding
does not subside despite the measures mentioned above.
Below is a guide to prevent postoperative bleeding after cleft palate repair.
• Careful evaluation of the patient considering diagnosis, associated pathologies,
antecedents, and auxiliary exams. Age, gender, and surgical technique are addi-
tional factors to take into account.
• Anesthetic plus vasoconstrictor (epinephrine) infiltration.
• Lateral incisions made using electrocautery may decrease the chance of bleeding.
• Mucoperiosteal flap elevation and nasal mucosa dissection should be performed
in the subperiosteal plane.
• Dissection of the velar muscles should be performed using microsurgical loupes
to allow proper visualization and cauterization of the vessels.
• The lateral dissection of the soft palate (Ernst’s space) should be done at the end
of surgery in order to limit bleeding during surgery and should be performed
using cautery.
The minor palatal vessels must be cauterized at the posterior border of the pala-
tine bone.
• Special attention should be paid during surgical closure of the gingival mucosa;
some vessels may be injured causing significant bleeding.
• In the case of persistent bleeding despite these recommended measures, it is
advised to use the Foley catheter as a posterior nasal packing, as we men-
tioned before.
• The lateral raw surfaces can be covered using cellulose polymer as a preventive
measure of control of bleeding and may be soaked in tranexamic acid.
• It is recommended that the patient should be extubated awaked. Under this con-
dition, it is more easy to detect any bleeding and manage it without the need of
reintubation (always difficult under bleeding and awake patient).
The use of tongue stitch to help during management during bleeding or tongue
edema has been described. However, two studies have been observed to have no
efficacy of this method [17, 18]. In our experience, we have observed that its use
causes discomfort to children, and we do not recommend its use regularly.
Case 1
Unilateral cleft lip and palate patient scheduled for cleft palate surgery at 1 year of
age. Preoperative hemoglobin: 12 g/Dl. Palatoplasty was performed without
complications using the one-flap technique. Estimated blood loss: 21 cc. The patient
went to PACU and hospitalization in good condition. During the night, a phone call
is received due to persistent and significant bleeding from the palate. The patient
was evaluated, and a voluminous clot was found into the oral cavity. The patient was
placed in lateral decubitus and carefully remove the clot using sterile gloves, and
then the palate was gently compressed with gauze for a few minutes. These simple
maneuvers allowed to control the bleeding. To prevent bleeding recurrence, poste-
rior nasal packing using a Foley catheter was used. The balloon was filled with 5 ml
of water and pulled positioning the balloon in the nasopharynx. The patient calmed
down after the procedure and didn’t present bleeding again. Control of hemoglobin:
10.5 g/Dl.
4.4 Airway Obstruction
Different authors have reported the presence of airway obstruction after cleft palate
repair [19–21]. Antony and Sloan in 2002 reported 5.7% of patients who evolved
with problems of the airway within 48 h of postoperative cleft palate repaired using
the Furlow technique. In 12 cases, this complication was severe and required rein-
tubation of the patients [22]. However, 93% of the studied patients were syndromic
(most of them Robin sequence). Ki-Bum Park reported a case of airway obstruction
after cleft palate repair in a 9-month-old patient. The obstruction was due to glos-
soptosis and required a tracheostomy to improve the patient’s condition [23].
Factors related to airway obstruction are associated craniofacial abnormalities,
radical muscular retroposition, laryngospasm, aspiration, and tongue edema [19].
The radical retroposition of the levator veli palatini muscle may produce mild to
moderate respiratory obstruction due to the narrowing of the velopharyngeal space.
Court Cutting has described cases of airway obstruction using his technique of
intravelar veloplasty with retroposition of the levator muscle and tenopexy [24].
A retrospective study published by van Lieshout observed postoperative respira-
tory distress in 30% of cleft palate repair in Robin sequence patients [25]. They
recommended the tongue position initial management in these patients, and treat-
ment consists of oxygen therapy, steroids, and observation in intermediate care [26].
If there is not a significant improvement, surgical correction is required.
Use of ventilation tubes is questionable. Gallagher [17] observed that there was
no greater utility using these tubes after primary cleft repair.
This is a good example why we recommend a day care surgery instead of ambu-
latory procedures so that prompt attention to the problem can be provided. In a
pediatric hospital in Shizuoka, Japan, the protocol is to extubate patients after cleft
palate repair at the ICU (intensive care unit) in order to manage an eventual airway
obstruction more effectively [27].
There are no reports about airway obstruction due to cleft lip repair; however,
immediate postoperative oxygen saturation below 80% has been reported [26]. This
could be explained because the cleft patients have a predominant oral breathing
58 P. Rossell-Perry
pattern [28]. The reduction of the air intake area due to lip and nose repair produces
some degree of obstruction, but this problem is always temporal, and the patient
recovers well after a period of adaptation.
4.5 Infection
Its association with cleft palate repair is not frequent (0.48% in our experience). The
rich vascularization of palatal tissues provides a defense against the infection.
Malnutrition is a common cause of decreased natural defenses which predisposes
the patient to infection. Other causes of immunosuppression are congenital defects
of immunity.
Zhang reported 9 cases of infection after primary palatoplasties in 2100 patients
[29], and Frolova observed 13 in 153 patients [30].
Remote infections must also be diagnosed and treated prior to surgery as they are
a common cause of operative wound infection development. Common sources in
these patients are respiratory, digestive, and urinary tract infection and skin. Gram
+ germs are more common [31, 32]. Staphylococcus aureus and B hemolytic strep-
tococcus have been found in swabs of the nose, throat, and ear of cleft lip and palate
patients [33].
We observed a case of severe infection after cleft palate repair due to an infec-
tious focus in the middle ear that was not identified and treated before surgery.
Another common cause is the presence of devitalized tissue or presence of for-
eign body (gauze). The infection is characterized by a bad smell and associated
fever. Removal of the foreign body is mandatory to control the infection as well as
the use of antibiotics. Rare infections such as calcaneal osteomyelitis have been
described after cleft palate surgery [34].
Regarding antibiotic prophylaxis, we use the UCLA Protocol of pre-incisional
antibiotics for plastic surgery in cases such as patients with difficult intubation and
history of recurrent respiratory infections. This considers a dose of first-generation
cephalosporins 1 h before the surgical incision (cefazolin 25 mg/kg is
recommended).
There is a lack of scientific validation to be used in cleft palate surgery; therefore,
it is used empirically.
4.6 Palatal Flap Necrosis (Fig. 4.5)
Soft tissue loss as a consequence of cleft palate surgery is not a frequent complica-
tion. Decrease blood supply to palatal flaps may be associated with the injury of the
palatine artery during the surgery but also associated with vascular congenital hypo-
plasia. Another event associated with this complication is the presence of hematoma
and infection.
a b
Fig. 4.5 Left: A 28-year-old patient with incomplete cleft palate undergoing primary palatoplasty
and during the sixth postoperative day has been evaluated observing a suspended necrotic muco-
periosteal flap (a). Right: A 7-year-old patient born with incomplete cleft palate who had a palatal
flap necrosis after primary palatoplasty and a severe sequel (b)
In a study carried out by us in three centers in Lima, Peru, a prevalence of 0.34%

was observed [35, 36]. Another study published by Diah observed 3.1% [37].
A case-control study observed as risk factors female sex, older age, and type of
cleft [38]. The palatal defect after flap necrosis is characterized by an extensive fis-
tula in the hard palate (Fig. 4.5). Speech, feeding, and psychosocial problems are
associated with this complication.
Necrosis of soft palate is rarer but has been observed in relation with the Furlow
technique [39].
This complication is characterized by discoloration (initially pale and then dark)
associated with bad odor few days after surgery. Signs of infection such as inflam-
mation, irritability, hyperthermia, and loss of appetite and persistent crying may be
observed. The loss of tissues with the consequent dehiscence occurs from 5 to
7 days postoperatively, and significant bleeding could be associated. Management
of this complication is based on the indication of antibiotics to prevent infection. In
cases when there is a significant bleeding, a revision of hemostasis in surgical room
is necessary. Sequels should be repaired at later age.
4.7 Premaxilla Necrosis
This is also a rare complication and can be seen after certain procedures used to
achieve a better position of the premaxilla in bilateral cleft lip and palate patients
(Fig. 4.6).
60 P. Rossell-Perry
Fig. 4.6 Patient born with

who developed a sequel
after primary cleft lip
repair with loss of the
premaxilla. The primary
palate defect can be seen
One of the associated procedures is the manual fracture of the premaxilla used
often long time ago [40]. Vomer fracture (manual or surgical) and extended dissec-
tion of the surrounding tissues during bilateral cleft lip repair may affect blood sup-
ply of this segment [41, 42]. Vomer osteotomy is not frequently indicated and very
rare during primary repair. The combination of vomer osteotomy and cheilorhino-
plasty is a risky procedure and should be avoided (see Chap. 3).
The management of this complication (in fact, a bad outcome) requires skeletal
support and mucous covering with flaps and grafts (see Chap. 3).
4.8 ssociated Complications to Surgery

A
of Velopharyngeal Insufficiency
Main complication observed in relation with velopharyngeal insufficiency surgery

is the obstruction of the airway. Use of pharyngeal flaps, sphincter pharyngoplasty,
and implants creates a reduction of the velopharyngeal space, and numerous studies
reported an increased incidence of this complication [43–47]. A severe and chronic
form of this problem is the obstructive sleep apnea [45].
Prada reported 81% of sleep apnea in patients with cleft lip and palate using the
Orticochea method (a sphincter pharyngoplasty technique).
This condition is characterized by obstruction of nasal breathing during the sleep
due to tongue retroposition forcing the breathing through the mouth with the conse-
quent snoring. Parents use to report that the child has respiratory pauses and snores
waking up during the night. These respiratory pauses are called apneas and make
children chronic mouth breathers. This condition generates poor oxygenation and
causes short- and long-term health problems. Feeding disorders, poor dental health,
morning headache, insomnia, tiredness during the day, sinusitis, cognitive disor-
ders, decreased school performance, anxiety, and depression may be observed.
Association with cardiovascular problems has been described such as pulmonary
hypertension, cor pulmonale, and sudden cardiac arrhythmia death in severe cases
[46–49]. In the long term, problems such as predisposition to diabetes and kidney
and cardiac diseases have been described. In severe cases, revision or flap removal
may be required to improve the patient’s condition.
This is the reason why any velopharyngeal insufficiency correction should be
carefully discussed with parents evaluating advantages and disadvantages of each
treatment.
Swanson observed 5.3% of complications using pharyngeal flaps in a sample of
225 patients. They recommend special care in patients with cardiological risk fac-
tors and asthma [50].
Bleeding is one of the described complications in relation to pharyngeal flap
surgery. The amount of bleeding may be significant (with transfusion requirement)
and may compromise the airway due to aspiration. The event can also be presented
up to 10 days after surgery [51, 52]. Eustachian tube obstruction and middle ear
disease have also been associated [53]. The patients may develop chronic otitis
media (Fig. 4.7). Long described affection of facial growth using pharyngeal
flaps [54].
Cases of death associated with pharyngeal flaps have been described in the litera-
ture [55–57]. Ralph Millard in his textbook Cleft Craft described the fatal event that
occurred to Schoenborn in 1886, who had 1 death in 20 cases operated using pha-
ryngeal flap.
Kindler in 1929 reported another death due to mediastinitis, and different authors
as Schroder, Skoog, and Owsley reported cases that required tracheostomy in the
postoperative period [55].
Less frequent complication is the glossopharyngeal nerve injury; this has been
described in relation with sphincter pharyngoplasties and tonsillectomies [51, 58].
Fig. 4.7 Patient with unilateral cleft lip and palate who underwent pharyngeal flap surgery in
association with primary cleft palate repair at 1 year of age. The patient developed symptoms
associated with sleep apnea, as well as chronic otitis media and sinusitis due to the obstructive
nature of this surgery. The velopharyngeal space has been dramatically reduced (very small lateral
ports can be observed)
62 P. Rossell-Perry
Carotid artery injury has also been described in patients with velocardiofacial
syndrome during this surgery. The artery may be in abnormal position in these
patients.
4.9 Alveolar Bone Graft Complications
Described complications in donor and recipient area are:

• Complications observed in the donor area depend on the chosen area for graft
taking. The most common areas are the iliac crest, tibia, olecranon, and chin.
Less frequently, the skull, femur, fibula, ribs mandibular branch, maxillary tuber-
osity, and radius may be used. The iliac crest is the most used donor site since it
provides a greater amount of cancellous bone [59]. The associated complications
described in the literature are infection, bleeding, hematoma, seroma, fracture,
nerve and vascular injury, chronic pain, hernias, and scar disorders [60, 61].
• The main complications observed in relation to the recipient area are infection,
bleeding, dehiscence, bone exposure, and graft reabsorption. Infection and
wound dehiscence including loss of the bone graft are not uncommon. These are
more associated with surgical technique deficiencies. Closure must be done
without tension and using well-designed gingivoperiosteal flaps. Antibiotic treat-
ment is required in the case of wound infection or graft exposure.
4.10 Orthognathic Surgery Complications
Complications related to the corrective surgery for dental occlusion disorders in

patients with cleft lip and palate vary in a range up to 40% [62–64].
The most important complications are as follows:
4.10.1 Relapse
Up to 60% of relapse have been described by Joss in a systematic review study [65].
This is probably due to soft tissue traction and/or skeletal instability.
4.10.2 Bleeding
This is probably the most frequent complication and can be serious and even lead to
death. The injury of large vessels such as the internal maxillary artery may be asso-
ciated with bleeding of greater magnitude [66]. These vessels, once sectioned, tend
to retract, making the hemostasis very difficult being an emergency. In a literature

review published by Silva, up to 4 l in 1 h may be observed after injury of the inter-
nal maxillary artery [67]. Late bleeding (beyond 2 weeks after surgery) has also
been described, and it is probably associated with pseudoaneurysms [68]. The ante-
rior and posterior nasal packing are initial management for bleeding control; how-
ever, external carotid artery ligation or its embolization may be necessary [66].
Controlled hypotension during anesthesia may help to decrease operative bleeding.
A clinical trial published by Choi concluded that the use of tranexamic acid
before surgery reduces bleeding in patients undergoing bimaxillary orthognathic
surgery [69].
4.10.3 Jaw Aseptic Necrosis
This severe complication has been reported and may occur in less than 1% of cases.
Observed common signs are mucous pallor, gingival retraction, tooth mobility, and
bone exposure [70]. The most frequent causes seem to be the section of vascular
pedicles.
This complication should be managed by maintenance of hygiene, antibiotic
therapy, and heparinization. Once diagnosed, the patient must be immediately reop-
erated repositioning the segment. Loss of the maxilla is a serious complication and
will require complex reconstructive surgery using bone grafts or vascularized fib-
ula flap.
4.10.4 Other Complications
Non-union of segments, unfavorable fractures, loss of teeth, periodontal disorders,

neurosensory deficit, maxillary sinusitis, nasolacrimal duct obstruction, blindness,
and death have been described by different authors as orthognathic surgery compli-
cations [71, 72].
References
1. Musgrave R, Bremner J. Complications of cleft palate surgery. Plast Reconstr Surg.

1960;26:180.
Surg. 2015;39(1):54.
3. Schneider P. Infant commissural burn management with reverse pull headgear. Pediatr Dent.
1988;10(1):34–8.
4. Rajesh M, Kuriakose S, Sukumar J, Ramdas E. Massive lingual swelling following cleft palate
repair. J Anaesthesiol Clin Pharmacol. 2013;29(2):262–3.
64 P. Rossell-Perry
5. Lee J, Kingston H. Airway obstruction due to massive lingual edema following cleft palate
surgery. Can Anaesth Soc J. 1985;32(3):265–7.
6. Chan M, Chan M, Mui K, Ho B. Massive lingual swelling following palatoplasty. An unusual
cause of upper airway obstruction. Anaesthesia. 1995;50(1):30–4.
7. Abdel-Aziz M, Ahmed A, Naquib N, Abdel-Khalik M. The effect of steroid injection of
the tongue base on reducing postoperative airway obstruction in cleft palate repair. J Oral
Maxillofac Surg. 2012;41(5):612–5.
8. Fillies T, Homann C, Meyer U, Reich A, et al. Perioperative complications in infant cleft
9. Rossell-Perry P, Schneider WJ, Gavino-Gutiérrez AM. A comparative study to evaluate a sim-
ple method for the management of postoperative bleeding following palatoplasty. Arch Plast
Surg. 2013;40(3):263–6.
procedures. Pediatr Anesth. 1992;2(2):139–45.
11. Rossell-Perry P. Cirugía de la fisura palatina. Lima: San Marcos; 2015.
12. Adeyemo WL, Ogunlewe MO, Desalu I, Ladeinde AL, Adeyemo TA, Mofikoya BO, et al.
Frequency of homologous blood transfusion in patients undergoing cleft lip and palate surgery.
Indian J Plast Surg. 2010;43:54–9.
13. Pang A, Zelken J, Dorafshar A, Strause J, et al. Congenital platelet disorder and type I Von
Willebrand disease presenting as prolonged bleeding after cleft lip and palate repair. Cleft
14. Skoll P. Surgicel in cleft palate repair. Plast Reconstr Surg. 2001;108(4):1083.
15. Durga P, Raavula P, Gurajala I, Gunnam P, Veerabathula P, et al. Evaluation of the efficacy of
tranexamic acid in the surgical field in the primary cleft palate surgery on children: a prospec-
tive randomized clinical study. Cleft Palate Craniofac J. 2015;52(5):183–7.
16. Arantes G, Pereira R, De Melo D, Alonso N, et al. Effectiveness of tranexamic acid for reduc-
ing intraoperative bleeding in palatoplasties: a randomized clinical trial. J Craniomaxillofac
Surg. 2017;45(5):642–8.
17. Gallagher S, Ferrera A, Spera L, Eppley BL, Soleimani T, Tahiri Y, Sood R, et al. Utility of
tongue stitch and nasal trumpet in the immediate postoperative outcome of cleft palatoplasty.
Plast Reconstr Surg. 2016;137(2):569–73.
18. Dorfman DW, Ciminello FS, Wong GB. Tongue suture placement after cleft palate repair. J
Craniofac Surg. 2010;21(5):1601–3.
19. Robison JG, Otteson TD. Increased prevalence of obstructive sleep apnea in patients with cleft
palate. Arch Otolaryngol Head Neck Surg. 2011;137:269–74.
20. Muntz H, Wilson M, Park A, Smith M, Grimmer JF. Sleep disordered breathing and obstruc-
tive sleep apnea in the cleft population. Laryngoscope. 2008;118:348–53.
21. Smith D, Abdullah S, Moores A, Wynne S. Post-operative respiratory distress following pri-
mary cleft palate repair. J Laryngol Otol. 2013;127:65–6.
22. Antony A, Sloan G. Airway obstruction following palatoplasty: analysis of 247 consecutive
operations. Cleft Palate Craniofac J. 2002;39(2):145–8.
23. Park K, Lee H, Jung H, Hong S. Airway obstruction following palatoplasty of a patient with
sleep disturbance. Korean J Anesthesiol. 2013;65(6):S119–20.
24. Flores R, Jones B, Bernstein J, Kamell M, Canady J, Cutting C. Tensor veli palatini preserva-
tion, transection, and transection with tensor tenopexy during cleft palate repair and its effects
on Eustachian tube function. Plast Reconstr Surg. 2010;125(1):282–9.
25. Van Lieshout M, Voshol I, Joosten K, Van der Schroeff M, et al. Respiratory distress following
cleft palate repair in children with Robin sequence. Cleft Palate Craniofac J. 2016;53(2):203–9.
26. Wood F. Hypoxia: another issue to consider when timing cleft repair. Ann Plast Surg.
1994;32(1):15–9.
27. Kanazawa T, Kawasaki T, Ueta I, Park S, Horimoto Y. Postoperative complications associ-
ated with extubation strategies following palatoplasty. A single center retrospective analysis. J
Anesth. 2016;30(1):20–5.
28. Hairfield M, Warren D, Seaton D. Prevalence of mouthbreathing in cleft lip and palate. Cleft
Palate J. 1988;25(2):135–8.
29. Zhang Z, Fang S, Zhang Q, Chen L, et al. Analysis of complications in primary cleft lips and
palate surgery. J Craniofac Surg. 2014;25(3):968–71.
30. Frolova ML, Dia C. Wound infection in the surgical treatment of children with congenital cleft
palate. Stomatologiya. 1993;72(3):66–9.
31. Costa B, Oliveira Lima J, Gomide M, Silva Rosa O. Clinical and microbiological evaluation
of the periodontal status of children with unilateral complete cleft lip and palate. Cleft Palate
Craniofac J. 2003;40(6):585–9.
32. Cocco J, Antonetti J, Burns J, Heggers J, Blackwell S. Characterization of the nasal, sublin-
gual, and oropharyngeal mucosa microbiota in cleft lip and palate individuals before and after
surgical repair. Cleft Palate Craniofac J. 2010;47(2):151–5.
33. Chuo C, Tommons M. The bacteriology of children before primary cleft lip and palate surgery.
Cleft Palate Craniofac J. 2005;42(3):272–6.
34. Insalaco L, Lee A, Scott A. Osteomyelitis following palatoplasty-A rare complication. Int J
Pediatr Otorhinolaryngol. 2017;94:52–3.
35. Rossell-Perry P. Flap necrosis after palatoplasty in patients with cleft palate. Biomed Res Int.
2015;2015:516375.
36. Rossell-Perry P, Cotrina-Rabanal O, Barranechea-Tarazona L, Vargas-Chanduvi R, et al.
Mucoperiosteal flap necrosis after primary palatoplasty in patients with cleft palate. Arch Plast
Surg. 2017;44(3):217–22.
37. Diah E, Lo L-J, Yun C, Wang R, Wahyuni LK, Chen Y-R. Cleft oronasal fistula: a review
of treatment results and a surgical management algorithm proposal. Chang Gung Med
J. 2007;30(6):529–37.
38. Rossell-Perry P, Figallo-Hudtwalcker O, Vargas-Chanduvi R, Calderón-Ayvar Y, et al. Risk
factors leading to mucoperiosteal flap necrosis after primary palatoplasty in patients with cleft
palate. J Plast Surg Hand Surg. 2017;13:1–7.
39. Furlow L. Cleft palate repair by double opposing Z plasty. Oper Tech Plast Reconstr Surg.
1995;2(4):223–32.
40. Aburezq H, Daskalogiannakis J, Forrest C. Management of the prominent premaxilla in bilat-
eral cleft lip and palate. Cleft Palate Craniofac J. 2006;43(1):92–5.
41. Freihofer HP, van Damme PA, Kuijpers-Jagtman AM. Early secondary osteotomy-stabilization
of the premaxilla in bilateral clefts. J Craniomaxillofac Surg. 1991;19(1):2–6.
42. Meazzini M, Lematti L, Mazzoleni F, Rabbiosi D, et al. Vertical excess of the premax-
illa in bilateral cleft lip and palate patients: a protocol for treatment. J Craniofac Surg.
2010;21(2):499–502.
43. Sloan G. Posterior pharyngeal flap and sphincter pharyngoplasty: the state of the art. Cleft
44. Liao Y, Noordhoof M, Huang C, Chen P, et al. Comparison of obstructive sleep apnea syn-
drome in children with cleft palate following Furlow palatoplasty or pharyngeal flap for velo-
pharyngeal insufficiency. Cleft Palate Craniofac J. 2004;41(2):152–6.
45. Pena M, Choi S, Boyiayan M, Zalzai G. Perioperative airway complications following pharyn-
geal flap palatoplasty. Ann Otol Rhinol Laryngol. 2000;109(9):808–11.
46. Paciello R, Kiemle I. Long term effects of pharyngeal flaps on the upper airways of subjects
with velopharyngeal insufficiency. Cleft Palate Craniofac J. 2008;45(4):364–71.
47. Esteller E, Barceló M, Segarra F, Estivill E, Girabent-Farrés M. Neurocognitive and behavioural
disturbances after adenotonsillectomy in obstructive sleep apnea. An Pediatr. 2014;80:214–20.
48. Prada J, Gómez V, Echeverri P, Londoño N. Prevalence of obstructive sleep apnea after
Orticochea pharyngoplasty for VPI management. Cleft Palate Craniofac J. 2015;52(6):682–7.
49. Hirschberg J. Results and complications of 1104 surgeries for velopharyngeal insufficiency.
ISRN Otolaryngol. 2012;2012:181202.
66 P. Rossell-Perry
50. Swanson J, Johnston J, Mitchell B, Alcorn K, Taylor J. Perioperative complications in poste-

rior pharyngeal flap surgery: review of the National Surgical Quality Improvement Program
Pediatric Database. Cleft Palat Craniofac J. 2016;53(5):562–7.
51. Tiner B, Waite P. Surgical and nonsurgical management of obstructive sleep apnea. In: Peterson
LJ, Indresano AT, Marciani RD, Roser SM, editors. Principles of oral and maxillofacial sur-
gery. Philadelphia: Lippincott; 1992. p. 1531–7.
52. Moore MD, Lawrence WT, Ptak JJ, Trier WC. Complications of primary palatoplasty: a
twenty-one-year review. Cleft Palate J. 1988;25(2):156–62.
53. Wan T, Wang G, Yang Y, Chen Y, Zhang Y, Liang Y, Wu Y. Analysis of postoperative bleeding
after posterior pharyngeal flap pharyngoplasty. J Craniofac Surg. 2017;28(3):600–3.
54. Long H, McNamara H. Facial growth following pharyngeal flap surgery: skeletal assessment
on serial lateral cephalometric radiographs. Am J Orthod. 1985;87(3):187–96.
55. Millard R Jr. The cleft craft. The evolution of its surgery, vol. III. 1st ed. Boston: Little Brown.
56. Valnicek SM, Zuker RM, Halpern LM, Roy WL. Perioperative complications of superior pha-
ryngeal flap surgery in children. Plast Reconstr Surg. 1994;93:954–8.
57. Wells MD, Vu TA, Luce EA. Incidence and sequelae of nocturnal respiratory obstruction fol-
lowing posterior pharyngeal flap operation. Ann Plast Surg. 1999;43:252–7.
58. Fischer I, Ludin S, Puente de la Vega K, Sturzenegger M. Neuralgia of the glossopharyngeal
nerve in a patient with post tonsilectomy scarring. Case Rep Neurol Med. 2015;2015:560546.
59. Ahlmann E, Patzakis M, Roidis N, Shepherd L, Holtom P. Comparison of anterior and poste-
rior iliac crest bone graft in terms of harvest-site morbidity and functional outcomes. J Bone
Joint Surg Am. 2002;84(5):716–20.
60. Younger EM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma.
1989;3(3):192–5.
61. Amin K, Khor W, Rosich-Medina A, Beala V. Alveolar bone graft: donor site review of 100
consecutive cases in cleft lip and palate. Cleft Palate Craniofac J. 2017;54(2):137–41.
62. Kim YK. Complications associated with orthognathic surgery. Korean Assoc Oral Maxillofac
Surg. 2017;43(1):3–15.
63. Van M, Groot J, Van Leeuwaarden Kroon R, F. Intra-operative complications in sagittal and
vertical ramus osteotomies. Int J Oral Maxillofac Surg. 1987;16:665–70.
64. Falter B, Schepers S, Vrielinck L, Lambrichts I, Thijs H, et al. Occurrence of bad split during
split osteotomy. Oral Surg Oral Med Pathol Oral Radiol Endod. 2010;110(4):430–5.
65. Joss C. Soft tissue profile changes after bilateral sagittal split osteotomy. J Oral Maxillofac
Surg. 2010;68:1260–9.
66. Lanigan D, Hey J, West R. Major vascular complications of orthognathic surgery: hemorrhage
associated with Le Fort I osteotomies. J Oral Maxillofac Surg. 1990;48(6):561–73.
67. Silva C, Turrini R. Complications in orthognathic surgery: a comprehensive review. J Oral
Maxillofac Surg Med Pathol. 2012;24:67–74.
68. Lanigan D, Hey J, West R. Major vascular complications of orthognathic surgery: false aneu-
rysms and arteriovenous fistulas following orthognathic surgery. J Oral Maxillofac Surg.
1991;49(6):571–7.
69. Choi W, Irwin M, Samman N. The effect of tranexamic acid on blood loss during orthognathic
surgery: a randomized clinical trial. J Oral Maxillofac Surg. 2009;67:125–33.
70. Hueto-Madrid J, Gutiérrez-Santamaría J. Complicaciones quirúrgicas de la cirugía
ortognática: presentación de 3 casos y revisión de la literatura. Rev Esp Cir Oral Maxilofac.
2012;34(2):56–74.
71. Lo L, Hung K, Chen Y. Blindness as a complication of the Le Fort I osteotomy for maxillary
distraction. Plast Reconstr Surg. 2002;109(2):688–700.
72. Hwang K, Choi Y. Postoperative monitoring following jaw surgery is essential. Arch Plast
Surg. 2013;40(1):66–7.
Chapter 5
Other Complications
Percy Rossell-Perry
Below are other complications related to cleft lip and palate surgery.
5.1 Body Temperature Disorders
The presence of hyperthermia during the postoperative period of cleft lip and palate
surgery is frequent and mostly associated with cleft palate surgery. High rates of
postoperative fever have been reported (up to 70%) by different authors [1, 2]. Mild
fever may be observed during the first 72 h postop, usually below 38.5 centigrade.
This event is a physiological response (increased heat production due to the
action of pyrogens released from the site of surgical injury) and seems to be associ-
ated with hydro-electrolytic disorder or lung atelectasis [1]. Other causes of fever
during the postoperative period are hematoma, bacterial pneumonia, and urinary
tract and intravenous catheter infections, although these usually present after 72 h.
Hypothermia (body temperature less than 36 centigrade) appears to be related to
direct inhibition of thermoregulation by anesthetics, decreased metabolism, use of
cold intravenous solutions, and the patient’s exposure to the cold environment. In a
study of 422 children operated under general anesthesia, hypothermia was observed
in 43.8% of cases [3]. Associated problems were delayed thermal emersion, meta-
bolic disorders, decreased ventilation, hypoglycemia, and bradycardia. Use of
devices such as thermal monitors and mattresses prevents the harmful effect of this
complication in pediatric patients [4, 5]. According to the National Institute for
Health and Care Excellence [6], some body warming measures must be taken to
maintain body temperature before entering the operating room for a minimum of
30 min. Some studies reveal that hypothermia observed after cleft lip and palate

Switzerland AG 2022
68 P. Rossell-Perry
surgery is related to the patient’s hydration deficit and prolonged fasting. Hence, it
is recommended to reduce the preoperative fasting period as much as possible [7].
5.2 Pain
Pain can be considered as a complication when crying generates increased bleeding

after cleft lip and palate surgery. Postoperative dehiscence may be associated to the
pain and crying however I do not share this opinion. This is mostly associated with
surgical deficiencies, mostly lip or palate closure under tension.
Patient’s response to the surgery is varied and individual; however, most of them
manifest agitation with crying and hyperkinesia. This should be taken in consider-
ation although crying is not always caused by pain; other reasons are hunger or fear.
In addition, crying may be the form of expression of other complications such as
hyperthermia, and any crying should be well evaluated and not underestimated.
Postoperative pain is controlled using acetaminophen in a multimodal form
(combined with intraoperative nerve blocks) [8, 9]. The dose administered is 10 mg/
kg/dose every 4–6 h and not exceeding 2000 mg/day. It may be used conditionally
after 48 h post-op. Kocaasian reported a case of acute liver failure and hepatic
encephalopathy associated with the use of acetaminophen after cleft palate repair
[10]. Another case published by Iorio described an 8-month-old cleft palate patient
who developed acute liver failure associated with postoperative use of acetamino-
phen [11].
Use of opioids are commonly used for pain management after cleft palate repair
[12, 13]. However, multimodal pain management has successfully reduced opioid-
related adverse events such as sedation, dizziness, nausea, vomiting, constipation,
respiratory depression, physical dependence, and death [14–18].
A recent systematic review published by us concluded that based on available
scientific evidence, vomiting and oxygen desaturation are associated with the use of
opioids, and definitive conclusions regarding safety of opioids to manage postop-
erative pain following primary cleft palate repair cannot be made [19].
Due to the possibility of increased postoperative bleeding, use of sedatives may
be indicated to control agitation. Single doses of midazolam (not greater than 1 mg/
kg) in association with analgesics are sufficient for agitation control during the post-
operative period [20]. Careful monitoring of patient’s breathing pattern in the PACU
should be done when sedation is performed or analgesic drugs such as morphine
were administered.
5.3 Vomiting
This complication may be associated with general anesthesia, postoperative drugs,

blood ingestion during surgery, and failure to follow preoperative fast indications. A
period of 6 h of fasting is regularly recommended.
5 Other Complications 69
In a recent systematic review about the safety of opioids in cleft palate surgery,
nausea and vomiting was the most commonly reported adverse event (ranging from
5% to 25%) associated with the use of this drug [19]. Use of multimodal analgesia
may reduce the postoperative opioid requirement. A study published by Satoh
observed an incidence of 21.7% [21]. In addition, this study identified the surgical
time as risk factor for nausea and vomiting development. Another study from China
observed nine cases of vomiting in 2100 operated patients [22]. This complication
may be associated with bleeding and aspiration.
During postoperative time of cleft palate repair, it is common to observe this
complication due to the passage of blood to the stomach during surgery. Use of
throat packs during the surgery may reduce the development of this adverse
event. An early initiation of the oral diet also causes vomiting in the postopera-
tive period. We recommend that the child may start the oral route about 2–3 h
after surgery. Management of this complication requires lateral decubitus posi-
tion of the patient to prevent risk of aspiration, aspiration of oral cavity content
to ensure that the airway is permeable, and parenteral hydration of the patient
until the oral route is tolerated. Complimentary use of antiemetic and antacid
drugs is indicated.
5.4 Diarrhea
It is defined as the change in consistency and/or number of stools during the post-
operative period. This has been associated with undetected infection process prior
to surgery or to the use of postoperative antibiotics. Use should be limited to a
few days.
A study published in Nigeria observed three cases of postoperative diarrhea in
155 studied patients [23]. Another case series study in China reported nine cases in
2100 patients [22]. Rajan and Krishnakumar in 2014 observed acute diarrhea in
17.9% of 70 patients after cleft lip and palate surgery [24]. This complication
requires a pediatrician evaluation to determine its nature. The initial management is
based on the replacement of hydro-electrolytic losses. Given the prophylactic nature
of antibiotic therapy after surgery, these drugs can be discontinued if they are sus-
pected to be the cause.
5.5 Lack of Appetite
This complication is frequent, and there is no real estimation of its magnitude due
to the lack of report in the medical literature. In addition, this is frequently underes-
timated because it is considered as part of an adaptation process and temporary in
the most of patients. This adverse event may develop other complications such as
hypoglycemia, dehydration, and weight loss. However, lack of appetite may reveal
an underlying condition that requires attention.
70 P. Rossell-Perry
Different causes seem to be associated with this problem, including pain, hypo-
glycemia, and use of general anesthesia. But the stress generated by the surgery
seems to be one of the most important.
If the condition is persistent, hydration must be compensated using dextrose
intravenously until guaranteeing the oral route and pediatrician evaluation is
necessary.
A randomized study published by Hughes concluded that nasogastric tube feed-
ing after palate surgery allowed these patients to receive an increased volume of
food compared to oral feeding [25]. However, it is unfrequently necessary to use a
nasogastric tube for feeding. Based on scientific evidence supporting oral feeding is
more physiological [26, 27]. Complications associated with the use of nasogastric
tube have been reported due to loss of integrity of the digestive tract and reflex dys-
function including aspiration pneumonia [28].
A systematic review published by Albeche regarding feeding after cleft palate
repair concluded that the sucking of food after surgery is possible and appropriate,
not observing associated complications [27]. This includes pressure bottles,
syringes, and spoons.
In our experience, use of syringes has been associated with cases of food aspira-
tion and should be used with caution and under supervision.
5.6 Hypoglycemia
Hypoglycemia is a condition observed in underweight patients or those with pro-

longed fasting. This is often underestimated. There is no report of its frequency in
the literature, but it is observed specially in surgical missions, where patients await
surgery longer than they should, prolonging the recommended fast.
The preoperative fasting period is important to prevent adverse events such as
aspiration pneumonia. This period should not exceed 6 h depending on the type of
eaten food. The intake of breast milk can be accepted up to 4 h before surgery and
clear liquids 2–3 h before [29].
Prolonged fasting periods expose the patient to low blood glucose levels and
associated complications (severe and long-lasting hypoglycemia may cause respira-
tory distress, hypothermia, hypotension, cardiac arrest, seizures, and brain
injury) [30].
The effect of hypoglycemia on the child’s physiology is deleterious because it
can lead to a stress response affecting brain autoregulation and causing neuronal
damage [31]. Children have the ability to regulate the concentration of glucose
within normal levels after an acceptable period of fasting. Surgical stress increases
also blood glucose [32, 33]. Intraoperative glucose monitoring may be recom-
mended in patients with risk (prematurity, low weight, and prolonged fasting).
The initial management is done regardless of the cause and must resort to breast-
feeding and glucose control for 30–60 min. If the oral route does not correct the
deficiency (blood glucose concentrations should be 50–60 mg/dL), intravenous
administration of glucose is indicated. After initial correction of blood glucose lev-

els, the cause must be identified and treated [33].
Case 1
A 1-year-old unilateral cleft lip and palate patient was scheduled for surgery during
surgical campaign. Preoperative evaluation based on physical exam, laboratory tests
(glucose not included), and parental information didn’t provide any contraindica-
tion for surgery. Hemoglobin: 13 g/dL
Patient was intubated on first attempt using endotracheal tube 4.5 without cuff.
The surgery was carried out smoothly with small bleeding, and 40 min after it was
started, the anesthesiologist detects cardiac arrest.
Pediatric advanced resuscitation maneuvers were performed. Rhythmic chest
compression was done, and a dose of epinephrine 0.01 mg/kg was administered.
Patient comes out quickly of cardiac arrest (less than 1 min). The surgical procedure
continued and concluded without other complications. After surgery, the reason of
this complication was not clear, and we presumed an association with use of halo-
genated anesthetic. However, after a complementary interview to the parents, they
revealed that the patient was fasting during 24 h. Apparently, dehydration and hypo-
glycemia were the associated factors that predisposed the complication. Controls of
arterial gases and hemoglobin were carried out observing normal values, and patient
evolved without other complications.
5.7 Seizures
It is defined as sudden abnormal electrical brain activity. It may be presented during

anesthesia induction or postoperatively (up to 72 h later). It is more common in the
pediatric population compared to adults. This complication can be associated with
hypoxic brain damage, cardiac arrhythmias, neurogenic pulmonary edema, sudden
death, postoperative apnea, and delay in patient’s awakening from anesthesia. It was
found in three cases of cleft lip and palate patients operated by an international
organization in Vietnam, who had postoperative seizures that ended in death [34].
Postoperative seizures would be related to hypoxia during surgery, hypoglyce-
mia or hyperpyrexia, as well as drug interaction (e.g., lidocaine). Use of lidocaine
as local anesthetic has been associated with the development of seizures apparently
due to intravascular injection [35].
The diagnosis of epilepsy (disorder in which nerve cell activity in the brain is
disturbed causing seizures) should be ruled out in all patients who develop periop-
erative seizures. It could occur more frequently in syndromic patients as in Walker-
Walburg syndrome [36]. Initial management is to establish a probable cause, and the
first measure is to improve ventilation by permeabilizing the airway as well as pro-
tecting the patient from violent movements and monitoring vital signs. Use of ben-
zodiazepines is recommended in cases of seizures that last more than 5 min and
phenobarbital in refractory cases.
72 P. Rossell-Perry
5.8 Hearing Disorders
Most common complications are presented below.
5.8.1 Otitis Media
Associated with the presence of cleft palate. Flynn et al. reported up to 74.7% of
otitis media with effusion [37], Sancho reported 84.8% [38], and Dhillon up to 97%
in children with cleft palate under 1 year [39]. The pathophysiological mechanisms
that explain this complication are related to the inflammatory changes around the
eustachian tube due to velopharyngeal sphincter dysfunction [40, 41]. The incom-
petence of this sphincter alters the bacterial flora favoring the infections process in
the middle ear [40].
Although common, it appears to be temporary in most patients, and the resolu-
tion of eustachian tube dysfunction is observed in 50% after repair of the cleft pal-
ate [39].
A study published by Alper et al. concluded that resolution of this complication
was observed in most of the studied patients [42].
Long-term tympanometric and audiological findings were evaluated by Tuncbilek
et al. showing that hearing function is relatively good in patients who did not receive
ear tubes [43]. The indication for ear tubes is limited to cases of recurrent otitis
media [44, 45]. A study published by Phua et al. concluded that the use of ear tubes
is recommended only in patients with symptomatic infection or significant associ-
ated hearing loss [46].
This condition is characterized by decreased hearing, pain, fever, and
leukocytosis.
Pain predominates in acute otitis media and hearing disorders in chronic forms.
Otorrhea may be present if there is infection. Otoscopic findings in acute otitis
media are characterized by reddening and bulging with or without collection. In
complicated chronic otitis media, perforation and retraction of the tympanic mem-
brane may be observed. Standard treatment included systemic and topical antibiot-
ics [46].
A study published by Paradise et al. suggested that breastfeeding has a protector
effect against the development of otitis media in patients with cleft palate [47].
5.8.2 Cholesteatoma
It is a complication associated with chronic otitis media. Up to 5.9% risk of choles-

teatoma has been reported in patients with cleft palate [48], and it is more common
between the ages of 2 and 6 years [49]. Accumulation of keratinized skin epithelium
within the middle ear is the cause of this problem. It is characterized by a history of
cleft palate and recurrent ear infections associated with hearing loss and occasion-
ally earache and otorrhea not improved by conventional treatment.
During otoscopic examination, collection, otorrhea, and tympanic perforation
can be seen. Audiometric evaluation may confirm conductive hearing loss. Osteitis
and surrounding bone destruction are described, and other complications have been
described such as deafness, facial paralysis, and meningitis [50]. Early detection of
cholesteatoma in patients with risk is important, and CT scan is justified. The indi-
cated treatment is surgical.
5.8.3 Hearing Loss
Auditory function disturbance is frequent in cleft palate population, being reported

in up to 75%, according to Dmello et al. [51]. The most common cause of hearing
dysfunction in these patients is acute otitis media with effusion (“ear glue”). It is
considered as conductive hearing dysfunction [52]. Neurosensorial deafness is rare
in patients with cleft palate and is more related to syndromic cases. Hearing dys-
function is confirmed by audiometry, and the use of hearing aids can improve this
condition.
5.9 Dentoskeletal Complications
Dental and skeletal complications are common in cleft lip and palate patients.
A systematic review and meta-analysis published by Nivoloni in 2012 observed
a high number of dental anomalies in permanent dentition in these patients [53].
The most common complications are presented below.
5.9.1 Dental Caries
A common problem due to dental malposition and poor hygiene habits, requiring
prevention and treatment (Fig. 5.1)
In a study developed in the United Kingdom, up to 40% of the cleft patients at
5 years old had dental caries [54]. A meta-analysis done by Worth et al. in England
has shown that patients with cleft lip and palate have a higher prevalence of caries
[55]. Similar conclusions were observed in another meta-analysis made by
Antonarakis et al. in Canada [56].
Richards et al. found an association between the palatal fistulas and development
of dental caries in these patients [57].
74 P. Rossell-Perry
Fig. 5.1 Four-year-old

patient with unilateral cleft
lip and palate and decidua
teeth with tooth decay
Factors related to dental caries are poor dental hygiene, presence of cleft palate,
enamel hypoplasia, use of intraoral plates, as well as use of orthodontic mecha-
nisms. Dental caries may be associated with other complications such as loos of
teeth, periodontal disease, and malocclusion. Adequate dental and periodontal
hygiene is necessary to prevent this condition. The visit to pediatric dentist should
start around the age of 2, and treatment should include oral prophylaxis, instructions
on oral hygiene, and dental restoration.
5.9.2 Periodontal Disease
It is a chronic inflammatory condition of the gums, which is characterized by bleed-

ing and halitosis, commonly observed in cleft lip and palate patients (Fig. 5.2). This
condition may generate loss of teeth due to gum retraction associated with dental
exposition and bone resorption [58]. Preventive measures and proper dental hygiene
are recommended. Surgical treatment may be necessary in severe forms to prevent
bone resorption.
5.9.3 Dental Anomalies
Abnormal growth and eruption of the dental pieces may affect the adjacent teeth.

developed periodontal
disease and dental caries
Alterations in number, shape, size, color, position, and development can be

observed in patients with cleft lip and palate. Anodontia or hypodontia is frequent
in these patients.
A study published by Konstantonis et al. in Greece showed dental agenesis in
50% of 154 studied patients. The most affected tooth was the upper lateral inci-
sor [59].
This condition makes dental hygiene more difficult favoring the development of
caries and periodontal disease. Ectopic tooth eruption is also common. Dental
pieces can be located at the hard palate or even into the nose (Figs. 5.3 and 5.4).
5.9.4 Maxillary Hypoplasia and Malocclusion
The frequency of this multifactorial complication is variable, being reported in up

to 40% of patients [60]. It is a consequence of different factors including cleft lip
and palate surgery. Poor development of the upper jaw causes an alteration of the
dental occlusion (Fig. 5.5). Orthodontics and/or orthognathic surgery is required for
its correction. The nature of this complication has been a subject of scientific debate
since it is presumed to be a consequence of primary cleft palate repair at an early
age. Different surgical protocols have been developed to prevent this complication.
The use of two stages (more common in Europe) are based on retrospective studies
that do not allow to confirm an association.
Currently, there are some clinical trials, systematic review, and meta-analysis
[61–63] which seem to indicate that there are no differences between one and two
surgical times regarding facial growth disturbance.
76 P. Rossell-Perry
Fig. 5.3 Eight-year-old

patient, born with
unilateral cleft lip and
palate who has an ectopic
tooth at the left nostril
Fig. 5.4 Adult patient with

incomplete cleft palate
palatoplasty developing a
severe palatal fistula. In
addition, the patient
present ectopic location of
dentition
Associated factors to this complication are cleft lip and palate repair, surgeon
skills, dental hygiene, cleft severity, hereditary factors, and others [60, 61].
A recent randomized clinical trial study made by Ozawa et al. from Brazil con-
cluded that the surgeon is the major factor that influenced the maxillary develop-
ment and dental occlusion. In addition, this complication was not influenced by lip
and palate repair technique or patient age at the time of surgical repair [64].
Based on the available evidence, it is difficult to ensure that early primary hard
palate surgery is the cause of the maxillary hypoplasia. Two-stage palatoplasty
favors the development of fistulas and dehiscence requiring additional surgeries and
more affection of the maxilla development [65, 66].
a b
Fig. 5.5 Dental occlusion articulated cast of a 5-year-old patient with cleft lip and palate who was
operated using palatoplasty without lateral relaxing incisions at 1 year of age, developing Class III
malocclusion. (a) Lateral view. (b) Frontal view
a b
Fig. 5.6 Unilateral cleft lip and palate patient who was operated for cleft palate repair at 1-year-
old. Developed wound dehiscence due to a history of trauma introducing a pencil into the mouth
by accident few days after the operation. (a) Preoperative view. (b) Postoperative view
5.10 Trauma (Fig. 5.6)
Given the restless nature of children and their instability during the learning process
of wandering, the chance of trauma to the operative wound is a possible
complication.
We have observed cases of accidents and trauma with partial or total dehiscence
of the surgical wound. Insertion of objects into the oral cavity is common among
children, and this behavior may produce trauma and dehiscence in patients after
cleft palate repair.
78 P. Rossell-Perry
For this reason, the use of splints in the upper limbs has been popularized, to
avoid contact of the hands or introduce objects into the mouth.
Different studies (including clinical trials) have evaluated the utility of these
devices, and no efficacy has been demonstrated [67, 68]. Conversely, the use of arm
splints generates discomfort and stress in children. Management of this complica-
tion depends on the nature of the wound damage generated by the trauma. Immediate
surgical repair is indicated in most of the cases.
5.11 Psychosocial Disorders
These are just as important as most of the complications mentioned here because
they are probably most difficult to be treated. Self-esteem and psychosocial adjust-
ment to the environment seem to be the most frequent. Different studies have high-
lighted the importance and impact of this problem in patients with cleft lip and
palate. In a systematic review published by Hunt [69], they observed that most of
the managed patients did not present major psychological issues. However, behav-
ioral disorders, learning problems, interpersonal relationship disorders, school bul-
lying, depression, and anxiety have been described. Other studies have found no
differences between a group of cleft patients and control group in relation to the
development of depression [70]. This complication requires the use of protocols
that allow to provide an optimal aesthetic and functional improvement of the lip,
nose, and palate at early age considering fewer number of surgeries in order to pre-
vent the impact of the outcomes on the psychosocial adaptation of the child.
5.12 Tumors
Oral and lingual mucosal neoplasms have been associated with a history of scarring
[71]. There are no reports of the development of oral mucosa cancer in scars from
cleft lip and palate surgeries. But interestingly, there is a report of a papilloma
developed in the lingual tissue used for fistula closure [72]. Another report in the
literature was made by Desai, who described a case of hairy polyp associated with
cleft palate [73]. These long-term complications (although rare) require careful
monitoring of patients.
5.13 Vascular Disorders
A proven case of vascular infarction of the posterior fossa has been reported in the
literature, in a 1-year-old non-syndromic unilateral cleft lip and palate patient.
Although of rare presentation, it is a serious complication that had a fatal out-

come [74]. This patient was operated on for a cleft palate using Furlow technique
having an immediate postoperative normal evolution. Fourteen hours after surgery,
the patient develops respiratory distress and seizures. MRI study showed extensive
infarction of the cranial posterior fossa. Authors of this article associated the event
with excessive extension of the neck. This maneuver can produce an occlusion of
the vertebral arteries at the foramen arcuate level. Therefore, it is recommended to
limit the extension of the neck during palatoplasties [75].
5.14 Death
The frequency of this complication is low according to the different reviewed

reports.
The risk of death for a healthy patient undergoing general anesthesia is 1 in
200,000–400,000; however, in patients with congenital diseases such as cleft lip and
palate, the incidence is higher. The highest mortality was reported by Brophy in
1923, which was 5.2% [76]. Wilhelmsen and Musgrave reported two deaths in a
series of 585 cleft lip surgeries (0.34%) in 1964. Both cases occurred in the postop-
erative period, and autopsies revealed acute respiratory infections [77]. Fogh-
Anderson in 1946 have reported up to 5% of mortality after cleft lip surgery and
0.55% mortality after cleft palate repair.
A literature review made by Musgrave and Bremner in 1960 reported a range
from 0 to 3.8%. The same authors reported two deaths in 780 palatoplasties (0.26%)
[78, 79].
First case was a syndromic cleft palate patient, and the death was associated with
unspecified anesthetic problem. The second reported case was a 23-month-old
patient operated using pushback technique with primary pharyngeal flap. After the
autopsy, they concluded that death may be caused by the volume of blood loss and
asphyxia. Based on these reports, mortality seems to be more related to child’s age
than the type of surgery. This conclusion is shared by Conway observing higher
mortality in the cleft lip group of patients compared to the group of palatoplasties
(1.17% vs 0.29%) [80].
The causes reported in this study were septicemia, respiratory failure, inadver-
tent extubation with heart failure, postoperative aspiration, and massive bilateral
atelectasis.
A report published by Mackeprang about deaths related to cleft palate repair
observed 1838 cases of a total of 12,553 operated patients, and 95% of the cases
occurred in children under 1 year of age [81]. The same study concluded that a cleft
lip and palate child has five times greater risk of death within the first year of life
compared to the normal population and prematurity, low birth weight, and associ-
ated congenital malformations (Robin sequence in special) were associated factors
to higher mortality.
80 P. Rossell-Perry
In a meta-analysis study published by Carlson in 2013, they concluded that com-

pared to the general population, cleft infants have nine times increased risk of death
during the first year of life [82]. Recently, Zhang reported three cases of death in
2100 operated cleft lip and palate patients (0.14%) [22].
Regarding the group of syndromic cleft lip and palate patients, a study published
by Van Nunen in the Netherlands observed higher mortality (2.09%) after primary
surgeries [83].
The reported cases in the literature seem to indicate that the majority of deaths
related to cleft lip and palate surgery are due to respiratory compromise, and the risk
factors are age, prematurity, associated malformations, and birth weight. Other risk
factors to be considered are acute respiratory, digestive, and urinary infection, non-
compliance with preoperative fasting indications, and prolonged fasting. Accidents
are a relatively frequent event in this complication such as postoperative aspiration
of food. In our experience, we had a case of death after primary cleft lip repair
related to postoperative food aspiration and respiratory distress.
Case 2
A 3-month-old cleft lip and palate patient was scheduled for lip repair. Her preop-
erative evaluation was completed without any contraindication for surgery. Weight:
6 kg. Hemoglobin: 10 g/dL. Preoperative fasting was confirmed. Anesthetic induc-
tion and endotracheal intubation without complications. Anesthesia was performed
by a pediatric cardiac anesthesiologist, and the cleft lip was repaired without com-
plications (bleeding, 9 cc). Patient was extubated awake and went to PACU in stable
condition. Surgeon and anesthesiologist evaluation was performed 3 h later, and the
patient was in good condition. Six hours after the surgery, the surgeon receives a
phone call from the nurse indicating respiratory distress. The anesthesiologist is
communicated, and she provides indications for patient management including ste-
roids, bicarbonate, and oxygen therapy. Two hours later, due to the lack of response
to the provided treatment, the anesthesiologist visits the patient and confirms her
poor condition. An X-ray reveals veiling of both lungs. Patient was intubated and
transferred to the ICU unit and dying 2 h later due to cardiac arrest refractory to
treatment. Autopsy revealed diffuse alveolar damage and presence of carbohydrates
and fat in the airway. During the legal process, it was known that the patient aspi-
rated during food administration by the nurse around midnight.
References
1. Duffy M. Fever following palatoplasty: an evaluation based on fever volume. Plast Reconstr
Surg. 1966;38(1):32–5.
2. Liang H, Zhang M, Wen Y, Xu X, Mao Z, She Y, Liu P. The incidence of and risk factors for
postoperative fever after cleft repair surgery in children. J Pediatr Nurs. 2019;45:e89–94.
3. Crisóstomo-Pineda M, Hernández-Pérez A, Ordóñez-Espinoza G, Riera-Kinkel C. La hipoter-
mia y sus efectos durante la anestesia en niños. Rev Mex Pediatr. 2011;78(4):131–8.
4. John M, Ford J, Harper M. Perioperative warming devices: performance and clinical applica-
tions. Anesthesia. 2014;69:623–8.
5. Bissonnette B. Temperature monitoring in pediatric anesthesia. Int Anesthesiol Clin.
1992;30(3):63–76.
6. Radauceanu D, Dragnea D, Graig J. NICE guidelines for inadvertent peri-operative hypother-
mia. Anaesthesia. 2009;64(12):1381–2.
7. Yi J, Lei Y, Xu S, Si Y, et al. Intraoperative hypothermia and its clinical outcomes in patients
undergoing general anesthesia: national study in China. PLoS. 2017;12(6):e0177221.
8. Ribeiro Soares P, Nivaldo A. Protocols in cleft lip and palate treatment: systematic review.
Plast Surg Int. 2012;2012:562892.
9. Bandyopadhyay R, Paul A. Postoperative analgesia for cleft lip and palate repair in children. J
Anaesthesiol Clin Pharmacol. 2016;32(1):5–11.
10. Kocaasian N, Tunar F, Tutar E, Celebiler O. Acute liver failure and hepatic encephalopathy
after cleft palate repair. Cleft Palate Craniofac J. 2015;52(5):629–31.
11. Iorio M, Cheerharen M, Kaufman S, Reece-Stremtan S, et al. Acute liver failure follow-
ing cleft palate repair: a case of therapeutic acetaminophen toxicity. Cleft Palate Craniofac
J. 2013;50(6):747–50.
procedures. Paediatr Anaesth. 1992;2:139–45.
13. Roulleau P, Gall O, Desjeux L, Dagher C, Murat I. Remifentanil infusion for cleft palate sur-
gery in young infants. Paediatr Anaesth. 2003;13(8):701–7.
14. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation.
Br J Anaesth. 1997;78(5):606–17.
15. Michelet D, Andreu-Gallien J, Bensalah T, Hilly J, Wood C, Nivoche Y, et al. A meta-analysis
of the use of nonsteroidal antiinflammatory drugs for pediatric postoperative pain. Anesth
Analg. 2012;114(2):393–406.
16. Thota R, Ramkiran S, Garg R, Goswami J, Baxi V, Thomas M. Opioid free onco-anesthesia. Is
it time to convict opioids? A systematic review of the literature. J Anaesthesiol Clin Pharmacol.
2019;35(4):441–52.
17. Nelson KL, Yaster M, Kost-Byerly S, Monitto CL. A national survey of American Pediatric
Anesthesiologists: patient-controlled analgesia and other intravenous opioid therapies in pedi-
atric acute pain management. Anesth Analg. 2010;110(3):754–60.
18. Justin G, Brietzke S. Cleft lip and cleft palate surgery: malpractice litigation outcomes. Cleft
19. Rossell-Perry P, Romero-Narvaez C, Rojas-Sandoval R, Gomez-Henao P, Delgado-Jimenez
MP, Marca-Ticona R. Is the use of opioids safe after primary cleft palate repair? A systematic
review. Plast Reconstr Surg Glob Open. 2021;9(1):e3355.
20. Wilton N, Leigh J, Rosen D, Pandit U. Preanesthetic sedation of preschool children using
intranasal midazolam. Anesthesiology. 1988;69(6):972–5.
21. Satoh K, Aizawa T, Kobayashi Y, Okui T, Takehara Y. Clinical study on postoperative nausea
and vomiting in pediatric patients with cleft lip and/or palate. Part 1. Assessment of incidence
and risk factors. Fujita Med J. 2018;4(2):42–4.
23. Adesina OA, Efunkoya AA, Omeje KU, et al. Postoperative complications from pri-
mary repair of cleft lip and palate in a semi-urban Nigerian teaching hospital. Niger Med
J. 2016;57(3):155–9.
24. Sheeja Rajan T, Krishnakumar K. Early postoperative complications and duration of hospital
stay after primary palatoplasty. J Evid Based Med Healthc. 2014;1(2):36–40.
25. Hughes J, Lindup M, Wrigth S, Nalk M, et al. Does nasogastric feeding reduce distress after
cleft palate repair in infants? Nurs Child Young People. 2013;25(9):26–30.
26. Kumar Jindal M, Khan SY. How to feed cleft patient? Int J Clin Pediatr Dent. 2013;6(2):100–3.
82 P. Rossell-Perry
27. Albeche G, Bossardi R, Almeida M. Feeding methods for children with cleft lip and palate: a
systematic review. Braz J Otorhinolaryngol. 2016;82(5):602–9.
28. Gomes G, Pisani J, Macedo E, Campos A. The nasogastric feeding tube as a risk factor for
aspiration and aspiration pneumonia. Curr Opin Clin Nutr Metab Care. 2003;6(3):327–33.
29. Rossell-Perry P. Tratamiento de la fisura labio palatina. 1st ed. Lima: San Marcos; 2009.
30. Ayala W, Burgstaller H, Lauber C, Noya B, López G, Monteiro K, et al. Modificaciones de
glicemia y natremia en anestesia pediátrica con la administración de SLR y suero tercio salino.
Anest Analg Reanim. 1996;13:40–53.
31. Nilsson K, Larsson LE, Andreasson S, Ekstron-Jodal B. Blood glucose concentration during
anaesthesia in children. Br J Anaesth. 1984;56:375–9.
32. Gosche H, Bar E, Girard J, Leutenegger A, Niederer W, Oberholzer M, et al. Glucagon, insu-
lin, cortisol and growth hormone levels following major surgery: their relationship to glucose
and free fatty acid elevations. Horm Metab Res. 1978;10:465–70.
33. Hamaji M, Nakao K, Kis K. Pancreatic glucagon and insulin response during surgery. Horm
Metab Res. 1979;11:488–9.
34. Link: http://www.thanhniennews.com/health/medical-charity-suspended-during-investigation-
ofinfant-deaths-in-central-vietnam-30364.html
35. Xhang-Xian H, Yung-Chi H, Chen-Hwan C, Chun-Chieh L, et al. Grand mal seizure
induced by low-dose fentanyl and lidocaine in a young child. Acta Anaesthesiol Taiwan.
2015;53(3):105–8.
36. Vajsar J, Baskin B, Swoboda K, Biggar D, et al. Walker-Warburg syndrome with POMT1
mutations can be associated with cleft lip and palate. Neuromuscul Disord. 2008;18(8):675–7.
37. Flynn T, Moller C, Jonsson R, Lohmander A. The high prevalence of otitis media with effu-
sion in children with cleft lip and palate as compared to children without clefts. Int J Pediatr
Otorhinolaryngol. 2009;73(10):1441–6.
38. Sancho M, Villafruela S, Álvarez V. Incidence and treatment of otitis with effusion in patients
with cleft palate. Acta Otorrinolaringol Esp. 1996;48(6):441–5.
39. Dhillon R. The middle ear in cleft palate children, pre and post palatal closure. J R Soc Med.
1988;81:710–3.
40. Gopalkrishna A, Goleria K, Raje A. Middle ear function in cleft palate. Br J Plast Surg.
1984;37:558–65.
41. Sheahan P, Miller I, Sheahan J, Earley M, et al. Incidence and outcome of middle ear disease
in cleft lip and/or palate. Int J Pediatr Otorhinolaryngol. 2003;67:785–93.
42. Alper C, Loose J, Seroky J, Mendel E, et al. Resolution of middle otitis with effusion in chil-
dren with cleft palate followed through 5 years of age. Cleft Palate Craniofac J. 2016;53(5):
607–13.
43. Tuncbilek G, Ozgur F, Belgin E. Audiologic and tympanometric findings in children with cleft
lip and palate. Cleft Palate Craniofac J. 2003;40:304–9.
44. Ramana Y, Nanda V, Biswas G, Chittoria R, et al. Audiological profile in older children and
adolescents with unrepaired cleft palate. Cleft Palate Craniofac J. 2005;42:570–3.
45. Zheng W, Smith J, Shi B, Li U, et al. The natural history of audiological and tympanometric
findings in patients with unrepaired cleft palates. Cleft Palate Craniofac J. 2009;46(1):24–9.
46. Phua Y, Salkeld L, De Chalain T. Middle ear disease in children with cleft palate: protocols for
management. Int J Pediatr Otorhinolaryngol. 2009;73(2):307–12.
47. Paradise J, Elster B, Tan L. Evidence in infants with cleft palate that breast milk protects
against otitis media. Pediatrics. 1994;94(6):853–60.
48. Domínguez S, Hraker L. Incidence of cholesteatoma with cleft palate. Ann Otol Rhinol
Laryngol. 1988;97(6):659–60.
49. Vincenti V, Marra F, Bertoldi B, Tonni D, et al. Acquired middle ear cholesteatoma in chil-
dren with cleft palate: experience from 18 surgical cases. Int J Pediatr Otorhinolaryngol.
2014;78(6):918–22.
50. Hafidh M, Keogh I, Walsh R, Walsh M, et al. Otogenic intracranial complications: a 7 year
retrospective review. Am J Otol. 2006;27(3):390–5.
51. Dmello J, Kumar S. Audiological findings in cleft patients attending speech camp. Indian J
Med Res. 2007;125:777–82.
52. Goudy S, Lott D, Canady J, Smith R. Conductive hearing loss and otopathology in cleft palate
patients. Otolaryngol Head Neck Surg. 2006;134:946–8.
53. Nivoloni P, Oliveira C, Cople L, Vieira A, et al. Prevalence of dental anomalies in non-
syndromic individuals with cleft lip and palate: a systematic review and meta-analysis. Cleft
54. Williams A, Bearn D, Mildinhalls S, et al. Cleft lip and palate care in the United Kingdom: the
clinical standards advisory group study. Part 2: Dentofacial outcomes and patient satisfaction.
55. Worth V, Perry R, Ireland T, Wills A. Are people with an orofacial cleft at a higher risk of
dental caries? A systematic review and meta-analysis. Br Dent J. 2017;223(1):37–47.
56. Antonarakis G, Palaska P, Herzog G. Caries prevalence in non-syndromic patients with cleft
lip and/or palate: a meta-analysis. Caries Res. 2013;47(5):406–13.
57. Richards H, van Bommel A, Clark V, Richard B. Are cleft palate fistulae a cause of dental
decay? Cleft Palate Craniofac J. 2015;52(3):341–5.
58. Moreyra A, Magalhaes C, Conceicao R, De Souza N. Enfermedad periodontal en el paci-
ente con hendidura del labio y/o paladar. Una revisión de la literatura. Rev Fundac Juan Jose
Carraro. 2005;10(20):31–5.
59. Konstantonis D, Alexandropoulos A, Knostantoni N, Nassika M. A cross-sectional analysis of
the prevalence of tooth agenesis and structural dental anomalies in association with cleft type
in non-syndromic oral cleft patients. Prog Orthod. 2017;18(1):20.
60. Lee JC, Slack GC, Walker R, Graves L, Yen S, Woo J, Ambaram R, Martz MG, Kawamoto
HK Jr, Bradley JP. Maxillary hypoplasia in the cleft patient: contribution of orthodontic dental
space closure to orthognathic surgery. Plast Reconstr Surg. 2014;133(2):355–61.
61. Rossell-Perry P, Cotrina-Rabanal O, Figallo-Hudtwalcker O, González-Vereau A. Effect of
62. Rautio J, Andersen M, Bolund S, Hukki J, et al. Scandcleft randomized trials of primary surgery
for unilateral cleft lip and palate. 2. Surgical results. J Plast Surg Hand Surg. 2017;51(1):14–20.
63. Reddy R, Reddy G, Vaidhyanathan A, Berge S, et al. Maxillofacial growth and speech outcome
after one-stage or two-stage palatoplasty in unilateral cleft lip and palate. A systematic review.
J Craniomaxillofac Surg. 2017 Jun;45(6):995–1003.
64. Ozawa TO, Dutka JCR, Garib D, Lauris RCMC, Almeida AM, Brosco TVS, et al. Influence
of surgical technique and timing of primary repair on interarch relationship in UCLP: a ran-
domized clinical trial. Orthod Craniofac Res. 2021;24(2):288–95. https://doi.org/10.1111/
ocr.12435.
65. Sommerlad B. A technique for cleft palate repair. Plast Reconstr Surg. 2003;112(6):1542–8.
66. Gundlach KK, Bardach J, Filippow D, Stahl-de Castrillon F, Lenz JH. Two-stage palatoplasty,
is it still a valuable treatment protocol for patients with a cleft of lip, alveolus, and palate? J
Craniomaxillofac Surg. 2013 Jan;41(1):62–70.
67. Jigjinni V, Kangesu T, Sommerlad B. Do babies require arm splints after cleft palate repair? Br
J Plast Surg. 1993;46(8):681–5.
68. Oxley J. Are arm splints required following cleft lip/palate repair? Paediatr Nurs.
2001;13(1):27–30.
69. Hunt O, Burden D, Hepper P, Johnston C. The psychosocial effects of cleft lip and palate: a
systematic review. Eur J Orthod. 2005;27:274–85.
70. Santos-Lima L, Nascimento Aquino S, Madalena-Volpe F, Reis D, et al. Prevalence of depres-
sive symptoms in patients with cleft lip and palate. Braz J Otorhinolaryngol. 2015;81(2):177–83.
71. Kerawala C, Roques T, Jeannon J, Bisase B. Oral cavity and lip cancer. J Laryngol Otol.
2016;130(Suppl 2):S83–9.
72. Ragavan M, Haripriya U, Rajesh Kumar S. Nasal papilloma, a rare late complication of tongue
flap repair of palatal fistula. Cleft Palate Craniofac J. 2013;50(4):491–3.
84 P. Rossell-Perry
73. Desai A, Kumar N, Waipayee M, Jatania H. Cleft palate associated with hairy polyp: a case
report. Cleft Palate Craniofac J. 2013;50(5):610–3.
74. Brown M, Verheyden C. Posterior fossa infarction following cleft palate repair and the arcuate
foramen. Plast Reconstr Surg. 2009;124(5):237–9e.
75. Yu J, Park JY, Kim DH, Koh GH, Kim S, Hwang JH, Oh TS, Kim YK. Effect of neck exten-
sion on ultrasonographic optic nerve sheath diameter as a surrogate for intracranial pressure in
patients undergoing palatoplasty: a prospective observational study. J Plast Reconstr Aesthet
Surg. 2020;73(2):369–75.
76. Brophy T. Cleft lip and palate. Philadelphia: Blakiston; 1923. p. 257.
77. Wilhelmsen H, Musgrave R. Complications of cleft lip surgery. Presentado en: Congreso
Sociedad Americana de Cirugía Plástica San Francisco. 1964.
78. Fogh-Andersen P. Hare lip and cleft palate: 1,000 patients submitted to operation. Acta Chir
Scand. 1946;94:213–42.
79. Musgrave R, Bremner J. Complications of cleft palate surgery. Plast Reconstr Surg.
1960;26:180.
80. Conway H, Bromberg B, Hoehn R, Hugo N. Causes of mortality in patients with cleft lip and
palate. Plast Reconstr Surg. 1966;37(1):51–61.
81. Mackeprang M, Hay S. Cleft lip and palate mortality study. Cleft Palate J. 1972;9:51–63.
82. Carlson L, Hatcher K, Vander Burg R. Elevated infant mortality rates among oral cleft and
isolated cleft cases: a meta-analysis of studies from 1943 to 2010. Cleft Palate Craniofac
J. 2013;50(1):2–12.
83. Van Nunen D, Van den Boogaard M, Don Griot P, Ruttermann M, et al. Elevated infant mortal-
ity rate among Dutch oral cleft cases: a retrospective analysis from 1997 to 2011. Front Surg.
2014;1(8):48.
Chapter 6
Bad Results in Unilateral Cleft Lip
Surgery
Percy Rossell-Perry
6.1 Introduction
The unilateral cleft lip is the most common form of presentation of this congenital
disease. It can be presented in isolation or associated with the primary or secondary
cleft palates.
The bad outcomes observed seem to be related to severity of the cleft and surgi-
cal technique used [1, 2]. However, the surgeon’s experience is probably the most
important factor to be considered in relation to the quality of surgical outcomes.
In craniofacial reconstructive surgery, the soft tissues are repaired before the
skeleton and creates a difficult scenario increasing the rate of non-desirable out-
comes. This limitation may be improved with the use of presurgical orthopedics
placing the segments in a more anatomical position; however, this method does not
have a proven efficacy based on the scientific evidence.
There are many surgical techniques for cleft lip repair, and all of them have
advantages and disadvantages depending on the form in which the surgeon executes
them. The unilateral whistler deformity is the most common bad outcome after
unilateral cleft lip repair. This is characterized by lip’s asymmetry due to a shorter
lip and seems to be more associated with rotation advancement techniques and scar
disorders. Secondary unilateral cleft nose deformities are mostly associated with
primary rhinoplasty deficiencies. Use of pre- and postoperative nasal moldings does
not have a proven efficacy based on the scientific evidence available at this time.
Below, I am presenting an analysis of the advantages and disadvantages observed
after using different techniques for unilateral cleft lip repair. This analysis may help
surgeons understand how the bad outcome is developed and prevent it.

Switzerland AG 2022
86 P. Rossell-Perry
6.1.1 Straight Line Techniques (Figs. 6.1 and 6.2)
The first straight line incision in the literature was described by Ambroise Pare in
1568 [3]. During modern times, this technique lost popularity, and the rotation
advancement and triangular techniques are the most widely accepted actually.
Carlos Navarro, Peruvian plastic surgeon with extensive experience in cleft lip and
palate surgery, proposed the use of limited incisions for correction of unilateral cleft
lip in order to obtain a better cosmetic result. This author published his minimal
incision technique in series of cases operated in Peru [4].
The method is supported by the Rose-Thompson effect and muscular interdigita-
tion and has some advantages and disadvantages to be considered.
Fig. 6.1 The straight line technique for unilateral cleft lip repair
Fig. 6.2 Five-year-old patient born with unilateral cleft lip after undergoing lip repair using a
straight line technique. The photo illustrates the lip asymmetry (A–B > a–b) (A–x > x–a) and the
development of hypertrophic scar
6 Bad Results in Unilateral Cleft Lip Surgery 87
Its greatest advantage is the possibility of obtaining a less visible scar, located
between the aesthetic units of the lip. Additionally, this incision makes easier any
correction of secondary deformity.
The main disadvantage is the sacrifice of lip tissue to obtain a longer incision.
This method extends the lip incisions to provide an adequate length of the upper lip.
In most of the cases, it is not possible to obtain a linear scar and preserve the dimen-
sions of the upper lip. This technique may provide a linear scar but creates an asym-
metric lip. In addition, the increased chance of hypertrophic scar using linear
incisions has been observed by other authors [5, 6]. We have to consider that the
scar always can be improved while the lip asymmetry cannot be corrected because
of the tissue resection.
6.1.2 Rotation Advancement Techniques (Figs. 6.3, 6.4, 6.5,

and 6.6)
This method for unilateral cleft lip repair is based on lip medial rotation at the non-
cleft side and lateral advancement from the cleft side leaving a vertical curved scar
on the repaired lip. Many modifications have been described based on this method
and considering some modifications. Millard’s is certainly the most famous tech-
nique in this group. Ralph Millard presented his method during the International
Congress of Plastic Surgery in Stockholm 1955 after using Le Mesurier’s technique
during his earlier years and observing limited results [7]. Knezevic [8] mentioned
that Dr. Sercer from Zagreb (Croatia) performed a very similar procedure decades
before the first Millard’s description. The simplicity, reproducibility, and use of lim-
ited incisions made this technique the most popular method for unilateral cleft lip
Fig. 6.3 The Millard’s technique for unilateral cleft lip repair
88 P. Rossell-Perry
Fig. 6.4 Two-year-old

patient born with complete
unilateral cleft lip after
undergoing lip repair using
Millard’s technique. The
repaired lip is short and
asymmetric
Fig. 6.5 The Mohler’s technique for unilateral cleft lip repair
repair during decades, and it is still used in many centers around the world. Some
authors have estimated that it is used by about 85% of surgeons [9].
The technique has been studied by different authors [5, 6, 10, 11], and although
these have not shown differences between compared methods, they observed the
following advantages and disadvantages.
A more cosmetic incision respecting the aesthetic units of the upper lip and sim-
plicity of the technique making it easier to be learned and performed are advantages
of the method. The main disadvantage is the limitation to obtain an adequate lip
height without compromising the width of the lip or the position of the base of the
alae, creating an asymmetric lip. In addition, difficulties to repair the white roll, a
Fig. 6.6 Eight-year-old patient born with unilateral cleft lip after undergoing lip repair using
Mohler’s technique. The figure shows same limitations as Millard’s (short and asymmetric lip) and
columellar defect (red circle)
tendency for hypertrophy of the lip scar, and use of subnasal incision which often
results in a visible scar were observed [5, 6].
In my personal experience using Millard’s technique, I have observed increased
rate of lip asymmetry in complete cleft lips (Fig. 6.4). A comparative study pub-
lished by us in 2016 observed better outcomes using Millard’s modification in
incomplete cleft lips [12].
Another modification of rotation advancement method is the Mohler’s technique.
It was developed by Lester Mohler, a reconstructive surgeon who gained his
experience in Columbus, Ohio (USA), during the 1960s. This method was initially
published in 1960 and then in 1987 in Plastic and Reconstructive Surgery journal in
a study conducted in 57 patients [13].
The rotational incision is slightly displaced toward the lower portion of the colu-
mella to create a longer medial incision. The lateral segment incision is the same as
Millard’s. Court Cutting from the Institute of Reconstructive Plastic Surgery of the
University of New York developed an additional modification using an extended
incision of the rotational incision on the nasal columella [14]. Both of them consid-
ered that the nasal columella defect is spontaneously corrected during the time. In
South America, Cassio Raposo de Amaral, from SOBRAPAR craniofacial center
from Brazil, has studied this technique observing good outcomes in their patients
[15]. As a modification of Millard’s, this method has similar advantages and
disadvantages.
The main one is the limitation to obtain a lip height without compromising the
width of the lip or the position of the base of the alae.
The proponents of the rotation advancement methods argue that the shortening
of the lip width of the lateral segment observed using these techniques is spontane-
ously corrected with lip growth. In addition, another important disadvantage using
90 P. Rossell-Perry
the Mohler’s modification is the defect created in the nasal columella. Both sequels
are very difficult to be corrected, and this is the reason why triangular methods have
increased their popularity during the last years.
6.1.3 Z Plasty Techniques (Figs. 6.7 and 6.8)
Nonlinear incision techniques were promoted initially by Le Mesurier around 1945

based on descriptions made by Hagerdon since 1982 [3]. A few years later, Charles
Tennison, a reconstructive surgeon from San Antonio, Texas (USA), presented his
cleft lip repair technique named as the “stencil method” (old system to make copies)
Fig. 6.7 The Z plasty technique for unilateral cleft lip repair

patient born with unilateral
cleft lip after undergoing
lip repair using Z plasty
technique. The figure
shows a long lip
[16]. This method was later modified and promoted by Peter Randall, a plastic sur-
geon from Philadelphia (USA), who developed his experience in clefts at the
Children’s Hospital of Philadelphia. His proposal was published in 1959 [17]. Thus,
the technique has been known worldwide as the Tennison-Randall’s.
It has been widely studied by different authors and compared with Millard’s
technique [5, 6]. Different techniques based on single Z plasty concept have been
developed by different authors including Davies, Spina, Skoog, Bardach, Pool,
and others.
Recently in 2005, David Fisher, a plastic surgeon from Toronto, Canada, updated
this technique with some modifications [18]. Like any surgical technique, it has
advantages and disadvantages. The main virtue of this method is its ability to
lengthen the lip without compromising the lateral segment or the position of the
nasal base, which allows to obtain a lip with better symmetry. In addition, the surgi-
cal design allows a better repair of the white line. Unlike the rotation advancement
method, the lip symmetry is privileged over the scar with this technique.
The main disadvantage is the broken line which violates the aesthetic unit of the
lip leaving the scar over the nasal philtrum which is more visible.
In addition, the chance of obtaining longer lip should be taken into account. For
this reason, the marking must be very precise. The learning curve is more slow in
comparison with linear or curved incision techniques, and the method requires a
mathematical design and a meticulous and detailed marking.
Finally, due to the nature of the scar created, it is more difficult to correct any
sequel originated in a lip operated with these techniques.
6.1.4 Curved Lines Techniques (Fig. 6.9)
This group of techniques is less popular than those mentioned above.
Fig. 6.9 The curved line technique for unilateral cleft lip repair
92 P. Rossell-Perry
Many surgical techniques have been described using this concept. Pfeifer’s is
probably the most known technique in this group. The wave line incision method for
cleft lip repair was developed by Gerard Pfeifer in the 1960s. He was the Director
of the Maxillofacial Surgery Department at the University of Hamburg in
Germany [3].
The technique is based on a waved line to provide lengthening to the affected
segments of the upper lip. In a study published by Gundlach, they observed an
increased rate of short lips using the wave line method in comparison with Tennison
and Le Mesurier modification [19]. An outcome study published by Reddy and
comparing Millard’s vs Pfeifer’s techniques observed better postoperative lip length
using Pfeifer’s cheiloplasty [20].
The advantages and disadvantages of this method are similar to Millard’s, but the
increased length of the wave incision may avoid compromise of lip width. However,
the wave incision requires an increased amount of tissue resection and creates a
smaller upper lip in special in complete cleft lips.
6.2 Lip Asymmetries
The lip asymmetries may be classified as shorter lips or longer lips and nasal phil-
trum asymmetries.
6.2.1 Short Lip
It is known as the whistler deformity because of the appearance of a whistling per-

son. During this action, produced by contraction of the orbicularis oris muscle, a
shortening of the lip height occurs. It is defined as the deficiency in the height of
the repaired lip (Fig. 6.10). This bad outcome has two components: lip and vermil-
lion. The short lip has been described in association with the use of rotation
advancement and curved line techniques as a result of insufficient lengthening of
cleft segments using these methods. In addition, the linear or curved scar has an
increased tendency for hypertrophy and retraction [5, 6]. An adequate repair of the
muscular components of the upper lip allows obtain an appropriate length of the
lip. The integrity of the repaired muscular plane should be verified during preop-
erative evaluation by observing the retraction of lip tissues secondary to the mus-
cular contracture. During my first years of practice, I observed shorter lips
frequently in association with the Millard’s technique. Diagnosis of this bad out-
come is established through the difference of lip heights between cleft and non-
cleft side. The differential diagnosis should be made with partial dehiscence of the
upper lip after surgery. Correction of the whistler deformity is related to the sever-
ity and nature of the problem and should be done respecting the transverse

patient who developed
unilateral whistler
deformity after primary
cleft lip repair
diameter of the lip. The defect may be limited to the vermillion, and this condition
does not require lip correction.
A common mistake is the use of diamond-shaped resection of the labial scar with
the intention of lengthening the shortening segments. This procedure has two prob-
lems: the final scar is straight which tends to hypertrophy and retract and the com-
promise of the width of the lateral segment creating a more asymmetrical lip.
This limitation must be well considered since the scar can always be improved
but not the lip asymmetry. We must note that the transverse diameter of the lip at the
cleft side may be previously shortened by primary surgery and/or by the congenital
hypoplasia of the lip. The diamond-shaped resection of the lip scar may be used for
minor deficiencies (less than 3 mm) without major compromise of the lip’s width.
For the surgical correction of the whistler deformity, the author developed a tech-
nique based on a double Z plasty [21]. This method preserves the width of the lip.
Surgical Technique
Markings for double unilimb Z plasty are illustrated in Fig. 6.11.
1. Intersection between the subalar sulcus and labial scar
2. End of cupid’s bow in the medial segment (2 mm over the white roll)
3. Midpoint of cupid’s bow
4. Medial end of the red roll
5. Intersection of the red line with cupid’s bow midpoint
A. Point located on the lateral segment at a distance similar to 1–2
B. Point located at a distance similar to distance 2–3 from point A
C. Point located 2 mm over the with roll at the same level of point A
D. Point located over the lateral vermillion at a similar distance as 2–4
94 P. Rossell-Perry
Fig. 6.11 Markings for unilateral whistler deformity repair using the double unilimb Z plasty
E. Point located on lateral vermillion at a distance similar to 4–5

F. Point located on lateral vermillion at the level of point D at a distance similar to
4–5 from the point E
Surgical incisions are made using a number 11 blade following the markings
through the skin and subcutaneous tissue in both sides after this, the scar tissue is
resected. Then, using fine scissors, the muscular component is dissected from each
segment.
The wound closure is made edge to edge from the mucosa to the skin using
resorbable sutures for deep planes and 6/0 or 7/0 non-absorbable sutures for the
skin. Once this is done, the medial rotation of the cupid’s bow and lateral segment
lengthening are achieved. Mupirocin or bacitracin ointment is applied to the wound
postoperatively (Fig. 6.12).
Another form of short lip is the asymmetry due to upper lip width’s asymmetry
(Fig. 6.13). Although there is a congenital deficiency of the cleft segment, the pri-
mary surgery can make it worse. As I mentioned before, curved or linear incision
techniques may compromise the width of the cleft side. The estimation of the lip
asymmetry can be done by comparison with the non-cleft side. Under my knowl-
edge, the only likely option of providing similar tissues to those of the upper lip is
performing a tissue transfer from the lower lip (Abbe flap). This flap, first described
by Robert Abbe from New York in 1898, is widely used for the reconstruction of
sequels in bilateral cleft lip patients. Its use in unilateral cleft lips is not well-known,
however was described by Millard in his book The Cleft Craft [3]. The main disad-
vantage is the creation of a visible scar on the lower lip, not always well tolerated by
patients. Risk and benefit must be carefully evaluated and discussed with patients or
parents in order to use this method in favor of the patient.
The Abbe flap is a two-stage axial flap based on the inferior labial artery. The
skin flap is designed in the middle third of the lower lip.
In unilateral cleft lips, it may be difficult to replace an anatomical subunit, and
the flap may increase lip width but not replacing the nasal philtrum as in bilateral
a b
c d
Fig. 6.12 (a) Twenty-five-year-old patient who developed whistler deformity after primary unilat-
eral cleft lip repair. (b) Double unilimb Z plasty technique markings. (c) Immediate postoperative
view. (d) Postoperative view after undergoing repair using the double unilimb Z plasty technique
clefts. After about 2 weeks, the pedicle can be sectioned without flap compromise.
Some authors have described the pedicle section in less time (around 1 week); how-
ever, I prefer to be conservative with the exception of a patient with intolerance to
this procedure. Because of the complexity of postoperative management, it is rec-
ommended to be performed in adult patients in order to prevent associated compli-
cations as dehydration or hypoglycemia in children.
Surgical Technique
Markings are illustrated in Fig. 6.14.
Upper lip deficiency must be determined by comparing both lip’s width (from
the oral commissure to the peak of the cupid’s bow).
The width of the flap should be equal to this difference (an average length of
15–20 mm). The height of the flap is easier to be determined and represents the
height of the upper lip. The pivot point of the flap is located about 2 mm below the
white roll of the lower lip (reference level to locate the labial artery). Since it is
96 P. Rossell-Perry
Fig. 6.13 Eighteen-year-

old patient with
postoperative lip
asymmetry after primary
unilateral cleft lip repair.
Lip width differences
between cleft and non-cleft
side are clearly observed
regularly indicated in adult patients, this surgery can be performed under local anes-
thesia and sedation. If a general anesthesia is necessary, a nasotracheal intubation is
recommended. Initially, the lip’s scar is resected leaving healthy edges in the cuta-
neous level. Sometimes, a small resection of healthy skin may be necessary in order
to centralize the flap and recreate a nasal philtrum.
After this resection, we may proceed with the lower lip incisions following pre-
operative markings and across the full thickness of the lip (lower labial vessels must
be ligated at this point). At the opposite side, the surgeon may visualize the pedicle
2 mm below the white roll; however, this is not essential to preserve the vessels. The
side where the artery enters the flap is indifferent. The flap is then rotated making a
precise correspondence of the anatomical lip landmarks. Mucosal, muscles, and the
skin are finally sutured. After 1 or 2 weeks, the flap can be divided and lip segments
repositioned (white and red rolls) after ligation of the artery (Fig. 6.15).
Feeding of the patient can be performed using thick drinking straws and provid-
ing liquefied unrestricted diet. Dental cleaning can be done with mouthwashes since
brushing is not possible to be done.
6.2.2 Long Lip
This bad outcome is less frequent to observe than the short lip.
It is defined as the lip asymmetry due to increased length of the lip compared to
the non- cleft side (Fig. 6.16).
This is more frequently associated with the Z plasty techniques and usually
occurs when an appropriate presurgical marking is not performed. The estimation of
the lip asymmetry is made by comparison of both sides (cleft and non-cleft). Thus,
a b
c d
Fig. 6.14 The Abbe flap for unilateral cleft lip asymmetry due to shorter lip’s width. (a) Lip asym-
metry after primary unilateral cleft lip repair (A > a). (b) Abbe flap. Lower lip axial flap based on
lower labial artery. (c) Transposition of the Abbe flap after upper lip scar resection. (d) Upper lip
reconstruction after flap division (2 weeks later)
the severity is determined and the surgical plan developed. The lip asymmetry may
be associated with a vermillion component. Proposed surgical technique for its cor-
rection is based on a lozenge resection of the skin excess on the affected side. This
resection can be done at two levels: subalar and above the white roll. Scar branches
of the Z plasty previously done may be used for lozenge incisions.
Surgical Technique
Markings for double unilimb Z plasty are illustrated in Fig. 6.17.
1. Intersection between the nasal philtrum column and the subalar groove on the
non-cleft side
2. Intersection between the nasal philtrum column and the peak of the cupid’s bow
on the non-cleft side
3. Cupid’s bow midpoint
98 P. Rossell-Perry
Fig. 6.15 Twenty-year-old patient who developed lip’s asymmetry after primary cleft lip repair
using Millard’s technique (upper left). Abbe flap reconstruction (upper right). Postoperative view
of the patient 8 months after flap division. The nasal philtrum and cupid’s bow have been restored
(lower view)

patient with postoperative
lip asymmetry after
primary unilateral cleft lip
repair associated with Z
plasty technique. Lip
height differences between
cleft and non-cleft side are
evident
Fig. 6.17 Surgical technique markings for lip height’s asymmetry repair using the lozenge method. 1.
Right columellar base. 2. Right peak of cupid’s bow. 3. Cupid’s bow midpoint. 4. Left columellar base.
5. Left peak of cupid’s bow. A: Subnasal correction of long lip. B: White roll correction of long lip
Fig. 6.18 Two-year-old patient with postoperative lip asymmetry after primary unilateral cleft lip
repair associated with Z plasty technique. Lip symmetry is obtained after using the lozenge
method. left: postoperative right: preoperative
4. Intersection between the nasal philtrum column and the subalar groove on the
cleft side
5. Intersection between the nasal philtrum column and the peak of the cupid’s bow
on the cleft side
The incisions are made with a number 11 scalpel blade through the skin and
subcutaneous tissue, and the excess of skin (previously marked) is resected. The
closure is done edge to edge using subdermal non-absorbable sutures and 6/0 fast
absorbing catgut for the skin. After this resection and closure, the height of the cleft
side is leveled and lip’s symmetry obtained (Fig. 6.18).
Finally, mupirocin or bacitracin ointment is applied to the wound.
100 P. Rossell-Perry
6.2.3 Nasal Philtrum Asymmetries
This is the most common bad outcome after cleft lip repair. Primary cheiloplasty
usually fails in the attempt to reproduce the nasal philtrum column. This sequel is
characterized by flattening at the level of the operative scar and due to a deficit of
volume and scar contracture. In addition, quality of the muscular repair should be
considered. The correction of this deficiency is done by adding volume to this area.
The objective is to mimic the characteristic elevation of the nasal philtrum column
observed on the non-cleft side. Different techniques based on muscular repair and
fillers have been described for this purpose: muscular flaps, grafts (dermis, fat, fas-
cia, and tendon), and synthetic fillers (hyaluronic acid).
A successful alternative is the use of tendon graft. For this purpose, the tendon of
the palmaris longus muscle of the forearm is used (Fig. 6.19). This is an accessory
Fig. 6.19 Thirty-three-year-old patient who had a philtrum column volume deficiency after pri-
mary cleft lip repair. Palmaris longus tendon graft is raised and placed into a subdermal pocket at
the level of the lip scar
muscle, and its use does not generate major functional deficit. This technique was
learned by the author from his professor Dr. Henry Kawamoto Jr. during his fellow-
ship at UCLA.
Surgical Technique
The length of the graft is determined by measuring the length of the lip. The tendon
is taken through small incisions in the crease of the wrist and another at the level of
the midpoint of forearm length. The patient is asked to flex the hand so that the relief
of the tendon can be easily palpated and located on the midline. Once the tendon is
identified and sectioned, it is pulled through one of the incisions. Finally, the inci-
sions are closed, and an elastic bandage is applied to prevent development of bleed-
ing and hematoma. Then, the tendon is transferred to the lip, and the recipient area
should be previously dissected doing a small tunnel below the skin through small
incisions. The graft should be prepared making folds (eight to ten layers) as neces-
sary to correct deficit of volume.
6.3 Vermilion Bad Results
These deficiencies are another frequent problem after cleft lip surgery because no
special attention is paid to this anatomical area during operative planning. It may be
isolated or associated with the lip whistler deformity described before and may be
observed at three levels: white roll, vermillion, and red roll.
6.3.1 White Roll Sequels
These are characterized by a misalignment of the white roll. This is frequent to

observe when linear incision techniques have been used. Z plasty methods allow a
more precise repair of this important segment (Fig. 6.20). A common problem dur-
ing cleft lip repair is the identification of the white roll. A recommendation to visu-
alize its trajectory is the lip stain with povidone iodine solution. The white roll can
be clearly identified due to its different color (Fig. 6.21). The reconstruction of the
white roll depends on the nature of the problem. Thus, in cases where the discrep-
ancy between segments is 1 and 2 mm, the rhomboid resection will allow an ade-
quate alignment without major compromise of the lip’s width. Discrepancies equal
or greater than 3 mm require the use of Z plasties in order to avoid shortening of the
lip’s width, a common problem after rhomboid resection (Fig. 6.22). Another prob-
lem associated with both methods is lip lengthening, creating a secondary asym-
metry. The correction must be carefully planned to prevent this bad outcome.
Fig. 6.20 Unilimb Z

plasty for correction of the
misalignment of the white
roll (deficiencies equal or
greater than 3 mm)
Fig. 6.21 Preoperative

view of a patient with
repaired unilateral cleft lip.
The characteristics of the
white line can be well
observed after the
application of povidone
iodine solution. This
maneuver helps visualize
the white roll and also the
lip scar
6.3.2 Vermillion Sequels
A frequent bad outcome after unilateral cleft lip repair. The surgeons generally pay
attention to the symmetry of the lip repairing the vermillion with simple approxima-
tion. The vermillion bad outcomes may be isolated or associated with lip sequels
and the problem may be due to excess or deficit of volume. To determine the type of
vermillion deficiency a comparison of the vermillion height in both sides is required.
The vermillion height is defined as the distance between the white and red rolls.
The vermillion deficiency, characterized by deficit of volume in this segment is
repaired depending on its severity. Minor deficiencies (up to 3 mm) can be repaired
Fig. 6.22 Three-year-old patient who had a white roll misalignment after primary cleft lip repair.
Postoperative outcome is appreciated 1 year after correction with Z plasty
Fig. 6.23 Unilimb Z

plasty technique based on
Noordhoff’s principles
used for correction of
vermillion deficiencies
after cleft lip repair
using Z plasties, muscular transposition or addition of volume (grafts or fillers)

(Figs. 6.23 and 6.24).
The use of synthetic fillers, as hyaluronic acid, has been shown to be useful for
correcting minor deficiencies [22]. Larger deficiencies (more than 3 mm) may
require addition of tissues for its repair. Kapetansky, tongue, and vermillion (cross-
lip) flaps are alternatives in these cases [23]. These flaps have the advantage of using
a similar tissue as the defect; hence, the results are acceptable. Some disadvantages
are the patch-like appearance and donor site sequels (scars and deficit of volume).
Fig. 6.24 Twenty-one-year-old patient with vermillion deficiency associated with primary cleft
lip repair and two failed secondary surgeries. Photos are illustrating surgical markings and postop-
erative outcome after 1 year using the unilimb Z plasty method
The vermillion excess is another common bad outcome and associated with the
use of Z plasties during primary repair (Fig. 6.25). Its surgical correction does not
depend on the severity since all the cases are corrected through resection of
the excess.
For this purpose, a careful marking is performed comparing the vermillion height
in both sides (Fig. 6.25). A lozenge excision is performed, and its extent is not
important since the scar at this level is very inconspicuous (Fig. 6.26).
6.3.3 Red Roll Sequels
This bad outcome after unilateral cleft lip repair is also frequent. It is associated
with a border to border closure of the vermilion during primary cheiloplasty
(Fig. 6.27).
Fig. 6.25 Preoperative markings of the surgical technique used for correction of lip asymmetry
associated with vermillion excess. Differences between vermillion heights (x, y, and z) are identi-
fied between cleft and non-cleft side, and lozenge excision of vermillion excess is performed
a b
Fig. 6.26 One-and-a-half-year-old patient who had excess of vermillion as a sequel of primary
cleft lip repair. Correction has been made using a lozenge excision, and 9 months’ postoperative
view is illustrated here. (a) Long term postoperative view. (b) Inmediate postoperative view. (c)
Long term postoperative view
Fig. 6.27 Z plasty technique used to correct red line misalignment after cleft lip repair
The red line has a different orientation on each segment, presenting a rotation in
the medial segment of the cleft lip compared to the lateral segment. This type of
repair leaves the oral mucosa exposed and tends to generate an aesthetic defect, dry-
ness, and ulceration.
The use of Z plasties for vermillion repair during primary cheiloplasty (based on
Noordhoff’s principles) [24] prevents this bad outcome. The reconstruction of this
sequel is also performed using a Z plasty to transpose the vermillion and oral
mucosa (Fig. 6.28).
6.4 Bad Results Associated with Muscular Repair
The reconstruction of the muscular component of the lip has a great importance.
The lip and nose as functional anatomical structures require muscular support
that allows them to perform their functions as well as ensuring facial aesthetics dur-
ing expression.
An inadequate muscular repair is characterized by depression and lateral bulging
in association with defects in the lip scar and lip’s length (Fig. 6.29). The compro-
mised functions are the facial expression, nasal ala elevation or dilation, and the
sphincter function of the lip. Depressions, asymmetries, and bulges can be observed
in association with muscular repair deficiencies in patients with unilateral cleft lip.
The repair of the sequel due to deficiency in reconstruction of the lip musculature in
patients with unilateral cleft lip is performed according to the following guidelines.
The surgical approach can be performed through the skin if this is not in good con-
dition but, if the lip scar is optimal, must be preserved, and the oral mucosa approach
may be used.
Fig. 6.28 Ten-year-old patient who had a lack of continuity of the red roll after primary cleft lip
repair. A Z plasty was performed for its correction observing good outcome
Fig. 6.29 Twenty-one-year-old patient who underwent primary cheiloplasty leaving aesthetic and
functional sequel associated with muscular component. Lip asymmetry is evident during whistling
Surgical Technique
After the skin or oral mucosa incision, the scar tissue must be resected and the mus-
cular plane dissected. Four muscular bundles may be identified after dissection:
labial and alar fascicle of the common elevator of the ala nasi and upper lip muscle
and marginal and peripheral portions of the orbicularis oris muscle (Fig. 6.30). After
this identification, the muscular plane is reconstituted by relocating each muscle
according to its anatomical position (Figs. 6.31 and 6.32). The alar fascicle of the
common elevator of the lip and nasal ala is inserted at the level of the base of the
caudal septum. The labial fascicle of the common elevator of the lip and nasal ala is
Fig. 6.30 Illustrative diagram and intraoperative photo of the labial muscles during secondary
cheiloplasty. (1) Levator labii superioris alaeque nassi. (2) Alar fascicle. (3) Labial fascicle. (4)
Peripheral portion of the orbicularis oris muscle. (5) Marginal portion of the orbicularis oris mus-
cle. (6) Levator labii superioris
Fig. 6.31 Illustrative diagram and intraoperative photo after repair of the labial muscles during
secondary cheiloplasty. (1) Levator labii superioris alaeque nassi. (2) Alar fascicle. (3) Labial fas-
cicle. (4) Peripheral portion of the orbicularis oris muscle. (5) Marginal portion of the orbicularis
oris muscle. (6) Levator labii superioris
Fig. 6.32 Four-year-old patient born with unilateral cleft lip and operated on for primary cheilo-
plasty. Photos show optimal labial musculature function of the lip during rest, whistling, smiling,
and depression, respectively
repositioned in combination with the marginal portion of the orbicularis oris mus-
cle. The marginal portions of the orbicularis oris muscle are overlapped or edge to
edge sutured above the white roll. The peripheral portions of the orbicularis oris
muscle are repaired edge to edge at the level of the lip vermillion.
6.5 Secondary Nose Deformities
The reconstruction of the nose in patients with cleft lip and palate remains a chal-
lenge for the surgeon. The characteristics of the secondary deformity of the nose
depend on the nature of the primary surgery. An adequate primary correction of the
nose will reduce the need for secondary surgeries. Primary nasal repair was consid-
ered during long time to affect normal growth of the nose as Gustav Aufricht estab-
lished around 1946 [3].
Actually, there is a consensus regarding the efficacy and safety of primary cor-
rection of the nose during cleft lip repair. Psychosocial impact suffered by children
with a facial deformity must be well considered. The secondary unilateral cleft lip
nasal deformity presents the following characteristics (Fig. 6.33):
• Malposition of the affected alar cartilage with the consequent asymmetry and
lack of nasal tip projection. There is not a cartilage deficiency, it is only displaced.
• “Short” columella on the cleft side as a result of the lateral displacement of the
affected alar cartilage. In fact, this is not short; it is “hidden in the nose” as
Mulliken pointed out.
• Ectopic insertion of the labionasal muscles.
• Nasal septum deviation.
• Maxillary hypoplasia in a variable degree.
Based in these conditions, surgical planning must be careful, and the nose should
not be considered repaired until the maxillary and septal deformities are corrected.
Regarding the age of the patient for the secondary rhinoplasty, in my opinion,
any severe aesthetic or functional affection should be treated at early age, which
means before school age, preventing the psychosocial impact of these conditions.
This position is in contrast to the conventional conservative management which
delays the treatment after skeletal correction (bone maturity completion age). Any
minor deformity may be delayed in order to avoid the negative effect of the anesthe-
sia in the development of the child.
The main objectives of secondary cleft rhinoplasty are the correction of nasal
asymmetry and function and may be achieved following these principles:
• Reposition of the affected alar cartilage
• Alar base position correction
Fig. 6.33 Secondary nasal

deformity in a patient with
a right unilateral cleft lip
and palate. Presented
characteristics are (1) alar
cartilage malposition on
the cleft side and nasal tip
asymmetry. (2) Columellar
shortening on cleft side.
(3) Nasal floor asymmetry.
(4) Nasal septum deviation
• Lengthening of the nasal vestibule

• Correction of the nasal septum deviation
• Alveolar cleft reconstruction
6.5.1 Nasal Tip
The author emphasizes the treatment of secondary nasal tip asymmetries based on
vestibular lengthening preventing the scar contracture and deformity recurrence.
The shortening of the nasal vestibule has been described by different authors;
however, it was John Potter, an English surgeon, who developed a technique for
vestibular lengthening using a V-Y advancement flap [25]. Rees and Cronin through
different techniques modified later Potter’s concept [26, 27]. These methods allow
the nasal cartilage to be repositioned giving symmetry to the nasal tip. The nasal
base usually requires reposition and support by muscular reconstruction. Finally,
septal deviation must be corrected if necessary to improve respiratory obstruction.
Cartilaginous grafts (widely used in cosmetic and reconstructive rhinoplasty) are
limited to be used to reinforce the area from which the alar cartilage has been dis-
placed medially using the V-Y technique. The surgical approach is left to the sur-
geon’s preference and can be performed openly or closed. The open rhinoplasty has
the advantage of allowing direct access to the septum after dissection between both
medial cruras (Fig. 6.34).
My personal proposal is based on the combination of Potter’s technique and
Berkeley’s lateral Z plasty [25, 28] (Fig. 6.35).
Surgical Technique (Figs. 6.35 and 6.36)
First, marking is done by identifying the lower border of the lateral crura and the
intercartilaginous border (limen nassi) located at the vestibule of the nose.
Fig. 6.34 Surgical

anatomy of the nose in a
lip and palate during
secondary open
rhinoplasty. (1) Skin flap.
(2) Malpositioned alar
cartilage (cleft side). (3)
Alar cartilage (non-cleft
side). (4) Deviated nasal
septum
Fig. 6.35 V-Y-Z technique for secondary correction of the unilateral cleft lip nose deformity
The V flap is created by combination of marginal and intercartilaginous incisions

and should include the vestibular skin and the alar cartilage (chondrocutaneous
advancement flap). The lateral Z plasty is designed on the edges of the mentioned
flap. This will help prevent the development of lateral web due to scar contracture.
During the open approach, the columellar incision extends laterally connecting
with the marginal incisions (anterior border of the alar cartilage) creating a superi-
orly based columellar flap. Through this incision, the cartilaginous structure of the
nose is exposed. After superiorly based columellar flap dissection and retraction, the
medial crura is dissected and separated to identify the anterior border of the cau-
dal septum.
Then, using a 15-blade scalpel, the submucoperichondrial plane is approached
and dissected. Once the nasal septum is exposed, the deviated portion is resected
leaving at least a 1 cm frame. The removed septal cartilage will serve as grafts to
reinforce the lateral area of the vestibule in order to prevent a pinched nose. Finally,
the approach is closed by suturing both medial cruras. The surgery is continued in
the vestibular region, and the incisions are made following the markings previously
described. The chondrocutaneous advancement flap is elevated using fine scissors in
the supraperiochondrial plane (Fig. 6.36d). The cartilage graft is then sutured to the
lateral end of the alar cartilage using nylon 5/0.
After identification of the alar dome, this is positioned using transcutaneous
stitches using Vicryl 5/0. This type of closure prevents the development of
a b
c d
e f
Fig. 6.36 Unilateral cleft lip nose deformity repair using the VYZ technique. (a) Unilateral cleft
lip nose deformity. (b) Nose cartilages showed through open rhinoplasty approach. (1) Alar carti-
lage cleft side. (2) Alar cartilage non-cleft side. (3) Nasal dorsum. (4) Nasal septum. (c) Nasal
septoplasty. (1) Alar cartilage cleft side. (2) Alar cartilage non-cleft side. (3) Nasal septum. (d)
Composite flap elevation (V-Y plasty). (1) Alar cartilage cleft side. (2) Alar cartilage non-cleft side.
(3) Nasal dorsum. (4) Nasal septum. Dotted line: Intercartilaginous border. (e) Cartilaginous cor-
rection of the nose after V-Y-Z and septoplasty. (f) Postoperative view
a b
c d
Fig. 6.37 (a) Secondary unilateral cleft lip nose deformity. (b) Nose cartilages showed through
open rhinoplasty approach (X, cleft side alar cartilage). (c, d) Postoperative views
hematomas or seromas between the cartilaginous and cutaneous planes. Lateral Z

plasty incisions are performed and closed using Vicryl 5/0 transcutaneous stitches.
The surgery culminates with the closure of the columellar flap and the correction of
the alar base position if necessary (Fig. 6.36e, f). Nasal packing is necessary at the
end of the surgery in combination with mupirocin or bacitracin ointment and must
be removed in the following days after confirming no active bleeding is observed. I
do not recommend regularly the use of postoperative nasal conformers after second-
ary correction of the nose.
The author’s philosophy based on his multiple studies follows a surgical protocol
according to the severity of the deformity. Thus, the described technique is used for
severe forms (nasal height is less than the non-cleft side) (Figs. 6.37 and 6.38).
Minor forms may be corrected using a limited vestibular incision [29] (Figs. 6.39
and 6.40).
a b
c d
Fig. 6.38 (a) Twenty-two-year-old patient with secondary unilateral cleft lip nose deformity. (b)
Preoperative lateral view. (c) Postoperative view after using VYZ technique showing nasal sym-
metry. (d) Postoperative lateral view showing improvement of nasal tip projection
Fig. 6.39 The rotational composite flap technique for minor secondary corrections of unilateral
cleft lip nose deformity
a
b
c d
Fig. 6.40 Three-year-old patient who had minor secondary nose deformity after primary cleft
rhinoplasty. (a) Preoperative frontal and worm eye’s views. (b) Postoperative frontal and worm’s
eye views after using the rotational composite flap technique. (c) and (d) inmediate postoperative
views of the same patient correcting nose and vermillion deficiencies
6.5.2 Nasal Ala
Even when the cleft lip deformity may present some degree of congenital defi-
ciency, most of the observed sequelae are due to scarring disorders or deficient
surgical performance. The asymmetry of the nasal ala is identified by compari-
son with the non-cleft side and may be due to its position (lower or higher) and
shortening. The lower position of the ala is observed with some frequency in
association with linear or curved incisions as I explained before. The surgeons
when using these techniques frequently lowered the base of the ala in order to
provide additional lengthening to the upper lip (Fig. 6.41). This non-desirable
outcome can be prevented performing an adequate preoperative lip marking pre-
serving the integrity and location of the base of the ala. Sometimes, the subnasal

patient born with unilateral
cleft lip and palate and
operated using Millard
technique and developed
nasal asymmetry due to a
lower position of the
alar base
sulcus is not clearly visible; its location can be easily located by flexion of the
ala during preoperative marking.
6.5.2.1 Nasal Ala in Lower Position
Frequently, this outcome has been considered an expected result after primary chei-
lorhinoplasty and explained as a consequence of bony support absence (alveolar
cleft). A lowered nasal ala occurs as a result of use of linear incision methods when
optimal lip height is desired on the cleft side and the base of the ala is left in a lower
position to compensate the lip height deficiency. The problem can be prevented
performing an adequate preoperatory lip marking. Sometimes, the subnasal sulcus
is not visible, and the alar base must be flexed to be identified and guarantee its
proper position after surgery. Another cause of this bad outcome is a deficient repair
of the labial muscles. The upper portion of the upper lip muscles supports the alar
base even in presence of a wide alveolar cleft and lack of skeletal support. The alar
fascicle of the levator labii superioris alaeque nasi muscle brings this support
through is insertion at the level of the base of the caudal septum during lip repair.
The diagnosis is made through careful physical examination of the lip. The differ-
ence between the position of the cleft and non-cleft alar bases will determine the
diagnosis and the degree of malposition.
Surgical Technique
The recommended surgical technique for its correction is a single Z plasty. This
method allows transposition of the alar base to its correct place. For its design, the
lowest branch of the Z plasty (external branch) is located on the cleft side alar base
(level Y), and the internal branch is located at the level of the non-cleft side alar base
(level X) (Figs. 6.42 and 6.43). Design of the Z plasty is completed by joining these
branches using a vertical line that passes through the axis of the labial scar.
After local infiltration, incisions are made using number 11 blade for more preci-
sion. Besides the Z plasty, a small incision is made on the skin of the pyriform fossa
in order to facilitate the release and medial displacement of the ala without tension.
After Z plasty release, the muscular component of the upper lip should be dissected
and repaired bringing support to the alar base. Finally, after Z plasty transposition,
the cutaneous closure is performed using 5/0 and 6/0 sutures. Antibiotic ointment is
applied to the operative wound (mupirocin).
a b
Fig. 6.42 Surgical technique used for correction of the nasal asymmetry due to lower alar base
position. (a) Upper horizontal line (X) passes through the non-cleft side alar base. Lower horizon-
tal line (Y) passes through the cleft side alar base. (b) Z plasty designed based on horizontal lines
and joined by vertical line through the lip scar. (c) Correction of the alar base after transposition of
the Z plasty
a b
d
c
Fig. 6.43 Three-year-old patient who developed secondary nasal deformity after primary cleft
rhinoplasty characterized by malposition of the alar base. (a) Z plasty was designed based on com-
parisons between cleft and non-cleft side alar base. (b) Preoperative view after Z plasty transposi-
tion and correction of the alar base. (c) Postoperative view showing nasal symmetry after 1 year.
(d) Long term postoperative view
6.5.2.2 Nasal Ala in Upper Position
Less frequently observed in comparison with the lowered ala and may be associated
with inadequate muscular repair of the lip. To prevent it, the subnasal sulcus should
be identified preoperatively and marked. For its diagnosis, a comparison between
cleft and non-cleft side alar base positions should be done as mentioned before. The
observed difference will allow the design of the skin area to be excised to reposition
the alar base properly.
Surgical Technique
The surgical technique used for its correction is a minor skin resection of the nasal
floor. This procedure allows the alar base to be positioned at the same level of the
non-cleft side. For this purpose, two lines should be designed: the upper line is
drawn through the base of the repaired ala and the lower line through the alar base
at the non-cleft side (Fig. 6.44). The area of the skin located between these two lines
a
b
Fig. 6.44 Surgical technique for nasal asymmetry correction due to malpositioned alar base. (a)
Lower horizontal line (X) passes through the non-cleft side alar base. Upper horizontal line (Y)
passes through the cleft side alar base. (b) Area of resection delimited between the two horizontal
lines. (c) Symmetry of the nose after skin resection
will be resected to allow the ala to descend according to Figs. 6.44 and 6.45. After
local infiltration, incisions are made using number 11 blade for more precision. In
addition, a small incision is made on the skin of the pyriform fossa in order to facili-
tate the release and displacement of the ala without tension. Finally, skin closure is
performed using 5/0 and 6/0 sutures, and antibiotic ointment is applied over the
surgical wound.
6.5.2.3 Wider Alar Base
This is a common non-desirable outcome after cleft lip repair and reported by dif-
ferent authors. This appears to be due to the pulling action of the facial muscles or
by widening and hypertrophy of the lip scar. Its diagnostic is made by measuring
Fig. 6.45 Twenty-year-old patient who had nasal asymmetry of the alar bases after primary cleft
lip nose repair (left). Postoperative view of the patient 1 year after nasal revision using the pro-
posed technique (right)
and comparison between the cleft and non-cleft alar base widths (points x, y, and z)
(Fig. 6.46).
The surgical technique used for its correction is based on resection of the nasal floor
skin excess. This area is estimated by comparison between the cleft and non-cleft
side and includes the labionasal scar. The extension is equal to the differences
between the two alar base diameters (Fig. 6.46). This resection can be performed as
a lozenge form, and special attention must be paid since this resection may lengthen
the lip creating a secondary lip asymmetry.
For its marking, a horizontal line is located passing at the level of both alar bases
(points x, y, and z), and then after comparing both nasal floor widths, the observed
difference will be the amount of skin to be excised. It is also necessary to extend a
small incision over the pyriform fossa in order to release the alar base flap and move
it medially without tension. Cutaneous closure is performed using 5/0 and 6/0
sutures, and antibiotic ointment is applied to the operative wound.
6.5.2.4 Narrower Alar Base (Fig. 6.48)
This bad outcome is less frequent to be observed than the previous one.
Although there are cases with severe hypoplasia of the alar tissues, this outcome
is mostly observed as a result of a bad planning and execution of the primary surgi-
cal correction. Careful observation of the nasal anatomy before primary surgery is
essential to prevent any shortening of the repaired nasal floor. Scar contracture may
be associated with this bad outcome too. Its diagnostic is made in a similar form as
the previous case, locating the position of the alar bases and establishing their diam-
eters differences (points x, y, and z).
a b
Fig. 6.46 Illustration showing markings of the proposed technique to correct wider nasal floor
after primary cleft lip repair. (a) Horizontal line passing through both alar bases (x, y, and z) to
establish differences between both sides. (b) Design of the skin is to be resected (difference
between both nasal floor widths). (c) Nasal symmetry obtained after resection of the described area
This bad outcome can be corrected using an asymmetric Z plasty. An option

would be the reduction of the alar base at the non-cleft side or combination of both
procedures in severe forms.
Surgical Technique (Fig. 6.49)
The recommended technique is an asymmetric Z plasty. This method allows the
mobilization of the alar base in a more external position correcting its diameter. For
its markings, the internal branch of the Z plasty is located at the level of the lip scar,
and the axis of the Z plasty follows the subalar groove to the alar base (Fig. 6.49).
Finally, from the previous point, the Z plasty external branch is designed locating
Fig. 6.47 Nine-year-old patient born with unilateral cleft lip and operated at 3 months old. She
developed a nose asymmetry having a wider nasal floor. Postoperative view is presented observing
symmetry of the nose using the proposed method
Fig. 6.48 Seven-year-old

patient with sequelae of
primary cleft lip repair and
narrower alar base
the desired point to reposition the alar base. (Point Z) The transposition of the Z
plasty branches will allow the alar base to be displaced laterally. Finally, the cutane-
ous closure is performed using 5/0 and 6/0 sutures, and antibiotic ointment is applied
to the surgical wound.
a b
Fig. 6.49 Illustrative diagram showing the marking for the proposed technique to correct the
shorter nasal floor. (a) Horizontal line passing through both alar bases and midpoint of the colu-
mellar base to establish the amount of difference. (b) Z plasty design: internal branch that passes
through the labial scar, axis of the Z plasty that passes through the subnasal sulcus, and the external
branch that joins this branch with the Z point (desired location of the base of the ala). (c)
Postoperative outcome may be observed after Z plasty transposition
6.5.2.5 Nose Alae Shortening
Even when there could be a congenital hypoplasia of the ala, this is rare, and this
bad outcome is mostly associated with the subnasal incision commonly used in
Millard technique. The identification of the subnasal sulcus may not be an easy
procedure.
In order to visualize properly, this structure is necessary to manipulate the ala
flexing it to be able to show the location of this structure. Sometimes, the subnasal
sulcus is not well identified, and the surgeon includes a portion of the ala for lip
repair generating a deficit in the alar’s length with the consequent asymmetry.
Another associated problem is the alar necrosis after primary cleft rhinoplasty. Its

patient with severe sequel
after primary cleft lip
repair showing nasal ala
shortening which develops
airway obstruction
diagnosis is made by carefully observing the alar’s length measured from the alar
base to the nasal tip and comparison between both sides (Fig. 6.50). Its correction is
challenging since it requires adding tissues to compensate the deficiency. The tissue
that has similar characteristics to those of the defect is the auricular pavilion. The
use of composite grafts from the auricular helix becomes the alternative of choice to
repair these sequels. The donor site is conspicuous and covered by the hair [30]. The
main disadvantage is the viability and contracture of these composite grafts, reduc-
ing their size and changing color and texture. It is recommended to be designed with
larger dimensions considering the scar contracture. An alternative is the reduction
of the non-cleft side; however, this is altering the anatomy of the ala and affecting
the natural appearance of the nose.
Marking is done at the level of the donor and recipient site. First, the size of the
defect must be estimated by comparison of the alar length of both sides. The differ-
ence between them is the size of the defect to be repaired. Due to the scar contrac-
ture of the grafts, its size must be greater than the defect; thus, the graft to be taken
should be estimated 50% longer. The cartilaginous portion should be a few millime-
ters larger than the skin component to provide stability and prevent the contraction.
It is also recommended to take the graft from the most anterior and superior portion
of the helix leaving a less visible scar and covered by the hair. The surgery begins
with a full-thickness incision at the level of the affected ala removing the scar tissue
and leaving healthy borders to optimize graft survival. The composite graft is taken
through full-thickness incision and the donor site closed.
The graft is then transferred and sutured to the skin edges of the recipient site.
Antibiotic ointment is applied to the operative wound (mupirocin). During the
first weeks, the graft tends to suffer and evolved with superficial epidermolysis
without affection of the graft viability. Its viability would be confirmed after 7 days
postoperatively.
Fig. 6.51 Illustrative diagram of the compound graft technique used for correction of the short-
ened nasal ala after primary unilateral cleft lip repair
6.5.3 Columella
Columellar bad outcomes are rare after primary unilateral cleft lip repair, and mal-
position is often associated with nose deformity. Secondary columellar deficiencies
may be observed in association with the use of Mohler’s cheiloplasty especially
with the extended modification published by Cutting. The use of columellar tissue
for lip repair creates a narrowing of the columellar’s width and leaves a scar some-
times visible depending on its extension. Sometimes, the defect is minor and does
not require any revision, but sometimes, the defect is evident and requires correction
(Fig. 6.53). The indication for surgery depends on surgeon’s criteria and patient’s
expectation.
The recommended technique for columellar repair is nasal tip advancement flap
[31]. Lateral skin excision (like Burow’s triangles) is designed as bilateral Tajima’s
incisions. The distance from the top of this incisions to the top of the columellar scar
should be the same as the length of the expected columellar length.
The columellar scar is removed, and then bilateral nasal tip incisions are per-
formed. The nasal tip flap is elevated at the level of the nasal cartilages and preserv-
ing artery perforators. After elevation, the cutaneous flap is mobilized down and
a b
c d
Fig. 6.52 Twenty-six-year-old female who has nose asymmetry after primary cleft lip nose repair.
(a) Nose asymmetry due to shortened of the ala. (b) Composite graft taken from the auricular
pavilion. (c) Immediate postoperative view showing nasal symmetry after using the composite
graft. (d) Postoperative view after 1 year shows improvement of the nasal symmetry and graft
survival
sutured to the base of the columella, caudal septum, and nostrils using 6/0 sutures,
and antibiotic ointment is applied over the surgical wound.
6.5.4 Nasal Floor
Nasal floor sequels after primary cleft lip repair are often associated with oronasal
fistulas; however, their presence should not be considered as a bad result since some
surgical protocols repair the alveolar cleft later. Based in our protocol, the alveolar
cleft is repaired during mixed dentition period. Failure to reconstruct the anterior
Fig. 6.53 Seven-year-old

patient who had a
columellar sequel after
primary cleft lip repair
using Mohler’s technique
Fig. 6.54 The nasal tip advancement flap for columellar reconstruction
nasal floor is generally associated with dehiscence of the junction between medial
and lateral flaps (Fig. 6.55).
The nasal floor is an anatomical structure made up of three anatomical segments:
nasal vestibule, and hard and soft palate. The anterior segment of the nasal floor
(vestibular segment) is repaired during primary repair using three flaps: lateral
(nasal ala), medial (base of the columella), and posterior flap (mucosal flap raised
from the lips) (Fig. 6.56).
In addition, the muscular repair is necessary to provide structural support to the
anterior nasal floor. For this purpose, the alar fascicle of the common elevator of the
lip and nasal ala is inserted at the level of the base of the caudal septum. The anterior
Fig. 6.55 Patient born

with unilateral cleft lip and
palate who had a
deficiency of the anterior
nasal floor repair after
primary cleft lip repair
a b
Fig. 6.56 Surgical technique to repair the nasal floor in patients with unilateral cleft lip. (a)
Anterior nasal floor defect after primary cleft lip repair. (b) Flap A: nasal ala. Flap B: columellar
base flap. (c) Repaired nasal floor after using the proposed technique
Fig. 6.57 Eleven-year-old patient born with unilateral cleft lip and palate who had a bad outcome
after primary cleft lip repair as a consequence of a deficiency of the anterior nasal floor repair (left).
Postoperative view shows nasal floor repair using the proposed technique (right)
nasal floor repair is carried out by raising the alar base and base of the columella for
vestibular nasal floor reconstruction and performing an adequate muscular repair
(Fig. 6.57).
6.5.5 Nasal Vestibule
The anatomy of the nasal vestibule favors the development of functional problems
after primary cleft rhinoplasty. Thus, the incisions made in this anatomical segment
may produce scar retractions or synechiae (Fig. 6.58). The development of hyper-
trophic scars and affection of the functional anatomy of the nasal vestibule may be
associated with the patient’s idiosyncrasy but also favored by using extended inci-
sions through the nasal vestibule during primary cleft rhinoplasty. Its diagnosis is
made through the physical exam and airway obstruction symptoms. Treatment of
these conditions is challenging for the reconstructive surgeon, and recurrence is a
common problem. Management is surgical, and different techniques are used for
this purpose, from skin grafts to local flaps.
Conservative use of steroid infiltration seems to help although only in the early
stages. In addition, due to the increased rate of recurrence, the use of postoperative
nasal stents during at least 6 months is recommended. In a recent study, we observed
reduced rate of this bad outcome after using these devices.
The proposed surgical technique for its correction is the V-Y composite flap plus
lateral Z plasty in combination with postoperative nasal conformers. The purpose of
this technique is to lengthen the nasal vestibule while the scar contracture is breaking.

developed a vestibular
synechia after primary cleft
rhinoplasty
Fig. 6.59 Illustrative diagram showing the markings of the V-Y-Z technique proposed to correct
the scar contractures and synechiae of the nasal vestibule

The design of the V-Y composite flap starts with the identification of the intercar-
tilaginous ridge; even in the presence of scar tissue, this structure can be located.
This structure represents the upper border of the V composite flap. Its lower border
is located along the lower edge of the alar cartilage. These borders join toward the
lateral segment of the vestibule and include the alar cartilage. The lateral Z plasty
can be designed intraoperatively after V flap mobilization. The surgery starts with
the help of double hook exposing the nasal vestibule and using a digital pressing
over the nasal tip helping to expose the anatomical structures. The incisions are
made using a 15-blade scalpel following the markings. The V composite flap is
elevated using fine scissors and mobilized medially, and then the Z plasty branches
are done on the linear segment left by the V flap. Cartilaginous graft may be required
to be used as a reinforcement on the lateral area depending on the extent of the
composite flap displacement.
Fig. 6.60 Eight-year-old unilateral cleft lip and palate patient who developed a vestibular syn-
echia after primary cleft rhinoplasty. Immediate postoperative outcome is presented here showing
the opening of the nasal vestibule using the proposed technique
Incisions closure is carried out using Vicryl 5/0 as transcutaneous stitches

(Fig. 6.59) Nasal packing is necessary after surgery and should be removed during
the next day. Regarding the use of postoperative nasal stents, they are essential dur-
ing at least 6 months to prevent recurrence of the scar contracture.
6.6 Lip Scarring Sequelae
The decision about when a cleft lip scar should be operated could be one of the
hardest decisions to make. The multifactorial etiology makes it difficult in order to
prevent its recurrence and worsening. The tension of the closure, tension lines of the
skin, anatomical upper lip subunits, age, raze, idiosyncrasy, and associated compli-
cations as infection or granulomas are associated factors to be considered.
The type of surgical skin incision has been attributed to the hypertrophic scar
development; thus, linear incisions (like Millard, Mohler, etc.) seem to favor this
poor result [5, 6]. Furthermore, some authors consider that techniques based on
triangular flaps present less tendency to scar hypertrophy [32].
Once the problem is diagnosed, the first decision is when to correct the scar.
The scar behavior varies over time, and the initial scar is frequently improved
during the months after surgery. Lip scars should not be revisited before 1 year of
evolution.
Based on expert opinion, there is an increased rate of hypertrophic scar develop-
ment seen in patients after 8 years of age and through adolescence.
In our consideration, any hypertrophic scar that generates retraction and aes-
thetic deformity should be treated early (before 5 years of age) in order to prevent
recurrence and affection of the psychosocial development of the child during
school time.
Common reasons of hypertrophic scars after cleft lip surgery are tension of the
closure, scars left by sutures, and retractions associated with linear scars.
Regarding sutures, the type and the time of permanence must be taken into
account. The suture material is still under debate since some surgeons prefer the use
of non-absorbable sutures due to their less tissue reactivity. The main problem using
these sutures is the need to remove them. Some centers use general anesthesia for
their removal due to the poor collaboration of the children.
This inconvenience is not observed using absorbable materials, but it depends on
the time of absorption. If the material remains in place more than 1 week, it will
probably leave a visible scar. Ideally, the maximum period of time to remove or drop
the applied sutures should be 5 days. Fast-absorbing sutures are the most indicated
although they are not available in all countries.
The suture caliber is another factor to be considered and usually 6-0 or 7-0 is the
most suitable to prevent associated scarring sequels.
Personal strategy to address scarring sequels is based on the following principles.
Conservative treatment should be initially considered (silicone gel or patch) starting
early (2 or 3 months postoperatively) and used once or twice a day depending on
severity. Corticosteroid infiltration is relegated to severe cases and refractory to
treatment with silicone. Surgical treatment is indicated for cases refractory to con-
servative treatment and having 1 year or more of evolution.
Different techniques have been proposed for the surgical management of
bad scars.
From Borges’s W plasties to lozenge excisions, most of them have a similar
problem; they create a longer lip. This limitation should be considered during surgi-
cal planning. The author proposes a surgical technique based on the use of a curved
incision according to the shape of the scar minimizing the tension of the closure. In
order to preserve the lip’s height the suspension of the skin should be done at an
upper level bringing it upwards (based on Lejour’s principle for vertical incision
mammoplasty) [33].
Markings are made according to the shape of the scar to be excised. Nerve block
may be used to prevent erasing the markings or scar distortion.
The scar can be more precisely performed using a number 11 scalpel blade. After
scar excision, subcutaneous dissection of the edges is performed decreasing the ten-
sion closure. The closure is then started using 5-0 monofilament absorbable sutures
for subdermal plane and few 6-0 or 7-0 fast-absorbing sutures for skin.
After closure mupirocin or bacitracin ointment is applied on the operative wound.
Fig. 6.61 Surgical technique for lip scar repair. The method preserves lip height. The postopera-
tive view shows how despite resection of the labial scar using a lozenge the lip height is not
increased
a b
Fig. 6.62 Illustration of the surgical technique for lip scar revision. (a) The area of the scar to be
resected is shown. (b) Location of the skin sutures seeking to position the lip skin in an upper level,
preventing the elongation of the upper lip. (c) Final appearance of the lip after using the proposed
technique
References
1. Rossell-Perry P. Nueva clasificación de severidad de fisuras labiopalatinas del Programa

Outreach Surgical Center Lima-Perú. Acta Med Peru. 2006;23(2):59–66.
2. Rossell-Perry P, Gavino-Gutiérrez AM. Nuevo enfoque en el tratamiento quirúrgico de las
fisuras labiales congénitas. Cir Plást Iberolatinoam. 2013;39(1):23–34.
3. Millard R. Cleft craft: the evolution of its surgery. Vol I: The unilateral deformity. 1st ed.
Boston: Little Brown; 1978.
4. Navarro CE. Working in Peru: a 25-year experience with voluntary cleft missions, and a tech-
nique for the primary repair of the unilateral cleft lip and nasal deformity. J Craniofac Surg.
2021;32(Suppl 3):1231–5.
5. Holtmann B, Wray R, Chris M. A randomized comparison of triangular and rotation advance-
ment unilateral cleft lip repairs. Plast Reconstr Surg. 1983;71(2):172–8.
6. Chowdry N, Darzi M. A comparative study of surgical results with rotation-advancement and
triangular flap techniques in unilateral cleft lip. Br J Plast Surg. 1990;43(5):551–6.
7. Millard R. The primary camouflage of the unilateral hare-look. In: Transactions of the inter-
national society of plastic surgeons, first congress, Stockholm (1955). The Williams & Wilkins
Company; 1957. p. 160–6.
8. Knežević P, Vuletić M, Blivajs I, Dediol E, Macan D, Virag M. The modification of rotation-
advancement flap made in 1950. Acta Stomatol Croat. 2017;51(1):60–4.
9. Sitzman T, Girotto J, Marcus J. Current surgical practices in cleft care: unilateral cleft lip
repair. Plast Reconstr Surg. 2008;121(5):261–70.
10. Reddy G, Webb R, Reddy R, Reddy L, Peter T, Markus A. Choice of incision for primary
repair of unilateral complete cleft lip: a comparative study of outcomes in 796 patients. Plast
Reconstr Surg. 2008;121(3):932–40.
11. Hoffman D, Dyleram D. Comparison of the Millard and Fisher technique for closure of the
unilateral cleft lip. Int J Oral Maxillofac Surg. 2011;40(10):e14.
12. Rossell-Perry P. A 20-year experience in unilateral cleft lip repair: from Millard to the triple
unilimb Z-plasty technique. Indian J Plast Surg. 2016;49(3):340–9.
13. Mohler L. Unilateral cleft lip repair. Plast Reconstr Surg. 1987;80(4):511–7.
14. Cutting C, Dayan J. Lip height and lip width after extended Mohler unilateral cleft lip repair.
15. Raposo-Amaral C, Giancolli A, Denadai R, Marques F, Somensi R, Raposo-Amaral C, Alonso
N. Lip height improvement during the first year of unilateral complete cleft lip repair using
cutting extended Mohler technique. Plast Surg Int. 2012;2012:206481.
16. Tennison C. The repair of the unilateral cleft lip by the stencil method. Plast Reconstr Surg.
1952;9(2):115–20.
17. Randall P. A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast
Reconstr Surg Transplant Bull. 1959;23(4):331–47.
18. Fisher D. Unilateral cleft lip repair: an anatomical subunit approximation technique. Plast
Reconstr Surg. 2005;116(1):61–71.
19. Gundlach KK, Schmitz R, Maerker R, Bull HG. Late results following different methods of
cleft lip repair. Cleft Palate J. 1982;19(3):167–71.
20. Reddy GS, Webb RM, Reddy RR, Reddy LV, Thomas P. Choice of incision for primary repair
of unilateral complete cleft lip: a comparative study of outcomes in 796 patients. Plast Reconstr
Surg. 2008;121(3):932–40.
21. Rossell-Perry P, Cotrina-Rabanal O. The doublé unilimb Z plasty technique for whistler
deformity reapir in unilateral cleft lip patients: an anthropometric study. Ann Plast Surg.
2015;74(3):324–9.
22. Stolic D, Jankovic M, Draskovic M, Georgiev S. The surgical lips deformity corrected with
hyaluronic fillers: a case report. Open Access Maced J Med Sci. 2015;3(3):423–5.
23. Kapetansky D. Double pendulum flaps for whistling deformities in bilateral cleft lips. Plast
Reconstr Surg. 1971;47(4):321–3.
24. Nordhoff S. Reconstruction of vermilion in unilateral and bilateral cleft lips. Plast Reconstr
Surg. 1984;73(1):52–61.
25. Potter J. Some nasal tip deformities due to alar cartilage abnormalities. Plast Reconstr Surg.
1954;13:358.
26. Rees T, Guy C, Converse J. Repair of the cleft lip nose: addendum to the synchronous technique
with full-thickness skin grafting of the nasal vestibule. Plast Reconstr Surg. 1966;37(1):47–50.
27. Cronin E, Rafols F, Shavani P, Al-Haj I. Primary cleft nasal repair: the composite V-Y flap with
extended mucosal tab. Ann Plast Surg. 2004;53:102–8.
28. Berkeley W. The cleft lip nose. Plast Reconstr Surg. 1959;23:567.
29. Rossell-Perry P. Rotational composite flap technique for primary incomplete cleft nose defor-
mity. Plast Reconstr Surg Glob Open. 2020;8(6):e2870.
30. Rossell-Perry P, Romero-Narvaez C. Evaluation of the use of auricular composite graft for
secondary unilateral cleft lip nasal alar deformity repair. Plast Surg Int. 2014;2014:270285.
31. Rossell-Perry P. An innovative method for nasal injury repair after use of continuous positive
airway pressure in newborns. Plast Reconstr Surg. 2021;147(1):179e–80e.
32. Wihelmi B, Blackwell S, Phillips L. Langer’s lines. To use or not to use. Plast Reconstr Surg.
1999;104(1):2018–4.
33. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg.
1994;94(1):100–14.
Chapter 7
Bad Results in Bilateral Cleft Lip Surgery
Percy Rossell-Perry
7.1 Introduction
The bilateral cleft lip has varied forms of presentation, being a challenge for the
craniofacial team. It is more frequently associated with bad outcome and complica-
tions. Brown described the nature of bilateral cleft lip and palate as follows: “twice
as difficult to repair compared to the unilateral cleft lips with outcomes that were
half as good” [1]. Because of its less frequency (comparing with unilateral cleft
lips), the surgeon requires more time to obtain competence addressing this pathol-
ogy. Its complexity is related to soft and skeletal tissue deficiency. Sir Harold Gillies,
pioneer of reconstructive surgery, noted “the skeleton first,” highlighting the impor-
tance of rebuilding the skeletal structure first in craniofacial reconstruction [1]. This
important principle of reconstructive surgery is violated during cleft surgery due to
the negative impact of primary surgery on the maxillofacial skeleton. This alteration
of the order explains many of the bad outcomes observed after bilateral cleft lip
surgery. Sequels are often observed after bilateral cleft lip surgery, mostly in severe
forms and practiced by inexperienced surgeons.
Asymmetries, hypertrophic scars, and dental skeletal sequels are common to be
observed after primary bilateral cleft lip surgery due to the unrepaired skeleton.
Preoperative evaluation requires an adequate classification to typify the different
forms and in special severe bilateral cleft lips and thus allows effective and timely
interdisciplinary team intervention.
Based in the author’s classification, a severe bilateral cleft lip and palate is one
that has an alveolar cleft wider than 1 cm [2] (Fig. 7.1). The author described the
clock diagram, a practical scheme to illustrate this pathology in a better way [3, 4].

Switzerland AG 2022
Fig. 7.1 Severe form of

bilateral cleft lip and
palate. The figure shows an
alveolar cleft width wider
than 1 cm
The management in this group of patients should be done early (during first
weeks of age) to be able to perform the primary repair in better condition and mini-
mize bad outcomes. Presurgical orthopedics is the method of choice to mobilize the
cleft segments in a more anatomical position and facilitate the primary surgical
repair in severe forms. Lip closure under tension without repositioning of the pre-
maxilla in severe forms has an increased rate of wound dehiscence, hypertrophic
scar, secondary nasal deformity, and bad positioning of the premaxilla with great
aesthetic and functional impairment.
The mild and moderate forms of bilateral cleft lip can be repaired surgically
without any previous treatment, because the orbicularis oris muscle will perform a
complementary orthopedic treatment over the cleft segments.
The more frequent bad outcomes after primary bilateral cleft lip are bilateral
whistler deformity, lip and nose asymmetries, muscular repair deficiencies, and bad
positioning of the premaxilla. The whistler deformity is characterized by postopera-
tive shorter prolabium and poor nasal philtrum and central vermillion. Techniques
like Veau, Manchester, and Spina are frequently associated with this sequel.
A different type of whistler deformity may be observed after using Millard’s
bilateral cheiloplasty (method that repairs the central portion of the lip using lateral
segments). This is because of the use of a vertical scar on the repaired vermillion.
The nasal deformity after primary bilateral cleft lip repair is frequent, and actu-
ally its surgery is still delayed to older age of patients by some authors. Presurgical
nasal shaping, proposed by a group from the University of New York [2], known as
NAM (nasoalveolar molding), is a useful alternative that allows the molding of the
nasal vestibule and facilitates primary cleft rhinoplasty. However, there is a lack of
scientific evidence supporting its long-term effect, and similar outcomes can be
achieved by using primary cleft rhinoplasty alone [5].
7 Bad Results in Bilateral Cleft Lip Surgery 139
Here, there is an analysis of the advantages and disadvantages of traditional sur-

gical techniques for bilateral cleft lip repair and frequent reasons of bad outcomes
helping the surgeons prevent this non-desirable outcomes.
7.1.1 illard’s Technique of Bilateral Cheiloplasty Repair

M
(Fig. 7.2)
Dr. Ralph Millard Jr. published his preliminary report using his technique for bilat-
eral cleft lip repair in a case series in the Plastic and Reconstructive Surgery journal
in 1967 [6]. His technique is based on the following principles:
a b
Fig. 7.2 Millard’s technique of bilateral cheiloplasty repair. (a) Preoperative view. (b) Banked
fork flaps from prolabium and postoperative view of lip repair. (c) Postoperative view of columel-
lar elongation using banked fork flaps
(a) Reconstruction of central vermillion and nasal philtrum white line from lateral
segments.
(b) Primary reconstruction of the upper labial muscles.
(c) Secondary reconstruction of the nasal deformity using the banked flaps elevated
from the prolabium as two-stage surgical procedure. Hence this technique
became popular as the banked fork flap [6, 7] (Fig. 7.2).
The proposed method has some advantages and disadvantages as follows:
(a) Advantages: allows the repair of nasal philtrum white roll and vermillion tuber-
cle as well as primary muscular repair.
(b) Disadvantages: the presence of a horizontal scar at the base of the nasal phil-
trum often visible and the tendency to reduce the width of the upper lip and
create longer lips, as well as the delayed repair of the nasal deformity and use
of subnasal incisions which often leave visible scar. The technique proposed by
Ralph Millard Jr. may develop central whistler deformity by creating a central
vertical scar. Finally, the two-stage nasal repair creates an adverse scenario for
secondary labial revision by division of the nose and lip tissues after the colu-
mella repair.
John Mulliken, a plastic surgeon from Boston Children’s Hospital, describes a
modification of Millard’s method and proposed a primary rhinoplasty based on
nasal marginal incisions and skin resection [8]. This is why some centers as the
Children’s Hospital of Philadelphia talk about the Millard-Mulliken technique for
bilateral cleft lip repair. Some advantages of Mulliken’s proposal are the one-stage
cleft rhinoplasty and the design of smaller prolabium (4 mm wide) giving additional
blood supply from the prolabium subcutaneous tissue. Observed disadvantages are
the same as Millard’s, and in addition I would mention the use of marginal incisions
and skin resection (nasal tip and vestibule) as an aggressive form leaving an adverse
scenario for any secondary nasal correction. There would be a functional impact due
to resection of the soft triangle of the nose and requires additional studies.
Nasal scars are often visible, and the technique develops a turn-up appearance of
the nose.
7.1.2 anchester’s Technique of Bilateral Cheiloplasty Repair

M
(Fig. 7.3)
William Manchester, a plastic surgeon from Auckland, New Zealand, develops a

surgical technique for bilateral cleft lips and published in 1970 based on the method
described by Veau. This technique uses vertical incisions and does not perform an
edge-to-edge muscle repair as a conventional surgical lip adhesion [9]. A similar
method was popularized in Brazil by Victor Spina [10]. Based in this technique, the
vermillion tubercle is reconstructed using the prolabium, and this is the reason why
a b
Fig. 7.3 The Manchester’s technique of bilateral cheiloplasty repair. (a) Preoperative view.
(b) Postoperative view
this method is often associated with bilateral whistler deformity. The prolabium
vermillion is hypoplasic (even in incomplete forms) and can hardly provide enough
tissues for optimal reconstruction of the central white roll and vermillion tubercle.
In addition, the technique does not consider the primary correction of the nose
deformity.
The advantages and disadvantages described using this technique are:
(a) Advantages: the most important is the absence of central scar observed using
the Millard’s method. In addition, the Manchester’s proposal preserves the
transverse diameter of the upper lip.
(b) Disadvantages: Different studies have found increased rate of bilateral whistler
deformity due to the hypoplasic nature of prolabium tissues. The white roll does
not exist in the bilateral cleft lip prolabium, and its vermillion is always smaller,
and the repaired nasal philtrum tends to be wider over time requiring further
correction.
Because of the unrepaired muscular plane, the method requires always a second-
ary surgery to perform the muscular repair. In addition the labial sulcus is not ade-
quately repaired using this technique. In fact, this is a surgical lip adhesion technique
requiring always additional repair being the Manchester’s technique the most fre-
quent reason of secondary bilateral cleft lip repair.
7.2 Philtrum Secondary Deformities
The secondary lip deformities after primary bilateral cleft lip repair are the most
common due to the hypoplasic nature of the prolabium. In a practical way, they can
be classified as shorter (bilateral whistler deformity) and longer lip.
7.2.1 Bilateral Whistler Deformity
As described in the previous chapter, this sequel is named for its appearance of a
person while whistling. In bilateral cleft lip patients, it is defined as a deficiency in
the central height of the repaired upper lip. The deformity has two components: lip
and vermilion. There are two types of bilateral whistler deformity: produced by use
of Manchester’s method and by use of Millard’s procedure.
The first one is characterized by upper lip height decreased in the central seg-
ment, wide nasal philtrum, absence of white line, deficient vermilion tubercle, bad
alignment of the red roll, and unrepaired muscular plane (Fig. 7.4).
Bilateral whistler deformity due to the Millard’s bilateral cheiloplasty is charac-
terized by shorter lip in transverse diameter of the upper lip and central lip height
deficiency due to central scar and limited to the vermillion component. To prevent
this problem, the vermillion of the lateral segments must be included in order to
obtain redundancy of tissue to rebuild the vermillion tubercle (Fig. 7.5). Its diagno-
sis is established through the difference between the lip height of the lateral seg-
ments and the central one.
The surgical treatment depends on the type of bilateral whistler deformity.
Management of whistler deformity associated with Millard’s procedure is easier,
and vertical scar retraction may be corrected using a simple Z plasty. For correction
of bilateral whistler deformity caused by use of Manchester’s type (most frequent
form of presentation), the author developed a technique based on the conversion to
Millard’s technique [11]. This technique uses the lateral segments to recreate the
poorly reconstructed central lip. Special attention must be paid to any lip asymme-
try which is frequent to be observed.
Fig. 7.4 Bilateral whistler

cleft lip repair using
Manchester’s type of repair
Fig. 7.5 Bilateral whistler

cleft lip repair using
Millard’s type of repair
Surgical Technique
Markings (Fig. 7.6)
Surgical incisions are performed following the markings using a scalpel and
blade 11 through the skin and subcutaneous tissue. The scar developed by the pri-
mary surgery is removed along with the excess tissue of the prolabium, which is
usually wider. Then using fine scissors, the orbicularis oris muscles are dissected in
both sides. The scar tissue may be used to provide volume for the vermillion tuber-
cle if necessary. It is often necessary to shorten the diameter of the alar bases which
are frequently wider. A 4/0 PDS suture is used to approximate the alar bases guar-
anteeing long-term outcome.
Secondary cleft rhinoplasty may be performed if necessary.
Wound closure is performed starting from the mucosa, then the muscular plane,
and finally the skin using absorbable sutures in children and nylon in adults
(Fig. 7.7).
The main disadvantage of this technique is the reduction of upper lip dimensions
(microstomy), and preoperative planning must evaluate the size of the lateral seg-
ments. Special care should be taken not to reduce too much the proportion and the
width of the upper lip using this technique because it may develop a small upper lip
(Fig. 7.8).
The presented technique is indicated for cases when the width of the lateral seg-
ments is not less than 1/3 of the total width of the lower lip. If the lateral segments
are too small, other techniques are recommended for correction of the central lip
deformity as grafts, fillers, or even the Abbe flap in severe forms. The use of V-Y
advancement may be used as alternative in these cases. The method provides addi-
tional length to the lip improving whistler deformity (Figs. 7.9 and 7.10).
Fig. 7.6 Conversion

technique for bilateral a
whistler deformity created
after using Manchester’s
type of repair. (a).
Preoperative view. (b).
Postoperative view. (1)
Cupid’s bow midpoint. (2)
Right cupid’s bow peak.
(3) Left cupid’s bow peak.
(4) Intersection between
columellar base and labial
scar in both sides. (5) Point
located in an equal
distance to 1–2 and 1–3
above the white roll. (6)
Intersection between the
point located 1 mm above
the white roll and the labial
scar. (7) Intersection
between the sub-alar sulcus
and labial scar. (8) Alar
bases. (A and B) Oral
b
commissures
The most severe forms of this central deformity are associated with scar disor-
ders, loss of prolabium, and the use of some surgical techniques. The severity of this
sequel may be estimated by comparing the width of the upper and lower lips.
A special case in which there is a dramatic reduction of upper lip tissues is the
loss of the prolabium (Fig. 7.11). Some primary bilateral cheilorhinoplasties like
Mulliken’s and Trott’s [12] may favor the possibility of having this problem.
Fig. 7.7 Eight-year-old patient with bilateral whistler deformity after primary repair using Spina
technique (a Manchester’s type of repair). A wide philtrum and lack of white roll and muscular
repair. The conversion technique was used obtaining good outcome
Fig. 7.8 Preoperative and postoperative view of a patient with bilateral whistler deformity oper-
ated using the conversion technique and developing microstomia. This is a bad indication for the
conversion technique
The form the prolabium is manipulated during surgery which also may produce
ischemia and necrosis. A case was observed in which the patient lost the prolabium
due to its improper manipulation during surgery. If necrosis occurs, topical antibiot-
ics such as mupirocin may be used until the scarified tissue is removed. The diagno-
sis is made by the presence of central scar and absence of the nasal philtrum
(Fig. 7.11). The sequel may be corrected once the tissues heal and the healing pro-
cess is completed.
Fig. 7.9 Illustration showing the V-Y advancement technique for bilateral whistler defor-
mity repair
Fig. 7.10 Twenty-one-year-old patient who developed bilateral whistler deformity after primary
repair using Manchester’s technique. Lip scars were resected, and V-Y advancement of the phil-
trum was carried out allowing correction of the lip and columellar base. Limitation of this method
is the persistence of absence of the white roll
The management of these defects are complex, since it requires adding tissues,
and the most appropriate option to provide similar tissues seems to be the transposi-
tion of a lip segment from the lower lip, known as the Abbe flap.
This is a widely used technique for upper lip reconstruction in patients with cleft
lip and palate. The main disadvantage is the creation of a visible scar on the lower
lip, not always well tolerated by patients. The risk benefit must be carefully evalu-
ated in order to use this technique for the benefit of the patient.
The indication for its use is when the upper lip has loss of the prolabium or it is
retracted with visible hypertrophic scars being the lip small in its transverse
a b
Fig. 7.11 (a) Patient born with severe form of bilateral cleft lip and palate suffering loss of the
prolabium and operative wound dehiscence. (b) Subsequently secondary cheiloplasty was per-
formed during cleft palate repair after premaxillary setback for cleft lip and nose repair
diameter. The following indications may be mentioned: loss of prolabium, very

hypoplasic prolabium, nasal philtrum retracted and with severe hypertrophic scars,
and secondary bilateral cases with a labial height of 1/3 or less of the lateral seg-
ments lip height.
The absence of prolabium has been described in association with some surgical
techniques used for columellar repair as the method described by Gillies [1].
He performed a reconstruction of the nasal columella at the expense of the pro-
labium [7]. This procedure generates a negative imbalance in the upper lip which
should be corrected using an Abbe flap (Fig. 7.12). The Abbe flap is a pedicle flap
based on the inferior labial artery and performed in two stages. A peninsular flap is
designed in the middle third of the lower lip and will replace the nasal philtrum
anatomic subunit. The second stage may be performed after 2 weeks sectioning the
pedicle of the flap and opening the mouth.
This method is limited only to adult patients as children cannot tolerate labial
adhesion for 2 weeks. The main disadvantage of the Abbe flap is the development
of microstomia and the requirement of a period of time in which the patient does not
open the mouth because of flap transposition imposing an excessive burden on the
patient.
Because this surgery is performed mostly in adults, local anesthesia under sedation
is used. In the case of children, we use general anesthesia, and intubation can be
endotracheal or nasotracheal (preferably). First, the deficiency of the upper lip must
be estimated by comparing the transverse diameters of the upper and lower lip (X
and Y in Fig. 7.12). The width of the flap will be half the difference between both
lips’ diameters. It can be considered as an average length of 15–20 mm although
proportions between the aesthetic units of the lip must be taken into account. The
height of the flap is easier to determine and corresponds to the height of the aesthetic
subunit (distance between the base of the columella and the lower edge of the ver-
million). This length may be extended if it is desired to repair the base of the
columella.
a b
c d
Fig. 7.12 The Abbe flap for secondary bilateral cleft lip repair. (a) Markings. (b) Elevation of
Abbe flap leaving a pedicle that allows vascular supply through the lower labial artery (red circle).
(1) Lower labial artery. (c) The flap is transposed into the lip defect. (d) Appearance of the upper
lip once the pedicle of the flap was sectioned and the donor site closed
Markings (Fig. 7.12)

• Right oral commissure
• Left oral commissure
• X. Upper lip transverse diameter
• Y. Lower lip transverse diameter
• Z. Width of the flap
• Z: (X − Y)/2
The pivot point of the flap is located 2 mm below the white roll of the lower lip
(where the labial artery passes). The incisions described are marked; then supra-
and infraorbital nerve block is performed using local anesthetics.
Initially, the scar tissue of the upper lip is excised leaving healthy edges in the
cutaneous plane. If there is any residual health tissue from nasal philtrum, it may be
used for columellar base repair.
The incisions in the lower lip are made using a scalpel and number 15 blade fol-
lowing the markings outlined across the full thickness of the lip. This incision must
be stopped 2 mm below the white line in one side of the designed flap (the choice of
the pedicle side is indifferent). At this level, the presence of the lower labial artery
can be confirmed and preserved to allow temporary blood supply to the transposed
flap until it is sectioned.
At the other border, the lower labial artery must be ligated. After flap elevation,
it is transposed following an exact correspondence with upper lip landmarks (white
and red roll), and mucosal, muscular, and cutaneous planes are sutured. The Abbe
flap will be temporarily attached to the donor site (lower lip) during 2 weeks; after
this period, the flap can be sectioned. The closure of the donor site is performed
edge to edge (looking for proper alignment of the white and red rolls).
During this time, the feeding of the patients can be done with thick and rigid
straws giving them a liquefied diet. Dental hygiene can be done doing mouthwashes
since brushing is difficult to do. The pedicle of the flap can be sectioned 2 or 3
weeks later under local anesthesia, and finally the donor site is closed. Special care
must be taken in aligning appropriately the white and red rolls in both lips. The
border of the divided flap should be carefully sutured to the upper lip in order to
align the white roll and avoiding major dissections as this maneuver can devascular-
ize the flap. It is better to perform minor corrections 1 year after (Figs. 7.13, 7.14,
and 7.15). Abbe’s flap is the workhorse of the secondary reconstruction of the bilat-
eral cleft lips and allows to repair all the anatomical structures of the central seg-
ment of the upper lip. This can be done once the patient can tolerate partial closure
of the mouth during 15 days. The youngest patient we practiced on with this surgery
was 10 years old.
7.2.2 Long Lips
This bad outcome is less frequent to observe in bilateral cleft lips. This is mostly
associated with Millard’s type of repair (using the lateral segments to repair the
philtrum and vermillion tubercle). First, it is necessary to differentiate an increased
length at the expense of the philtrum or by a longer vermillion tubercle. The last one
may be associated with secondary correction using the conversion technique to cor-
rect the bilateral whistler deformity. There could be associated a phenomenon of
hypertrophy, something similar to the problem observed after primary surgery of
cleft lips. The estimation of this non-desirable outcome is made by comparing lip
height between the central and lateral segments; the severity of the deformity is
determined and the surgical planning is done.
Fig. 7.13 Patient with bilateral cleft lip and sequel after primary repair. Photos show the Abbe flap
elevation and transposition. Finally, the flap is divided and upper lip repaired after 2 weeks.
Secondary cleft rhinoplasty is required
The first step is to estimate the transverse diameter of the lateral segments choos-
ing the largest one as a parameter to determine the desired lip height. The lip height
should be equal to the largest transverse diameter of the lateral segments.
To correct this sequel, skin resection is performed at the upper or lower level of
the lip. It is more cosmetic when it is done at the sub-alar level although it is advis-
able to use the lower scar to preserve the irrigation of the philtrum.
Fig. 7.14 Twenty-five-year-old male patient with complete bilateral cleft lip and palate who
underwent lip surgery at early age leaving the upper lip with reduced dimensions and hypertrophic
scars. The transposition of the lower lip flap and the patient’s appearance are shown after 1 year
showing a better proportion of the aesthetic subunits of the upper lip and nose
Surgical Technique
The marking of the technique is illustrated in Fig. 7.16.
The area to be resected is delimited using a marking pen. The incisions are made
using scalpel and number 11 blade, following the markings through the skin and
subcutaneous tissue. Subsequently, using fine scissors, the excess of marked skin is
resected, and subcutaneous dissection is performed around the edges to release ten-
sion closure. Closing it is made using PDS in the subdermal plane and few stitches
on the skin (fast-absorbing catgut). Finally, mupirocin or bacitracin ointment is
applied to the operative wound.
Fig. 7.15 Eighteen-year-old male patient with complete bilateral cleft lip and palate who under-
went lip cleft lip repair leaving a small philtrum and whistler deformity. The flap transposition and
the appearance of the patient are shown 2 months after the section of the flap illustrating a better
proportion of the upper lip aesthetic units and symmetry. The small philtrum was used to recon-
struct the labial columellar angle
7.3 Lip Asymmetries
This postoperative condition is very common to observe since the congenital hypo-
plasia of lateral segments is mostly asymmetric. Primary surgical techniques for
bilateral cleft lip repair use symmetrical incisions causing a secondary asymmetry
of the lip (Fig. 7.17). Furthermore, the skeletal deformity (often asymmetric also)
tends to exaggerate these differences. This problem has been addressed before by
other authors. Yuzuriha and Mulliken have published techniques for correction of
lip asymmetries in bilateral cleft lips but limited to minor forms [13]. The primary
bilateral cleft cheiloplasty described by John Mulliken corrects the congenital
asymmetry by reduction of the longer segment [8]. However, this proposal tends to
create a smaller lip.
a b
Fig. 7.16 Marking the surgical technique for upper lip sequels of bilateral cleft lip due to long lip
after primary cheiloplasty (a). Lip heights should be identified at different levels in order to mea-
sure the area of lip to be excised. (b) Final appearance after lip excision
Fig. 7.17 Cases of patients with bilateral cleft lip who developed lip asymmetries as a result of
primary surgeries
The author published a technique that proposes lengthening of the shorter seg-
ment or combination of lengthening and reduction in severe forms [14]. The surgi-
cal lip adhesion as method of orthopedic treatment of the premaxilla allows the
improvement of the lateral segments congenital asymmetries by stimulating the
expansion of the skin.
The diagnosis is established by measuring the labial heights at the level of the
labial scar from the nasolabial sulcus up to the white roll on each side and compar-
ing them.
In mild asymmetries, the use of lozenge excision of lip scar allows to provide
additional length to the lip and correct asymmetries. For major corrections, we may
use the following options (or combination of them): shortening of the longest side
or lengthening of the shorter side. The choice of the strategy is made based on the
ideal lip height. This is equal to the largest transverse diameter of the lateral
segments.
Shortening of the longest side is done by performing skin resection (sub-alar
or above the white roll) at the level of the lip scar. The amount to be resected is
estimated through the differences between both lip heights (Fig. 7.18). The
lengthening of the shorter side is done using a unilimb Z plasty (Fig. 7.19). The
base of the triangle has the same distance as the difference between both lips
heights, and it is recommended to not be greater than 3 mm. This Z plasty can be
performed at the upper or lower level of the lip (Fig. 7.20). The combination of
these options is recommended in cases where the discrepancy is severe (greater
than 1 cm) (Fig. 7.21). Thus, the difference between the labial heights must be
corrected by skin resection of the longest side and Z plasty lengthening of the
shortest side.
Surgical Technique
Markings of these techniques are illustrated in Figs. 7.18, 7.19, 7.20, and 7.21.
a b
Fig. 7.18 Surgical technique for labial asymmetry repair shortening the longest side. (a) 1. Right
nasal floor. 2. Right cupid’s bow peak. 3. Columella. 4. Left nasal floor. 5. Left cupid’s bow peak.
Red lines: Alternative areas for skin resection. (b) Lip symmetry obtained after surgical correction.
Red lines: Alternative location of final scars
a b
Fig. 7.19 Surgical technique for labial asymmetry repair lengthening the shortest side. (a) 1.
Right nasal floor. 2. Right cupid’s bow peak. 3. Columella. 4. Left nasal floor. 5. Left cupid’s bow
peak. Marked area for skin resection. (b) Lip symmetry obtained after surgical correction.
X−Y=4−5
a b
Fig. 7.20 Alternative surgical technique for labial asymmetry repair lengthening the shortest side.
The unilimb Z plasty can be performed above the white roll. (a) 1. Right nasal floor. 2. Right
cupid’s bow peak. 3. Columella. 4. Left nasal floor. 5. Left cupid’s bow peak. Marked area for skin
resection. (b) Lip symmetry obtained after surgical correction. X − Y = 4 − 5
The incisions are designed using a marking pen. The incisions are made using
scalpel and number 11 blade, following the markings through the skin and subcuta-
neous tissue, and the skin is resected using fine scissors in case it is indicated. The
closure is made edge to edge using PDS in the subdermal plane and catgut fast
absorbing for the skin.
a b
Fig. 7.21 Combined technique for the correction of bilateral labial asymmetries. It is used in cases
with severe height discrepancy (greater than 1 cm in adults). (a) Preoperative. (b) Postoperative
7.4 Vermilion Bad Outcomes
7.4.1 Vermilion Deficiency
The upper lip vermilion is frequently reconstructed with deficiencies due to the
congenital hypoplasia of the prolabium in bilateral cleft lips. This concept supports
the hypothesis that the only way to provide volume for vermilion tubercle repair is
from the lateral segments or from the lower lip using the Abbe flap. The absence of
the white roll and deficiency of vermilion characterize the prolabium, and these
structures should be repaired during primary surgery. Its absence gives an appear-
ance of a gap at the lower portion of the philtrum. The red line of the lip corresponds
to the transition zone from keratinized epithelium to the non-keratinized one (lip
mucosa), also called wet line, and it is located about 10 mm from the white line
although this position is variable among patients.
The height’s discrepancy between prolabium vermillion and lateral segment one
allows us to determine the diagnosis and severity of the deformity, providing three
options for its repair:
(a) Vermilion tubercle reconstruction using tissues from the prolabium.
This option is limited to provide good outcomes; however, the use of fillers
to give additional volume to the tubercle may optimize the results. The main
advantage of this option is the preservation of the upper lip’s width.
(b) Vermilion tubercle reconstruction using tissues from the lateral segments of the
cleft lip. This option provides enough tissue for tubercle repair; however, it may
compromise the upper lip’s width in cases with short lateral segments. Thus,
they may use at least 1/3 of the width of the lower lip for this method; other-
wise, the upper lip will be significantly reduced creating lip microstomia.
(c) Vermilion tubercle repair using both (prolabium and lateral segment tissues).
This combination uses three flaps for vermilion tubercle repair (prolabium and
two lateral segments). The vermilion height may be improved and prevents
microstomia; however, the appearance of the repaired vermilion is not adequate.
An example of this concept is the technique described by Donald Glover, a
plastic surgeon from the USA, combining the use of lateral segment and
prolabium for lip repair [7]. The method avoids the transverse scar, but the main
disadvantage is the patch-like appearance that the lip acquires. In addition, the
vermilion of the prolabium is different in color and texture, and there is absence
of white roll (Fig. 7.22).
The vermilion reconstruction should consider its three components: white
roll, vermilion tubercle, and red roll.
Secondary white roll deficiencies are characterized by absence or misalignment
of this roll. This is commonly observed after using the prolabium tissues, and it is
more likely to have bad outcomes. For diagnostic purposes, the first step is to visual-
ize properly the path of the white roll and then determine the severity of the sequel.
In mild cases of white roll misalignment, a lozenge resection may allow correc-
tion of the deformity (Fig. 7.23). In case of severe forms or white roll absence, the
reconstruction from the lateral segments is indicated if they are wider than 1/3 of the
length of the lower lip in order to avoid lip microstomia (Figs. 7.24 and 7.25).
If the lateral segments are shorter, it is important to prioritize the size of the
upper lip, and the use of lozenge resection is recommended.
A common deficiency of the white roll repair is the absence of cupid’s bow
which may be associated with the Millard’s type of repair because the central scar
tends to distort this structure. It is characterized by the absence of the natural curva-
ture of the cupid’s bow. Its correction can be performed by resection of the skin
above the white line designing the characteristic curvature of this anatomical area
(Fig. 7.26).
Fig. 7.22 Three cases of bilateral cleft lips are shown; they were repaired using a combined tech-
nique (lateral and prolabium flaps). Patch appearance is acquired due to lymphatic edema. In addi-
tion, the repaired philtrum lacks white line, and the vermilion tubercle has a different color
Fig. 7.23 Twenty-eight-year-old patient with deficiency in the alignment of the white roll. The
defect has been corrected using a lozenge resection improving the position of the white roll
a b
Fig. 7.24 Illustrative diagram showing the usefulness of the conversion technique to correct white
roll defects. (a) Preoperative view. (b) Postoperative view
Surgical Technique
The incisions are made using a scalpel and blade number 11, and a lot of preci-
sion is required following the marking described through the skin 1 mm above the
white roll.
It is recommended to start with the upper incision to prevent the distortion of the
lower markings due to wound bleeding. Only the skin is resected, and limited
Fig. 7.25 Male patient presenting sequel after primary bilateral cleft lip repair characterized by
absence of central white roll and secondary nose deformity. Surgical repair is done using lateral
segments (Fig. 7.24) for reconstruction of the white roll and vermilion tubercle
a b
Fig. 7.26 Illustration showing the cupid’s bow correction technique in patients with this kind of
sequel after bilateral cleft lip repair. (a) Preoperative view. (b) Postoperative view
dissection is performed on the edges. Wound closure is performed only in the cuta-
neous plane using 6/0 catgut fast-absorbing sutures.
Regarding deficiencies in the reconstruction of the red roll, they are commonly
observed in combination with defects of the other components of the central seg-
ment of the lip.
In Manchester’s type of primary repair, the hypoplasic prolabium has a short
vermilion; therefore, the red roll is in upper position compared to one of the lateral
segments creating a misalignment and exposure of the moist mucosa. This condi-
tion creates a tendency to dryness and ulceration of the mucosa (Fig. 7.27).
Fig. 7.27 A case of

reconstruction of the
bilateral cleft lip using the
Manchester’s technique
developing a whistler
deformity characterized by
short vermilion and lack of
red roll leaving exposed
wet mucosa with a visible
cosmetic defect
In Millard’s type of primary repair, there is a vertical scar over the repaired ver-
milion, and the red roll tends to be shorter due to deficit of tissue or scar
contracture.
The secondary correction of the red roll is carried out according to the primary
reconstructive method.
The conversion technique should be indicated for cases operated using
Manchester’s technique if the lateral segments are not small (less than 1/3 of the
lower lip).
The red roll can be repaired using the Abbe flap if the lateral segments are too
small to prevent secondary microstomia. In secondary cases after Millard’s type of
primary repair, a single Z plasty or combined with lozenge excisions may be enough
for red roll alignment in mild cases, avoiding excessive lengthening of the vermil-
lion tubercle.
The use of fillers and grafts does not offer help with red roll deformities since it
does not correct its position and misalignment persists. Conversely, it may exagger-
ate the exposure of the moist mucosa.
The vermilion tubercle deficiencies are commonly observed after Manchester’s
type of primary repair and often associated with red roll sequels. Deficiencies in
vermilion tubercle and red roll repair are diagnosed by estimation of the distance
between the white and red roll and comparison with the similar distance at the lat-
eral segments. These deficiencies can be corrected through local flaps (conversion
technique in combination with muscular transposition) and/or adding volume using
grafts of dermis, fat, fascia, and tendon or from the use of synthetic absorbable sub-
stances such as hyaluronic acid. The bilateral Kapetansky technique is an option for
the vermilion tubercle secondary deformities [15] (Figs. 7.28 and 7.29). This is a
pedicle pendulum flap taken from the vermilion lateral segments in a V-Y
a b
Fig. 7.28 Marking of Kapetansky flaps for secondary correction of vermilion deficiency in
patients with bilateral cleft lip. The labial heights of the lateral segments (X) and the height of the
vermilion at the tubercle level (Y) can be appreciated. The height of the flap (Z) is estimated as the
difference between the distances X and Y. (a) Preoperative view. (b) Postoperative view
a b
Fig. 7.29 (a) Female patient 22 years old born with bilateral cleft lip develops vermilion tubercle
defect after primary repair. (b) Tubercle reconstruction has been performed using two Kapetansky
flaps according to the illustration in Fig. 7.28
advancement form having the advantage of using similar tissues. The main disad-
vantage of this method is the postoperative edema giving the flap a patch appearance.
Surgical Technique
The marking of this technique is illustrated in Fig. 7.28.
A. Right oral commissure
B. Left oral commissure
C. Flap’s pedicle
X. Vermilion height of lateral segments
Y. Vermilion height of the central segment
Z. Estimated height of the flaps
A vermilion island is designed on both sides in a triangular shape (medial base

and lateral vertex). The scar tissue from recipient site is removed leaving the moist
mucosa below this level. Surgical incisions are made using a scalpel and blade num-
ber 15 following the markings and superficial subcutaneous dissection parallel to
the skin and mucosal planes to the extent necessary to allow mobilization of the
pedicle flaps toward the defect.
Thus, there are two superior subcutaneous pedicle island flap which is mobilized
as a pendulum bilaterally. The donor area closes linearly on both sides mobilizing
the V flaps and closing in Y form. The closure is done using 5/0 Vicryl, and mupiro-
cin or bacitracin ointment is applied to the wound (Fig. 7.29).
It is important to mention that the secondary deformities of the white and red roll
rarely occur in isolation. Generally, it is in combination with deficiencies in vermil-
ion tubercle and red roll repair. Hence, the correction is made simultaneously.
The Abbe’s flap (previously described in this chapter) is the workhorse in sec-
ondary repair of bilateral cleft lips and a good alternative in the reconstruction of the
severe forms of secondary vermilion deformities. This reconstructive method has
the great disadvantage of leaving a visible scar on the lower lip (Fig. 7.30).
Other transposition flaps for vermilion repair are the vermilion lower lip and
tongue flap. Another common problem associated with vermilion bad outcomes is
lip dehiscence after primary repair due to closure under tension. It is recommended
that any complete bilateral cleft lip and palate whose width of the alveolar cleft is
greater than 1 cm must receive any type of presurgical treatment prior to lip surgery
in order to prevent this bad outcome. Its surgical treatment is done through reopera-
tion using the conversion technique.
7.4.2 Vermilion Excess
This poor outcome is less commonly observed. When it happens, it is more associ-
ated with the Millard’s type of repair. Sometimes, a hypertrophic component is
added, possibly due to tension and expansion of lip tissues (Fig. 7.31). For its cor-
rection, the surgical technique consists of resection of the excess vermilion in a
lozenge form.
Surgical Technique
The marking of the technique is illustrated in Fig. 7.32. The area to be resected must
be delimited by comparison of the vermilion heights of both lips to prevent overcor-
rection or exposure of the wet mucosa of the lip. It is recommended to place traction
sutures at the lip border to create tension and to be able to perform the incision with
precision. These incisions are performed using a scalpel and number 11 blade fol-
lowing the described markings through the skin and subcutaneous tissue of the ver-
milion. Then, the excess of the vermilion is resected using fine scissors. Careful
hemostasis is necessary due to the presence of labial artery and its branches. Finally,
the wound is closed linearly edge to edge using Vicryl 5/0.
a b
Fig. 7.30 (a) Thirty-two-year-old patient with sequel of primary bilateral cleft lip repair charac-
terized by a deficiency of philtrum and vermilion tubercle. (b) Reconstruction was performed
using an Abbe flap. (c) Postoperative view after 1 year of evolution is presented
Fig. 7.31 Three-year-old

patient born with a
bilateral cleft lip who
developed a bad outcome
characterized by longer
vermilion after primary
repair
a b
Fig. 7.32 Marking the surgical technique for upper lip sequels of bilateral cleft lip due to an
excess of vermilion after primary cheiloplasty (a). (b) Vermilion heights should be identified at
different levels in order to measure the area of vermilion to be excised. (c) Final appearance of the
vermilion after tissue excess removal
7.5 Bad Results Associated with Muscular Repair
The prolabium in bilateral cleft lip patients is always hypoplasic in different degrees,
and there is absence of muscular plane. This condition has been emphasized by
Victor Veau who called it as “the muscular sterility of the prolabium” [7]. This situ-
ation is noticeable in bilateral cleft lips reconstructed using the Manchester’s type
of repair. In these cases, the muscular repair through an additional surgical time is
required to obtain an adequate aesthetic and functional outcome. It is difficult to
perform muscular repair from the lateral segments, especially in wide clefts.
Because of this condition, deficiencies in repair of the muscular plane are more
frequently observed in bilateral cleft lips. Associated muscles of the upper lip are
Fig. 7.33 An example of a patient operated using Manchester technique who had deficiencies in
the muscular plane repair. It is characterized by central depression and lateral bulging during con-
traction of the orbicularis oris muscle
labial and alar fascicle of the common elevator of the ala nasi and upper lip muscle
and marginal and peripheral portions of the orbicularis oris muscle. Inadequate
muscle repair is characterized by central depression (at the level of the philtrum)
and lateral bulging (Fig. 7.33). For diagnostic purposes, the patient is asked to real-
ize the different functions of facial muscles, opening and closing the mouth, kissing,
smiling, etc., so any specific alteration can be detected.
Affected functions are distortion of the elevation of the nasal ala and elevation of
the upper lip as the sphincter function of the upper lip.
Repair of the sequel due to deficiency in surgical correction of the upper lip muscles
in patients with bilateral cleft lip is performed according to the following guide-
lines. The marking is made on the lip scar (the scar tissue is resected) following by
the approach incision, and the muscular plane is dissected below this plane bilater-
ally. Once the muscular plane is dissected, the four muscles are identified. The alar
fascicle of the common elevator of the lip and nasal ala can be visualized as a
fibrous tendon at the base of the ala, and the labial fascicle is located posteriorly to
the orbicularis oris muscle in its marginal portion (Fig. 7.34). The marginal portion
of the orbicularis oris muscle occupies most of the upper lip from the sub-alar
groove to the white roll, and its peripheral portion occupies the portion of the upper
lip from the white roll to the red roll. After their identification, the muscular plane
is reconstituted by relocating each muscle according to their anatomical position as
a b
Fig. 7.34 (a) Illustrative diagram and (b) intraoperative photo of the upper labial muscles during
secondary bilateral cheiloplasty in a patient with sequelae due to deficient muscular repair. 1.
Levator labii superioris alaeque nassi. 2. Alar fascicle. 3. Labial fascicle. 4. Peripheral portion of the
orbicularis oris muscle. 5. Marginal portion of the orbicularis oris muscle. 6. Levator labii superioris
a b
Fig. 7.35 (a) Illustrative diagram and (b) intraoperative photo after repair of the labial muscles
during secondary cheiloplasty. 1. Levator labii superioris alaeque nassi. 2. Alar fascicle. 3. Labial
fascicle. 4. Peripheral portion of the orbicularis oris muscle. 5. Marginal portion of the orbicularis
oris muscle. 6. Levator labii superioris
follows (Fig. 7.35). The alar fascicle of the common elevator of the lip and nasal ala
should be inserted at the base of the nasal septum bringing support to the alar base,
and the labial fascicle is inserted in combination with the marginal portion of the
orbicularis oris muscle. The marginal and peripheral portions of the orbicularis oris
muscle are sutured border to border with the same muscle from the opposite side.
This muscular reconstruction is performed using single or mattress 5/0 PDS stitches.
Finally, the cutaneous plane is closed after careful hemostasis revision. Some fixa-
tion points from the subcutaneous plane to the muscle can be applied to reduce the
created space after muscular dissection reducing the development of bruises or sero-
mas (Fig. 7.36).
Fig. 7.36 Four-year-old patient born with bilateral cleft lip and palate underwent secondary chei-
loplasty using the proposed technique. The optimal function of the labial musculature is observed
at rest, during sphincter contraction, when smiling, and in labial depression respectively with opti-
mal aesthetic and functional characteristics
7.6 Secondary Nose Deformities
There seems to be some consensus regarding the need for performing primary nasal
repair. The results presented in different publications show a significant improve-
ment in the bilateral nasal deformity after primary repair reducing the need for
subsequent surgeries and will also allow to minimize psychological impact suffered
by patients with these sequels [16–18].
The secondary nasal deformity of bilateral cleft lip presents the following char-
acteristics (Fig. 7.37):
• Bad position of alar cartilages and lack of projection of the nasal tip.
• Absence or shortened of nasal columella. In fact, it is hidden in the nose as what
Mulliken said.
• Obtuse labial columellar angle.
• Wide nasal floor.
• Ectopic insertion of nasal muscles.
• Maxillary hypoplasia in different degrees.
Fig. 7.37 Secondary nasal

deformity in a patient with
bilateral cleft lip.
Components of this bad
outcome are as follows: 1.
Nasal tip lack of
projection. 2. Alar
cartilages malposition. 3.
Short columella. 4. Wider
nasal floor
Common mistakes during primary nasal repair have been seen in the following
methods: banked fork flaps (Millard) using lip tissues for nose repair obtaining an
unnatural outcome, lengthening of the nasal columella using grafts creating a
retracted columella without normal appearance, lengthening of the nasal columella
using the prolabium creating a discrepancy in the upper lip as proposed by Von
Langenbeck [7] and skin resection from the soft triangle area popularized by Tajima
and Mulliken bringing a turned-up appearance of the nose, functional disorders
related to the soft triangle resection and also visible scars, and finally the Mc Comb’s
concept based on transcutaneous suspension due to the high rate of recurrence [19]
(Figs. 7.38, 7.39, and 7.40).
My philosophy for secondary correction of the bilateral cleft lip nose deformity
is based on the following principles:
• The outcome depends on the severity of the cleft. It is very difficult to correct the
nasal deformity in a severe bilateral cleft lip with the premaxilla in an inappropri-
ate position. Vomer osteotomy and setback of the premaxilla may be necessary
in few cases.
• Columella lengthening based on alar cartilage reposition and vestibular
lengthening.
• Nasal septum and nasal floor repair achieved through alveolar bone graft and
orthognatic surgery when necessary. The need for septal correction is less fre-
quent in comparison with unilateral clefts.
The first decision to be considered regarding secondary correction of the bilateral
cleft lip nose deformity is about the patient’s age at the time the operation should be
Fig. 7.38 Twenty-year-old bilateral cleft lip patient operated with Manchester technique and cor-
rection of the secondary nasal deformity using skin grafts. Despite nasal tip projection improve-
ment, poor aesthetic outcome can be observed
Fig. 7.39 Two nasal bilateral cleft lip secondary deformities repaired using skin grafts. The limita-
tions of the technique can be observed with pigmentation, unsightly scars, and broad nasal tip
Fig. 7.40 A patient with

sequel of primary bilateral
cleft lip nose repair. The
prolabium has been used to
provide length to the nasal
columella. The
disproportion developed by
bringing lip tissues to the
nose creates a short upper
lip without philtrum
carried out. According to our protocol, any severe aesthetic or functional condition
should be treated at early age; this is before school age, preventing the psychosocial
and functional impact of the patient. Any minor sequela can be corrected later in
adulthood preventing the potential effect of the anesthesia/surgery in the develop-
ment of the child. A careful physical examination and photographic documentation
are recommended to establish aesthetic and functional problems to be treated. The
anatomical areas to analyze are nasal tip, columella, vestibule, alar bases, and septum.
7.6.1 Nasal Tip
The proposed surgical technique for secondary nasal tip correction is based on
medial reposition of the alar cartilages allowing lengthening of the columella and
nasal tip projection, lengthening of the nasal vestibule, medial reposition of the alar
bases, and correction of the nasal septum (if necessary). The used technique is a
combination of V-Y (Potter’s concept) and lateral Z plasty (Berkeley’s concept) [20,
21]. By lengthening the nasal vestibule, it is possible to reposition the alar cartilages
improving the nasal tip projection, and the lateral Z plasty prevents scar contracture
of the lateral incisions. Cartilaginous grafts are required to reinforce the area of the
nasal vestibule that remains without cartilaginous reinforcement after medial dis-
placement of alar cartilages. The surgical approach can be performed in an open or
closed manner; however, open rhinoplasty has the advantage of allowing direct
access to the septum.

Based on the open rhinoplasty concept, marking is done by design of the cutaneous
incisions (transcolumellar incision, columellar, and marginal) (Fig. 7.42b).
At the nasal vestibule area, the marking continues along the intercartilaginous
border (limen nassi) on both sides of the nose. The intersection of the marginal and
intercartilaginous incisions will design the chondrocutaneous advancement flap.
The lateral Z plasty is designed along the lateral portion of the chondrocutaneous
advancement flap.
Fig. 7.41 The V-Y-Z technique for correction of the bilateral secondary nasal deformity. Red cir-
cle: area for cartilaginous graft. 1. V composite flap. 2. Lateral Z plasty. Black circles: transcutane-
ous stitches. Upper: preoperative view. Lower: postoperative view
a b
c d
e f
Fig. 7.42 (a) Five-year-old patient with bilateral cleft lip and secondary nasal deformity. (b)
Approach through open rhinoplasty shows nasal cartilaginous structure. (c) Plication of alar
domes. (d) Bilateral V-Y advancement flaps. (e) Nasal tip appearance after dome release and plica-
tion. (f) Postoperative view. 1. Alar cartilages. 2. Nasal dorsum. 3. Columella
The patient is prepared depending on the type of anesthesia (local/general).

Nasal packing is recommended to limit the flow of blood into the pharynx. The
surgery starts performing the transcolumellar incision which extends laterally con-
necting with the marginal incisions bilaterally allowing the exposure of the nasal
cartilage framework. The cutaneous flap is elevated using fine scissors, and alar
cartilage and dorsum are exposed (Fig. 7.42b). If a septoplasty is required due to a
functional disorder, the dissection continues between the medial cruras in order to
identify the caudal portion of the nasal septum.
Once identified, the submucoperichondrial plane is carefully approached up to
the posterior region of the septum. Then, the deviated portion is resected leaving a
frame (at least 1 cm). The removed cartilage will serve as grafts to reinforce the
lateral area of the nasal vestibule. Finally, the septoplasty ends with the closure of
the medial cruras of alar cartilages.
Surgery continues in the vestibular area, performing an intercartilaginous inci-
sion creating the V composite flap in both sides. The bilateral chondrocutaneous
advancement flaps are elevated in the supraperychondric plane (Fig. 7.42b).
The cartilage graft is then fixed to the lateral end of the composite flap using PDS
5/0. This graft will reinforce the donor area left without cartilaginous support after
medial displacement of the composite flaps. After flap elevation, transdomal sutures
using PDS 5/0 are performed and continued using transcutaneous stitches for flap
repositioning and correction of the columella and nasal tip (Fig. 7.42c).
The use of transcutaneous stitches also prevents the possibility of hematomas or
seromas between dissected planes. The surgical technique ends with the closure of
the columellar approach incision and the correction of any widening and asymmetry
of the alar bases, if necessary (Fig. 7.42f). Nasal packing is necessary at the end of
the surgery which can be removed during the following days if no active bleeding is
observed.
As you may see in the presented cases (Figs. 7.43 and 7.44), the nasal columella
can be effectively reconstructed through the lengthening of nasal vestibule and
repositioning of alar cartilages during primary and secondary repair. Delay of the
nose deformity correction until adulthood (still used today by some surgeons)
exposes the patients to live during their first years of life suffering the effects of the
psychosocial impact, a condition that cannot be treated surgically.
7.6.2 Nasal Ala
The most common form of presentation of the nasal ala in bilateral cleft lips is the
wide and asymmetric alar base. Both conditions are identified by comparison
between both sides. Asymmetries due to wider, higher, and lower position of the
nasal ala are observed with some frequency. These non-desirable outcomes can be
prevented performing adequate preoperative marking.
The surgical alternatives for their treatment are similar than those presented for
unilateral secondary deformities. I would like to emphasize in this chapter the most
common form of presentation which is the asymmetry due to the wider position of
the alar bases.
This appears to be due to the pulling action of the facial muscles or by widening
and hypertrophy of the lip scar. Its diagnosis is made by measuring and comparing
the right and left alar base widths. This area is estimated by comparison between
both sides (including the lip scar) and the extension equal to the difference between
a b
c d
e f
Fig. 7.43 Eight-year-old patient born with bilateral cleft lip and palate that developed nose defor-
mity with short columella and lack of nasal tip projection (a–c). Secondary cleft rhinoplasty has
been performed using the proposed technique with improvement of the nasal outcomes (d–f)
the two alar base diameters. The used technique for its correction is based on resec-
tion of the excess of the skin of the wider alar base (or both if necessary) consider-
ing the anthropometric parameters. Based on this concept, the length of the alar base
should be equal to the vertical length of the philtrum. Therefore, the first step is the
determination of the desired lip height according to the width of the largest lateral
segment.
a b
c d
e f
Fig. 7.44 Twenty-six-year-old patient born with bilateral cleft lip that presented nose deformity
and airway obstruction. (a–c) Secondary cleft rhinoplasty has been performed, and improvement
of nasal aesthetics and respiratory function has been obtained (d–f). 1. Alar cartilages. 2. Nasal
dorsum. 3. Columella. X. Bilateral V composite flaps
If the lip height is greater than the estimated width, it is better to reduce it; oth-
erwise, it will be a disproportionate and longer lip. On the contrary, if the labial
height is less than the largest lateral segment, this should be taken as desired
lip height.
It is important to understand that the objective in the reconstruction of the sec-

ondary bilateral cleft lip deformity is the lip’s symmetry and better proportions of
the anatomical subunits. After estimation of the desired lip’s height, the alar bases
can be shortened and positioned considering its diameter as equal to the lip’s height.
This correction can be done by resecting a skin lozenge as necessary looking for
symmetry.
The diagnosis is made through a careful physical examination of the lip.
Surgical Technique (Figs. 7.45, 7.46, and 7.47)
Two horizontal lines should be drawn, the superior one passes through the desired
lip’s height (X), and the lower one passes through the base of the contralateral alar
base (Y).
For its marking, a horizontal line is located passing at the level of both alar bases;
then, after comparing both alar base diameters, the observed difference will be the
a b c
Fig. 7.45 Illustrative design for a surgical technique used for correction of alar asymmetry in
patient with bilateral cleft lip. This case is characterized by alar width asymmetry associated with
asymmetry of the labial heights. Correction of the alar bases is shown after asymmetric lozenge
resection. X: Left alar base. Y: Right alar base. (a) Width of the largest alar base. (b) Upper lip
height right side. (c) Midpoint of the base of the columella
a b c
Fig. 7.46 Illustrative design for secondary bilateral cleft lip deformity characterized by asymme-
try of the alar bases and labial heights. The height of the left side is longer than the width of the
lateral segment on the same side. Repair is performed by asymmetric resection of the skin in both
sides and lengthening of the shorter side using a Z plasty. X. Left alar base. Y: Right alar base. (a)
Width of the largest alar base. (b) Upper lip height right side. (c) Midpoint of the base of the colu-
mella. Final formula: A1 + A2: A
a b
Fig. 7.47 Another illustrative design for secondary bilateral cleft lip deformity characterized by
asymmetry of the alar bases and labial heights. The height of the right side is equal to the width of
the lateral segment on the same side. Repair is performed by asymmetric resection of the skin in
both sides and lengthening of the shorter side using a Z plasty. X. Right alar base. Y. Left alar base.
(a) Width of the largest alar base. (b) Upper lip height left side. (c) Midpoint of the base of the
columella. Final formula: A1 + A2: A
amount of skin to be excised. This resection is performed as a lozenge form. It is

also necessary to extend a small incision over the pyriform fossa in order to release
the alar base flap and move it medially without tension. If lip’s height asymmetry is
observed between the two sides, a resection/elongation of the lip height as neces-
sary may be considered to obtain lip symmetry. It is recommended to use a 4/0 PDS
suture from one alar base to the other passing below the nasal columella to stabilize
the desired width of the alar bases.
Cutaneous closure is performed using 5/0 and 6/0 sutures, and antibiotic oint-
ment is applied to the operative wound. This distance represents the ideal phil-
trum’s height.
7.6.3 Columella
The most frequent sequelae to observe after primary reconstruction of the nasal
columella in patients with bilateral cleft lips are short, wide columella and outcomes
after repair using regional flaps or grafts.
7.6.3.1 Short Columella
This sequel is most commonly observed related to the absence of primary nasal
surgery or poor reconstruction. The height of the columella based on anthropomet-
ric parameter varies depending on the patient’s age and race (Farkas) [22]. The
objective for secondary surgery of nasal columella in adults is lengthening of the
columella in 1 cm, on average. The surgical treatment for short columella is based
on vestibular lengthening previously described in detail in this chapter (Figs. 7.41,
7.42, 7.43, 7.44, 7.45, 7.46, 7.47, and 7.48). The method has been described in the
literature by the author as the V-Y-Z method [5, 21].
7.6.3.2 Wide Columella
This sequel is not frequently observed. It is characterized by presence of a columella

with increased width and usually accompanied by a wide philtrum (Fig. 7.49). This
is probably due to tissue expansion and scar retractions of nostrils. It is also associ-
ated with congenital defects of the nasal pyramid with widening of the nasocolu-
mellar area, seen in syndromic patients. Its diagnosis is established through physical
exam, and correction is done by central resection of the skin excess giving the colu-
mella a more natural appearance.
The surgical procedure is illustrated in Fig. 7.50; this technique is based on the
resection of the skin excess of the central segment and the plication of the cartilagi-
nous structures of the nose.
Marking is carried out first; the upper limit of surgical incision is the point of maxi-
mum projection of the nasal tip and the lower limit the base of the columella. The
amount of skin to be resected is based on anthropometric parameters according to
the age and race of the patient. This is an average of 4 mm. First, after skin incisions,
this is resected leaving the cartilaginous plane exposed identifying the alar carti-
lages. Then, under direct vision, the fibrous structures located between the medial
cruras are resected too and the cruras joined using 5/0 PDS from medial portion up
to the domes. Finally, the skin is closed in two planes using fine absorbable sutures.
Mupirocin or bacitracin ointment is applied to the wound.
Fig. 7.48 Twenty-five-year-old patient with secondary nasal deformity after primary bilateral lip
repair. The nose is characterized by broad base, short columella, and lack of tip projection. A sec-
ondary cleft rhinoplasty was performed with open approach improving the nasal tip projection and
columellar lengthening using the V-Y-Z method. Postoperative outcome is presented showing
improvement of the nasal balance
Fig. 7.49 Patient born with bilateral cleft lip and palate who developed a secondary deformity
characterized by wide columella and scar contracture of the nasal vestibules. The deformity was
corrected using the proposed method. 1. Medial cruras
ad Outcomes After Using Regional Flaps, Grafts, or Synthetic Materials

B
Skin grafts, simple or composite, have been used in order to provide tissues for
columellar repair. However, there is possibility of loss as well as a significant sec-
ondary scar contracture and pigmentation. They could even be considered as com-
plementary treatment in complicated cases (Fig. 7.51). An example of these
outcomes using flaps is the proposal of Gillies who used the entire prolabium for
columellar repair. This type of repair requires the use of Abbe flap for reconstruc-
tion of the absent prolabium [7]. Correction of these secondary deformities can be
done through repositioning of the prolabium for philtrum reconstruction losing tip
projection but providing more naturalness to the nose (Fig. 7.52). The use of
a b
Fig. 7.50 Illustrative image of the technique used to correct wide columellar deformity in bilateral
cleft lip. A lozenge resection is performed along the columella. (a) Preoperative view. (b)
Postoperative view
synthetic materials such as silicone prostheses is not well accepted by most of sur-
geons because they often cause extrusion.
7.6.4 Nasal Floor
The anterior portion of the nasal floor (nasal vestibule) is repaired during primary surgery
using three flaps: alar base, columellar base, and mucosal flap. Failure in this objective is
generally related with dehiscence of the surgical wound or technical deficiencies
(Figs. 7.53 and 7.54). Reconstruction of this sequel is carried out by raising the lateral
and medial flaps and performing a new repair without tension. The medial flap is elevated
using the base of the columella and caudal septum. The lateral one is raised using the alar
base, taking care to maintain the symmetry of the nose. A third flap is required from the
muscular plane using the alar fascicle of the common elevator of the ala nasi and upper
lip muscle to bring support to the repaired nasal floor (Figs. 7.53, 7.54, 7.55, and 7.56).
7.6.5 Nasal Vestibule
A critical area for the development of scar contractures is the nasal vestibule. Any
incision made in this area has the potential effect of developing a pathological scar
with contracture and synechia obtaining aesthetic and functional bad outcomes.
Any primary cleft rhinoplasty based on vestibular incisions should consider the
Fig. 7.51 Nineteen-year-old patient with bilateral cleft lip and palate who developed a sequel after
secondary cleft rhinoplasty using skin graft. The severe deformity obtained after using this method
is illustrated here. The sequel was repaired by reposition of the columellar skin losing some tip
projection but acquiring more naturalness. Postoperative outcome is presented here after 10 months
Fig. 7.52 (a) Eight-year-old patient born with bilateral cleft lip and palate who developed a
secondary deformity after nasal repair using the prolabium. The aesthetic sequelae can be seen
having a longer columella, but the lip is short and deficient of philtrum. (b) Repositioning of the
philtrum was performed leaving a more natural appearance of the lip and nose
complementary use of nasal stent postoperatively during at least 6 months to pre-

vent these bad outcomes [23, 24].
A recent study published by us observed that the group of patients operated using
postoperative nasal stents had lower rate of these complications [25]. This type of
surgical technique requires proper execution and adequate postoperative care; in
inexperienced hands, they can cause a catastrophe difficult to be repaired. Since the
treatment of this sequel is difficult and presents frequent recurrences, prevention is
the most advisable measure to follow (Fig. 7.57). The diagnosis is made through the
physical examination of the airway and patient’s symptoms. Its treatment is surgical
after initial conservative management including corticoid injection from skin grafts
Fig. 7.53 Ten-year-old patient with secondary deformity after bilateral cleft lip repair character-
ized by deficiency in the reconstruction of both nasal floors. Correction has been made using the
proposed technique. Postoperative outcome is presented here after 2 years
Fig. 7.54 Ten-year-old patient with sequel after primary bilateral cleft lip characterized by wound
dehiscence of the right nasal floor. Surgical repair was made using the medial and lateral flaps
showing postoperative outcome after 6 months
to local flaps. Conservative use of corticoid infiltration seems to help although only
in early time; however, it is difficult to apply with the patient awake. The technique
use for these sequels is the V-Y-Z method in combination with postoperative nasal
stents during at least 6 months. In case of severe contractures and synechia, the use
a b
Fig. 7.55 Surgical technique to repair the nasal floor in patients with bilateral cleft lip. (a) Anterior
nasal floor defect after primary cleft lip repair. (b) Flap A: nasal ala. Flap B: columellar base flap.
(c) Repaired nasal floor after using the proposed technique
of auricular composite grafts is an alternative. The graft should be larger than the
defect because of the secondary contracture of the graft (Figs. 7.58, 7.59, and 7.60).
7.7 Bad Results Associated with Labial Sulcus Repair
The labial sulcus is a space between the gingiva and labial mucosa. This space is
partially divided by the labial frenulum. Surgical techniques such as Manchester
and Spina leave a shorter labial sulcus. Millard’s technique allows reconstruction of
the sulcus by using the mucosa of the prolabium and mucosa from the lateral
Fig. 7.56 Different bilateral cleft lip cases who developed adherence of the lip to the premaxilla
due to bad labial sulcus repair
segments to elongate the superior labial sulcus. It is a frequent complaint from

orthodontists that the sulcus is short and deepening of the labial sulcus is required
for orthodontic treatments. Speech therapists recommend about the need of release
the upper lip by deepening of the sulcus to allow the patients a correct pronunciation
of the words.
The diagnosis is made by physical examination and the severity must be esti-
mated. The use of grafts is reported in the literature; however, associated complica-
tions such as infection, loss of grafts, or retractions are frequent. In mild forms, a Z
plasty will be sufficient to deepen the sulcus, and in case of severe forms in which
the vermilion tubercle is attached to the mucosa of the premaxilla, the technique
with healing by second intention is used.
The method was described by Alfred Falcone from New York [7] (Fig. 7.61).
The technique is based on release of the lip using cautery and repairing the labial
mucosa by medial advancement of lateral flaps, then the wound leave over the
Fig. 7.57 (a) Bilateral cleft lip case who developed adherence of the lip to the premaxilla due to
bad labial sulcus repair. (b) Postoperative view
a b
Fig. 7.58 (a) Bilateral cleft lip case who developed adherence of the lip to the premaxilla view.
(b) Intraoperative view. (c) Postoperative view
Fig. 7.59 Surgical

technique for the
correction of vestibular
synechia in patients with
bilateral cleft lip using
composite auricular grafts.
1. Nasal vestibule scar
contracture is illustrated. 2.
Release of the scar
contracture leaving raw
surfaces. 3. Placement of
composite auricular grafts
and correction of the
vestibular synechia
premaxilla will be re-epithelized spontaneously by second intention within

2–3 weeks (Fig. 7.62). The postoperative period proceeds without major discom-
fort for the patient. The main disadvantage of this method is the recurrent
adherence.
7.8 Scarring Sequelae
Pathologic scarring may be observed after primary bilateral cleft lip repair.
The characteristics of bilateral cleft lip promote the development of sequels
related to lip scars. Tension of the primary closure is associated with an increased
likelihood of developing hypertrophic scars. Although it is true that the etiology of
poor healing is usually multifactorial, it seems that the skeletal deformity acquires a
preponderant role in the formation of bad labial scars by increasing tension after the
closure. Proper reposition of the premaxilla through nonsurgical or surgical meth-
ods may allow to reduce the rate of scar disorders. When the scar disorder is diag-
nosed, the first decision to take is what is the optimal age for its correction. First, we
must take in consideration that any scar should not be corrected surgically before 1
year postoperatively. In order to facilitate that decision, the following factors must
be taken in account: severity of the skeletal deformity, functional nature of the scar
(nasal vestibule synechia requires early care), and severity of the aesthetic defor-
mity (early correction may prevents development of psychologic sequels). In addi-
tion, the hypertrophic reaction of the scar observed in patients after 8 years of age
Fig. 7.60 Three-year-old patient born with bilateral cleft lip and palate who developed scar con-
tracture of the nasal vestibule after primary repair. Silicone nasal stents have been used after sec-
ondary correction of the nose
and through adolescence should be well considered during surgical planning. Based
on my personal experience, any hypertrophic scar that generates functional retrac-
tion and aesthetic deformity must be treated at early age (before school time) so it
does not affect the psychosocial development of the child during the school.
The basic principles of the treatment of these sequel are:
• A reasonable period of time must be waited (1 year at least) always taking into
account the considerations mentioned here.
Fig. 7.61 Three-year-old bilateral cleft lip patient presenting retraction of the upper labial sulcus.
(left) Retraction release is performed, and the oral mucosa is repaired using advancement flaps. A
raw area is left on the premaxilla which heals by second intention (right)
• Conservative treatment is always the first line of treatment. Silicone gel or

patches work well. Infiltration using intralesional corticoids is done in severe
cases with refractory response to the silicone treatment.
• Surgical treatment is indicated only for refractory cases to conservative treatment
and after 1 year postoperatively.
Other nonsurgical treatments such as dermabrasion, pulsed light, or laser appear
to be useful in correcting cleft lip scars; however, more studies are required to dem-
onstrate their efficacy.
Different techniques have been proposed as an option for the surgical manage-
ment of lip scars after primary bilateral cleft lip cases. The surgical treatment pro-
posed by the author is based on the following concepts:
• Incisions should be limited to the scar tissue preserving healthy tissue and pre-
venting non-desired elongation of the lip after scar repair. This minimizes ten-
sion of the closure and prevents the recurrence of the scar.
• The surgical planning must consider the upper lip symmetry and the proportions
between both lips.
Fig. 7.62 Three-year-old patient born with bilateral cleft lip and palate who developed scar con-
tracture of the nasal vestibule after primary repair (left). Silicone nasal stents have been used after
secondary correction of the nose (right)
References
1. Brown J, McDowell F, Byars L. Double clefts of the lip. Surg Gynecol Obstet. 1947;85:20.
2. Grayson B, Santiago P, Brecht L, Cutting C. Presurgical nasoalveolar molding in infants with
cleft lip and palate. Cleft Palate Craniofac J. 1999;36(6):486–98.
3. Rossell-Perry P. Nueva clasificación de severidad de fisuras labiopalatinas del Programa
Outreach Surgical Center Lima-Perú. Acta Med Per. 2006;23(2):59–66.
4. Rossell-Perry P, Gavino-Gutiérrez AM. Nuevo enfoque en el tratamiento quirúrgico de las
fisuras labiales congénitas. Cir Plást Iberolatinoam. 2013;39(1):23–34.
5. Rossell-Perry P, Olivencia-Flores C, Delgado-Jimenez MP, Ormeño-Aquino R. Surgical naso-
alveolar molding: a rational treatment for bilateral cleft lip nose and systematic review. Plast
Reconstr Surg Glob Open. 2020;8(9):e3082.
6. Millard R. Bilateral cleft lip and a primary forked flap: a preliminary report. Plast Reconstr
Surg. 1967;39(1):59–65.
7. Millard R. Cleft craft: the evolution of its surgery. In: The bilateral deformity, vol. II. 1st ed.
Boston: Little Brown; 1978.
8. Mulliken J. Principles and techniques of bilateral complete cleft lip repair. Plast Reconstr Surg.
1985;75(4):477–87.
9. Manchester WM. The repair of bilateral cleft lip and palate. Br J Surg. 1965;52(11):878–82.
10. Spina V, Kamakura L, Lapa F. Surgical management of bilateral cleft lip. Ann Plast Surg.
1978;1(5):497–505.
11. Rossell-Perry P, Gavino-Gutiérrez A. Surgical technique for whistler deformity repair in bilat-
eral cleft lip patients: an anthropometric study. Ann Plast Surg. 2016;77(2):183–9.
12. Trott J, Mohan N. A preliminary report on one stage open tip rhinoplasty at the time of lip repair
in bilateral cleft lip and palate: the Alor Setar experience. Br J Plast Surg. 1993;46(39):215–22.
13. Yuzuriha S, Oh A, Mulliken J. Asymmetrical bilateral cleft lip: complete or incomplete and
contralateral lesser defect. Plast Reconstr Surg. 2008;122(5):1494–504.
14. Rossell-Perry P, Gavino-Gutierrez A. Técnica quirúrgica para el tratamiento de fisuras labiales

bilaterales asimétricas. Acta Méd Peruana. 2012;29(1):28–34.
15. Kapetansky D. Double pendulum flaps for whistling deformities in bilateral cleft lips. Plast
Reconstr Surg. 1971;47(4):321–3.
16. Talmant J, Talmant J, Lumineau J. Primary treatment of cleft lip and palate. Its fundamental
principles. Ann Chir Plast Esthet. 2016;61:348–59.
17. Cronin E, Rafols F, Shayani P, Al-Haj I. Primary cleft nasal repair: the composite V-Y flap with
extended mucosal tab. Ann Plast Surg. 2004;53:102–8.
18. La Rossa D, Donath G. Primary nasoplasty in unilateral and bilateral cleft nasal deformity.
Clin Plast Surg. 1993;20:781–91.
19. Rossell-Perry P. Primary cleft rhinoplasty: surgical outcomes and complications using three
techniques for unilateral cleft lip nose repair. J Craniofac Surg. 2020;31(6):1521–5.
20. Potter J. Some nasal tip deformities due to alar cartilage abnormalities. Plast Reconstr Surg.
1954;13:358.
21. Rossell-Perry P. Primary unilateral cleft lip nasal deformity using V-Y-Z plasty: an anthropo-
metric study. Indian J Plast Surg. 2017;50:180–6.
22. Farkas L, Hajnis K, Posnick J. Anthropometric and anthroposcopic findings of the nasal
and facial region in cleft patients before and after primary lip and palate repair. Cleft Palate
Craniofac J. 1993;30(1):1–12.
23. Yeow V, Chen P, Chen Y, Noordhoof S. The use of nasal splints in the primary management of
unilateral cleft nasal deformity. Plast Reconstr Surg J. 1999;103(5):1347–54.
24. Méndez R, López-Cedrun J, Tellado M, Somoza I, et al. Nostril retainers in the primary cleft
rhinoplasty. Cir Pediatr. 2005;18(4):200–3.
25. Rossell-Perry P, Romero-Narvaez C, Chavez-Gonzalez A, Marca-Ticona R, Gavino-Gutierrez
A, Figallo-Hudtwalcker O. Postoperative nasal conformers in cleft rhinoplasty: are they effica-
cious? J Craniofac Surg. Accepted for publication.
Chapter 8
Bad Results in Cleft Palate Surgery
Percy Rossell-Perry
8.1 Introduction
There are a large number of treatment protocols for cleft palate; the Eurocleft study
observed that 201 centers in Europe used 194 different surgical protocols for cleft
palate repair [1]. The absence of scientific evidence makes it difficult to establish
consensus at the moment. The most frequent variants in relation to these protocols
are 9 to 12 months of age closure of the hard and soft palate in a single surgical time,
early closure of the soft palate followed by posterior closure of the hard palate, and
early closure of the hard palate followed by posterior closure of the soft palate (two
surgical stages).
In a study carried out in the USA by Katzel et al. in 2009 [2], it was observed that
96% of surgeons perform cleft palate surgery in a single stage and 85% operate
between 6 to 12 months of age. In addition, the most used technique was the
Bardach’s (also known as the two-flap technique) in combination with the intravelar
veloplasty used by 45% of surgeons and secondly the Furlow technique practiced
by 42% of them.
The main advantage of this protocol is the possibility of closing the cleft without
tension; this proposal is reflected in a very low incidence of palatal fistulas. The
major disadvantage of this strategy appears to be related to the development of max-
illary hypoplasia.
This hypothesis represents one of the biggest discussions in the field of cleft lip
and palate. Available scientific evidence based on systematic review and meta-
analysis seems to indicate that the etiology of this bad outcome is multifactorial.
Two stages protocols, designed to prevent maxillary hypoplasia development,
are associated with increased rate of palatal fistulas and speech impairment [3–5].
The best reports of palatal fistula range from 0 to 0.8% with the use of the two-flap

Switzerland AG 2022
technique; regarding the development of velopharyngeal insufficiency, the best out-

comes are around 5% using intravelar veloplasty and Furlow techniques. Likewise,
there have been reports of up to 10% of maxillary hypoplasia using the Oslo proto-
col [6–8]. These outcomes indicate that the objective to be achieved in primary cleft
palate repair is the prevention of palatal fistulas since it is possible to avoid them.
Velopharyngeal insufficiency and maxillary hypoplasia depend on the degree of
congenital hypoplasia, and even with proper techniques and expert surgeons, they
are not possible to be avoided. Based in our personal opinion, most of the bad out-
comes after primary cleft palate repair are associated to deficiencies of the surgical
techniques and surgeon’s skills and experience.
8.2 Palatal Fistulas
Although it can be considered a complication in the author’s opinion, this sequel is

a bad result in most cases. It can be considered as a complication when it is devel-
oped after postoperative infection or trauma.
Technically, it is defined as the abnormal communication between two cavities
with epithelized surfaces. In cleft palate surgery, it is defined as the anatomical com-
munication (not always functional) through the palate, between the oral cavity and
the nostrils [9, 10]. Clinically, they are manifested by the passage of food (liquid or
solid, depending on the size of the fistula) from the oral cavity to the nose, and when
the location is posterior, it is severe and may be the cause of velopharyngeal insuf-
ficiency. Different studies show a variable degree of incidence of palatal fistulas
after primary cleft palate repair; thus it is observed from 0 to 76% [9–11]. A way to
estimate the severity of the cleft palate has been developed by the author and named
as the cleft palate index [12]. This is an instrument that allows determining the rela-
tionships between the width of the cleft and the amount of availability of oral
mucosa for its reconstruction. The index is expressed as a fraction with the width of
the cleft as numerator and the sum of the width of the cleft segments as denominator
(Fig. 8.1).
This fraction will determine three ranges of severity:
• Mild cleft palate: Index less than 0,2
• Moderate cleft palate: Index between 0,2 to 0,4
• Severe cleft palate: Index greater than 0,4
The application of this index for severity of the fistula estimation requires a mod-
ification as follows: transverse diameter of the fistula/summation of transverse
diameters of the lateral segments of the palate at the same level. This estimation in
combination with the Veau’s classification (based on affected anatomical segment
of the palate) allows better assessment of the cleft palate and stablishing a more
individualized protocol. This principle is used to provide estimation of palatal fistu-
las and has been systematized as the Lima Comprehensive Fistula Classification and
Algorithm for management of palatal fistula (AHS). This classification is based on
8 Bad Results in Cleft Palate Surgery 195
Fig. 8.1 The cleft palate

index. X: Width of the cleft
palate. Y1: Width of the
right palatine segment. Y2:
Width of the left palatine
segment. These
measurements should be
taken by drawing a
transverse line that passes
through the bases of the
maxillary tuberosities
Fig. 8.2 The Lima

Comprehensive Fistula
Classification and
Algorithm for management
of palatal fistula (AHS). A:
Alveolar segment. H: Hard
palate. S: Soft palate. F:
Fistula. X: Width of the
right palatine segment. Y:
Width of the left palatine
segment
location and severity (Fig. 8.2). The location can be as follows: alveolar segment
and primary palate, secondary hard palate, and soft palate. This is a simplification
of the Pittsburgh’s classification but included severity criteria. The severity of the
palatal fistulas depends on its location as follows:
• Alveolar and primary palate (A):

–– Mild: Fistula diameter less than 1 cm
–– Moderate: Fistula diameter between 1 to 2 cm
–– Severe: Fistula diameter greater than 2 cm
• Hard palate (H) and soft palate (S):
–– Mild: Cleft palate index less than 0,2
–– Moderate: Cleft palate index between 0,2 to 0,4
–– Severe: Cleft palate index greater than 0,4
The main advantage of this proposal is the simplicity and individualized surgical
protocol for fistula management and emphasizing the anatomical defect. The func-
tional impact of the soft palate defects is described in the velopharyngeal insuffi-
ciency section.
Here we are presenting a guide to prevent the development of palatal fistulas
after primary cleft palate repair:
(a) The preoperative condition of the patients should be well evaluated.
Malnourishment and/or infection may be a cause (not frequent) of palatal
fistula.
(b) The estimation of the type of cleft and its severity are essential to select an
adequate surgical technique that prevents development of fistulas.
(c) Surgical incisions on the mucosa of the palate should be made leaving regular
and well-vascularized edges; therefore, the use of scalpel is recommended to
perform the cleft border incisions. Electrocautery is useful for lateral inci-
sions only.
(d) Use of lateral relaxing incisions is the key element in fistula prevention. They
are made using electrosurgical bisturi following the palato gingival mucosa line.
(e) The dissection of the flaps should be done in the subperiosteal plane providing
easier dissection and better vascularization of the flaps.
(f) An important element in the prevention of fistulas is the use of two mucosal
planes to repair the cleft (oral and nasal mucosa).
(g) The second key element is the skeletonization of the greater palatine pedicle.
Dissection of this important anatomical structure is performed in the four quad-
rants as follows:
Anterior border: The access is done through the subperiosteal plane visual-
izing the greater palatine pedicle a few millimeters behind the maxillary spine.
Medial border: It is related to the insertion of the velar muscles and its apo-
neurosis. The release of these structures will facilitate dissection of the pedicle
as well the nasal mucosa.
Lateral border: It is firmly adhered due to ligament structures that start from
the palatal aponeurosis and insert into the submucous plane.
Posterior border: It is related to the palatine bone and mentioned ligament
attachments. These structures extend fascicles toward the aponeurosis sur-
rounding the vascular pedicle and are being firmly adhered to the deep plane.
The dissection is difficult at this level and should be performed carefully to
prevent the vascular pedicle injury. At the level of the posterior border of the
palatine bone, there are the lesser palatine foramina and the corresponding ves-
sels. Careful hemostasis should be performed at this level.
To release this adherence, the dissection should be performed using a blunt
instrument and pulling up the ligament structures attached to the pedicle until this is
released. This maneuver produces a characteristic sound which is accompanied by
adequate mobility of the flap (Figs. 8.3, 8.4 and 8.5). One can corroborate the effi-
cacy of the procedure by displacing the flap medially and confirm that it easily
reaches the midline or more.
(h) Another important element is the adequate closure of the nasal mucosa. The
nasal mucosa is thin, and frequently, its dissection causes tears that favor the
development of fistulas. The surgeon must use appropriate instruments and dis-
sect the nasal mucosa at the subperiosteal plane. If any important defect is cre-
ated unwittingly, the use of buccal fat pad is recommended to ensure the
anatomical closure in two planes [13].
(i) The third key point in this guideline is the closure of the mucosal planes using
5/0 resorbable sutures, the thin gauge of the suture allows to confirm that there
is a low tension of the closure. This is a critical point to prevent palatal fistulas
development.
Once the closing is completed, the tension of the closure should be confirmed by
making gentle pressure with the index finger and observing the smooth balance of
the repaired palate.
Fig. 8.3 Anterior fistula in

a bilateral cleft lip and
palate patient
Fig. 8.4 Anterior fistula in

a unilateral cleft lip and
palate patient
Fig. 8.5 Hard palate

fistula
In summary, we can say that the most relevant considerations to prevent palatal
fistulas after primary cleft palate repair are palatal closure in a single stage, use of
relaxing incisions, closure using two mucosal planes (oral and nasal), skeletoniza-
tion of the greater palatine vascular pedicle, and wound closure using 5/0 absorb-
able sutures to confirm an adequate tension closure.
8.2.1 Diagnostic and Classification of Palatal Fistulas
Based on Lima Comprehensive Fistula Classification and Algorithm for manage-

ment of palatal fistula (AHS), the palatal fistulas are classified based on two criteria:
location and severity. According to their location, they can be anterior (alveolar and
primary palate), middle (secondary hard palate), and posterior (soft palate). The
severity is in relation with the location, and anterior fistulas can be mild (up to
1 cm), moderate (up to 2 cm), or severe (greater than 2 cm). Middle and posterior
fistulas are estimated based on the cleft palate index (Figs. 8.1 and 8.2). Any severe
fistula should be closed before 2 years of age due to the functional impact of these
defects. Mild or moderate forms may be delayed. Palatal fistulas must be differenti-
ated from dehiscence; this complication is affecting larger segments of the palate or
the entire palate, while fistulas affect small portion of them.
(a) Anterior fistulas. (A) (Figs. 8.3 and 8.4)
This is the most common location for palatal fistulas. Alveolar clefts are not
closed primarily in the majority of surgical protocols, and the cleft turns into a fis-
tula when the lip is closed. The alveolar cleft is closed during alveolar bone graft
(mixed dentition period).
These fistulas correspond from the anatomical point of view to the primary pal-
ate, and they exist in all complete cleft palate (types III and IV of Veau’s classifica-
tion). It is characterized by having two components: alveolar (extended from the
nasal floor to the line of dental eruption) and palatal (extending from the line of
dental eruption to the incisive foramen). The anterior fistulas in bilateral cleft lip
have a communication between both sides forming a big one called retropremaxil-
lary fistula. This is usually complex and difficult to be repaired.
(b) Hard palate fistulas. (H) (Figs. 8.5 and 8.6)
From the anatomical point of view, this segment corresponds to the hard palate
between the incisive foramen and the hard and soft palate junction. After anterior
fistulas, these defects are the most frequent. They are mostly associated with non-
relaxing incision and two stages palatoplasties [3–5].
(c) Soft palate fistulas (S) (Figs. 8.7 and 8.8)
They are also located on the midline, from the junction between hard and soft
palate to the uvula. The fistulas are developed as a result of a deficiency in close the
cleft palate without tension or tear and/or perforation of the nasal and/or oral mucosa
may be associated. They must be differentiated from dehiscence. The soft palate
fistulas are frequently associated with velar muscle repair deficiencies observing
velopharyngeal insufficiency.
Fig. 8.6 Soft palate fistula
Fig. 8.7 The cleft palate

fistula index. X: Width of
the fistula (maximum
diameter) Y: Hard palate
segments diameter at the
same level
LOCATION SEVERITY SURGICAL TECHNIQUE

MILD Local gingivoperiosteal flaps
ANTERIOR MODERATE Combined gingivoperiosteal and palatal flaps.
SEVERE Anteriorly based Facial Artery Mio Mucosal flap or tongue flap.
MILD Local unilateral mucoperiosteal flaps.
HARD PALATE MODERATE Local bilateral mucoperiosteal flaps.
SEVERE Posteriorly based Facial Artery Mio Mucosal flap.
MILD Furlow technique.
SOFT PALATE MODERATE Von Langebeck type veloplasty.
SEVERE Buccinator flap or Posteriorly based Facial Artery Mio Mucosal flap.
Fig. 8.8 The Lima Comprehensive Fistula Classification and Surgical Protocol for management
of palatal fistula (AHS)
8.2.2 Treatment of Palatal Fistulas
The treatment requires a comprehensive evaluation of the patient, considering the

following:
(a) Functionality of the fistula
(b) Age of the patient
(c) Type of cleft palate
(d) Location
(e) Severity
(f) Previous surgeries
(g) Surgeon’s skills and experience
The first step is the functionality. The indication for surgery is more related to the
associated symptoms than the existence of an anatomical defect. Rarely, a fistulog-
raphy or imaging studies are used to confirm its diagnosis. This is made generally,
by the symptoms referred by the parents and its magnitude. If there are no passage
of food (liquid and/or solids), it is preferred to observe the evolution of the patient
even when a defect is visible. After confirmation of fistula functionality, the next
decision is when the surgery should be performed. Based on our experience, any
mild fistula and functional for liquids can wait until the patient is 5 years or older.
This is considering the potential negative effect of the surgery on the development
of the maxilla. Any severe fistula that is functional to the passage of liquids and
solids and additionally presents hypernasality and nasal emission of air should be
operated at early age, that is, before 2 years of age due to the impact of the speech.
An alternative for these cases is the use of obturator prostheses. The type of cleft
palate is important to determine the surgical plan. Unilateral cleft palate has the
advantage of having enough tissue from non-cleft side. A different situation is
observed with bilateral cleft palates; there is often limited availability of tissues for
secondary reconstruction.
The location of the defect becomes important, since the surgical technique to
choose depends on anatomical location and availability of tissues. Anterior fistulas
in bilateral cleft palates are more difficult to be closed due to limited availability of
surrounding tissues.
The severity of anterior fistulas can be estimated according to the size; however,
the anatomical defect does not necessarily correlate with symptoms. Small fistulas
can be very symptomatic for liquid and food passage. The severity of the anterior
fistulas is estimated as follows:
(a) Mild: Transverse diameter less than 1 cm
(b) Moderate: Transverse diameter between 1 to 2 cm
(c) Severe: Transverse diameter greater than 2 cm
The hard and soft palate fistulas are estimated through the cleft palate index, and
the width of the cleft is compared to the width of the remaining lateral segments of
the palate at the level of the central axis of the fistula. This is called the palatal fistula
index and considered the proportion of the tissues (mucosa) existing on both sides
of the defect. This index is estimated as follows: (Fig. 8.7)
(a) Mild: Index less than 0.2
(b) Moderate: Index between 0.2 to 0.4
(c) Severe: Index greater than 0.4
The number of previous surgeries and the amount of scar tissue formed are other
guidelines that give us an idea about the possibility of use of local tissues for fis-
tula repair.
Finally, the skills and experience of the surgeon will guarantee greater success in
treating difficult fistulas.
Based in these considerations, the surgical protocol for fistula repair is presented
further (Fig. 8.8).
8.2.2.1 Anterior Fistulas (A)
These fistulas are a bad outcome observed in unilateral and bilateral cleft palates
(types III and IV of Veau’s classification). According to the anatomical location and
severity, they are classified as follows:
Anterior Unilateral Cleft Palate Fistulas
These fistulas are characterized by having an alveolar and palatal component. Most
of them can be closed using local tissues, the gingivoperiosteal flaps. The oral
mucosa is not recommended to be used for fistula repair because the tooth eruption
is made through the gingival mucosa and not the oral.
The method is similar for the three degrees of severity (mild, moderate, and severe).
Fig. 8.9 A 5-year-old patient born with unilateral cleft lip and palate who develops an anterior
fistula. The defect has been repaired using local gingivoperiosteal flap, and the result is presented
at 6 years of age
a b
Fig. 8.10 Surgical technique for anterior fistula closure in unilateral cleft lip and palate. (a)
Anterior fistula illustrating the palatal and alveolar components. The gingiva and mucosa incisions
are shown. (b) Elevation of mucoperiosteal and gingivoperiosteal flaps in the subperiosteal plane.
(c) The fistula is closed after mobilization of the palatal and gingival flaps
The first stage is aimed at closing the palatal component of the fistula using local
mucoperiosteal flaps. The extent of the palatal flap dissection depends on the size of
the defect. The surgery continues with closure of the alveolar component of the
fistula using the gingivoperiosteal flaps. The surgical incision is made at the level of
the alveolar edges, and then the gingivoperiosteal flaps are released using a fine
periosteal elevator. The nasal mucosa can be easily closed using these flaps. The
oral side of the closure is made using gingival flaps. Superiorly based flaps are
designed, and gingival incision is made a few millimeters above the gingival border,
to the posterior region where it ends. A lateral relaxing incision is performed at this
level to facilitate flap mobilization, and the flap is elevated in the subperiosteal
plane. Relaxing incisions are required over the periosteum, which allows it to
advance medially and sutured without tension at the medial segment of the cleft.
The surgery is completed by suturing the lower edge of the flap to the remaining
gingival mucosa. The alveolar reconstruction should be completed using the bone
graft (Fig. 8.11).
Anterior Bilateral Cleft Palate Fistulas
These fistulas have alveolar and palatal components, giving them a U shape.
The palatal segment is known as retropremaxillary fistula. They are developed as
a result of surgical technique deficiencies to close the retropremaxillary space dur-
ing primary palatoplasty. The proposed technique for fistula repair requires gingivo-
periosteal flaps for the alveolar segment closure and mucoperiosteal flaps for
a b
c d
Fig. 8.11 (a) A 6-year-old female patient born with unilateral cleft lip and palate at 1 year of age
developing an anterior fistula. (b) X-ray study is shown with the incisor in an adequate position to
perform the bone graft. (c) Cancellous bone taken from the iliac crest is placed in the alveolar cleft.
(d) The anterior fistula is closed (1 year of evolution view)
retropremaxillary component [14] (Fig. 8.40). The advancement palatal mucoperi-

osteal flaps are recommended surgical technique for the palatal segment and bilat-
eral gingivoperiosteal flaps for the alveolar segment [15].
The surgery is performed under general anesthesia and using a Dingman mouth
opener. The operative area is infiltrated with local anesthetic and vasoconstrictor.
The first stage is aimed at closing the palatal component of the fistula. A surgical
incision is made on the mucosa of the premaxilla in continuity with the alveolar
incisions and creating a posteriorly based mucoperiosteal flap. I like to perform the
premaxilla incisions using a cautery since the blood supply of this segment is rich
and may develop important postoperative bleeding. The mucoperiosteal flap is ele-
vated in the subperiosteal plane (Figs. 8.14 and 8.15).
a b
Fig. 8.12 Surgical technique for anterior bilateral fistula in patients with bilateral cleft lip and
palate. (a) Anterior bilateral fistula. (b) Elevation of palatal mucoperiosteal flap and bilateral gin-
givoperiosteal flaps. (c) Final closure. Red line: transverse relaxing incision for more severe cases
Fig. 8.13 Male patient born with a complete bilateral cleft lip and palate who developed a retrop-
remaxillary fistula after primary cleft palate repair. The fistula was closed using the proposed
technique advancing the mucoperiosteal flaps
Fig. 8.14 A 5-year-old patient born with bilateral cleft lip and palate who developed 2 cm anterior
fistula. The fistula is closed using bilateral mucoperiosteal flaps. The successful outcome is pre-
sented 6 months after surgery
Fig. 8.15 A 5-year-old patient born with a bilateral cleft lip and palate that develops an anterior
fistula after primary repair using the two-flap palatoplasty. The correction of the fistula using bilat-
eral mucoperiosteal flaps is shown observing total closure 4 years postoperatively
Then bilateral oral mucoperiosteal flaps are elevated, and both greater palatine
pedicles are carefully dissected to release the flaps and facilitate their mobilization
anteriorly.
Dissection of palatal flaps is done in the subperiosteal and scar (between oral and
nasal mucosa previously repaired) planes and should be extended to the soft palate
to facilitate oral mucosa advancement. Sometimes lateral relaxing incisions are
required.
This dissection can be difficult to be performed specially in the central segment
where both planes must be separated releasing the scar tissue and preserving them.
Also the elevation of the mucosal plane at the level of the soft palate should preserve
velar muscle integrity. Bleeding can be important and requires careful hemostasis.
Once the dissection has been completed and the full advancement of the palatal flap
has been verified, we proceed to close the anterior border of the palatal flap with the
mucosal border of the premaxilla using 4/0 absorbable suture. The surgery contin-
ues with the closure of the alveolar component. For this purpose, the surgical inci-
sion is made along the alveolar borders. After the incisions, a subperiosteal dissection
is performed to release the mucoperiosteum and proceed to close the nasal plane of
the fistula using 5/0 absorbable sutures. Regarding the oral component of the alveo-
lar fistula, the incision is made at the level of the gingiva a few mm from the dental
edge until the posterior region where it ends with a vertical incision that allows the
flap to advance medially.
Eventually, bilateral gingivoperiosteal flaps are elevated using a fine periosteal
elevator, and periosteal relaxing incisions may be necessary to facilitate flap
mobilization.
Both flaps are advanced medially, and the oral plane closure is finally performed
without tension using 5/0 absorbable sutures as in Figs. 8.16 and 8.17. The anterior
fistula closure may or may not be complemented with alveolar bone graft.
Sometimes, the anterior bilateral fistulas must be in combination with surgical pre-
maxillary setback, and it is recommended to be performed around 5 years of age or
later. If the premaxilla is off the axis of the maxillary arch at a distance greater than
1 cm, then orthopedic or surgical setback will allow closure of the anterior fistula.
Repositioning of the premaxilla can be achieved through orthopedic treatment;
however, technology and trained professionals are required. The premaxillary set-
back is performing through limited incision and dissection of the premaxilla mucosa
in order to preserve its blood supply. The blood supply of this segment reaches
through its mucous covering and should be preserved to prevent necrosis of the
premaxilla. Once the bone segment is exposed, an osteotomy is performed using a
3 mm osteotome until the mobility of the premaxilla is obtained. The bone is then
resected using a fine gouge. By doing this, the premaxilla can be repositioned and
allow the retropremaxillary fistula to be closed. The premaxilla is fixed in its posi-
tion by the alveolar component closure of the fistula, and wire fixation is not usually
necessary. The rest of the surgery is completed as we mentioned before to close
bilateral anterior fistulas. The anterior displacement of the palatal tissues created by
the anterior fistula closure may develop velopharyngeal insufficiency and may
require surgery for its correction. Severe bilateral anterior fistulas (greater than
2 cm) require for their correction tissues from other anatomical areas. The surgical
options include facial artery, buccinator, and tongue flaps. The one most used by the
author is the musculomucosal facial artery (FAMM) flap described by Pribaz in
1992. This flap is described later in this chapter. Another alternative is the tongue
flap described by Lexer in 1909 [16]. This is a two-staged flap, and different authors
report a high percentage of success (85–100%). Its main limitation is the need to
perform two surgical times, and it is indicated only for older patients to better toler-
ate this particular condition.
Based in our protocol, the indications for tongue flaps are as follows:
(a) Severe anterior bilateral cleft palate fistulas (greater than 2 cm)
(b) Recurrent anterior fistulas
(c) Severe palatal fistulas with excessive scar tissue
The surgery is carried out under general anesthesia and endotracheal intubation.
The first stage is done by taking the flap from the tongue. It can serve as anterior or
posterior based, being the anterior type most used. The anterior-based flap is
a b
c d
e f
Fig. 8.16 Patient born with complete bilateral cleft lip and palate. (a) Bilateral anterior fistula is
presented. (b) X-ray showing location of the tooth in relation with the alveolar cleft. (c) The gin-
givoperiosteal flap is elevated and closes the nasal plane. (d) Cancellous bone graft has been taken
from the iliac crest and applied in the alveolar cleft. (e) Immediate postoperative view illustrating
the fistula closure. (f) Final view after 1 year
designed taking into account the diameter of the defect to be repaired considering a
larger size due to flap tissue retraction after its raising (20% more). The width is
estimated to be half the width of the tongue, and the length is estimated also to
guarantee the mobility of the flap. Average measurement is considered to be
3 × 6 cm. Traction sutures are used to facilitate tongue incisions (Fig. 8.18). Surgical
incisions are made up to the muscular plane which is partially incorporated into the
Fig. 8.17 A 5-year-old patient born with bilateral cleft lip and palate who underwent surgery due
to alveolar fistulas. Closure is performed using gingival flaps
flap providing more vascularity (8 to 10 mm thick). Careful hemostasis of the donor

site is recommended preventing the development of postoperative hematoma. Then
the donor site is closed. The first stage of this technique is completed by closing the
nasal plane of the defect; in such way, a peripheral incision is made dissecting the
fistula edges to allow reversion of the mucosal borders and nasal mucosa repair
(Fig. 8.18). Then the tongue flap is fixed to the wound edges using 4/0 absorbable
sutures.
A liquid diet is recommended for the first 24 hours and blended until the flap is
divided. The second surgical stage is carried out 3 weeks after under general
anesthesia.
The base of the flap is sectioned, and the remnant tissue is repositioned on the
tongue. The flap is finally sutured to the edges of the defect.
a b
c d
e f
Fig. 8.18 Tongue flap surgical technique for severe anterior palatal fistula repair. (a) The surgery
starts under general anesthesia and local infiltration. (b) The closure of the nasal mucosa plane. (c)
The flap is designed with anteriorly base. (d) Elevation of the tongue flap including muscle in its
base. (e) Donor site. (f) The flap is attached to the edges of the defect
a b
c d
e f
Fig. 8.19 (a) Male patient 24 years old with severe anterior palatal fistula as a sequel of a primary
surgery for bilateral cleft palate. (b) Closure of the nasal mucosa using turn over mucosal flaps. (c)
Elevation of tongue flap. (d) Closure of the donor area. (e) Tongue flap attached to the fistula bor-
der. (f) Appearance of the palate after tongue flap division
8.2.2.2 Middle Fistulas (H)
These fistulas (as most of the others) are developed as a consequence of tension
closure. Surgical techniques using local flaps (such as Z plasties) are not recom-
mended due to the high rate of recurrence. Although the fistula is mild, we consider
the best option is the use of local mucoperiosteal flaps.

The markings are done following the oral mucosa edge, and then the incision con-
tinues with the cleft borders and fistula edges. The lateral incision is made using
cautery starting at the level of the maxillary tuberosity and culminates 1 cm above
a b
c d
Fig. 8.20 (a) Patient born with severe unilateral cleft palate. (b) He underwent surgery using the
two-flap method and developed a hard palate fistula (c). One year later, the fistula was repaired
using the von Langenbeck concept (d). The outcome is present at 1 year of evolution observing
complete fistula closure (e)
the upper level of the fistula. The medial incision and fistula borders are performed
using the scalpel and end 1 cm below the lower level of the fistula.
The first stage corresponds to the elevation of the nasal mucosa around the fistula
creating turn over flaps. Using fine scissors, the oral mucosa is elevated allowing the
closure of the fistula in one level without tension.
The second stage is the elevation of the oral mucoperiosteal flaps. In unilateral
cleft palates, the fistula can be corrected using local tissues from the non-cleft side.
In case of bilateral cleft palates, it is better to consider the use of bilateral bipedicled
flaps due to the tissue hypoplasia. For this purpose, using a fine periosteal elevator
the flap is elevated in the subperiosteal plane identifying previously the location of
the greater palatine pedicle. This vascular structure must be carefully released in
order to provide necessary mobility to the flap. After flap elevation, the oral mucosa
is carefully closed without tension, and muscular plane is previously repaired if
necessary. Depending of the severity of the fistula, lateral raw surfaces may be nec-
essary (unilateral or bilateral). The utility of the local tissues for fistula repair
depends on the quality of the tissues. The oral mucosa generated by re-epithelization
of the defects is not safe to be used. A careful examination should be done to assess
the viability of these tissues. In severe fistulas (index greater than 0.4), the use of
bipedicled bilateral mucoperiosteal flaps is recommended (based on von Langenbeck
concept). Management of these severe defects is based on the evaluation of the
remaining lateral segments. If the oral mucosa is healthy, the reconstruction can be
performed using the mucoperiosteal flaps. In case of fistulas in which its width does
not exceed the width of the congenital cleft, the remaining oral mucosa is usually
enough for fistula repair.
If this is not the case, pedicled flaps are required for fistula repair (tongue flaps,
facial artery myomucosal (FAMM) flaps or buccinator flaps). The buccal fat pad
may be used in combination with these techniques. This type of fistula is also asso-
ciated with velopharyngeal insufficiency requiring its evaluation and diagnostic to
determine the need of speech surgical correction.
8.2.2.3 Soft Palate Fistulas (S)
Soft palate fistulas are characterized by being associated to defects during the pri-
mary repair when perforating and tearing the nasal or oral mucosa of the soft palate.
In addition, tension closure or flap necrosis is also related with these fistulas. These
fistulas are often associated with velopharyngeal insufficiency, and functional repair
is required. Mild fistulas can be effectively repaired using the Furlow technique
(mild hard/soft palate junction are included in this group). This method allows clos-
ing the fistula and additionally improves velar function. The flap transposition and
overlapping allow the suture lines without continuity preventing fistula recurrence
(Figs. 8.21 and 8.22).
Fig. 8.21 Soft palate fistulas
Fig. 8.22 A 12-year-old female patient with incomplete cleft palate who developed a hard/soft
palate fistula after primary palatoplasty. The defect was repaired using the Furlow technique

The Furlow’s is the recommended method for mild soft palate fistulas. The surgical
procedure begins with the Dingman mouth opener placement and local infiltration
of the surgical area.
a b
c d
Fig. 8.23 Illustrative diagram of the Furlow technique for mild soft palate fistulas. (a) Fistula and
oral flap design are presented. (b) Right oral mucous flap and left oral myomucosal flap are ele-
vated. One hemi-uvula is excised (c) Left nasal mucosa and right myomucosal flaps are transposed
and uvula is repaired. (d) Finally, oral flaps are transposed repairing the fistula and improving
muscular sphincter function
Markings are then carried out, delimiting the edges of the fistula leaving a mar-
gin of 1 cm. Then marking is continued 1 cm above and below the fistula following
the midline. The lower marking is extended to the base of the uvula. The technique
is based on four flaps: two mucous and two musculomucosal.
The incision starts around the fistula and continues with the flaps as follows:
Fig. 8.24 Examples of three cases of patients who had mild soft palate fistulas repaired using
Furlow technique
Oral Mucosal Anterior Flap (Fig. 8.23a)

The oral mucosa anterior flap is designed on the right side. The angle of the incision
can vary from 90 to 60 degrees. This flap is elevated exposing the muscular plane
and should be carefully performed at the base of this triangular flap as it is attached
to the palatine bone. A fine periosteal elevator is required for this purpose, and any
damage of the oral mucosa should be avoided to preserve flap vascularity. After its
elevation, the flap is transposed to the left side to determine the location of the oral
musculomucosal flap at the left side.
Oral Musculomucosal Anterior Flap (Fig. 8.23b)
The left oral flap is musculomucosal and includes the velar muscles. The dissection
must be performed with caution leaving the nasal mucosa without any damage. It is
likely to perform this dissection using the scalpel, but fine scissors would be a
good option.
After this flap elevation, the nasal mucosa (blue color) is exposed.
Nasal Mucosa Posterior Flap (Fig. 8.23c)
The left side nasal mucosa flap is designed following the base of the oral musculo-
mucosal anterior flap. After the surgical incision following this line, this flap is
elevated and transposed to the right side to determine the location of the nasal mus-
culomucosal posterior flap.
Nasal Musculomucosal Posterior Flap (Fig. 8.23b, c)
This flap is elevated including the right side velar muscles. The velar muscle dissec-
tion is performed as non-radical intravelar veloplasty preserving the tensor tendon
attachments. After flap elevation, these are transposed and sutured using 5/0 absorb-
able sutures creating an overlapping muscular reconstruction on the lower half of
the soft palate and mucosal flaps (oral and nasal) on the upper half of the soft palate
(Fig. 8.23d).
Using this technique, two objectives are achieved: closure of the fistula and velar
sphincter repair.
Moderate and severe soft palate fistulas are often associated with functional defi-
ciencies. Moderate fistulas due to the extension of the defect and limited tissue for
reconstruction require bilateral flaps (based on von Langenbeck concept) (Figs. 8.25
and 8.26).
Bilateral lateral markings are done along the line between the gingiva and palatal
mucosa continuing to the soft palate 1 cm outside making the flaps larger and better
vascularized. Midline marking surrounds the fistula leaving a margin of 1 to 2 mm
according to the width of the fistula.
After surgical incisions, the edges are dissected in such a way that the oral and
nasal mucosa can be closed without tension. Elevation of the oral flaps is performed
Fig. 8.25 Examples of moderate soft palate fistulas

Fig. 8.26 Patient with moderate soft palate fistula after primary palatoplasty used for primary
correction of the cleft palate. Postoperative view is shown after fistula repair using the von
Langenbeck concept
in the subperiosteal and submucosal plane releasing tension and allowing its mobi-
lization towards the midline. This dissection requires the dissection of the greater
palatine pedicle to preserve vascularization of the tissues and avoid tension closure.
The location of the muscular plane must be identified and carefully released pre-
serving the integrity of the nasal mucosa. The velar muscle reconstruction can be
performed doing a border to border repair following the non-radical intravelar velo-
plasty method. Finally, bilateral oral and nasal mucosa flaps are closed using absorb-
able 5/0 sutures without tension. Hemostatic material (surgicel) is frequently used
to cover the lateral raw surfaces.
Severe forms of soft palate fistulas are not common, and most of them are created
by loss of tissue (infection and/or flap necrosis). These defects differ from dehis-
cence in the extension; the fistulas usually maintain the uvula segment (Fig. 8.28).
Pedicled flaps are required for this type of fistulas. The flap recommended for
this purpose is the buccinator flap, and unilateral or bilateral type can be required.
Surgical incision is performed around the fistula (2 mm from the edge) releasing the
mucosal plane to be repaired without tension using 5/0 absorbable sutures. Then, a
full thickness incision is performed at the level of hard and soft palate junction, and
the remaining oral mucosa is elevated leaving the muscular plane exposed.
Secondary intravelar veloplasty is required to provide functional outcomes for
this repair.
Buccinator myomucosal flaps are taken from one or two sides of the cheeks. The
length of the flap is usually from the intermolar level to the oral commissure and the
width around 2 cm. The flap includes oral mucosa and the buccinator flap. The dis-
section is performed at the muscular fascia level preserving the small vessels located
a b
Fig. 8.27 Illustrative diagram of the surgical technique used for moderate soft palate fistulas. (a)
Moderate posterior fistula and lateral relaxing incisions are shown. One hemi-uvula is resected. (b)
Elevation of bilateral bipedicled flaps is performed and secondary intravelar veloplasty. (c) Finally,
the flaps are close on the midline repairing the fistula and velar muscles
at the base of the flap. After elevation, the donor site is closed, and the flaps are
transposed to repair the nasal and oral coverage of the soft palate in combination
with the oral soft palate flaps.
Final closure is performed using absorbable 5/0 sutures. In addition, these type
of fistulas are frequently related to defects in uvular repair. Thus, absence, dehis-
cence, duplication, retraction, etc. may be observed. The buccal fat pad is a very
useful technique in the palatal fistula repair. This flap is used to reinforce or replace
a b
c d
Fig. 8.28 Male patient, 6 years old born with bilateral cleft lip and palate (a) who developed a
severe soft palate fistula after primary palatoplasty (b, c). Combination of five flaps was used for
its repair. The nasal mucosa was repaired by reinforce of buccal fat pad flaps (d). Oral mucosa was
repaired using two buccinator flaps (e)
oral or nasal mucosa planes when there is any damage of the mucosa after its surgi-
cal dissection. This technique can be used in combination with the techniques men-
tioned before. It is of great value in cases of recurrent fistulas with increased amount
of scar tissue where the use of local flaps is not possible. This flap has a rich vascular
plexus, and it is considered as an axial flap type. Its arc of rotation is dependent on
the volume of fat. Sometimes the buccal fat pad can cover defects in the anterior
palate; however, its main indication is in the reconstruction of middle and posterior
palate. One disadvantage to be considered is the development of facial asymmetry;
however, a study published by Bennett et al. [17] observed no facial asymmetry
after using this flap for primary and secondary cleft palates. The main complication
is postoperative infection.
a b
Fig. 8.29 Illustrative diagram of the surgical technique used for severe soft palate fistulas. (a) 1
and 2. Oral mucosa flaps. (b) 1 and 2. Oral mucosa flaps. 3 and 4. Buccal fat pad flaps. 5. Buccinator
flap. (c) Postoperative view

The approach is made through the oral mucosa, and the parotid duct papilla must
be previously identified in order to prevent its injury. This anatomic structure is
located between the first and second molars. During primary palatoplasty, the buc-
cal fat pad can be easily accessed through the lateral soft palate relaxing incision.
After careful spreading of the buccinator muscle fibers and ligament structures, the
fat is identified after its spontaneous protrusion. Once visualized, it is gently pulled
preserving its delicate capsule and vascular plexus. The necessary amount of this
flap should be exposed, depending on the location and size of the defect to be
repaired. After this, the flap is sutured to the edges of the defect using absorbable
5/0 sutures. The buccal fat pad flap does not require any epithelized surface and
may be used as single layer since the reepithelization process occurs spontane-
ously from the edges within a month. However, it is recommended to use the oral
or nasal mucosa to ensure closure of the defect preventing fistula recurrence
(Figs. 8.31 and 8.32).
Fig. 8.30 Buccal fat pad

flap surgical technique.
Traction through the lateral
relaxing incision and its
medial displacement
preserving its capsule. 1.
Palatal flap. 2. Relaxing
incision. 3. Buccal fat pad.
4. Soft palate
Other Techniques
Different strategies have been designed as alternatives to conventional techniques
mentioned here before. These techniques seek to minimize the extent and impact of
the surgery on the palate. The main disadvantage is that they are biological or syn-
thetic material that need to be assimilated or incorporated into the palatal tissues to
be effective. Among the most common are acellular dermal matrix, amnion, carti-
lage, and temporal fascia [18–24]. Another alternative are the distant flaps as micro-
vascular; however, these do not represent a first-line alternative and may be indicated
in selected cases [25–29].
a b
c d
e f
Fig. 8.31 A 7-year-old female patient with a history of incomplete cleft palate who developed a
severe hard palate fistula that had two previous failed closure attempts. (a) The nasal mucosa is
repaired using local turnover flaps. (b) Buccal fat pad flap is dissected (c) and transposed over the
defect. (d) The oral mucosa was repaired using the buccinator flap. (e) Closure of the fistula is
presented after 1 year. (f) Final postoperative view
a b
c d
e f
Fig. 8.32 Patient born with bilateral cleft lip and palate who developed a palatal fistula. After two
unsuccessful closure attempts the fistula is recurrent (a) The nasal mucosa is repaired using local
turnover flaps. (b) Buccal fat pad flap is dissected. (c) and transposed over the defect (d) and (e)
Closure of the fistula is presented after one year after total mucosa re-epithelization. (f) Final post-
operative view
Recurrent cases and cases in which the patient does not accept surgery represent
good indication to use occlusive prostheses. They may help the patient to solve
problems when talking or feeding.
8.3 Palatal Dehiscence
This is a less common bad outcome in comparison with palatal fistulas. It is defined
as the spontaneous separation of the wound edges after cleft palate repair. This is
happening usually during the first postoperative week. It differs from palatal fistulas
by the extension. Thus, dehiscences tend to affect anatomical segments (hard or soft
palate) or the entire one and are located in the midline. Dehiscence can be a compli-
cation or a bad outcome. It is a complication that occurs as a consequence of acci-
dent, infection, or trauma (rare events).
Other factors as malnutrition are not well supported by scientific evidence, but it
is accepted that it could have a role in cases of recurrent palatal dehiscence. It is
widely accepted that this bad outcome is due to the tension of the surgical wound
closure; therefore, it can be prevented. The recommendations are the same as for
fistula prevention.
8.3.1 Palatal Dehiscence Diagnostic and Classification
These problems can be classified according to the affected anatomical segment, as

follows:
8.3.1.1 Anterior Palate Dehiscence
This bad outcome is commonly observed in association with the two-flap palato-
plasty. In this technique, both mucoperiosteal flaps are anchored anteriorly in the
primary palate mucosa. Due to tension, technical deficiency of the closure, self-
inflicted trauma, hematoma, or infection can open the closure at this level caus-
ing the palatal flaps to fall downward (hanging palate). This situation creates a
great concern to the parents as the mobile flap can be seen within the oral cavity
(Fig. 8.33). The attempt for reposition and suture of the flap usually fails since
the mucosa is inflamed, and it is not retaining the suture. It is likely to recom-
mend that this flap adheres spontaneously. The tongue movements make the flap
come into contact with the palatal plane producing adhesion of the flap after 2 or
3 weeks.
8.3.1.2 Hard Palate Dehiscence (Figs. 8.34, 8.35, and 8.36)
This type of dehiscence is associated with the two-stage surgical techniques (use of
vomerine flap) and palatoplasties without relaxing incisions. The closure of the hard
palate using the vomer flap (proposed by two-stage cleft palate protocols) has some
Fig. 8.33 Male 12 years

old patient, who had a
complication after primary
cleft palate repair. The
patient developed an
anterior dehiscence
Fig. 8.34 Patient with a

history of primary cleft
palate repair operated
using the two-flap
technique. Anterior fistula
is developed as a
consequence of anterior
dehiscence
disadvantages since it is done in a single anatomical plane, which is more vulnera-

ble to dehiscence and palatal fistulas also. Under these considerations, the repair is
not always effective leaving the second stage in disadvantageous conditions for an
anatomical and functional closure.
8.3.1.3 Soft Palate Dehiscence (Figs. 8.37 and 8.38)
These are the most frequent form of dehiscence after primary cleft palate repair and
generally associated to surgical technique deficiencies and development of velopha-
ryngeal insufficiency.

lip and palate who
underwent primary cleft
palate repair and developed
a wound dehiscence of the
hard palate

lip and palate who had a
dehiscence of the hard
palate after cleft palate
repair
8.3.1.4 Total Palate Dehiscence (Fig. 8.39)
They are rare to observe and related to technical deficiencies. Some factors as mal-
nutrition or infection may be considered, especially in cases of recurrence [30, 31].
Recurrence of total palate dehiscence requires a careful evaluation of the local
tissues and rules out local and distant infections. Oropharyngeal and middle ear
infections have been associated with postoperative wound infection and partial or
total dehiscence [32]. The development of postoperative hematomas (associated or
not with infection) can also explain total dehiscence of the cleft palate repair.
Fig. 8.37 Cleft palate

patient who underwent
primary palatoplasty and
developed soft palate
dehiscence
Fig. 8.38 Patient born

with cleft lip and palate
who had a primary cleft
palate repair and developed
wound dehiscence of the
hard and soft palate
8.3.2 Treatment of Palate Dehiscence
The treatment requires careful evaluation identifying those factors that could be
decisive in the development of this outcome. The aspects to be considered are nutri-
tional status, age, type of cleft, quality of the remaining tissues, number of previous
surgeries, used surgical technique, history of infection, trauma, etc. and surgeon’s
experience and skills. Unlike palatal fistulas, palatal dehiscence always requires
corrective surgery. These defects often result in speech and eating disorders of the
patient; therefore, an early correction is mandatory. However, we must wait at least
1 year after the complication to proceed with a new surgical repair.
a b
Fig. 8.39 Female patient born with bilateral cleft lip and palate, who was operated at 1 year of age
using the two-flap technique. (a, b) The photo shows a complete dehiscence of the operative
wound during the first postoperative week (c)
8.3.2.1 Hard Palate Dehiscence Treatment
As mentioned before, the type of cleft palate may determine the surgical treatment.
In unilateral cleft palates, the correction of the dehiscence can be performed effec-
tively using the one-flap technique (from the non-cleft side) (Fig. 8.40).
Surgical Technique
The medial edges of the dehiscence are incised using a 15 blade scalpel and the
lateral relaxing incision with an electrosurgical knife. Lateral incision should be
performed following the edges of the gingival mucosa to provide greater extension
to the flap.
After this, using a fine periosteal elevator, the flap is elevated in the subperiosteal
plane, and the dissection should be extended to the soft palate to prevent fistulas.
This dissection acquires greater degree of difficulty at the level of the greater pala-
tine vascular pedicle. The scar tissue makes difficult the visualization of the
Fig. 8.40 Patient with unilateral cleft lip and palate who developed a dehiscence of the hard palate
after primary repair. Immediate postoperative view of the repair using the one-flap method is
presented
anatomical landmarks and creates resistance for tissue dissection, as well as increase
bleeding. Under this scenario, special care must be taken when skeletonizing the
vascular pedicle in order to prevent its injury.
Once this dissection is completed, the mobility of the flap must be verified by
transposition over the defect.
On the non-cleft side, the cleft border is elevated in the subperiosteal level avoid-
ing injury of the vascular pedicle. The nasal mucosa is elevated in the subperiosteal
plane in both sides, dissecting to an extent necessary to perform a closure without
tension. Then, dissected tissues are sutured in the midline using 5/0 absorbable
sutures without tension. The muscular plane should be evaluated to determine if
surgical correction is necessary. Hemostatic material is used to cover lateral raw
surface.
In bilateral and incomplete cleft palate dehiscence, it is recommended to avoid
the use of monopedicled flaps. Vascular pedicles tend to be more hypoplastic in
these type of clefts. In bilateral clefts, the size of palate segments is smaller; hence,
it is more difficult to use one flap for dehiscence repair. The use of a surgical tech-
nique based on bipedicled bilateral flaps (von Langenbeck concept) is
recommended.
Surgical Technique
The cleft margin incisions are made using a scalpel and the lateral ones using the
electrosurgical knife. Lateral incision is located at the mucosa gingival junction and
extended to the soft palate. Dissection of the bipedicled flaps is done in the subperi-
osteal plane using a fine periosteal elevator. Special care must be paid for greater
palatine pedicle dissection as described before for unilateral clefts. Skeletonization
of the greater palatine pedicle must necessarily be carried out on both sides to
release tension at closing. The mobility of both flaps towards the midline must be
verified. The nasal mucosa must also be elevated in the subperiosteal plane, dissect-
ing them in a necessary extension to perform a closure without tension. The surgery
ends with the suture in the midline using 5/0 absorbable suture without tension.
Hemostatic material is used to cover the bilateral raw surfaces. The muscular plane
requires correction in these clefts frequently.
8.3.2.2 Soft Palate Dehiscence Treatment (Figs. 8.41 and 8.42)
In mild forms of soft palate dehiscence, it is recommended to use the Furlow’s tech-
nique; this is a technique that in addition to performing the closure of the dehiscence
allows the reconstruction of the muscular plane [33]. For its use, it must be taken in
consideration that the palatal mucosa be healthy and without scars that could affect
the viability of the flaps. For other forms of dehiscence of the soft palate, the von
Langenbeck concept may be used for its correction. Medial advancement of these
flaps leaves lateral raw surfaces allowing the midline closure without tension.
Surgical Technique
Medial incision of the dehiscence is made with scalpel and extended to the hard
palate and the lateral incisions with electrosurgical knife. The lateral incisions begin
at the level of the base of the soft palate and are extended laterally towards the hard
palate above the hard and soft palate junction (around 1 cm above the level of the
dehiscence). Then, both sides are dissected in the submucous and subperiosteal
plane using fine scissors and periosteal elevator. Depending on the extension of the
hard palate dissection, the greater palatine vessel dissection is required. This is not
performed under direct visualization through the lateral incisions, there being for
Fig. 8.41 A 7-year-old patient, with dehiscence of the soft palate after primary cleft palatoplasty.
Correction of this bad outcome was performed using the Furlow technique plus unilateral
uvuloplasty
Fig. 8.42 Male patient, 9 years old, born with unilateral cleft lip and palate who developed a soft
palate dehiscence associated with hard palate fistula. Correction of both defects using the von
Langenbeck technique plus unilateral uvuloplasty plus buccal fat pad is presented here
this reason the risk of vascular injury. After surgical dissection, the mobility of the
flaps must be confirmed, and the nasal mucosa is closed first using 5/0 absorbable
sutures. A secondary intravelar veloplasty is performed with careful dissection of
the velar muscles separating them from the scar tissue. If there is any damage of the
nasal mucosa, the buccal fat pad may be used to prevent fistula development. The
surgery finishes with the oral mucosa closure using 5/0 absorbable sutures without
tension. Finally, hemostatic material is used to cover lateral raw surfaces.
Bifid uvula is a common sequel observed in soft palate dehiscence. The conven-
tional technique for its repair is joining the both uvulas in the midline; however, in
our experience, this method hardly reproduces normal characteristics of the uvula
due to scar retraction. The author prefers to repair the uvular dehiscence using only
one of them that allows better surgical outcomes.
8.3.2.3 Total Palate Dehiscence Treatment (Figs. 8.43, 8.44, and 8.45)
This is a bad outcome which requires special attention. Patient’s evaluation should
consider aspects related to the previous procedure and its general condition.
Regarding the previous surgery, before planning a new reconstruction, the sur-
geon must know who was the surgeon, surgical conditions, used surgical technique,
and circumstances related to the development of the problem (days, events, etc.). In
relation to the surgeon, it is known that its experience and skills allow to decrease
the number and severity of bad outcomes. Some studies suggest that malnutrition is
associated with an increase in bad outcomes [30] and should be considered.
Fig. 8.43 Two cases of complete palatal dehiscence after primary cleft palate repair are presented
here. Tissue retraction and loss of uvula are characteristics of these bad outcomes
Successful surgical treatment of total palate dehiscence will require planning and
choice of a surgical technique (or combination of them) in combination with muco-
periosteal flaps performing a tension free closure based on lateral relaxing incisions
and skeletonization of the greater palatine vessels. With regard the surgical tech-
nique recommended for its treatment, it is important not to use the same technique
that was used before (although this information may not always obtain). A combina-
tion of procedures may be considered (such as pharyngeal flap, buccinator flap,
FAMM flap, buccal fat pad, and others) in recurrent total cleft palate repair
dehiscence.
Finally, an alternative to surgical treatment is the use of prostheses to correct
symptoms. This method may be an alternative or also a temporal solution until the
surgical correction is performed.
8.4 Palatal Flap Necrosis
This is the worst postoperative bad outcome having a great impact on the quality of
life of the patient being devastating for both, patient and surgeon, in terms of
prognosis.
At first hand, after having this kind of outcome in a bilateral cleft palate patient,
it motivated us to carry out different studies including literature review, case report,
and case control study to determine risk factors for flap necrosis development seek-
ing to better understand the development of this bad outcome [34–36]. Based in
these studies, the prevalence was estimated in 0.34% [34] similar to other studies as
the study published by Deshpande observing less than 1% [37].
a b
c d
e f
Fig. 8.44 (a) A female 1-year-old patient born with unilateral cleft lip and palate. (b) Patient was
operated using the one-flap technique. (c) Wound dehiscence was observed as a result of this pri-
mary repair. (d) The bad outcome was repaired using the von Langenbeck technique. (e) Recurrence
of the operative wound dehiscence occurred as a consequence of this treatment. (f) This recurrence
was corrected 1 year after combining the von Langenbeck with the buccal fat pad allowing the
correction of the palate
a b
c d
e f
Fig. 8.45 Case of recurrent dehiscence of cleft palate repair. (a) This bad outcome was repaired
using multiple flaps; thus in (b) and (c), we show the use of superiorly based pharyngeal flap for
nasal mucosa repair (d) and, in photos (e) and (f), the closure of the oral mucosa using bilateral
mucoperiosteal flaps in combination with buccal fat pad
8.4.1 Palatal Necrosis Diagnostic
This outcome is characterized by changes in the color of the flap (pale initially then
dark) associated with bad odor during the postoperative period. Later, signs of
infection are added with inflammation associated with irritability, fever, and loss of
appetite.
Subsequently, after 5 to 7 days, dehiscence of the surgical closure can be observed
with loss of necrotic tissue and bleeding, occasionally significant (Fig. 8.46). Loss
of tissues and bone exposure favor its resorption creating defects of greater size.
This event leaves as a sequel a defect characterized by widespread tissue deficiency
generally larger than the original cleft. This characteristic differentiates the flap
necrosis from other bad outcomes like palatal fistulas and dehiscence (Fig. 8.47).
The most severe cases may present almost complete absence of palatal tissues rep-
resenting a big challenge for the reconstructive surgeon (Fig. 8.48). The functional
impact of these anatomical defects is great, and they have psychosocial conse-
quences in the development of the affected patients. The defect allows the free flow
of food into the nasal cavity with alterations in taste, bad breath, and poor oral
hygiene. In addition, creates hearing impairment and alteration of the speech with
hypernasality and audible nasal air emission. Different etiologies have been
described for the development of severe defects after cleft palate surgery; among
these are technical deficiencies of the surgeon, infection, bruising, and lesion of the
palatal vascular pedicle (compression, tension, section or vascular thrombosis) [34].
However, there is not enough scientific evidence to explain the pathophysiology of
mucoperiosteal flap necrosis.

patient born with
incomplete cleft palate
cleft palate surgery in a
surgical campaign. One
week later, we observed
loos of the left
mucoperiosteal flap,
devitalized tissue, and
dehiscence of the surgical
wound
Fig. 8.47 Patients born with cleft palate who had palatal flap necrosis as a consequence of primary
palatoplasties. The defects are larger than the congenital cleft
Fig. 8.48 Patients born with bilateral cleft palate who developed palatal flap necrosis and almost
complete loss of the palatal tissue
Surgical injury of the greater palatine vessels is not frequent, although some
authors have described their association [36–38]. A study published by Kuwahara
et al. found that older patients are more likely to develop flap necrosis, apparently
due to the compression of the vascular pedicle by abnormal bony protrusion [38].
The abnormal congenital development of palatine vessels may be observed in cleft
palates, according to our studies. In this study, we observed that females, older
patients, and bilateral and incomplete cleft palates were risk factors associated to
the development of flap necrosis [35]. Postoperative infection can be the cause
when this is severe. This association has been described by Sancho et al. in a case
report of a patient with suppurative otitis media [39].
Finally, another related factor is the hematoma because of vascular compression,

although it has not been well-established and more evidence is required.
The possibility of developing this bad outcome can be prevented with careful
preoperative evaluation, such as assessment of nutritional status, ruling out middle
ear infections, and severity and type of the cleft palate (bilateral and incomplete).
The bilateral cleft palate is in higher risk for palatal necrosis development (accord-
ing to our studies), due to bilateral congenital hypoplasia, and use of monopedicu-
lated flaps in primary palatoplasties should be avoided based on our protocol: the
Lima Protocol for Primary Cleft Palate repair [40].
8.4.2 Treatment of Palatal Flap Necrosis
The initial management of this bad outcome may require debridement of the necrotic
tissue, but most of the cases, it occurs as autolytic form (spontaneously). Most of the
patients come to the hospital with the defect exposed after loss of palatal tissue. In
this moment, only tissue irrigation and antibiotic therapy are required during 5 days.
Bleeding is frequently associated and may be severe since the artery is amputated
after necrosis producing great hemorrhage and requiring reoperative hemostasis.
Reconstruction of the defects should be delayed for 6 months to 1 year and per-
formed at early age (before 5 years old) because of the functional impact of these
sequels.
The surgical correction involves a wide variety of local and distant flaps or com-
bination of both. The aspects to be considered are as follows:
(a) Surgeon experience and skills
(b) Age of the patient
(c) Quality of the remaining tissues
(d) Antecedents (infection, trauma, and others)
The surgeon is perhaps the most important factor to be considered. Severe defects
require more complex surgical techniques, and the reconstructive surgeon should be
familiar with all of these techniques in order to have greater chance of success. The
age of the patient becomes important since severe defects and their impact on
speech, hearing, and feeding are great requiring early correction (ideally, before
2 years old to prevent speech sequels). The quality of the remaining tissues must be
evaluated in order to know if they are well vascularized or not. Patency of the greater
palatine artery should be confirmed by Doppler. If the remaining palatal tissues are
well vascularized, the use of local flaps is a good alternative.
Regarding the surgical options, one of the most used flaps by the author is the
FAMM flap (facial artery myomucosal), an axial myomucosal flap of the facial
artery. This flap includes oral mucosa, submucosa, part of buccinator and orbicu-
laris oris muscles, as well as the facial artery. The flap has two variants: anterior and
posterior based.
Based on the author’s experience, the posterior-based flap is safer to perform.

The anterior-based flap is indicated for defects in the anterior half of the palate, and
the posterior-based flap is a good indication for the posterior half; although it is well
designed, it can cover defects in the anterior region. The author designed a variant
of this flap adding a cutaneous island to guarantee the closure of the nasal mucosa.
It has been called FAMMC (facial artery myomucosal cutaneous) flap and used in
cases in which the closure of the nasal mucosa plane is not possible to be performed
[41]. An important limitation is that the flap’s pedicle may interfere with dental
occlusion. It has been estimated that 26% of posterior-based flaps require additional
surgery to section the base of the pedicle about 3 weeks later [42]. The anterior-
based flap requires a 2 cm space at the level of the upper dental arch (alveolar cleft
level) to avoid any interference with dental occlusion.
Surgical Technique (Figs. 8.49, 8.50, 8.51, 8.52, 8.53, 8.54, 8.55, 8.56, and 8.57)
Firstly, the surgeon must identify the location of the facial artery. This can be done
by using a Doppler or by palpation. The facial artery is a branch of the external
carotid artery and enters the region at the intersection of the anterior border of the
masseter muscle with the inferior border the jaw. The pulse of the facial artery is
easy to palpate at this level. Then, the artery runs diagonally forward and upward
following a path outside the corner of the mouth and superficial to the buccinator
muscle. The artery ends outside the nasal ala bringing branches to the nose and its
Fig. 8.49 Illustrative

diagram of the anatomical
relationships in the face of
the facial artery
myomucosal flap (FAMM).
1. Parotid gland. 2.
Stensen’s duct. 3. Frontal
branch of facial nerve. 4.
Zygomatic branch of the
facial nerve. 5. Marginal
branch of the facial nerve.
6. Masseter muscle. 7.
Facial vein. 8. Facial
artery. 9. Angular artery.
10. Nasal artery. 11.
Superior labial artery. 12.
Inferior labial artery. 13.
FAMM flap. 14.
Buccinator muscle
Fig. 8.50 Illustrative photos of facial artery myomucosal (FAMM) elevation
Fig. 8.51 Male patient with unilateral cleft lip and palate who developed flap necrosis after pri-
mary cleft palatoplasty leaving an extensive defect on the palate. Postoperative surgical outcome
using the posterior-based FAMM flap is presented
terminal branch (angular artery) at the periorbital level. Based in these anatomical
references, the facial artery trajectory may be located between two points: the inter-
section between anterior border of the masseter muscle and jaw and the point
located 1 cm outside the nasal ala. The artery location can be confirmed by finger
palpation at the level of the cheeks, and the pulse of the artery can be clearly felt.
An important structure to be preserved in this surgery is the parotid duct. Its
papilla is located in the jugal mucosa at the level of the first and second upper
molars and must be preserved during flap elevation. The first surgical stage corre-
sponds to the closure of the nasal mucosa. The surgical incision is made a few
a b
c d
Fig. 8.52 (a) A 28-year-old female patient who had as a result of primary cleft palatoplasty a
severe defect due to necrosis of mucoperiosteal flaps. (b) The first surgical stage is shown with
closure of nasal mucosa plane. (c) Oral mucosa is repaired using a combination of mucoperiosteal
flap and posterior-based FAMM flap. (d) Postoperative view after 1 year successfully rebuilt.
Patient still has soft palate deficiency and requires surgery for velopharyngeal insufficiency
millimeters from the edge of the defect depending on the size of the defect. In bilat-
eral defects, an incision should be made on the vomer to use its mucosa for nasal
plane repair. In most of the cases, the nasal mucosa can be well repaired using local
flaps even in extensive defects. After this stage, the FAMM flap elevation is contin-
ued. The width of the flap can be up to 4 cm to allow the defect to be closed primar-
ily, and its length can reach 9 to 10 cm. Traction of the mucosal edges is helpful
using 4/0 silk sutures to create the necessary tension to the cheek and to be able to
make the incisions with more precision. The flap is elevated starting the dissection
at its distal portion. This area is located at the level of the superior labial sulcus (in
the posterior-based variant) and at the level of the retromolar trigone (in the anterior-
based variant).
In the posterior-based flap, the dissection is extended along the estimated mark-
ings of the flap using a scalpel. This incision exposes the muscular plane (orbicu-
laris oris muscle) and then the subcutaneous fat. Through this incision, the superior
Fig. 8.53 Illustrative diagram of the case presented in Fig. 8.52. (a) Mucoperiosteal flap elevation
and closure of the nasal mucosa. Incision for posterior-based FAMM flap. (b) Closure of the defect
in two anatomical planes using both flaps
a b
c d
Fig. 8.54 Male patient, 18 years old born with bilateral cleft lip and palate who underwent surgery
for surgical correction of the cleft palate developing necrosis of palatal flaps and leaving a severe
defect in the palate. (a) First surgical time with closure of the nasal mucosa. (b) Facial artery myo-
mucosal flap is used for oral mucosa repair. (c) Immediate postoperative view. (d) One-year post-
operative view
Fig. 8.55 Illustrative diagram of the surgical technique used in the previous case. Design of the
posterior-based FAMM flap is presented here
a b
c d
Fig. 8.56 Male patient, 19 years old born with bilateral cleft lip and palate operated at 1 year of
age developing a severe defect due to flap necrosis. (a) Anterior-based FAMM flap was used for
oral mucosa repair, and previously nasal mucosa was repaired. (b, c) Evolution of the flap is shown
immediately and after 1 year with complete closure of the defect. (c) The pedicle of the flap is
shown which will require its release for adequate closure of the alveolar cleft. (d) Long term post-
operative view
Fig. 8.57 Illustrative diagram of the case presented in the previous figure. (a) The design of the
FAMM flap and closure of the nasal mucosa is presented. (b) Postoperative view
labial artery should be identified and indicated in the anatomical plane in which the
facial artery is located. The superior labial artery is ligated, and the dissection con-
tinues in the subcutaneous plane until the retromolar trigone level. This dissection
will allow the flap to have an adequate arc of rotation to reach the palatal defect.
After flap elevation, the donor site is closed using 5/0 absorbable sutures, and the
flap is transposed to the palatal defect through a gingival incision at the alveolar
cleft level.
In the anterior-based FAMM flap, the dissection starts in the oral mucosa behind
the level of the retromolar trigone. The mucosal incision exposes the muscular plane
(buccinator), and through the incision, the facial artery can be easily identified for
its section and ligation. After this, the dissection continues in the subcutaneous level
up to the level to the superior labial sulcus. The donor site is closed using 5/0 absorb-
able sutures, and the flap is transposed through an incision made in the palatal
mucosa from the base of the flap behind the retromolar trigone in direction of the
palatal defect. Finally, the flap is sutured to the edges of the palatal defect using 5/0
absorbable sutures.
The release of the pedicle is not always required and consists of sectioning it
medial to the retromolar trigone allowing a segment of the flap to be returned to the
cheek (Fig. 8.58). This additional mucosa will provide a greater extension to the
buccal cheeks facilitating the feeding in patients. Mucoperiosteal flap necrosis and
its associated severe defects are frequently associated with deficiencies in the velo-
pharyngeal function requiring surgical correction such as pharyngoplasties as addi-
tional surgical time. A series of alternatives have been described in the literature as
useful methods for correction of these defects. The temporalis fascia and muscular
flap, tongue flap, and microvascular flaps have been used. In case where all the
mentioned alternatives are not possible or the patient does not accept the surgery,
the use of prosthesis represents a good option temporarily or permanently [43–45].
Fig. 8.58 Illustrative diagram of the surgical technique used by the author for the section and
replacement of the base of the flap in cases where it causes problems in dental occlusion
8.5 Velopharyngeal Insufficiency
8.5.1 elopharyngeal Insufficiency Diagnosis

V
and Classification
Velopharyngeal insufficiency is defined as the inability of the velopharyngeal

sphincter to be competent avoiding the passage of air into the nasal cavity during
speech and also produces swallowing and hearing disorders (Figs. 8.59 and 8.60).
Cleft palates with more tissue hypoplasia (like bilateral clefts) have a greater chance
of developing this bad outcome despite having a good surgery [46]. The failure to
regulate the passage of air through the velopharyngeal sphincter causes two situa-
tions: appearance of compensatory mechanisms by the other two sphincters and
passage of air into the nasal cavity during the speech increasing nasal resonance
[47]. The first condition is manifested through compensatory sounds produced by
the other sphincters. The list of compensatory sounds includes glottis and laryngeal
stops and pharyngeal, nasal, and velopharyngeal fricatives.
The inability of the palate to perform its sphincter function can be observed in up
to 30% of patients with cleft palate [48–52]. This condition requires treatment at an
early age since this is difficult to correct at later age. The speech therapy is indicated
6 months after cleft palate repair, and the objectives to be achieved are elimination
of the compensatory sounds and nasal emission of air from non-nasal phonemes
[53]. The resonance disorders, commonly observed as increase of the resonance of
the voice known as hypernasality, require surgical treatment for its correction when
this is moderate to severe.
The causes of velopharyngeal insufficiency can be summarized as follows:
degree of hypoplasia, deficiencies of primary cleft palate repair, and atrophy of the
velar muscles (observed in patients who have undergone surgery at a late age due to
Fig. 8.59 Female patient 21 years old born with incomplete cleft palate who develops a short pal-
ate after primary palatoplasty and severe velopharyngeal insufficiency. Nasoendoscopy view
shows: 1. Adenoids. 2. Side walls (poor mobility). 3. Velum. 4. Velopharyngeal space
Fig. 8.60 Two cases of patients with cleft palate who evolved with short palate and uvular retrac-
tion after primary palatoplasty. Both cases develop velopharyngeal insufficiency and severe
hypernasality
inactivity of the muscles) [50–52]. The diagnosis of this condition is established

initially through physical examination, and additionally, it is carried out through
diagnosis supported by nasoendoscopy and fluoroscopy. This evaluation is per-
formed by the interdisciplinary team.
The presence of pathologies that obstruct the upper airway, such as the turbinate
hypertrophy, nasal septum deviation, and tonsil hypertrophy should be considered
since they can mask the presence and severity of hypernasality.
Based on the interdisciplinary evaluation, we considered three degrees of velo-
pharyngeal insufficiency, as follows:
(a) Mild velopharyngeal insufficiency
Anatomy: Any type of cleft palate with adequate length. It is a functional
problem essentially.
Physical exam: Adequate movement of the lateral walls of the pharynx and
deficiency of the movement of the central portion of the velum, showing mal-
position of the velar muscles. Mild hypernasality is observed.
Nasoendoscopy: Most common pattern is the sagittal.
Fluoroscopy: Abnormal position of the velar muscles
(b) Moderate velopharyngeal insufficiency
Anatomy: Cleft palates with shorter length. These palates have a combina-
tion of malfunction and hypoplasia.
Physical exam: Combination of limited movements of the lateral walls of the
pharynx and shorter length of the palate as well deficiencies of the movement
of the central portion of the velum. Moderate hypernasality is observed.
Nasoendoscopy: Patterns are varied observing sagittal, coronal, and circular
patterns.
Fluoroscopy: Abnormal position and function of the velar muscles
(c) Severe velopharyngeal insufficiency
Anatomy: Mostly bilateral cleft palates with short length or some incom-
plete cleft palates independent of its length. Cleft palates with several surgeries
and scar tissue are included in this group. This group has a combination of
malfunction, hypoplasia, and scar tissue.
Physical exam: Very short palates may include scar tissue from previous
surgeries, poor mobility, and association with severe fistulas. Passavant’s ridge
is common to be observed. Severe hypernasality is observed (Fig. 8.61).
Nasoendoscopy: Varied patterns and circular type are being observed more
frequently. Fluoroscopy: Abnormal position of velar muscles and limited mobil-
ity of them.
Fig. 8.61 Patient with cleft palate and velopharyngeal insufficiency. Upon physical exam, it is
possible to observe the presence of Passavant’s ridge. Nasoendoscopic view: 1. Adenoids. 2.
Pharynx lateral walls. 3. Velum. 4. Passavant’s ridge
8.5.2 Treatment of Velopharyngeal Insufficiency
The first concept to be considered regarding velopharyngeal insufficiency treatment

is this: the surgery is indicated only for hypernasality correction and not for devel-
oped compensatory sounds; they can be improved by speech therapy. The speech
therapy also improves the quality of the surgical outcomes.
Different protocols have been published based on nasoendoscopic findings; how-
ever, there is not any consensus regarding its utility. Some centers, like UCLA cra-
niofacial center, are not considering these differences and use a single form of
treatment for different nasoendoscopic patterns. Recent studies published by Lam
et al. [54] and Ma et al. [55] consider the movement of the lateral walls of the phar-
ynx as a better parameter. If there is an adequate movement, they use a pharyngeal
flap as surgical treatment, and sphincter pharyngoplasties are used when there is not
an adequate movement.
This proposal is not shared by authors such as Kawamoto [56] and Peat [57]. A
study carried out by Kawamoto et al. at UCLA, USA, did not find differences
between groups regarding the association between the lateral wall movement and
the type of surgery for velopharyngeal insufficiency correction.
They recommend the use of sphincter pharyngoplasties for any type of cases.
The treatment of this condition requires careful evaluation of the patient. The
aspects to be considered are surgeon’s experience and skills, age of the patient, type
of cleft palate, and degree of velopharyngeal insufficiency.
The surgical treatment of this condition depends on the severity of the problem,
and the surgeon must be familiar with the different surgical techniques for velopha-
ryngeal insufficiency. Regarding the age of the patient, older patients (adults) tend
to develop atrophy of the velar muscles due to the inactivity of them during long
time. Thus, these patients require obstructive surgery to be able to overcome the
insufficiency.
It is also important to consider the evaluation of other anatomical structures, such
as muscular tone of the velum, cranial base angulation, and other functional aspects
[58, 59]. The presence of tonsil hyperplasia should be determined, and tonsillec-
tomy may be indicated several months before velopharyngeal surgery in order to
prevent the development of sleep apnea after surgical correction of velopharyngeal
insufficiency. The same consideration must be provided to other conditions as turbi-
nate hypertrophy, nasal septum deviation, and adenoid hypertrophy. All these condi-
tions may affect the assessment and outcome of hypernasality treatment.
There are two basic types of surgical treatment for velopharyngeal insufficiency:
functional and obstructive.
The functional methods seek to adequately reposition the musculature of the
velum, especially the levator veli palatini muscle. The most common methods of
repair are the Furlow’s and secondary intravelar veloplasty techniques.
The first one produces elongation of the palate and retroposition of the velar
muscles.
The author published recently an innovative secondary palatoplasty as a modifi-

cation of the Furlow’s method using the nasal plane and muscular Z plasty in com-
bination with the unilateral uvuloplasty [60] (Fig. 8.62). This proposal eliminates
the use of oral Z plasty reducing the associated complications observed after using
this method.
Recently, the use of the buccinator flap has been popularized, and this method
works by lengthening of the palate requiring adequate velar function [61]. However,
this method is considered non-functional, since the thickness of the repaired palate
is thicker due to the two-flap transposition, based on a recent study published by
Mann [62].
Recently, one study observed an increased thickness of the palate using these
flaps [62], and additional studies are required to determine if this method works by
elongation or airway obstruction. Associated complications have been described as
follows: infection, open mouth limitation, flap necrosis, injury of the parotid duct,
and facial nerve among others.
The obstructive methods occlude partially the nasopharyngeal in order to reduce
air passage through the nose. Most common techniques in this group include pha-
ryngeal flaps and sphincter pharyngoplasties. The pharyngeal implants are also in
this group, and the use of fat grafts stands out, very currently used in plastic surgery
[63]. The fat graft increases its volume when the patient gain weight may be associ-
ated with airway obstruction and middle ear problems.
Fig. 8.62 Unilateral Y Y

uvuloplasty technique for
primary and secondary
uvular repair
X X
1 2 3 4
2 4
1 3
The choice of surgical technique to be used will depend on the degree of velo-
pharyngeal insufficiency, as follows:
(a) Treatment of Mild Velopharyngeal Insufficiency
In this group, hipernasality is generally associated with a poor position of the
velar muscles. This is regularly due to a technical deficiency during primary cleft
palate repair. Surgical treatment should be carefully considered given the minor
severity of the problem. We use the secondary intravelar veloplasty as surgical treat-
ment for mild velopharyngeal insufficiency [64] (Fig. 8.63). This method is based
on the concept of performing a correct dissection and retroposition of the muscular
plane. The technique consists of identifying the muscular plane and releasing it
from the scar tissue generated by the primary surgery to later reposition it appropri-
ately. Brian Sommerlad considers that this technique is well indicated in cases with
a smaller velopharyngeal space (velopharyngeal closure greater than 80%) [64].
(b) Treatment of Moderate Velopharyngeal Insufficiency
Patients with moderate hypernasality present a combination of congenital hypo-
plasia and primary surgery sequel. The surgical strategy may require lengthening of
the palate and adequate replacement of the palatal muscles. We use the Furlow
method in these cases (Figs. 8.64, 8.65, 8.66, and 8.67), and it is performed in a
similar way to that described for primary clefts. The muscular component should be
carefully dissected from the scar tissue so as not to damage it [65–67]. The author
combines this method (the nasal component and muscular overlapping) with the
unilateral uvuloplasty limiting the use of oral incisions as an effective method for
this condition [60]. In a study published by Afrooz et al. in 2013, the results were
compared using the intravelar veloplasty and the Furlow’s technique in a group of
patients with velopharyngeal insufficiency and did not observe differences in the
outcomes [68]. Adult patients with moderate velopharyngeal insufficiency may
require obstructive surgery because of muscular hypotrophy [69, 70].
(c) Treatment of Severe Velopharyngeal Insufficiency
In this group of patients, the palate is usually short due to the congenital hypo-
plasia and sequels from the primary cleft palate repair. The surgical treatment is
aimed at reducing the airway space limiting the air passage during phonation. These
techniques are obstructive and associated with partial airway occlusion (often
observed as sleep apnea). This is the reason why these methods should be discussed
in detail with parents. Sleep apnea has now been linked to chronic conditions such
as diabetes and heart disease, although in non-cleft patients [70–72]. The technique
most used in this group is the modified Hynes sphincter pharyngoplasty (Fig. 8.66).
A greater number of complications have been observed with the use of pharyngeal
flaps in comparison with pharyngoplasties, and this is the reason why we do not use
them [73–79]. Sphincter pharyngoplasty is essentially based on the elevation of two
myomucosal flaps (one from each side) taken from the posterior pillar of the tonsil-
lar cell, including mucosa and palatopharyngeus muscle (Figs. 8.67 and 8.68). The
a b
c d
e f
Fig. 8.63 (a) Case of mild-to-moderate velopharyngeal insufficiency. (b) Abnormal position of
the velar muscles can be observed. (c) The secondary intravelar veloplasty is presented in pho-
tos (c–f)
level of attachments of these flaps is important, and C1 has been considered of

utmost importance for the correction of the problem, as described by Risky et al.
[80] reporting 93% of efficacy using this modification [80]. The central gap must be
less than 5 mm in diameter or 20 mm2 to optimize the correction [81, 82]. Using
pharyngeal flaps, a common failure to correct hypernasality is the contracture of the
flap leaving a thin structure and wide gaps on both sides resulting in recurrence of
a b
c d
Fig. 8.64 (a) Patient with moderate velopharyngeal insufficiency. (b) Problem has been corrected
using the Furlow technique. (c) Preoperative nasoendoscopy view with velopharyngeal gap. (d)
Postoperative nasoendoscopy view showing velopharyngeal closure and effectiveness of the
method. 1. Posterior pharyngeal wall. 2. Lateral walls 3. Velum
the speech disorder. Pharyngeal flaps are used in many centers as indication for
nasoendoscopic sagittal pattern; however, this has been questioned by different
authors because this velopharyngeal closure pattern is due to function of the supe-
rior constrictor of the pharynx, and this muscle is affected by the pharyngeal flap
surgery (it is partially included in the flap). A study by Karling et al. [83] observed
that the movement of the lateral walls is decreased after pharyngeal flap surgery.
Another findings have been described by Zwitman et al. and Witt et al. [84, 85]
regarding sphincter pharyngoplasty, and they observe no affection of lateral wall
movements. After literature review, most of the studies observed no differences in
the efficacy of pharyngeal flaps versus sphincter pharyngoplasties for correction of
the velopharyngeal insufficiency, but higher incidence of complications has been
a b
Fig. 8.65 (a) Illustrative scheme of the Furlow technique combined with the unilateral uvulo-
plasty for moderate velopharyngeal insufficiency. (b) Flap elevation. (c) Postoperative view shows
the lengthening of the palate that is achieved and the reduction of the velopharyngeal space
observed (snoring, airway obstruction, and sleep apnea) using pharyngeal flaps. The
sphincter pharyngoplasty seeks construct a new velopharyngeal sphincter reducing
the airway. The method used by the author is the modified Hynes technique.
(Figures) This pharyngoplasty uses the posterior pillars of the tonsils to create a new
sphincter. This new sphincter is not always dynamic as the muscles appear to be
denervated once they are dissected to be transposed.
The technique is indicated for cases of severe velopharyngeal insufficiency.
Sphincter Pharyngoplasty Surgical Technique (Figs. 8.69, 8.70, 8.71, and 8.72)
The technique begins with the application of the Dingman mouth opener. Neck
extension (done conservatively) is also a factor to be considered to facilitate field
vision to the surgeon. The palate and pharynx are infiltrated using local anesthetic
plus vasoconstrictor. The soft palate and uvula may be displaced using sutures or
Foley catheter to facilitate access to C1 vertebral level. If the soft palate requires
surgical correction, it may be divided.
a b
c d
e f
Fig. 8.66 (a) Patient with severe velopharyngeal insufficiency. (b) Sphincter pharyngoplasty tech-
nique. 1. Sectioned soft palate. 2. Palatopharyngeus myomucosal flaps). (c) Immediate postopera-
tive view. (d) One-year postoperative view. (e) Preoperative nasoendoscopy view. (f) Postoperative
nasoendoscopy view
Once an adequate exposure of the pharyngeal region has been achieved (very
important condition), the flap elevation is proceeded. Bilateral flaps will be made up
of mucosa and the palatopharyngeus muscle. The length of these flaps should be
a b
c d
Fig. 8.67 (a) Patient with sequelae of cleft palate surgery presenting severe fistula and velopha-
ryngeal insufficiency. (b) The fistula was repaired using the FAMM flap + local flap. (c) After
1 year, the velopharyngeal insufficiency was repaired using the sphincter pharyngoplasty (intraop-
erative view). (d) Postoperative view
estimated based on the transverse diameter of the pharynx. In order to perform the
flap incisions easily, the posterior pillar of the tonsil is pulled up using fine dissec-
tion forceps. Creating enough tension to facilitate the performance of mucosal inci-
sions. It begins in the distal portion by making a transverse incision through the
mucosa and muscle. Then, longitudinal incisions are made at the level of the ante-
rior and posterior sulcus of the tonsillar pillar. The dissection is continued at the
level of the muscular plane, trying to include an adequate amount of muscle giving
volume to the flap. This is a key point, as it required enough volume of the flaps to
be able to obstruct the airway. In this area of dissection, special care must be taken
with two anatomical structures: the internal carotid artery and the glossopharyngeal
a b
c d
e f
Fig. 8.68 Male patient 18 years old born with bilateral cleft lip and palate that had mucoperiosteal
flap necrosis after primary cleft palate repair. The defect was repaired using a posterior-based
FAMM flap. (a–c) Corrective pharyngoplasty and unilateral uvuloplasty were used for velopha-
ryngeal insufficiency correction. (d) Pre- and postoperative nasoendoscopy views are presented
here (e, f)
Fig. 8.69 Upper: Patient

with primary palatoplasty
dehiscence and
velopharyngeal
insufficiency. Lower:
Sphincter pharyngoplasty
view. 1. Uvula retracted. 2.
and 3. Palatopharyngeus
flaps. 4. Velum. 5. Closed
donor sites. 6. Posterior
pharyngeal wall
nerve. The carotid artery may be too close as in velocardiofacial syndrome, and its
damage should be avoided. Loss of sensation and taste has been reported after this
surgery due to nerve injury.
Once the flaps have been raised on both sides, the donor sites are closed. Then, a
transverse incision is performed with the help of the cautery over the pharyngeal
mucosa and muscle up to the aponeurotic plane. This incision is located just below
the adenoid tissue (which corresponds to the first cervical vertebra). The insertion
of the myomucosal flaps starts attaching the distal end of the flap to the opposite
border of the transverse incision of the pharynx; then, the closure is completed at the
level of the upper edge of the flap. The second flap is also attached to the opposite
end of the pharyngeal incision and sutured to the lower edge of the incision made in
the pharynx. Finally, both flaps are sutured together. The surgery culminates with
the placement, under direct visualization, of a ventilation tube through the nose and
passing through the central port of the pharyngoplasty. Postoperative antibiotics and
analgesics are indicated as well as liquid diet during the first days and then liquefied
until the patient can tolerate the intake of solids without pain.
a b
c d
e f
Fig. 8.70 (a) Male patient 8 years old born with unilateral cleft palate who developed a short and
poor functional palate after primary repair. (b) Sphincter pharyngoplasty has been used, and pala-
topharyngeus myomucosal flaps [1] were elevated on each side. (c) Myomucosal flaps were trans-
posed. (d) Immediate postoperative view using ventilation tube. Pre- and postoperative
nasoendoscopy views (e, f)
a b
Fig. 8.71 Hynes-type pharyngoplasty surgical technique. (a) Preoperative view and myomucosal
flap design. (b) Bilateral palatopharyngeus flap elevation, posterior wall incision, and uvular
retraction. (c) Transposition of the myomucosal flaps, donor site closure, and placement of the
ventilation tube
Fig. 8.72 Patient after sphincter pharyngoplasty repair. Photos are illustrating the closure of the
velopharyngeal gap during phonation
In case of refractory to surgical treatment and patients not candidates for surgical
management, the use of pharyngeal obturator is indicated. The use of pharyngeal
bulb stands out, an obturator with a special design that seeks to stimulate velopha-
ryngeal musculature mobility and improve sphincter function. The method requires
trained professionals as well as the multidisciplinary team participation. More stud-
ies are required to determine its efficacy in the treatment of velopharyngeal
insufficiency.
References
1. Shaw W, Semb G, Nelson P, Brattstrom V, Molsted K. y col. The Eurocleft project: 1996-2000:
overview. J Craniomaxillofac Surg. 2001;29(3):131–40.
2. Katzel E, Basile P, Koltz P, Marcus J, Girotto J. Current surgical practices in cleft care: cleft
palate repair techniques. Plast Recons Surg. 2009;124(3):899–906.
3. Friede H, Eenemark H. Long term evidence for favorable midfacial growth after delayed hard
palate repair in UCLP patients. Cleft Palate Craniofac J. 2001;38(4):323.
4. Lilja J, Mars M, Elander A, Enocson L, Hagberg C, et al. Analysis of dental arch relation-
ships in Swedish unilateral cleft lip and palate subjects: 20-year longitudinal consecutive series
treated with delayed hard palate closure. Cleft Palate Craniofac J. 2006;43:606–11.
5. Malek R, Psaume J. New concept of the chronology and surgical technique on the treatment of
cleft lip and palate. Results in 220 cases. Ann Chir Plast Esthet. 1983;28:237–47.
6. Sommerlad B. A technique for cleft palate repair. Plast Recons Surg. 2003;112(6):1542–8.
7. Cutting C, Rosenbaum J, Rovati L. The technique of muscle repair in the cleft soft palate. Oper
Tech Plast Surg. 1995;2:215–22.
8. La Rossa D, Hunenko O, Kirschner R, Low D, et al. The Children’s Hospital of Philadelphia
modification of the Furlow double opposing z plasty: long term speech and growth results.
Clin Plastic Surg. 2004;31:243–9.
9. Bykowsky M, Noran S, Winger D, Losee J. The rate of oronasal fistula following primary cleft
palate surgery: a meta-analysis. Cleft Palat Craniof J. 2015;52(4):e81–7.
10. Cohen SR, Kalinowski J, LaRossa D, et al. Cleft palate fistulas: a multivariate statistical analy-
sis of prevalence, etiology, and surgical management. Plast Reconstr Surg. 1991;87:1041–7.
11. Liau JY, Sadove AM, van Aalst JA. An evidence-based approach to cleft palate repair. Plast
Reconstr Surg. 2010;126:2216–21.
12. Rossell-Perry P, Cáceres-Nano E, Gavino-Gutiérrez A. Associations between palatine index
and cleft palate repair outcomes in patients with complete unilateral cleft lip and palate. JAMA
Facial Plastic Surg. 2014;16(3):206–10.
13. Levi B, Kasten S, Buchman S. Utilization of the buccal fat pad flap for congenital palate repair.
Plas Recons Surg. 2009;123(3):1018–21.
14. Rahpeyma A, Khajehahmadi S. Premaxillary palatal flap as an aid to créate nasal floor in ante-
rior palatal fistula closure of cleft patients. Int J Surg. 2016;30:35–7.
15. Kang NH. Current methods for the treatment of alveolar cleft. Arch Plast Surg.
2017;44(3):188–93.
16. Vasishta SMS, Krishnan G, Rai YS, Desai A. The versatility of the tongue flap in the closure
of palatal fistula. Craniomaxillofac Trauma Reconstr. 2012;5(3):145–60.
17. Bennet K, Thurston T, Vercler C, Kasten S. Harvesting the buccal fat pad does not result
in aesthetic deformity in cleft patients: a retrospective analysis. Plas Recons Surg
J. 2017;140(2):362–8.
18. Kirschner R, Cabiling D, Slemp A, Siddiqi F, Larossa D, Losee J. Repair of oronasal fistulae
with acellular dermal matrices. Plas Recons Surg. 2006;118:1431.
19. Aldekhayel SA, Sinno H, Gilardino MS. Acellular dermal matrix in cleft palate repair: an
evidence-based review. Plas Recons Surg J. 2012;130(1):177–82.
20. Shridharani SM, Tufaro AP. A systematic review of Acelluar Dermal matrices in head and neck
reconstruction. Plastic Recons Surg. 2012;130(5S-2):35S–43S.
21. Rohleder N, Loeffelbein D, Feisti W, Eddicks M, y col. Repair of oronasal fistulae
by interposition of multilayered amniotic membrane allograft. Plast Reconstr Surg.
2013;132(1):172–81.
22. Jeffery S, Boorman J, Dive D. Use of cartilage grafts for closure of cleft palate fistulae. Br J
Plast Surg. 2000;53(7):551–4.
23. Ohsumi N, Onizuka T, Ito Y. Use of a free conchal cartilage graft for closure of a palatal fistula:
an experimental study and clinical applications. Plast Reconstr Surg. 1993;91:433.
24. Fallah D, Baur D, Ferguson H, Helman J. Clinical application of the temporoparietal-galeal
flap in closure of a chronic oronasal fistula: review of the anatomy, surgical technique, and
report of a case. J Oral Maxillofac Surg. 2003;61(10):1228–30.
25. Schwabegger AH, Hubli E, Rieger M, Gassner R, Schmidt A, Ninkovic M. Role of free tissue
transfer in the treatment of recalcitrant palatal fistulae among patients with cleft palate. Plast
Reconnstr Surg. 2004;113(4):1131–9.
26. Zemann W, Kruse A, Luebbers H, Jacobsen C, Metzier P, Obwegeser J. Microvascular tis-
sue transfer in cleft palate patients: advocacy of the prelaminated radial free forearm flap. J
Craniofac Surg. 2011;22(6):2006–10.
27. Eufinger H, Machtens E. Microsurgical tissue transfer for rehabilitation of the patient with
cleft lip and palate. Cleft Palate Craniofac J. 2002;39(5):560–7.
28. Duffy F. Anterolateral thigh perforator flap in palatal reconstruction. J Reconstr Microsurg.
2006;22:A007.
29. Ninkovic M, Hubli EH, Schwabegger A, Anderl H. Free flap closure of recurrent palatal fistula
in the cleft lip and palate patient. J Craniofac Surg. 1997;26(1):491–5.
30. Maine R, Hoffman W, Palacios-Martínez J, Corlew D, Gregory G. Comparison of fistula rates
after palatoplasty for international and local surgeons on surgical missions in Ecuador with
rates at a craniofacial center in the United States. Plas Recons Surg. 2012;129(2):319–26.
31. Tuna E, Topcuoglu N, Ilhan B, Gencay K. Staphylococcus aureus transmission through orona-
sal fistula in children with cleft lip and palate. Cleft Pala Craniof J. 2008;45(5):477–80.
33. Furlow L. Cleft palate repair by double opposing Z plasty. Plast Reconstr Surg. 1986;78:724.
34. Rossell-Perry P. Flap necrosis after palatoplasty in patients with cleft palate. Biomed Res Int.
2015;2015:Article ID 516375.
35. Rossell-Perry P, Figallo-Hudtwalcker O, Vargas-Chanduvi R, Calderón-Ayvar Y, Romero-
Narváez C. Risks factors leading to mucoperiosteal flap necrosis after primary palatoplasty in
patients with cleft palate. J Plastic Surg Hand Surg. 2017;51(5):348–51.
36. Rossell-Perry P, Cotrina-Rabanal O, Barrenechea-Tarazona L, Vargas-Chanduvi R, Paredes-
Aponte L, Romero-Narváez C. Mucoperiosteal flap necrosis after primary palatoplasty in
patients with cleft palate. Arch Plast Surg. 2017;44(3):217–22.
37. Deshpande G, Campbell A, Jagtap R, et al. Early complications after cleft palate repair: a
multivariate statistical analysis of 709 patients. J Craniofac Surg. 2014;25(5):1614–8.
38. Kuwahara H, Yoshimoto S. Investigation of the cause of mucoperiosteal flap necrosis in older
children and adults an anatomical perspective. J Showa Univ Soc. 2013;73(5):439–43.
39. Sancho M, Parri F, Raigosa J, Lerena J, et al. Palatal necrosis in children. Case Report. Cir Ped.
2006;19(2):115–6.
40. Rossell-Perry P, Luque-Tipula M. The Lima surgical protocol for cleft palate repair. J Craniofac
Surg. 2020;31(6):1533–8.
41. Rossell-Perry P, Arrascue HM. The Nasal Artery Mio Mucosal Cutaneous (NAMMC) flap in
difficult palatal fistulas closure. Craniomaxillofacial Trauma Reconstr. 2012;5(3):175–84.
42. Freedlander E, Jackson IT. The fate of buccal mucosal flaps in primary palatal repair. Cleft
Palate J. 1989;26(2):110–2.
43. Pinborough-Zimmerman J, Canady C, Yamashiro D, Morales L. Articulation and nasal-
ity changes resulting from sustained palatal fistula Obturation. Cleft Palate Craniofac
J. 1998;35(1):81–7.
44. Goiatp M, Dos Santos D, Moreno A. Prosthetic treatments for patients with oronasal commu-
nication. J Craniofac Surg. 2011;22(4):1445–7.
45. Reisberg D, Gold H, Dorf D. A technique for obturating palatial fistulas. Cleft Palate
J. 1985;22(4):286–9.
46. Rossell-Perry P. Cirugía de la fisura palatina. Lima: Ed. San Marcos; 2015.
47. Peterson-Falzone S, Trost-Cardamone J, Karnell M, et al. The clinician’s guide to treating cleft
palate speech. St. Louis: Elsevier; 2006.
48. Hopper RA, Cutting C, Grayson B. Cleft lip and palate. In: Thorne CH, editor. Grabb and
smith plastic surgery. Philadelphia: Lippincott and Williams; 2007. p. 201–25.
49. Ysunza A, Pamplona C, Ramírez E, Molina F, Mendoza M, Silva A. Velopharyngeal sur-
gery: a prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties. Plast
Reconstr Surg. 2002;110:1401–505.
50. Yun Shan P, Tristan de Chalain P. Incidence of oronasal fistulae and velopharyngeal insuf-
ficiency after cleft palate repair. Cleft Palate Craniofacial J. 2008;45:2.
51. Inman D, Thomas P, Hodgkinson P, Reid C. Oronasal fistula development and velopharyngeal
insufficiency following primary cleft palate surgery. Br J Plast Surg. 2005;58:1051–4.
52. Leclerc J, Godbout A, Arteau-Gauthier I, Lacour S, Abel K, McConnell E. We can pre-
dict postpalatoplasty velopharyngeal insufficiency in cleft palate patients. Laryngoscope.
2014;124(2):561–9.
53. Kummer A. Cleft palate and craniofacial anomalies: effects on speech and resonance. San
Diego: Singular Press; 2001.
54. Lam E, Hundert S, Wilkes G. Lateral pharyngeal wall and velar movement and tailoring velo-
pharyngeal surgery: determinants of velopharyngeal incompetence resolution in patients with
cleft palate. Plast Reconstr Surg. 2007;120(2):495.
55. Ma L, Shi B, Li Y, Zheng Q. Velopharyngeal function assessment in patients with cleft
palate: perceptual speech assessment versus nasopharyngoscopy. J Craniofac Surg.
2013;24(4):1229–31.
56. Kawamoto H Jr. Pharyngoplasty revisited and revised. Oper Tech Plast Reconstr Surg.
1995;2(4):239–44.
57. Peat B, Albery E, Jones K, Pigott R. Tailoring velopharyngeal surgery: the influence of etiol-
ogy and type of operation. Plast Recons Surg. 1994;93:948–53.
58. Zhang J, Li Y, Cao X, Xian J, Tan J, Dong J. The combination of anatomy and physiology in
predicting the outcomes of velopharyngeal surgery. Laryngoscope. 2014;124(7):1718–23.
59. O’Connell B, Dobble A, Oyer S, Montiel M, Hufnagle K, Patel K, et al. The impact of adenoid
size on rate of revision sphincter pharyngoplasty. Laryngoscope. 2014;124(9):2170–5.
60. Rossell-Perry P. An innovative palatoplasty for primary cleft palate repair. Plastic Reconstr
Surg Global Open. 2021;9(6):e3610.
61. Ahl R, Harding-Bell A, Wharton L, Jordan A, Hall P. The Buccinator Mucomuscular flap: an
in-depth analysis and evaluation of its role in the management of velopharyngeal dysfunction.
Cleft Palate Craniofac J. 2016;53(5):e177–84.
62. Mann SA, Mann RJ, Haenssler AE. An magnetic resonance imaging case study: the anatomic
palate restoration concept utilizing buccal flaps in a primary palatoplasty. Plastic Reconstr
Surg Global Open. 2020;8(9S):112–3.
63. Bishop A, Hong P, Bezuhly M. Autologous fat grafting for the treatment of velopharyngeal
insufficiency: state of the art. J Plast Reconstr Aesthet Surg. 2014;67(1):1–8.
64. Sommerlad B, Mehendale F, Birch M, Sell D, Hatlee C, Harland K. Palate re-repair revisited.
65. Furlow LT. Chapter 40Correction of velopharyngeal insufficiency by double-opposing
Z-Plasty. In: Kirschner JLR, editor. Comprehensive cleft care. New York: McGraw-Hill
Companies; 2009. p. 641–7.
66. Pet M, Marty-Grames L, Blount-Stahl M, Saltzman BS, Molter DW, Woo A. The Furlow
Palatoplasty for velopharyngeal dysfunction: velopharyngeal changes, speech improvements,
and where they intersect. Cleft Palate Craniofac J. 2015;52(1):12–22.
67. Nayar HS, Cray JJ, MacIsaac ZM, Argenta A, Ford M, Fenton R, et al. Improving speech
outcomes after failed palate repair: evaluating the safety and efficacy of conversion Furlow
palatoplasty. J Craniofac Surg. 2014;25(2):343–7.
68. Afrooz P, MacIsaac Z, Stephen A. A comparison of speech outcomes using radical Intravelar
Veloplasty or Furlow Palatoplasty for the treatment of velopharyngeal insufficiency associated
with occult submucous cleft palate. Ann Plastic Surg. 2015;74(2):182–6.
69. Gosain A, Arneja J. Management of the black hole in velopharyngeal incompetence: com-
bined use of a Furlow palatoplasty and sphincter pharyngoplasty. Plast Reconstr Surg.
2007;119(5):1538–45.
70. Bohm M, Padgitt N, Tibesar R, Lander T, Sidman J. Outcomes of combined Furlow palato-
plasty and sphincter pharyngoplasty for velopharyngeal insufficiency. Otolaryngol Head Neck
Surg. 2014;150(2):216–21.
71. Oldenburg O, Spiehofer J, Fox H, Prib N. Performance of conventional and enhanced adaptive
servoventilation (ASV) in heart failure patients with central sleep apnea who have adapted to
conventional ASV. Sleep Breath. 2015;19(3):795–800.
72. Kendzerska T, Gershon A, Hawker G, Tomlinson G. Obstructive sleep apnea and incident
diabetes: a historical cohort study. Am J Resp Crit Care Med. 2014:130604084050003.
73. De Serves L, Deleyamnis F, Eblen L, Gruss J, Richardson M, Sie K. Results with sphincter
pharyngoplasty and pharyngeal flap. Int J Pediatr Otorhinolaryngol. 1999;25: 48 (1):17–25.
74. Liao Y, Noordhoff M, Huang C, Chen P, Chen N, Yun C, et al. Comparison of obstructive sleep
apnea syndrome in children with cleft palate following Furlow palatoplasty or pharyngeal flap
for velopharyngeal insufficiency. Cleft Palate Craniofac J. 2004;41(2):152–6.
75. Liao Y, Chuang M, Chen P, Yun C, Huang C. Incidence and severity of obstructive sleep
apnea following pharyngeal flap surgery in patients with cleft palate. Cleft Palate Craniofac
J. 2002;39(3):312–6.
76. Pena M, Choi S, Boyiayan M, Zalzal G. Perioperative airway complications following pharyn-
geal flap palatoplasty. Ann Otol Rhinol Laryngol. 2000;109(9):808–11.
77. Paciello R, Kiemle I. Long term effects of pharyngeal flaps on the upper airways of subjects
with velopharyngeal insufficiency. Cleft Palate Craniofac J. 2008;45(4):364–71.
78. Losken A, Williams JK, Burstein FD, Malick D, Riski JE. An outcome evaluation of sphinc-
ter pharyngoplasty for the management of velopharyngeal insufficiency. Plast Reconstr Surg.
2003;112:1755–61.
79. Sie KC, Tampakopoulou DA, de Serres LM, Gruss JS, Eblen LE. Sphincter pharyngoplasty:
speech outcome and complications. Laryngoscope. 1998;108:1211–7.
80. Riski J, Ruff G, Georgiade G, Barwick W, Edwards P. Evaluation of the sphincter pharyngo-
plasty. Ann Plast Surg. 1992;29:254.
81. Tsshiki N, Honjou I, Morimoto M. Effects of velopharyngeal incompetence upon speech. Cleft
Palate J. 1968;5:297.
82. Warren D. Aerodynamic assessments and procedures to determine extent of velopharynngeal
inadequacy. In: Bzoch KR, editor. Communicative disorders related to cleft lip and palate. 4th
ed. Austin: Pro-ed; 1997. p. 411–37.
83. Karling J, Henningsson G, Larsson O, Isberg A. Comparison between two types of pharyn-
geal flap with regard to configuration at rest and function and speech outcome. Cleft Palate
Craniofac J. 1999;63:154.
84. Zwittman D. Oral endoscopic comparison of velopharyngeal closure before and after pharyn-
geal flap surgery. Cleft Palate J. 1982;19:40.
85. Witt P, McKatyn T, Marsh J, Grama L. Does preexisting posterior pharyngeal wall motion
drive the dynamism of sphincter pharyngoplasty? Plast Reconstr Surg. 1998;101:1457–62.
Chapter 9
Dental Skeletal Bad Results in Cleft Lip
and Palate Surgery
Carlos Estrada Vitorino, Rossell-Perry Percy, and Omar Cotrina Rabanal
9.1 Introduction
The cleft lip and palate nature is complex; the defect has a skeletal structure and soft
tissue coverage, making its treatment a challenge for the reconstructive surgeon.
Sir Harold Gillies, a New Zealand otolaryngologist, considered as the father of
plastic surgery, established one of the principles of the reconstructive surgery by
saying: “the skeleton first,” highlighting the importance of reconstructing the skel-
eton before the soft tissues. This principle is not respected in cleft lip and palate
surgery, since the soft tissues are repaired first by deferring the skeletal reconstruc-
tion due to the negative impact of the surgery on the facial skeleton growth. This
situation could explain most of the poor outcomes obtained after the surgery. Thus,
dehiscence, fistulas, asymmetries, and hypertrophic scars may be associated to the
soft tissue reconstruction over a malformed bone structure. Different strategies have
been developed in order to solve this problem. Early pre-surgical orthopedic has
been used as an alternative to improve the harmony of the skeleton; however, it has
also been associated with an effect on the maxilla growth by its retrusion [1, 2].
Primary bone grafts and gingivoperiosteoplasty strategies aimed at correcting the
distortion of the facial skeleton and have been excluded from most of surgical pro-
tocols due to its harmful effect observed over the skeletal growth in different studies
[3, 4]. The most common dentoskeletal bad outcome is the maxillary hypoplasia
and its associated occlusal disorder as well as dental abnormalities. It was Gillies
C. Estrada Vitorino
CIRMAX Institute Lima, Lima, Perú
R.-P. Percy (*)
O. Cotrina Rabanal
Department of Dental, ARMONIZAR Foundation, Lima, Peru

Switzerland AG 2022
268 C. Estrada Vitorino et al.
and Fry in 1921 who noted the inhibition of the upper jaw development in patients
operated on for cleft palate [5]. Fernando Ortiz Monasterio, a Mexican plastic sur-
geon, emphasized this aspect observing better skeletal growth in non-operated cleft
lip and palate adult patients [6, 7] (Fig. 9.1). This hypothesis was not well clarified
since the problem is multifactorial, and the cleft lip surgery could be the most
important risk factor for maxillary hypoplasia development. The prevalence of this
bad outcome varies and ranges from 25% to 60% [8–10] (Fig. 9.2). Multiple factors
have been associated with impaired development of the maxillary, as congenital
hypoplasia and the effect of lip and/or palate surgery. It is interesting to note the
effect of the cleft lip surgery. The studies of Janusz Bardach, a Polish plastic sur-
geon, observed this association through experimental models in animals and obser-
vational studies in humans [11–15]. In addition to the mentioned factors, the
surgeon’s performance has been described by different authors; however, scientific
validation is required.
Fig. 9.1 Four cases of non-operated adult patients are presented here, where you can see an appar-
ent better development of the maxilla. No collapse is observed, and the anteroposterior and trans-
verse dimensions do not appear to be affected
9 Dental Skeletal Bad Results in Cleft Lip and Palate Surgery 269
a b
c d
e f
Fig. 9.2 Female patient, 18 years old born with a cleft lip and palate who was operated and devel-
oped severe maxillary hypoplasia with dental occlusion disorder. The facial aesthetic distortion is
observed, and it is associated with voice and eating problems. (a) Facial appearence of a patient
with maxillary hypoplasia. (b) X-ray image illustrating skeletal deformity. (c) Anterior view of the
occlusal disorder. (d) Lateral view of the occlusal disorder. (e) Anterior view of the patient’s dental
model. (f) Lateral view of the patient’s dental model
The following factors have been associated with facial bone growth disturbance:
(a) Interruption of vascular supply during palatal surgery [16]

(b) Scar contracture of the relaxing incisions [17–20]
(c) Subperiosteal dissection of the maxilla [18–22]
(d) Incorporation of the maxillary periosteum in the mucoperiosteal flaps [21, 22]
(e) Severity of the cleft [23, 24]
(f) Dental hygiene.
(g) Hereditary factors [25]
The multifactorial nature of maxillary hypoplasia associated with cleft palate

surgery has been evidenced in different studies. Most of them are observational
studies, and this type of scientific research makes difficult to assess the associa-
tion between the primary surgery and maxillary hypoplasia development.
Associated variables such as age, surgeon, type of cleft palate, severity, and effect
of presurgical treatments among others have not been adequately controlled in
these studies; hence, the results are contradictory. Prospective experimental stud-
ies are required to determine causal association between these variables and max-
illary hypoplasia.
At the moment, it cannot be concluded that there is adequate evidence to demon-
strate this association. Different systematic reviews [26–28] observe that more pro-
spective controlled studies are required to be able to demonstrate differences
between different protocols for cleft palate repair.
In addition, experimental studies comparing groups of cleft palate patients did
not observe differences between different surgical protocols [29, 30].
A prospective multicenter study carried out in Northern Europe, called
SCANDCLEFT, in patients with complete unilateral cleft palate compared four dif-
ferent protocols for cleft palate repair (one stage and two stages) and observed no
significant differences between these protocols during mixed dentition period
regarding development of maxillary hypoplasia [31]. Other multicenter studies, the
EUROCLEFT and AMERICLEFT [32, 33], have shown better outcomes in terms of
facial growth using the two stages protocols; however, these are observational stud-
ies (cohorts) which have a lower level of evidence compared to the SCANDCLEFT
[31]. A randomized clinical trial published by the author of this book was able to
verify only 6.94% of hypoplasia at 5 years of age [34, 35]. This study compared two
groups of patients with unilateral cleft lip and palate and operated using bilateral
and unilateral relaxing incisions to determine the role of this procedure in maxillary
hypoplasia development. It was observed that there were no significant differences
between the studied groups and concluded that there is not association between the
use of relaxing incisions and impaired maxillary growth at this age (Figs. 9.3
and 9.4).
Although it is accepted that the assessment of the growth of the facial skeleton
should be done after completing bone maturity, this theory has recently been ques-
tioned, and a study published by Qureshi et al. featuring Peter Mossey, orthodontist
professor of craniofacial development at the University of Dundee, Scotland, has
Fig. 9.3 Here are the occlusal casts of two 5 years old patients, born with unilateral cleft lip and
palate operated using different surgical techniques. Case 1 was operated using a technique without
relaxing incisions, and case 2 was operated using two flap method (bilateral relaxing incisions)
showing better maxillary development. Although it is true that this does not represent enough sci-
entific evident to have practical conclusions to follow, it is an illustrative case of our experience
during the last 25 years
observed that there are not differences between the dental arch measurements at 5,
10, and 15 years [36].
This study is limited by the methodology and size of the sample and requires
more studies. In summary, in relation to the primary surgical treatment of cleft pal-
ate and its effect on the facial growth of the maxilla, there is insufficient scientific
evidence to suggest differences between the different protocols for cleft palate repair.
a b
c d
Fig. 9.4 Two cases that correspond to a prospective observational study carried out by the author,
in which the development of the maxilla was compared using two different techniques in patients
with unilateral cleft palate. One group was operated using the Oslo protocol (two stages) (a and b)
and the other using the one flap method (single stage) (c and d). It can be seen in the photos that
both maxillary arches have developed without major affection, and no differences have been
observed regarding dental occlusion using these different protocols; however, longer follow-up is
required to confirm these findings
9.2 iagnostic and Prevention of Dental Skeletal Bad

D
outcomes in Patients with Cleft Lip and Palate
The diagnostic of these bad outcomes observed in patients operated on for cleft lip
and palate is still supported today by a careful physical examination of the patient.
In addition, he most used auxiliary examinations, the radiographic analysis, and
computerized tomography. There are three basic elements in the diagnostic of
occlusal dentoskeletal disorders: physical exam, image studies, and analysis of
articulated casts.
During physical examination of the dentoskeletal sequels in patients with cleft

lip and palate, this is characterized by the following:
(a) Maxillary hypoplasia with type III dental occlusion. The maxilla is retruded in
the horizontal plane (concave midface profile), short in height, and with associ-
ated deficiencies of the transverse diameter. Collapsed discrepancies between
the cleft and non-cleft segment may be also present, and the occlusal pattern
may be variable (Fig. 9.5).
(b) Alveolar cleft and oronasal fistula. It is present frequently, since most of the
protocols consider the delayed closure of the alveolar cleft and bone graft dur-
ing mixed dentition period.
(c) Residual bone defects. Along the alveolar and palatal cleft (Fig. 9.6)
(d) Absence of teeth. It often occurs congenitally with the lateral incisor (Fig. 9.6).
(e) Pseudoprognathism
Cephalometric analysis often indicates decreased maxillary height and dental

malocclusion type III. The study of occlusal molds can show interdental space at the
level of the fissure, negative relationship of the dental arches, and crossbites.
Regarding bilateral cleft lip and palates, during physical examination, the skele-
tal deformity is characterized by the following:
(a) Maxillary hypoplasia. This is more common in comparison with the unilateral
type. The transverse diameter of the maxilla is frequently deficient and associ-
ated to bilateral crossbites (Fig. 9.7).
(b) Bilateral alveolar clefts. This is common to be observed in association with
retropremaxillary fistulas (See Chap. 5).
(c) Deviations of the dental and maxillary midline

male patient born with a
left unilateral cleft lip and
palate, who underwent
cleft palate surgery using
the two flap technique. The
development of maxillary
collapse is illustrated
Fig. 9.6 Panoramic

radiograph of unilateral
cleft lip patient during
mixed dentition period.
Dental gap is observed at
the level of the alveolar
cleft on the left side with
the absence of the lateral
incisor
Fig. 9.7 Bilateral cleft lip

and palate patient who was
operated and develops as
sequel a collapse of the
maxilla with involvement
of its transverse diameter,
creating severe distortion
of the maxillary arch that
leaves the premaxilla
protruded
(d) Absence of teeth

(e) Pseudoprognathism
The physical exam should include chewing problems, the presence of crossbite,
and perception of facial aesthetics, phonetics, and dental and periodontal health
[37]. Diagnosis of the anatomical characteristics of the upper jaw and dental occlu-
sion is carried out through molds and dental occlusion simulators. The development
of the maxilla is affected by a number of factors mentioned above, and it is mani-
fested by alterations in the diameters of the maxillary arch, its occlusal relationships
with the lower jaw, and loss or poor position of teeth. The most frequent form of
presentation of this sequela is type III dental occlusion, according to the Angle clas-
sification. The cleft lip and palate patient may develop vertical, anteroposterior, and
transverse involvement of the maxilla where the maxilla is hypoplastic in relation to
the mandible showing a transverse crossbite deficiency with superoanterior crowd-
ing and absence of unilateral or bilateral incisor.
Radiographic Analysis
In the radiographic analysis, the following studies should be considered: panoramic,
frontal and occlusal profile, and the periapical one. The cephalometric analysis
often indicates decreased jaw height and dental malocclusion type III. The study of
occlusal molds can show interdental space at the level of the cleft, negative relation-
ship of the dental arches, and crossbites (Fig. 9.2).
Prevention is the product of understanding the problem, identifying its cause,
and knowing the impact of each alternative solution. In clinical terms, to carry out
prevention, we must first understand how this bad outcome happens and its conse-
quences and know the scope and limitations of each solution (technique). In order
to develop this concept, Dr. Estrada developed an individualized protocol. For this
purpose, in the management of dentofacial deformities, Dr. Estrada raises a system-
atized sequence of diagnosis and planning named as “the six pillars of AITRE” that
allows diagnosis, planning, and also prevention (Fig. 9.8). The pillars are inherent
to the diagnosis and planning of these patients. The pillars: airway, TMJ muscles,
dental arch, and facial harmony define the reason for consultation or clinical prob-
lems of the patient, in this case associated to dentofacial deformities after lip and
palate surgery. For treatment, planning starts at the reason of the consultation look-
ing for a midpoint in preserve health or solving clinical problems of each pillar.
Pillar 1: Body
Genetic-systemic: Identify the medical and surgical history affecting each compo-
nent. Identify genetic aspects, predisposing factors to CLP.
Position: Identify changes in head posture as a consequence of adaptation to
dentofacial abnormalities. This pillar and the cervical one have an impact on the
natural position of the head (Fig. 9.9).
Growth: Evaluate the stage of body and jaw growth and its impact on the timing
of treatment monitoring.
Psychology: Assess motivation and emotional response to the treatment.
Cranial base: Identify cranial base anomalies as an etiology or that increase the
dentofacial deformities in CLP.
Pillar 2: Cervical
Cervical spine: Assess changes in cervical curvature and rotations as a consequence
of postural adaptation to dentofacial deformity.
1 2 3 4 5 6
FACIAL
BODY CERVICAL AIRWAY TMJ TEETH
HARMONY
Fig. 9.8 The six pillars of AITRE, a systematized sequence for the diagnosis and planning of
dentofacial deformities by Dr. Carlos Estrada
a b
c d
Fig. 9.9 Postural compensation for dentofacial deformity after cleft lip and palate (anterior rota-
tion and preposition of the head) that alters the register of the natural posture of the head. (a)
Postural correction with physical therapy. (b) Maxillary advancement (osteogenic distraction) (c)
Follow-up after 1 year observing posture preservation. (d) Final lateral postoperative view (Case
presented by Dr. Estrada)
Cervical muscles: Assess the presence of cervical muscle dysfunction and symp-
tomatology that impacts the recording of the natural position of the head and the
functional response of the cervical and masticatory system to corrective surgery of
the jaws.
Pillar 3: Airway
Sleep disorder: Identify sleep-related problems that could influence the assessment
of the resolution of the narrowing of the airway.
Airway: Assess obstruction (TEM, MRI) and collapse of the upper airway in
nasal, retronasal, retroglossal, and hypopharyngeal spaces.
Velopharyngeal competence: Identify velopharyngeal incompetence, the timing
of its resolution, and its impact on the planning of dentomaxillary treatment.
Evaluate the presence of pharyngeal flap.
Pillar 4: TMJ
TMJ: Assess the health and stability of the TMJ.
Masticatory muscles: Assess the health of the chewing muscles.
Occlusion: Assess the type of open bite, deep, edge to edge, crossed in normo,
and mesio disto relation. Assess the impact of the bite in physiology and mastica-
tory dysfunction.
Pillar 5: Teeth and Dental Arch
Teeth: Assess tooth problems and their support.
Dental arch: Identify the occlusal plane (occlusal resolution plane of the treat-
ment of orthodontics). Identify the transversal problem of the jaws.
Alveolar cleft: Assess its presence, moment of resolution, and its impact on the
planning of dental maxillary treatments.
Pillar 6: Facial Harmony
Maxillary: Assess the position and size of the facial bones.
Soft tissues: Check soft tissue related to lip and nose morphology and function.
Skeletal biomechanics: Assess the impact of the position of the jaws on skeletal
biomechanics and impact of this on each pillar.
9.3 reatment of Dentoskeletal Sequels in Patients with Cleft

T
Lip and Palate
The objectives to be achieved in the treatment of dentoskeletal sequels in patient

with cleft lip and palate are as follows:
(a) Alignment and leveling of the maxillary arches
(b) Normalization of dental occlusion
(c) Early correction of transverse deficiencies of the maxilla
(d) Improvement of the patient facial aesthetics
The used treatments for dentoskeletal sequel management are as follows:

(a) Maxillary Protraction
This procedure is performed at the beginning of the mixed dentition period,
before the alveolar bone graft, and allows to correct the sagittal discrepancies of
the maxilla.
Some authors, such as Berkowitz, indicate this treatment from the age of 12,
and the Petit mask is the most used for this purpose. This is an orthopedic tech-
nique that uses elastic extraoral forces in the anteroposterior direction to stimu-
late maxillary development during early age. It requires 6 months of treatment
plus 6 months of maintenance. The method reduces the need for orthognathic
surgery later, and it is recommended to be used at the beginning of the mixed
dentition period [38–40]. The maxillary protraction begins using removable
myofunctional orthopedics, followed by the use of the protraction for 14 h a day
and a force of 900 g for 12–18 months on average, although this depends on the
severity of the case (Figs. 9.10 and 9.11). The purpose of myofunctional braces
is to modify the anteroposterior occlusion between the two dental arches. These
act through the action of the facial and maxillary muscles inducing changes on
the maxilla, mandible, and glenoid fossa. They are used in the different types of
malocclusion observed in cleft patients, being the Frankel type the most indi-
Fig. 9.10 Maxillary protraction mask. This is a brace that uses elastic orthopedic forces of antero-
posterior traction, which stimulates advancement of the maxilla and development of its sagittal
axis. It is composed of three elements: extraoral, intraoral, and elastic devices.
a b
c d
e f
Fig. 9.11 Unilateral cleft lip and palate female patient, who developed early maxillary hypoplasia
with type III dental occlusion. (a–c). Petit mask was applied during 14 h daily and force of 900 g
for 10 months. (d) Patient profile result is displayed after foxed orthodontic treatment to correct
relapse of the initial treatment. The treatment improves the patient’s profile and dental occlusion
and reduces the possibility of needing orthognathic surgery. (e) Final post treatment view. (f)
Frontal pre and postreatment occlusal views (Case treated by Dr. Omar Cotrina)
cated for type III malocclusion (Fig. 9.12). This treatment, like orthognathic
surgery, has recurrence problems, for which it requires posttreatment using
fixed orthodontics or removable myofunctional braces to guarantee the results.
(b) In addition, prior to the alveolar bone graft, it is recommended to complement
the following treatments: alignment of incisor with orthodontics, leveling of
segment using orthopedics, and removal of supernumerary teeth, at least
40 days before the bone graft is performed [41].
Fig. 9.12 Use of Frankel

type myofunctional
orthopedics
(c) Correction of the position of the premaxilla in bilateral clefts. Discrepancies

between the premaxilla and lateral segments should be done at early age (pre-
surgical orthopedics or surgical lip adhesion) (see Chap. 4).
However, the persistence of the premaxilla projection (often associated with lip
closure dehiscence and severe facial deformation) requires surgical replacement
using vomer osteotomies to align the maxillary arch. This surgery may produce a
type III malocclusion later, but this condition is better than the type II observed
previously (Figs. 9.13 and 9.14). The premaxilla is a structure derived from the
frontonasal process of the embryo and makes up the primary palate. Its base is con-
stituted by the nasal septum, specifically, by the vomer. At this level, there is a joint
area called the vomero-premaxillary junction, with a widened appearance, which
corresponds to the growth zone of the premaxilla (1.5 cm behind it) (Fig. 9.15). Two
types of osteotomy are used for this purpose: Veau and Cronin types (Fig. 9.15). The
Veau type is performed anteriorly to the vomero-premaxillary junction, and it is
easier to be done; however, the risk of premaxilla necrosis is higher. The blood
a b
c d
e f
Fig. 9.13 One-year-old patient with a history of three previous surgeries to correct the lip dehis-
cence leaving severe aesthetic sequel presented in photos (a and b). The upper lip is opened and
the anatomical area between the premaxilla and vomer. (c) A mucous flap is elevated from the
premaxilla. The osteotomy is performed (black arrow). (d) Once a segment of the vomer is
resected, the premaxilla may be repositioned to a suitable place. (e) The postoperative result is
displayed and then 1 year later with correction of the premaxilla position and adequate lip and pal-
ate closure (f)
Fig. 9.14 Male patient

with severe facial
deformity caused by a
severe bilateral cleft lip
and palate closed primarily
which evolved with partial
dehiscence and protrusion
of the premaxilla through
the dehiscent operative
wound. A vomer
osteotomy should be done
to reposition the premaxilla
and thus be able to perform
the closure of the lip and
nose without tension
supply of this segment is determined by branches of the facial artery through the
medial structures (nose, columella, and prolabium) according to King and Slaughter
studies [42, 43]. Maher’s studies [44] concluded that the irrigation of the premaxilla
comes from three main arteries: facial and ethmoid (anterior and posterior) arteries
(Fig. 9.15). This blood supply allows vomer osteotomies to be performed safely.
The Cronin type is performed posteriorly to the vomero-premaxillary junction
and requires an extended dissection and increased resection of the septum. Other
complications as septum collapse and bleeding are associated.
During our experience, we have observed a large number of cases who live suf-
fering the stigma of a facial deformity due to the tension closure that resulted in
partial dehiscence or the presence of distorted soft tissue with hypertrophic scars
and occlusal problems. A special case of partial dehiscence is the protrusion of the
premaxilla through the operative wound, leaving the upper lip repaired below the
premaxilla, causing great aesthetic and functional deformity (Fig. 9.16). Most of
these patients will not be able to recover since the psychosocial impact they suffered
during years cannot be corrected by any surgery.
Managing these poor results is complex and requires interdisciplinary team par-
ticipation. Two types of treatment can be adopted:
(a) Conservative, when trying to manage skeletal deformity using maxillary ortho-
pedics (these procedures are difficult to be performed at later age and require
technology and trained team) [45]
(b) Surgical, through the fracture of the vomer and repositioning of the premaxilla
Fig. 9.15 Vascular anatomy of the bilateral cleft lip and palate. (1) Greater palatine artery. (2)
Descending palatal artery. (3) Ascending palatine artery. (4) Area for osteotomy of the vomer. (5)
Branches of the infraorbital artery. (6) Superior alveolar artery. (7) Branches of the upper lip arter-
ies. (8) Dorsal nasal artery. (9) Anterior ethmoidal artery. (10) Posterior ethmoidal artery. (a)
Vascular anastomosis between the descending palatine artery and the ascending palatine artery
through the lesser palatine vessels. (b) Columella. (c) Prolabium. (d) Premaxilla. (e) Vomero-
premaxillary suture. (f) Vomer. X: Veau type osteotomy. Y: Cronin type osteotomy
The main disadvantage is the harmful effect of surgery on maxilla development;

hence, many authors recommend its use in specific cases, only after 5 years old.
Currently, there are protocols that include the osteotomy of the vomer and
replacement of the premaxilla during primary cleft lip and palate surgery [46–48].
In the author’s opinion, the indications for practicing a vomer osteotomy and repo-
sitioning of the premaxilla before the age of 5 are recurrent dehiscence of the pri-
mary bilateral cheiloplasty after 6 months, failure of presurgical orthopedic
techniques, and patient with severe maxillofacial deformity with aesthetic and func-
tional affection that hinders its psychosocial development during their early years.
In summary, this treatment can be done in two moments: early age, to facilitate the
closure of severe bilateral cleft lip and palate using orthopedics or surgical lip adhe-
sion, and later age, due to the functional and aesthetic sequel using vomer osteotomy.
Fig. 9.16 Different cases of secondary aesthetic and functional deformity of the upper jaw and
facial soft tissues associated with a repair of severe bilateral cleft lip and palate
Surgical Technique
(a) The proposed surgical technique consists of partial ostectomy of the vomer
bone, in such a way that allows their mobilization and replacement to a func-
tional location. This procedure is carried out in all cases under general anesthe-
sia. The surgery begins with the application of the Dingman mouth opener
exposing the premaxilla and its continuity with the vomer bone. Then we pro-
ceed to infiltrate with local anesthetic and vasoconstrictor. The mucosal incision
is made on the vomer bone, in the segment between the vomero-premaxillary
junction and premaxilla. This is a straight incision along the axis of the vomer
(Figs. 9.17 and 9.18). Then, using a periosteal elevator, the mucoperiosteum
that covers the vomer is elevated to both sides of the incision, preserving the
integrity of the mucosa that carries irrigation to the premaxilla. Once the vomer
has been exposed to an extent of about 2 cm, the osteotomy is performed. The
proximal osteotomy is done first (close to the premaxilla) and then the distal
a b
c d
Fig. 9.17 A 2-year-old patient with a history of two attempts to close a bilateral cleft lip with
consequent dehiscence. It was decided to perform the vomer ostectomy and reposition of the pre-
maxilla. Black rectangle: area of vomer osteotomy. (a) Resection of a segment of the vomer
through a mucous incision. (b) The incision is closed primarily and the premaxilla repositioned.
(c) Finally, the position achieved for the premaxilla 1 year later after primary simultaneous palato-
plasty (d)
osteotomy to avoid mobility of the premaxilla which makes the second cut
more difficult. The distance between two osteotomies depends on the length of
the segment.
(b) Osteotomy and ostectomy can be performed using a gouge or pneumatic oscil-
lating saw. After this procedure, the premaxilla is gentle pressed and displaced
to the required position. The mucosal incision is then closed. If simultaneous lip
repair is performed, it is better to use the labial adhesion type in order to avoid
any compromise of the premaxilla blood supply (Fig. 9.13). Manual fractures
of the premaxilla, still practiced today, are easier to perform, but they can cause
a badly positioned premaxilla or even mucosal damage and necrosis. This is the
reason why the author does not recommend it. A catastrophic event in cleft lip
a b
c d
e f
Fig. 9.18 A 6 years old patient with a history of operated bilateral cleft lip and palate leaving
severe aesthetic sequel presented in photo (a). The premaxilla is rotated and malpositioned (b). A
mucous flap is elevated from the premaxilla through midline incision (c). The osteotomy is per-
formed and a segment of vomer is resected (d). After the vomer is resected, the premaxilla may be
repositioned to a suitable place (e). The postoperative result is displayed and then 1 year later with
correction of the premaxilla position and adequate lip and palate closure. Orthodontics are required
for final dental alignment (f)
and palate surgery is the necrosis of the premaxilla. This event, rare today,
seems to be associated with aggressive surgeries using vomer osteotomies or
manual fractures of the premaxilla.
The blood supply of the premaxilla comes mainly from branches of the
facial artery through the vascular system of the nose (Fig. 9.14). Thus, any lip
and nasal surgery associated to the surgery of the premaxilla will greatly
increase the chance of premaxilla necrosis. The affection of the blood supply is
characterized by the paleness of its mucous covering which does not improve at
the end of the surgery, becoming dark later with spontaneous amputation of the
segment. The premaxilla necrosis leaves an aesthetic and functional sequel
including maxillary hypoplasia, dental occlusion problems, and severe palatal
fistula. The treatment is complex and requires reconstruction of the bone seg-
ment, mucosal coverage, and use of dental implants (Figs. 9.19, 9.20, and 9.21).
(c) Correction of Alveolar Clefts
Alveolar clefts and associated fistula correction are made during the mixed
dentition period (Fig. 9.22). The alveolar bone graft is made using cancellous
bone graft raised from the iliac crest or tibia (Figs. 9.20 and 9.21). The graft
should be done before the eruption of the tooth adjacent to the fissure, usually
when the root is 1/3 to 1/2 of the total length of the permanent tooth [49]. The
main purpose of the alveolar bone graft is to provide bone support. The bone is
taken from the iliac crest with a trephine through a small incision.
(d) In the period of 10 to 15 years, the evaluation of orthodontic treatment is carried
out (Figs. 9.23, 9.24, 9.25, 9.26, and 9.27).
(e) Orthognathic surgery to correct occlusal problems and facial aesthetics
Between 16 and 18 years (age of bone maturity completion), the evaluation of

the patient by the orthodontist and maxillofacial surgeon should be done to deter-
mine occlusal deficiencies.
Fig. 9.19 A 28-year-old female patient with sequelae of bilateral cleft lip and palate surgery and
loss of the premaxilla. A severe fistula of the anterior segment of the palate is observed. The fistula
was repaired using a facial artery myomucosal flap (FAMM). It shows 2 years postoperative with
complete closure of the fistula. It requires dentoskeletal reconstruction
a c f
b d e g
Fig. 9.20 Cleft lip and palate patient with absence of premaxilla without timely orthodontic treat-
ment and alveolar cleft. (a) Trace of the occlusal plane, defining the canines. (b) Alveolar cleft with
absence of alveolar support. (c, d) Alveolar bone graft using lyophilized bone and plasma rich in
growth factors (PRGF) providing dental support. (e) Occlusal plane mark obtained prior to correc-
tive surgery (f, g) (Patient treated by Dr. Estrada)
Fig. 9.21 Reconstructive surgical technique for premaxilla loss defects. The first stage of the
reconstruction consists of closing the nasal mucosa plane and covering it using the FAMM flap
(Fig. 9.16). The second surgical stage is carried out placing a cortical cancellous bone graft taken
from the iliac crest. Reconstruction of the bone segment will allow the subsequent use of dental
implants
a b`
c d
e f
g h
Fig. 9.22 Patient born with a unilateral cleft lip and palate presenting alveolar cleft. (a) The alveo-
lar cleft is closed using gingival flaps. (b) It shows the radiological study done at 7 years (mixed
dentition period) confirming the moment for bone graft surgery. (c, d) A cancellous bone graft is
taken from the tibia. (e–g) The result is finally displayed of the alveolar cleft repaired with a viable
graft 1 year after. (h) Long term postoperative view (Case treated by Dr. Percy Rossell)
a b
c d
e f
g h
Fig. 9.23 Female patient, born with a left unilateral cleft lip and palate that comes at 6 years of
age for correction of alveolar cleft and type III dental occlusion due to maxillary hypoplasia. (a, b)
Orthodontic treatment and use of a face mask were started. You can see how the mobilization of a
tooth and the expansion of the maxilla are carried out. (c, d) Once the maxillary arch has been cor-
rected, the alveolar bone graft using cancellous bone is performed taken from the tibia. (e, f)
Radiographic views are shown illustrating alveolar cleft and position of erupting teeth. (g)
Panoramic X-ray of the presented case. (h) CT-scan view of the presented case (Case treated by Dr.
Omar Cotrina and Dr. Percy Rossell)
a b
c d
Fig. 9.24 The profile is shown before and after the treatment in the case shown in Fig. 9.19. (a, b)
Anterior maxillary arch is presented before and after treatment even in orthodontics process for
final corrections. (c) Frontal pre treatment view. (d) Frontal post treatment view (Case treated by
Dr. Omar Cotrina and Dr. Percy Rossell)
a d f
e g
Fig. 9.25 Alveolar cleft in cleft lip and palate patient. (a–c) Virtual planning of the dentoalveolar
movement due to transport distraction. (d, e) Splint that expresses dentoalveolar movement. (f)
Digital view image of the presented case. (g) Dental model image of the presented case
a b d
c e
Fig. 9.26 Continuation of the previous case. (a) Model with the expression of the transport move-
ment at the expense of the splint. (b) Elaboration of the dentoalveolar distractor device. (c)
Removal of the silicone that joins the dentoalveolar segment to the model, device closure verify-
ing, testing, and displaying the distraction vector. (d, e) Subapical dentoalveolar osteotomy.
Placement and fixation of the supported dental appliance (Case presented by Dr. Estrada)
a c d
b
e
Fig. 9.27 Continuation of the previous case. (a, b) Closure of the anterior alveolar cleft at the
expense of the dentoalveolar distraction. (c) Four months after distraction, the dentoalveolar appli-
ance is removed and alveolar bone graft is placed. (d, e) Completion of the surgical closure of the
alveolar cleft (Patient treated by Dr. Estrada)
Cephalometric study and radiographs are indicated to confirm bone maturity.

Mild type III dental malocclusion cases (up to 5 mm occlusal discrepancy) can be
corrected with orthodontics, bringing the mandibular incisors back and the maxil-
lary incisors forward using dental arches [50]. It is considered that 25% of occlusal
discrepancies cannot be corrected using orthodontics [9]. Orthognathic surgery is
indicated in case of confirming the severity of the malocclusion and is planned
based on cephalometric and dental occlusion simulators. A useful assessment is the
angle ANB (A: most posterior point of the maxillary anterior profile, B: most pos-
terior point of the mandibular anterior profile, and N: nasion). When this angle is
less than 4 degrees, the orthognathic surgery is indicated [51]. Complementary use
of orthodontics should be considered, and any compensation should be corrected to
optimize surgery outcomes. The evaluation of the speech pathologist and nasoen-
doscopy may be necessary, if there is postsurgical velopharyngeal insufficiency.
The complex dentomaxillary alterations observed in cleft patients such as palate
collapse, common in cases of bilateral clefts, should be treated through the combi-
nation of orthodontics, palate expanders (Hyrax), and the use of surgery (orthogna-
thic and distraction techniques). Orthognathic surgery consists of mobilizing
segments of the maxillary bones when the arches of teeth are not properly aligned
and the occlusion is altered.
The requirements to indicate orthognathic surgery in patients with cleft lip and
palate are bone maturity growth, moderate to severe dental occlusion problems
(more than 5 mm), and proper dental hygiene.
The sequence of patient management in relation to the orthognathic surgery is as
follows:
1. Diagnosis based on cephalometric study

2. Planning based on dental models. This allows the design of the occlusal splints
used during surgery to guarantee the position of the mobilized segments.
Photographs are also useful to assess the role of soft tissues, and the complete
radiographic study is essential.
3. Tooth extractions and dental hygiene
4. Presurgical orthodontics. This stage takes 12–18 months, depending on the com-
plexity of the case. The objective is to coordinate the maxillary and mandibular
arches, leveling of the occlusal plane and elimination of occlusal interferences,
repositioning of the incisors to improve the prediction of the postsurgical posi-
tion of the lip, and creating interdental spaces for the location of segmental
osteotomies.
Once the position of the arches is correct, we proceed with orthognathic surgery.
5. Orthognathic surgery.
6. Postsurgical orthodontics, starting 4 weeks after surgery and during 6 months to
1 year and contributes to the stability of the occlusion [52]
The use of intermaxillary elastic traction begins in the immediate postoperative

period to guide the arches of teeth to the desired position.
Surgical techniques in orthognathic surgery basically involve two types:

(a) The classic osteotomy advancement and/or retrusion with osteotomies and fixa-
tion using mini plates. The most common technique is the Le Fort I type maxil-
lary advancement in which a cut is made in the maxillary bone that allows the
entire upper dental arch to be advanced in bloc and correct the occlusal problem
(Figs. 9.28, 9.29, 9.30, 9.31, 9.32, 9.33, and 9.34).
Le Fort II or III osteotomies are also indicated in these patients.
In cases with large defects, greater than 1 cm, it is recommended to advance
the maxilla and bring the jaw back (combined surgery) or use the distraction
osteogenic method. The most used technique for mandibular setback is the sag-
ittal cutting method (Obwegeser) [53].
(b) Osteogenic Distraction (Fig. 9.35)
This technique consists of making a cut in the maxilla or mandible, for
applying a device called distractor, which will progressively separate the edges
of the bone that will form in parallel between these edges.
This technique is highly recommended specially in cases of major occlusal
defects, where more relapse is observed [54, 55]. Depending on the type of
a b c
d e f
Fig. 9.28 Surgical technique for correction of maxillary hypoplasia and type III malocclusion in
a patient with unilateral cleft lip and palate (a) The type of osteotomy is shown (Le Fort I) (b)
Approach incision through the mucosa to the subperiosteal plane. (c) The transverse maxillary
osteotomy is performed with reciprocating saw, sectioning also the nasal septum. (d)
Pterygomaxillary disjunction using a Kawamoto’s osteotome (e, f) Displacement of the maxillary
segment and correction of the occlusion securing the jaws with intermaxillary fixation. Bone grafts
are used at level of the space created by maxillary displacement
a b c
a b c
Fig. 9.29 Image of dentofacial and airway deformity on admission. (a) In presurgical image
4 years after admission, observe the airway reduction coinciding with the increase in body mass
index. (b) Image after bimaxillary orthognathic surgery (advancement and descent 5–6 mm of the
maxilla with clockwise rotation mandibular surgery) (c) Note that the airway was not increased
(Case presented by Dr. Estrada)
distraction mechanism, it can be internal or external. The advancement of the

bone segment is 1 mm per day, but it can vary. Recurrence of malocclusion is
the most common cause of poor outcome after orthognathic surgery (15–20%)
[56], and fewer rates have been observed when using the distraction method
[57]. Maxillary mandibular discrepancies greater than 8 mm are more likely to
recur. The bimaxillary surgery or the osteogenic distraction is recommended in
these cases [56]. The orthognathic surgery can present serious complications,
such as blindness or death.

The surgery is carried out under inhalational general anesthesia and, in some cases,
hypotensive. The upper gingival mucosa is infiltrated with local anesthetic plus
vasoconstrictor. The approach incision is made on the buccal mucosa, extending
from side to side at the level of the zygoma. A subperiosteal dissection is performed
through this incision, exposing the anterior and lateral aspect of the maxilla as well
as the nasal floor.
The extent of this dissection will depend on the level of the osteotomy and should
be limited to preserve the blood supply of the segment which comes from its con-
nection with the oral mucosa. Maxillary necrosis is not rare. One of the causes is
widespread dissection of the mucosa as well as excessive mucosal scar tissue due to
previous surgeries. Once the maxilla is exposed, the maxilla is performed using a
reciprocating saw. This osteotomy is done by sectioning the base of the septum and
is extended to the pterygomaxillary junction. This type of osteotomy corresponds to
the Le Fort I level. Then, using a Kawamoto osteotome, the pterygomaxillary
a INITIAL b PRE QX c POST QX
A1 B1 C1
A2 B2 C2
A3 B3 C3
A4 B4 C4
A5 B5 C5
Fig. 9.30 In continuation of the previous case (b1 and c1) pre and postoperative upper airway
lateral views. (a2), observe the hypertrophy of the right turbinate that in image (b2) has been
removed. (a4 and b4) observe the sagittal and transverse reduction of the airway coinciding with
the increase in body mass index (a5 and b5). Observe the same reduction of the airway. (c2, c3, c4,
c5) note that the airway cannot be increased after orthognathic surgery, in its sagittal and transverse
dimensions. Consider the future body mass index status of that airway. (a1, b2, c2) Retronasal. (a3,
b3, c3) Retropalatal. (a4, b4, c4) Retroglossal. (a5, b5, c5) Hypopharyngeal. (a–c): airway changes
during the treatment
a1 a2
a3 a4
Fig. 9.31 (a1) Maxillary retrusion after CLP surgery with normal mandibular projection. (a2)
Corrective surgery planning advancement of the maxilla with 12–13 mm osteogenic distraction in
the first stage and mandibular surgery in the second stage. (a3 and a4) In maxillary advancement
prior to the procedure, the assessment is carried out (speech therapy and/or endoscopic) of velo-
pharyngeal competence. Osteogenic distraction culminates when the maxilla is in position within
facial harmony parameters, and velopharyngeal function modulates the limit and process of activa-
tion of the distractor for maxillary advancement (Patient treated by Dr. Estrada)
b1 b2 b3 b4
c1 c2 c3 c4
d1 d2 d3 d4
Fig. 9.32 Continuation of the previous case (b1, b2, and b3) result of maxillary advancement up
to facial harmony parameters and respecting its velopharyngeal competence. Observe the enlarge-
ment of the airway in its retronasal space and retropalatal (b4) retroglossal space reduced in sagit-
tal direction (c1). Second surgical stage (bilateral sagittal osteotomy) (c2, c3) note the widening of
the airway in the retropalatal, retroglossal and hypopharyngeal (b4, and c4) note the significant
enlargement of the airway in its retroglossal space (d1-d4). Pre- and postoperative outcomes
(Patient treated by Dr. Estrada)
disjunction is performed. At this level, the branches of the internal maxillary artery
are the cause of significant bleeding. The osteotomized segment of the maxilla is
moved with gentle pressure of the fingers and completed with the deimpaction of
the maxilla using the Tessier hooks. Special care must be taken with this maneuver
since it may produce an avulsion and total detachment of the maxillary segment
with the consequent necrosis. The maxillary segment can be made up of one or two
pieces depending on whether the alveolar bone graft was performed or not. The
displaced maxillary segment must be fixed using an acrylic occlusal splint to per-
form the intermaxillary fixation with the mandible. Then the desired vertical height
is estimated (according to the presurgical planning), and the segments of the upper
jaw are fixed with miniplates at the level of the zygomatic buttress and piriform
fossa. The space between segment can be filled with bone grafts to decrease the
likelihood recurrence and fixed with miniplates and screws.
a1 a2
a3
a4
Fig. 9.33 (a1) Maxillary retrusion in cleft lip and palate patient. (a2) The presence of pharyngeal
flap. (a3) Maxillary advancement using distraction osteogenesis (11–12 mm) to obtain facial har-
mony and occlusal correction. (a4) Pharyngeal flap distraction preserving its function (Case treated
by Dr. Estrada)
Finally, after verifying the position of the maxilla, the intermaxillary fixation is
removed and dental occlusion corrected. The mucosal edges of the vestibular inci-
sion are finally sutured with 5/0 vicryl. The need to perform a simultaneous correc-
tion in the jaw is frequent in cleft lip and palate population, especially in cases with
discrepancies greater than 10 mm. The Obwegeser technique is used for this pur-
pose, separating the ramus segments for displacement of the lower jaw. Thus, the
a b c d
e f g h
Fig. 9.34 (a–d) Maxillary retrusion in patient with cleft lip and palate. (e–h) Postoperative view
after orthognathic surgery. Mild maxillary advancement without velopharyngeal incompetence.
(g) Observe the upper airway enlargement after maxillary advancement (Patient treated by Dr.
Estrada)
aim of a bimaxillary surgery is as follows: the benefit of making minor displace-

ments in the jaws, less recurrence of the deformity, and the most common bad out-
come observed after orthognathic surgery. Distraction osteogenesis is also an
alternative that seeks to reduce the chances of relapse when mobilizing the seg-
ments slowly and forming new bone.
Figures 9.29 and 9.30 show the case of orthognathic surgery, airway, and velo-
pharyngeal competence. The maxillary advancement must be measured under the
concept of stability. The literature described that the maxillary advancement
between 5 and 6 mm in cleft lip and palate patients is stable with orthognathic sur-
gery, and greater advances should be made using distraction osteogenic to guarantee
long-term stability. The impact of the airway after maxillary advancement should be
well considered, and if there is a need to retract the mandible, this double jaw sur-
gery has an impact on the reduction of the retroglossal and hypopharyngeal spaces.
On Figs. 9.31 and 9.32, we show the case of maxillary advancement with osteogenic
distraction up to the clinical parameter of facial harmony, preserving velopharyn-
geal function and indirectly achieving greater airway enlargement. This type of
maxillary advancement prevents the mandibular surgery requirement but indirectly
increases the airway and the development of velopharyngeal insufficiency. The
osteogenic distraction, in addition to allowing great advances and being more sta-
ble, allows the monitoring of velopharyngeal competence during its activation;
therefore, if there are signs of pharyngeal velum incompetence, activation may be
Fig. 9.35 Patient with maxillary hypoplasia after cleft lip and palate surgery (vertical retrusion
deficiency and normal mandibular projection), 11–12 mm maxillary advancement with distraction
osteogenesis up to facial harmony parameters achieving engagement occlusal without discrepancy,
respecting pharyngeal competence (Patient treated by Dr. Estrada)
delayed, slowed down, stopped, or sometimes backed off. This decision should be
validated subjectively (patient operator) and objectively (speech therapist and naso-
endoscopy). Figure 9.33 shows a maxillary advancement with osteogenic distrac-
tion in a maxilla with a pharyngeal flap. Note the distraction of the pharyngeal flap
resulting in another advantage of maxillary advancement with osteogenic distrac-
tion. The auditory symptoms should be additionally monitored during the activation
process of the distractor device.
We have to take in consideration that the mandibular advancement and/or coun-
terclockwise rotation indirectly increases the upper airway (Fig. 9.34). On the con-
trary, the mandibular setback and/or clockwise rotation indirectly reduces the
airway (Figs. 9.29 and 9.30). In cleft lip and palate patients, is frequent the develop-
ment of hypodivergence of the occlusal plane, maxillary edging, mesial occlusal
relationship (class III) and cross bites. The presence of a discrepancy between maxi-
mum intercuspation and centric relation at the occlusal and articular level turns out
Fig. 9.36 Patient with maxillary hypoplasia after cleft lip and palate surgery (vertical retrusion
deficiency of the maxilla and normal mandibular projection), 11–12 mm maxillary advancement
with distraction osteogenic not reaching occlusion due velopharyngeal insufficiency development
so that at the time of removal of the distractor device, mandibular surgery was performed to achieve
occlusion (Patient treated by Dr. Estrada)
to be the most harmful factor to generate joint overload and masticatory system
dysfunction. Despite the problems of skeletal biomechanics of cleft lip and palate,
patients do not frequently develop dysfunction of the masticatory system. This
problem becomes more harmful in cases of presence of gynecological disorders
(polycystic ovary, estrogen and prolactin disorder, and vitamin D deficiency)
(Fig. 9.36).
References
1. Berkowitz S. The facial growth pattern and the amount of palatal bone deficiency relative
to cleft size should be considered in treatment planning. Plast Reconstr Surg Glob Open.
2016;4(5):e705.
2. Yu Q, Gong X, Shen G. CAD presurgical nasoalveolar molding effects on the maxil-
lary morphology in infants with UCLP. Oral Surg Oral Med Oral Pathol Oral Radiol.
2013;116(4):418–26.
3. Berkowitz S. Gingivoperiosteoplasty as well as early palatal cleft closure is unproductive. J
Craniofac Surg. 2009;20(Suppl 2):1747–58.
4. Cagañova V, Borsky J, Smahel Z, Veleminska J. Facial growth and development in unilateral
cleft lip and palate: comparisons between secondary alveolar bone grafting and primary peri-
osteoplasty. Cleft Palate Craniofac J. 2014;51(1):15–22.
5. Walter J, Hale V. A study of the long term results achieved by the gillies fry procedure. Br J
Plast Surg. 1987;40(4):384–90.
6. Ortiz-Monasterio F, Serrano A, Barrera G, Rodríguez-Hoffman H, Vinageras E. A study of
untreated adult cleft palate patients. Plast Reconstr Surg. 1966;38(1):36–41.
7. Ortiz-Monasterio F, Rebeil A, Valderrama M, Cruz R. Cephalometric measurements on adult
patients with non-operated cleft palates. Plast Reconstr Surg Transplant Bull. 1959;24(1):53–61.
8. Zhang Z, Stein M, Merce N, Malic C. Postoperative outcomes after cleft palate repair in syn-
dromic and non-syndromic children: a systematic review protocol. Syst Rev. 2017;6(1):52.
9. Antonarakis G, Tompson B, Fisher D. Preoperative cleft lip measurements and maxillary growth
in patients with unilateral cleft lip and palate. Cleft Palate Craniofac J. 2016;53(6):198–207.
10. Van Aalst J, Kolappa K, Sadove M. MOC-PSSM CME article: nonsyndromic cleft palate.
11. Bardach J. The influence of cleft lip repair on facial growth. Cleft Palate J. 1990;27(1):76–8.
12. Bardach J, Eisbach K. The influence of primary unilateral cleft lip repair on facial growth.
Cleft Palate J. 1977;14(1):88–97.
13. Bardach J, Bakowska J, McDermott-Murray J, Mooney M, Dusdieker L. Lip pressure changes
following lip repair in infants with unilateral clefts of the lip and palate. Plast Reconstr Surg.
1984;74:476–9.
14. Bardach J, Kelly K. The influence of lip repair with and without soft tissue undermining on
facial growth in beagles. Plast Reconstr Surg. 1988;82:747–55.
15. Bardach J, Kelly K, Jakobsen J. Simultaneous cleft lip and palate repair: an experimental study
in beagles. Plast Reconstr Surg. 1988;82:31–9.
16. Carstens M. Sequential cleft management with the sliding sulcus technique and alveolar exten-
sion palatoplasty. J Craniofac Surg. 1999;10:503–18.
17. Friede H. Maxillary growth controversies alter two stage palate repair with delayed hard palate
closure in unilateral cleft lip and palate patients. Cleft Palate Craniofac J. 2007;44:2.
18. Hotz M, Gnoinski W. Effects of early maxillary orthopaedics in coordination with delayed
surgery for cleft lip and palate. J Maxillofac Surg. 1979;7:201–10.
19. Friede H, Eenemark H. Long term evidence for favorable midfacial growth after delayed hard
palate repair in UCLP patients. Cleft Palate Craniofac J. 2001;38(4):323–9.
20. Lilja J, Mars M, Elander A, Enocson L, Hagberg C, Worrell E, Batra P, Friede H. Analysis
of dental arch relationships in Swedish unilateral cleft lip and palate subjects: 20-year lon-
gitudinal consecutive series treated with delayed hard palate closure. Cleft Palate Craniofac
J. 2006;43:606–11.
21. Friede H, Moller M, Lilja J, Lauritzen C, Johanson B. Facial morphology and occlusion at the
stage of early mixed dentition in cleft lip and palate patients treated with delayed closure of the
hard palate. Scand J Plast Reconstr Surg Hand Surg. 1987;21:65–71.
22. Rossell-Perry P, Cáceres-Nano E, Gavino-Gutiérrez A. Associations between palatine index
and cleft palate repair outcomes in patients with complete unilateral cleft lip and palate. JAMA
Facial Plast Surg. 2014;16(3):206–10.
23. Rossell-Perry P, Cotrina-Rabanal O, Cáceres-Nano E. Nuevo enfoque en el tratamiento
quirúrgico de las fisuras palatinas congénitas. Cirugía Plástica IberoLatinoAmericana.
2015;41(4):409–17.
24. Neiswanger K, Cooper M, Weinberg S, Flodman P, Bundens A, Liu Y, et al. Cleft lip with
or without cleft palate and dermatoglyphic asymmetry: evaluation of a Chinese population.
Orthod Craniofac Res. 2002;5(3):140–6.
25. Yang I, Liao Y. The effect of one-stage vs two-stage palate repair on facial growth in patients
with cleft lip and palate: a review. Int J Oral Maxillofac Surg. 2010;39(10):945–50.
26. Lee Y, Liao Y. Hard palate repair technique and facial growth in patients with cleft lip and pal-
ate: a systematic review. Br J Oral Maxillofac Surg. 2013;51(8):851–7.
27. Liao Y, Mars M. Hard palate repair timing and facial growth in cleft lip and palate: a sys-
tematic review. Cleft Palate Craniofac J. 2006;43(5):563–70.
28. Liau J, Sadove A, Aalst J. An evidence based approach to cleft palate repair. Plast Reconstr
Surg. 2010;126(6):2216–21.
29. Richard B, Russell J, McMahon S, Pigott R. Results of randomized controlled trial of soft
palate first vs hard palate first repair in unilateral complete cleft lip and palate. Cleft Palate
Craniofac J. 2006;43(3):329–38.
30. Wada T, Tachimura T, Satoh K, Hra H, Hatano M, et al. Maxillary growth after two-stage pala-
tal closure in complete clefts of the lip and palate from infancy until 10 years of age. J Osaka
Univ Dent Sch. 1990;30:53–63.
31. Karsten A, Marcusson A, Hurmerinta K, Heliövaara A, Küseler A, Skaare P, Bellardie
H, Rønning E, Shaw W, Mølsted K, Sæle P, Brinck E, Rizell S, Najal Chalier M, Eyres P,
Semb G. Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate. 7.
Occlusion in 5 years old according to the Huddart and Bodenham index. J Plast Surg Hand
Surg. 2017;51(1):58–63.
32. Mølsted K, Brattström V, Prahl-Andersen B, Shaw WC, Semb G. The Eurocleft study:
Intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 3:
dental arch and relationships. Cleft Palate Craniofac J. 2005;42(1):78–82.
33. Hathaway R, Daskalogiannakis J, Mercado A, Russell K, Long RE Jr, Cohen M, Semb
G, Shaw W. The Americleft study: an intercenter study of treatment outcomes for patients
with unilateral cleft lip and palate. Part 2: dental arch relationships. Cleft Palate Craniofac
J. 2011;48(3):244–51.
34. Rossell-Perry P. Cleft Palate Surgery. San Marcos Ed. Lima 2015.
35. Rossell-Perry P, Cotrina-Rabanal O, Figallo-Hudtwalcker O, González-Vereau A. Effect of
36. Qureshi N, McIntyre G, Mossey P. Does relative maxillary arch constriction worsen with
growth in patients with cleft lip and palate? A pilot study. J Cleft Lip Palate Craniofacial
Anomalies. 2016;3(2):77–82.
37. Williams A, Bearn D, Mildinhall S, Murphy T, Sell D, Shaw WC, Murray JJ, Sandy JR. Cleft
lip and palate care in the United Kingdom: The clinical standards advisory group study. Part 2:
Dentofacial outcomes and patient satisfaction. Cleft Palate Craniofac J. 2001;38(1):24–9.
38. Manosudprasit M, Wangsrimongkol T, Pisek P, Chowchuen B, Somsuk T. Growth modification
in unilateral cleft lip and palate patients with face mask. J Med Assoc Thail. 2012;95(Suppl
11):S42–8.
39. Buschang P, Porter C, Genecov E, Genecov D, Salyer K. Face mask therapy of preadolescents
with unilateral cleft lip and palate. Angle Orthod. 1994;64(2):145–50.
40. Dogan S. The effects of face mask therapy in cleft lip and palate patients. Ann Maxillofac
Surg. 2012;2(2):116–20.
41. Kiellgren B. Serial extraction as a corrective procedure in dental orthopaedic therapy. Acta
Odontol Scand. 1948;8:17–43.
42. King T. The anatomy of hare-lip in man. J Anat. 1954;88:1–12.
43. Slaughter W, Henry J, Berger J. Changes in blood vessel patterns in bilateral cleft lip. Plast
Reconstr Surg Transplant Bull. 1960;26:166–79.
44. Maher W. Distribution of palatal and other arteries in cleft and non-cleft human palates. Cleft
Palate Craniofac J. 1977;14:1–2.
45. Vura N, Gaddipati R, Palla Y, Kumar P. An intraoral appliance to retract the protrusive premax-
illa in bilateral cleft lip patients presenting late for primary lip repair. Cleft Palate Craniofac
J. 2018 Apr;55(4):622–5.
46. Koh K, Han W, Jeong W, Oh T, Kwon SM, Choi JW. Premaxillary repositioning in the severe
form of bilateral cleft lip and palate. J Craniofac Surg. 2016;27(6):1440–4.
47. Fakih-Gómez N, Sánchez-Sánchez M, Iglesias-Martín F, García-Perla A, Belmonte-Caro R,
Gonzalez-Perez LM. Repair of complete bilateral cleft lip with severely protruding premaxilla
performing a premaxillary setback and vomerine ostectomy in one stage. Med Oral Patol Oral
Cir Bucal. 2015;20(4):500–7.
48. Raj M, Kim D, Padwa B, Mulliken J. Primary premaxillary setback and repair of bilateral com-
plete cleft lip: indications, technique and outcomes. Cleft Palate Craniofac J. 2016;53(3):302–8.
49. Lilja J. Alveolar bone grafting. Indian J Plast Surg. 2009;42(Suppl):S110–5.
50. Posnick J, Ricalde P. Cleft orthognatic surgery. Clin Plast Surg. 2004;31(2):315–30.
51. Epker B, Fish L. Dentofacial deformities-integrated orthodontics and surgical correction. St.
Louis: Mosby; 1986.
52. Zide B, Grayson B, McCarthy J. Cephalometric analysis: part I, II and III. Plast Reconstr Surg.
1981;68:816.
53. Obwegeser H. The indications for surgical correction of mandibular deformity by the sagittal
splitting technique. Br J Oral Surg. 1964;1:157.
54. McCarthy J, Schreiber J, Karp N. Lenghtening of the human mandible by gradual distraction.
Plast Reconstr Surg. 1992;89:1.
55. Molina F. Distraction osteogenesis for cleft lip and palate patients. Clin Plast Surg.
2004;31(2):291–302.
56. Bailey LJ, Cevidanes LHS, Proffit WR. Stability and predictability of orthognathic surgery.
Am J Orthod Dentofac Orthop. 2004;126(3):273–7.
57. Hralabakis N, Papadakis G. Relapse after orthodontics and orthognathic surgery. World J
Orthod. 2005;6(2):125–40.
Index
A Manchester´s type bilateral cheiloplasty

Abbe flap, 146–150 technique, 140, 141
Airway obstruction, 17, 18, 57 Millard´s type bilateral cheiloplasty
Airway spasm, 2 technique, 139, 140
Algorithm for management of palatal fistula muscular repair, 164–167
(AHS), 195, 199 philtrum secondary deformities
Alveolar bone graft complications, 62 bilateral whistler deformity, 142–150
AMERICLEFT, 270 long lips, 149, 151
Anaphylaxis, 20 scarring sequele, 188–190
Anesthetic complications, 3, 4 secondary nose deformities, 167–170
airway obstruction, 17, 18 columella, 178, 180–183
anaphylaxis, 20 nasal ala, 173, 174, 176, 177
aspiration pneumonia, 19, 20 nasal floor, 181, 184, 185
associated to venous cannulation, 22 nasal tip, 170–174
cleft lip and palate surgery, 11 nasal vestibule, 181, 183, 184, 188, 189
cognitive disorders, 21 severe form, 137, 138
endotracheal related complications, 12–14 vermilion bad outcomes
malignant hyperthermia, 22 vermilion deficiency, 156–162
pediatric emergence delirium, 22 vermilion excess, 162, 163
pneumothorax, 21 Bilateral whistler deformity, 142, 145, 146
preoperative evaluation, 12 Abbe flap, 147–150
respiratory depression, 15–17 disadvantage, 143
respiratory infections, 20 loss of prolabium, 146, 147
subcutaneous emphysema, 21 management of, 142
Anterior bilateral cleft palate fistulas, 204–210 markings, 143, 144
Anterior unilateral cleft palate fistulas, Millard´s procedure, 142
200, 202–204 operative wound dehiscence, 147
Aspiration pneumonia, 19, 20 preoperative and postoperative view,
143, 145
primary cleft lip repair, 143
B V-Y advancement, 143, 146
Bilateral cleft lip surgery, 4 Bleeding, 54–56, 61
labial sulcus repair, 185, 186, 190 Body temperature disorders, 67
lip asymmetries, 152–156 Burns, 52, 53
© The Editor(s) (if applicable) and The Author(s), under exclusive license to 307
Springer Nature Switzerland AG 2022
Surgery, https://doi.org/10.1007/978-3-030-98400-7
308 Index
C postoperative cleft lip dehiscence, 32

Carotid artery injury, 62 postoperative wound infection, 30, 31
Central deformity, 144 premaxilla necrosis, 59, 60
Cephalometric analysis, 273 presurgical orthopedic
Cheiloplasty techniques, 1, 2 aspiration of impression material, 28
Cholesteatoma, 72 associated infections, 29
Cleft lip and palate characteristics, 2 children pain, stress and discomfort, 29
Cleft lip and palate secondary deformities, 4 facial growth disturbance, 28
Cleft lip surgery, 69 maxillary incisors, 29
airway obstruction, 57 nasal and intraoral bleeding, 28
alveolar bone graft complications, 62 skin irritation and pressure sores, 28
bleeding, 54–56 primary cleft rhinoplasty
burns, 52, 53 bleeding, 40
endotracheal tube compression, 52 foreign body, 41
granuloma, 39, 44, 46 hypertrophic scar, 40
hypertrophic scar, 33–38 implants, 43–45
infection, 58 infections, 42
keloid scar, 38 nasal stenosis, 42
lip and tongue injury, 53 skin necrosis, 43, 44
mouth gag, 52 prolabium necrosis, 44, 46
orthognatic surgery, 63 skin lesions on chest, 54
bleeding, 62, 63 temporomandibular joint luxation, 54
jaw aseptic necrosis, 63 tooth loss/damage, 52
relapse, 62 velopharyngeal insufficiency, 60, 61
palatal dehiscence mild, 247, 248
anterior palate dehiscence, 226, 227 moderate, 248
definition, 226 severe, 248
hard palate dehiscence, speech therapy, 246
226–228, 230–232 swallowing and hearing
soft palate dehiscence, 227, 229, disorders, 246
232, 233 treatment, 248–256, 258–261
total palate dehiscence, 228, 233–236 Cognitive disorders, 21
palatal fistulas Columella, 126, 128
adherence, 197 Congenital platelet disorder, 54
anterior bilateral cleft palate Cormack-Lehane scale, 12
fistulas, 204–210 Cupid´s bow correction technique, 159
anterior fistulas, 197–199 Curved lines techniques, 92
anterior unilateral cleft palate fistulas,
200, 202–204
classification, 194–196 D
cleft palate index, 194, 195 Death, 79, 80
complication, 194 Dental anomalies, 74, 75
development of, 196, 197 Dental caries, 73, 74
hard palate fistulas, 198–200 Dental occlusion disorders, 62
middle fistulas, 211–214 Dental skeletal bad outcomes
mucosal planes, 197 airway, 277
nasal mucosa, 197 AITRE, 275
patient evaluation, 201, 202 alveolar cleft, 289, 290
soft palate fistulas, 199, 214–225 anterior maxillary arch, 291
palatal flap necrosis, 58, 59 body, 275
diagnosis, 237–239 bone segment, mucosal coverage and
treatment, 239–246 dental implants, 287
postoperative bleeding, 29 cervical, 275
Index 309
characterization, 273 E
dentofacial deformity, 275, 276 Electrical burns, 52
diagnostic and prevention of, 272–277 Endotracheal tube compression, 52
facial bone growth disturbance, 270 Endotracheal tube extubation, 14
facial harmony, 277 EUROCLEFT, 270
growth of facial skeleton, 270 Eustachian tube obstruction, 61
and loss of the premaxilla, 287
mandibular advancement and/or
counterclockwise rotation, 301 F
maxillary advancement with osteogenic Facial artery myomucosal cutaneous
distraction, 300, 301 (FAMMC) flap, 240
maxillary hypoplasia, 273, 274, 302 Facial artery myomucosal flap
maxillary protraction mask, 278, 279 (FAMM), 243–246
non-operated adult patients, 268 Fiber optics, 12, 13
orthognatic surgery, airway and Fistula classification, 195, 199
velopharyngeal Frankel type myofunctional orthopedics, 280
competence, 300 Furlow technique, 253, 254
osteogenic distraction, 294, 301
osteotomy advancement and/or retrusion
with osteotomies and G
fixation, 294–300 Glossopharyngeal nerve injury, 61
premaxilla loss defects, 288 Granuloma, 2, 39, 44, 46
prospective controlled studies, 270
prospective experimental studies,
270, 272 H
radiographic analysis, 275 Hearing disorders
secondary aesthetic and functional cholesteatoma, 72
deformity, 284 hearing loss, 73
severe aesthetic sequel, 286 otitis media, 72
severe maxillary hypoplasia with dental Hynes type pharyngoplasty surgical
occlusion disorder, 268–270 technique, 260
surgical technique, 271, 295, 298 Hypertrophic scars, 2
teeth, dental arch, 277 Hypoglycemia, 70
TMJ, 277 Hypothermia, 67
treatment of, 277, 280
type III dental occlusion, 290
variables, 270 I
vascular anatomy, 283 Infection, 58
with absence of premaxilla without timely
orthodontic treatment and alveolar
cleft, 288 J
with consequent dehiscence, 285 Jaw aseptic necrosis, 63
with severe facial deformity, 282
Dental skeletal evaluation, 7
Dentofacial deformity, 275, 276 K
Dentoskeletal complications Keloid scar, 38
dental anomalies, 74, 75
dental caries, 73, 74
maxillary hypoplasia and L
malocclusion, 75, 76 Labial asymmetry repair, 154, 155
periodontal disease, 74 Labial sulcus repair, 185, 186, 190
Diarrhea, 69 Lack of appetite, 69, 70
Distraction osteogenesis, 300 Laryngeal mask, 12
310 Index
Le Mesurier’s technique, 87 Oral musculomucosal anterior flap, 216, 217

Lip and tongue injury, 53 Orthognatic surgery complications, 63
Lip asymmetry, 152–156 bleeding, 62, 63
long lip, 96–99 jaw aseptic necrosis, 63
nasal philtrum asymmetries, 100, 101 relapse, 62
short lip, 92–98 Osteogenic distraction, 294, 301
Lip function, 4 Otitis media, 72
Lip scarring sequelae, 132–134
Long lips, 96–99, 149, 151
Lung atelectasis, 14 P
Pain, 68
Palatal dehiscence
M anterior, 226, 227
Malignant hyperthermia, 22 definition, 226
Malocclusion, 75, 76 hard, 226–228, 230–232
Manchester´s technique, 140–142, 146, 160, 165 soft, 227, 229, 232, 233
Maxillary hypoplasia, 75, 76, 270, 273, 274, 302 total palate dehiscence, 228, 233–236
Maxillary protraction mask, 278, 279 Palatal fistula index, 201–202
Middle ear disease, 61 Palatal fistulas
Millard’s technique, 36, 87, 88, 92, 138–140, 142 adherence, 197
Modified Hynes sphincter pharyngoplasty, 251 anterior bilateral cleft palate
Mohler’s technique, 88, 89, 126 fistulas, 204–210
Mouth gag, 52 anterior fistulas, 197–199
Muscular repair, 106–109, 164–167 anterior unilateral cleft palate fistulas,
200, 202–204
classification, 194–196
N cleft palate index, 194, 195
Narrower alar base, 121–124 complication, 194
Nasal ala, 173, 174, 176, 177 development of, 196, 197
in lower position, 117–119 hard palate fistulas, 198–200
narrower alar base, 121–124 middle fistulas, 211–214
nose alae shortening, 124–127 mucosal planes, 197
in upper position, 119–121 nasal mucosa, 197
wider alar base, 120–123 patient evaluation, 201, 202
Nasal deformity, 138 soft palate fistulas, 199, 214–225
Nasal floor, 127–130, 181, 184, 185 Palatal flap necrosis, 58, 59
Nasal mucosa posterior flap, 216, 218 diagnosis, 237–239
Nasal musculomucosal posterior flap, 218 treatment, 239–246
Nasal philtrum asymmetries, 100, 101 Palate evaluation, 7
Nasal tip, 111–116, 170–174 Palatopharyngeous myomucosal flaps, 259
Nasal tip advancement flap, 128 Pediatric emergence delirium, 22
Nasal vestibule, 130–132, 181, 183, 184, Peninsular flap, 147
188, 189 Periodontal disease, 74
Naso alveolar molding (NAM), 138 Pfeifer’s techniques, 92
Nose alae shortening, 124–127 Pharyngeal flaps, 253
Nose reconstruction, 7 Philtrum secondary deformities
bilateral whistler deformity, 142, 145, 146
Abbe flap, 147–150
O disadvantage, 143
Obwegeser technique, 299 loss of prolabium, 146, 147
Occlusal dento skeletal disorders, 272 management of, 142
Operative wound, 2 markings, 143, 144
Oral and lingual mucosal neoplasms, 78 Millard´s procedure, 142
Oral mucosal anterior flap, 216, 217 operative wound dehiscence, 147
Index 311
preoperative and postoperative view, nasal vestibule, 130–132, 181, 183, 184,
143, 145 188, 189
primary cleft lip repair, 143 Secondary unilateral cleft lip nasal
V-Y advancement, 143, 146 deformity, 110
long lips, 149, 151 Seizures, 71
Pneumothorax, 21 Sentinel event, 2
Post anesthesia care unit (PACU), 55 Short columella, 178
Potter´s concept, 170 Short lip, 92–98
Premaxilla necrosis, 59, 60 Simple Z plasty, 142
Primary cleft palate repair, 4 Skeletal biomechanics, 302
Primary cleft rhinoplasty Skin lesions on chest, 54
bleeding, 40 Sphincter pharyngoplasty repair, 260
foreign body, 41 Spina technique, 145
hypertrophic scar, 40 Stencil method, 90
implants, 43–45 Straight line techniques, 86, 87
infections, 42 Subcutaneous emphysema, 21
nasal stenosis, 42 Sudden abnormal electrical brain activity, 71
prolabium necrosis, 46 Surgeon, 1
skin necrosis, 43, 44 Surgical technique, definition of, 1
Primary palatoplasty dehiscence, 258
Prolabium necrosis, 44
Psychosocial disorders, 78 T
Temporomandibular joint luxation, 54
Tennison-Randall’s technique, 91
R Tooth loss/damage, 52
Red roll sequels, 104, 106, 107 Transillumination technology, 23
Reoperative hemostasis, 4 Trauma, 77, 78
Respiratory depression, 15–17
Respiratory infections, 20
Retropremaxillary fistula, 199 U
Robin sequence, 12 Unilateral cleft lip revision, 4
Rose-Thompson effect, 86 Unilateral cleft lip surgery, 4
Rotation advancement techniques, 87–89 curved lines techniques, 92
lip asymmetry
long lip, 96–99
S nasal philtrum asymmetries, 100, 101
SCANDCLEFT, 270 short lip, 92–98
Scarring sequele, 188–190 muscular repair, 106–109
Secondary nose deformities, rotation advancement techniques, 87–89
109–111, 167–170 secondary nose deformities, 109–111
columella columella, 126, 128
bad outcomes, 181–183 lip scarring sequelae, 132–134
short, 178 nasal ala, 117–124
wide, 178, 180, 181 nasal floor, 127–132
lip scarring sequelae, 132–134 nasal tip, 111–116
nasal ala, 173, 174, 176, 177 nose alae shortening, 124–127
columella, 126, 128 straight line techniques, 86, 87
in lower position, 117–119 vermilion bad results
narrower alar base, 121–124 red roll sequels, 104, 106, 107
nose alae shortening, 124–127 vermillion sequels, 102–105
in upper position, 119–121 white roll sequels, 101–103
wider alar base, 120–123 Z plasty techniques, 90, 91
nasal floor, 127–130, 181, 184, 185 Unilateral whistler deformity, 93
nasal tip, 111–116, 170–174 Unilimb Z plasty technique, 103
312 Index
V Vermilion excess, 104, 162, 163

Vascular disorders, 78, 79 Vermillion sequels, 102–105
Vascular infarction, 78, 79 Vomiting, 68, 69
Velocardiofacial syndrome, 62 Von Willebrand disease, 54
Velopharyngeal insufficiency V-Y advancement technique, 146
mild, 247, 248 V-Y-Z technique, 43, 171
moderate, 248
severe, 248
speech therapy, 246 W
swallowing and hearing disorders, 246 Walker-Walburg syndrome, 71
treatment, 60, 61, 248–256, 258–261 Whistler deformity, 138
Vermilion bad outcomes White roll sequels, 101–103
red roll sequels, 104, 106, 107 Wide columella, 178, 180, 181
vermilion deficiency, 156–162 Wound dehiscence, 4
vermilion excess, 162, 163
vermillion sequels, 102–105
white roll sequels, 101–103 Z
Vermilion deficiency, 102, 156–162 Z plasty techniques, 90, 91

Cleft Lip and Palate Surgery

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Cleft Lip and Palate Surgery

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Atlas of Non-Desirable

Outcomes in Cleft Lip

ISBN 978-3-030-98399-4 ISBN 978-3-030-98400-7 (eBook)

Henry K. Kawamoto Jr.

Lima, Peru Percy Rossell-Perry

About the Editor

Percy Rossell-Perry, MD, PhD, FACS Born in

Casimiro Ulloa Hospital (2004–2008) and Cayetano

He is reviewer of the most important plastic sur-

Percy Rossell-Perry, MD PhD San Martin de Porres University of Lima,

The expected results of a surgical intervention cannot be guaranteed 100%. The

© The Author(s), under exclusive license to Springer Nature 1

surgical technique or an inadequate postoperative care of the wound. The shortcom-

common complication being vomiting in 19 patients and respiratory depression in

1.4 Patient Evaluation

Fig. 1.1 Anesthetic complications (n: 38/640 – 38.90%)

(c) Labionasal muscle function

8. Rossell-Perry P, Segura E, Salas-Bustinza L, Cotrina-Rabanal O. Comparison of two models

Percy Rossell-Perry and Mision Noriega-Ambulodegui

© The Author(s), under exclusive license to Springer Nature 11

2.2 Endotracheal-Related Complications

Endotracheal intubation is difficult to be performed in cleft lip and palate intubation

Fig. 2.2 The image shows

After auscultation, the endotracheal tube was confirmed in good position.

2.3 Respiratory Depression

It can be estimated as the condition in which the oxygen saturation measured by

immediate postoperative period prevents aspiration of blood and gastric contents,

2.4 Airway Obstruction

This anesthetic complication is mainly due to airway reactivity (spasm), a common

2.5 Aspiration Syndrome

2.6 Respiratory Infections

2.7 Other Anesthetic Complications

At the moment, it is advisable in a preventive way to reduce surgical times and

Fig. 2.3 Use of

1. Von Ungern-Sternberg B, Boda K, Chambers N, Rebmann C, et al. Risk assessment for

3.2 Associated with Presurgical Orthopedic

© The Author(s), under exclusive license to Springer Nature 27

3.2.1 Aspiration of Impression Material

3.2.2 Skin Irritation and Pressure Sores

3.2.3 Nasal and Intraoral Bleeding

3.2.4 Facial Growth Disturbance

Different studies (especially those published by Samuel Berkowitz) [7] have

The retroposition of the vomero-premaxillary junction caused by presurgical

3.2.5 Associated Infections

3.2.6 Premature Eruption of the Maxillary Incisors

3.2.7 Children Pain, Stress, and Discomfort

3.3 Postoperative Wound Bleeding

Postoperative bleeding is not an infrequent complication to observe after cleft lip

3.4 Postoperative Wound Infection

This complication is produced by a breakdown of the balance between the tissues

Fig. 3.2 Patient with

Regarding systemic antibiotic therapy, in recent years, it has been observed an

3.5 Postoperative Cleft Lip Dehiscence

Fig. 3.3 Patient with

Fig. 3.4 Patient with

3.6 Hypertrophic Scar

Fig. 3.5 Patient with

Fig. 3.6 Long-term

Few or no evidence exist regarding the preventive effect of hypertrophic scar

Fig. 3.7 Long-term

3.7 Keloid Scar

This complication is generally associated with the use of surgical sutures.

Fig. 3.11 A case of

3.9 Complications Associated with Primary

Lima, Peru Percy Rossell-Perry

1.4 Patient Evaluation

2.2 Endotracheal-Related Complications

2.3 Respiratory Depression

2.4 Airway Obstruction

2.5 Aspiration Syndrome

2.6 Respiratory Infections

2.7 Other Anesthetic Complications

3.2 Associated with Presurgical Orthopedic

3.2.1 Aspiration of Impression Material

3.2.2 Skin Irritation and Pressure Sores

3.2.3 Nasal and Intraoral Bleeding

3.2.4 Facial Growth Disturbance

3.2.5 Associated Infections

3.2.6 Premature Eruption of the Maxillary Incisors

3.2.7 Children Pain, Stress, and Discomfort

3.3 Postoperative Wound Bleeding

3.4 Postoperative Wound Infection

3.5 Postoperative Cleft Lip Dehiscence

3.6 Hypertrophic Scar

3.7 Keloid Scar

3.9 Complications Associated with Primary

3.10 Prolabium Necrosis

4.2 Related to the Use of the Mouth Opener

n asopharyngeal intubation or tracheostomy to guarantee the patient’s airway [5,

4.4 Airway Obstruction

4.6 Palatal Flap Necrosis (Fig. 4.5)

4.7 Premaxilla Necrosis

4.8 ssociated Complications to Surgery

4.9 Alveolar Bone Graft Complications

4.10 Orthognathic Surgery Complications

4.10.3 Jaw Aseptic Necrosis

4.10.4 Other Complications

5.1 Body Temperature Disorders

5.5 Lack of Appetite

5.8 Hearing Disorders

5.8.1 Otitis Media

5.8.3 Hearing Loss

5.9 Dentoskeletal Complications

5.9.1 Dental Caries

5.9.2 Periodontal Disease

5.9.3 Dental Anomalies

5.9.4 Maxillary Hypoplasia and Malocclusion

5.10 Trauma (Fig. 5.6)

5.11 Psychosocial Disorders

5.13 Vascular Disorders

6.1.1 Straight Line Techniques (Figs. 6.1 and 6.2)

6.1.2 Rotation Advancement Techniques (Figs. 6.3, 6.4, 6.5,