Jian Min Yao Editor, Jing Hong Xu Editor Atlas of Cleft Lip and

Jian-min Yao
Jing-hong Xu
Editors
Atlas of Cleft Lip

and Palate & Facial
Deformity Surgery
123
Atlas of Cleft Lip and Palate & Facial
Deformity Surgery
Jian-min Yao • Jing-hong Xu
Editors
Atlas of Cleft Lip and Palate

& Facial Deformity Surgery
Editors
Jian-min Yao Jing-hong Xu
Hangzhou Plastic Surgery Hospital Department of Plastic Surgery
Hangzhou Zhejiang University
China Hangzhou
China
The First Affiliated Hospital
Zhejiang University School of Medicine
Hangzhou
China
Jointly published with Shanghai Scientific and Technical Publishers, Shanghai, China
ISBN 978-981-15-4418-7 ISBN 978-981-15-4419-4 (eBook)
https://doi.org/10.1007/978-981-15-4419-4
© Shanghai Scientific and Technical Publishers 2020

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Foreword
Cleft lip and palate and facial deformity surgery has been recorded for thousands of years.
Numerous books and articles had been published for cleft lip and palate and facial deformity.
Cleft lip and palate and facial deformity surgeries are the basic clinical skills of plastic sur-
geons. Plastic surgeon is “the craftsman of the human body” to some extent. To be a good
plastic surgeon, we should learn more, practice more, and summarize more. So, I recommend
the book Atlas of Cleft Lip and Palate & Facial Deformity Surgery to all plastic surgeons. It
introduces the details of surgical procedures, key points, and outcomes of cleft lip and palate
and facial deformity with graphs. This book will be undoubtedly of value to plastic surgeons.
The highest level of ethics is like water, so is medical ethics. A good doctor must be a noble
person. Medical is a lifelong journey. The book Atlas of Cleft Lip and Palate & Facial Deformity
Surgery written by Dr. Yao is based on his 30 years’ experience of “Operation Smile China.”
Working with Dr. Han Kai, the founder of “Operation Smile China,” Dr. Yao treated more than
30 thousand children with cleft lip and palate for free. He brought them a new life with smiles.
I think Atlas of Cleft Lip and Palate & Facial Deformity Surgery is a textbook of plastic sur-
gery, as well as a textbook of medical ethics. So, I recommend this book to you and write this
as the foreword.
Shanghai, China
Wang Wei
July 31, 2018
v
Editorial Board of Atlas of Cleft Lip and
Palate & Facial Deformity Surgery
Editor, Jian-min Yao, Hangzhou Plastic Surgery Hospital

Editor, Jing-hong Xu, Department of Plastic Surgery, Zhejiang University
The First Affiliated Hospital, Zhejiang University School of Medicine
Chief Umpire, Wei Wang, Shanghai Ninth People Hospital, Shanghai Jiaotong University
School of Medicine
Adviser, Kai Han, Hangzhou Operation Smile Charity Hospital
Compilers (Surnames Arranged in Number of Strokes)
Jin-ping Ding, Beijing Hospital

Sheng Ding, Hangzhou Plastic Surgery Hospital
Liang Ma, Hangzhou Plastic Surgery Hospital
Lei Zhu, Hangzhou Plastic Surgery Hospital
Sheng Chen, Hangzhou Plastic Surgery Hospital
Feng-jing Zhao, Hangzhou Plastic Surgery Hospital
Wen-feng Zhang, Hangzhou Plastic Surgery Hospital
Jian-min Yao, Hangzhou Plastic Surgery Hospital
Yun-ping Huang, Hangzhou Plastic Surgery Hospital
Wei-hua Wu, Hangzhou Plastic Surgery Hospital
Cheng Liu, Jiangxi Provincial People’s Hospital
Bao Zhu, Zhejiang Provincial people’s Hospital
Hui Xu, Xinjiang Uygur Autonomous Region People’s Hospital
Chang-long Zhou, Ningbo Medical Treatment Center Lihuili Hospital
Yong-hong Zhu, The Third Affiliated Hospital of Nanchang University
Wen-yan Wu, Chengdu Bada Medical Aesthetics Hospital
Rui-yu Qin, Xiaoshan Hospital
Wen-yang Wang, Hangzhou Operation Smile Charity Hospital
Wei-jun Fan, Hangzhou Operation Smile Charity Hospital
Kai Han, Hangzhou Operation Smile Charity Hospital
Li-min Tang, Hangzhou Operation Smile Charity Hospital
Jing-hong Xu, The First Affiliated Hospital, , Zhejiang University School of Medicine
Yi-jia Yu, The First Affiliated Hospital, Zhejiang University School of Medicine
Chiao-yun Chiu, The First Affiliated Hospital, Zhejiang University School of Medicine
Ze-ren Shen, The First Affiliated Hospital, Zhejiang University School of Medicine
Ming-yuan Xu, The First Affiliated Hospital, Zhejiang University School of Medicine
Wei-qiang Tan, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine
Zheng-cai Wang, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine
Tao Zhang, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine
Xiao-feng Wang, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine
vii
Preface
Congenital cleft lip and palate is a kind of facial deformity with a high incidence. The criterion
for evaluating the effect of repair lies in the aesthetic appearance and functional recovery after
repair, and the former is particularly important. Without good appearance, good functions are
hard to achieve for cleft lip and palate patients. Because of the different manifestations of the
deformity and the different degrees of the defect in cleft lip and palate patients, the surgical
methods are various. Each method has its own advantages and disadvantages. As professor
Wang Wei said: “there is no best way of any operation, only the most suitable indications.” To
make best use of the advantages and bypass the disadvantages, and in line with the principle of
minimally invasive, efficient, and simple surgery, the author compiled the book Atlas of Cleft
Lip and Palate & Facial Deformity Surgery with his colleagues. Based on the experience of
various clinical operations in this field over the past 30 years, this book consists of the basic
theories and comprehensive skills of surgery, plastic surgery, and maxillofacial surgery and
integrates the knowledge and wisdom of dozens of experts in China. This monograph illus-
trates the surgical methods and procedures one by one in order to make them intuitive and easy
to understand. In order to enrich the content, besides the surgical methods of cleft lip and pal-
ate, the book also introduces the repair methods of other facial deformities, which also con-
tains the wisdom of the author and many experts and scholars. We hope that the book is
self-explanatory and understandable to readers.
The book contains more than 1900 colorful surgical photographs, which are mainly from
the “Operation Smile China” project of Lip and Palate Surgery and the accumulation of
decades of clinical practice. This book is divided into two sections with five chapters and
briefly introduces various surgical methods of cleft lip and palate, including recommended
methods, alternative methods, procedures, and steps of repair surgeries by the way of pictures
and graphics. It also emphasizes on describing common and practical surgical methods for
cleft lip and palate and also explores innovative surgical skills and operative techniques.
The purpose of the book is to provide a high-quality bibliography for colleagues in plastic
surgery, oral and maxillofacial surgery, cosmetic surgery, and otolaryngology to improve the
ability of repairing cleft lip and palate and other facial deformities.
Due to the limitation of time, experience, and academic level, there are inevitably shortcom-
ings and mistakes in this book. We urge our readers to criticize and correct them while refer-
ring to them.
Hangzhou, China Jian-min Yao

18, 2018
July Jing-hong Xu
ix
Introduction
Atlas of Cleft Lip and Palate & Facial Deformity Surgery is a book which systematically intro-
duces the classification, surgical methods, and outcomes of cleft lip and palate and facial
deformities with diagrams. “Operation Smile China” offers more than 1900 photographs to
this book, as well as our 30 years of clinical experience.
This book is divided into two parts. Part I contains the classification, special suture tech-
niques, surgical procedures, and case series of cleft lip and palate. Part II mainly contains the
reparation of congenital facial deformities and facial defects.
This book is suitable for junior plastic surgeons, oral surgeons, cosmetic surgeons, and
otolaryngologists. We wish this book will be of benefit to improving clinical skills of repara-
tion of cleft lip and palate and facial deformities.
xi
Contents
Part I Classification and Operation of Cleft Lip and Palate
1 Classification of Cleft Lip and Palate�� 3

Yi-jia Yu and Jian-min Yao
2 Repair Methods for Cleft Lip and Palate�� 17
Liang Ma, Li-min Tang, and Jian-min Yao
3 Surgical Instruments of Cleft Lip and Palate�� 51
Wen-yang Wang, Yun-ping Huang, and Jian-min Yao
4 Special Suture Technique�� 55
Wei-qiang Tan and Jian-min Yao
Part II Repair of Cleft Lip
5 Repair of Unilateral Cleft Lip�� 75

Cheng Liu and Jian-min Yao
6 Repair of Bilateral Cleft Lip �� 127
Wen-feng Zhang, Hui Xu, Sheng Chen, and Jian-min Yao
7 Repair of Median Cleft Lip�� 147
Wen-yan Wu and Jian-min Yao
8 Repair of Secondary Cleft Lip Deformity�� 153
Lei Zhu, Feng-jing Zhao, Chang-long Zhou, and Jian-min Yao
Part III Repair of Cleft Palate
9 Repair of Unilateral Cleft Palate�� 211

Jian-min Yao
10 Repair of Bilateral Cleft Palate�� 237
Wei-jun Fan and Jian-min Yao
11 Repair of Alveolar Cleft�� 247
Jing-hong Xu and Jian-min Yao
12 Pharyngoplasty (Posterior Pharyngeal Flaps)�� 255
Kai Han and Jian-min Yao
13 Repair of Postpalateplasty Complications�� 257
Chiao-yun Chiu and Jian-min Yao
xiii
xiv Contents
Part IV Repair of Other Congenital Facial Deformities
14 Repair of Congenital Eye Deformity�� 269

Ze-ren Shen, Rui-yu Qing, and Jian-min Yao
15 Repair of Congenital Nasal Deformity�� 277
Yong-hong Zhu and Jian-min Yao
16 Repair of Congenital Oral Lip Deformity �� 281
Wei-hua Wu and Jian-min Yao
17 Repair of Congenital Ear Deformity�� 289
Bao Zhu, Sheng Ding, and Jian-min Yao
18 Repair of Congenital Torticollis Deformity �� 291
Ming-yuan Xu and Jian-min Yao
Part V Repair of Acquired Facial Deformity
19 Repair of Eye Defect�� 297

Jin-ping Ding and Jian-min Yao
20 Repair of Nasal Defect �� 317
Zheng-cai Wang and Jian-min Yao
21 Repair of Oral Lip Defect�� 333
Tao Zhang and Jian-min Yao
22 Repair of Auricle Defect�� 357
Xiao-feng Wang and Jian-min Yao
Epilogue�� 381
About the Editor
Jian-min Yao is Chief surgeon, the first leader of key medical

specialties in Hangzhou, a member of the fifth and sixth session of
Plastic Surgery Branch of Zhejiang Medical Association, a mem-
ber of the second session of Medical Cosmetology and Aesthetics
Branch of Zhejiang Medical Association, the vice chairman in the
first session of Society of Plastic Surgery and Microsurgery of
Hangzhou Medical Association, a member of experts for medical
malpractice appraisal of Hangzhou Medical Association, a mem-
ber of the standing committee in the first session of Hand Surgery
Branch of Zhejiang Medical Association, the vice chairman in the
first session of limb function reconstruction specialized committee
of Zhejiang Rehabilitation Medical Association, a member of spe-
cial editorial board in the seventh and eighth session of Chinese
Journal of Microsurgery, a member of communication editorial
board in the ninth session of Chinese Journal of Microsurgery, and
the vice chairman in the first session of Microsurgery Branch of
Zhejiang Medical Association.
He has published more than 50 academic papers, including 14
SCI papers and 23 papers in Chinese core journals, and obtained a
national utility model patent. Besides, he has undertaken and com-
pleted 11 provincial and municipal research projects, which
achieved advanced levels domestically and abroad, respectively. In
1995, he won the third prize of Zhejiang Science and Technology
Progress Award. In 1997, he won the third prize of scientific and
technological achievements of the Ministry of Health and the first
prize of Hangzhou Science and Technology Progress Award. He is
the chief editor of Atlas of Clinical Surgery for Hand-foot Wound
Flap Repair and Congenital Deformities of Hand and Upper Limb
in Chinese and English versions. And he was the deputy editor of
many academic monographs, Errors and Complications
Management in Plastic Surgery for example. In 1997, he studied at
Beckman Laser Institute & Medical Clinic in the University of
California. And in 2007, he visited for communication at
Luisenhospital Aachen in Germany. In 1997, he was listed as the
third-level training candidate of the trans-century scientific and
technological talents in Hangzhou.
xv
xvi About the Editor
Jing-hong Xu is medical doctor of plastic surgery, chief sur-

geon, and doctoral supervisor of Zhejiang University. He is a stu-
dent of Wang Wei, who is a famous plastic and cosmetic professor
in China. And he is in charge of the plastic surgery degree pro-
gram in the Medical College of Zhejiang University and the direc-
tor of plastic surgery in the First Affiliated Hospital of Medical
College of Zhejiang University as well. Besides, he is a member
of plastic and aesthetic surgeon branch of Chinese Medical Doctor
Association, the vice chairman of plastic surgery branch of
Zhejiang Medical Association, a member of experts for medical
malpractice appraisal of Zhejiang Medical Association, and a
member of microsurgery branch of Zhejiang Medical Association.
Being engaged in aesthetic plastic surgery career for 27 years
and participated in more than 20,000 plastic and cosmetic opera-
tions, he has obtained a national invention patent and directed
three national research projects and three provincial research proj-
ects. Also, he has published 36 SCI papers and guided 32 doctoral
students and postgraduates so far.
Part I
Classification and Operation of Cleft Lip and Palate
Classification of Cleft Lip and Palate
1
Yi-jia Yu and Jian-min Yao
1.1 Classification of Cleft Lip 1.1.1.3 U nilateral Complete Cleft Lip (Third-
Degree Cleft Lip)
Cleft lip can be classified into three groups according to the The split is completely from the upper lip to the nasal base
fissure site: unilateral cleft lip, bilateral cleft lip, and median (Fig. 1.4).
cleft lip [1].
1.1.2 Bilateral Cleft Lip

1.1.1 Unilateral Cleft Lip
Bilateral cleft lip is classified into three groups according to
Unilateral cleft lip can be classified into three levels: mini- whether the anterior jaw is protruding.
mal cleft lip, unilateral incomplete cleft lip, and unilateral
complete cleft lip. 1.1.2.1 Type One Bilateral Cleft Lip
The anterior jaw is not protruding. Both sides are first-degree
1.1.1.1 Minimal Cleft Lip (First-Degree Cleft Lip) cleft lip or second-degree cleft lip (Fig. 1.5).
The split is limited in red lip, with or without orbicularis oris
disruption (Fig. 1.1). 1.1.2.2 Type Two Bilateral Cleft Lip
The anterior jaw of one side is protruding, with third-degree
1.1.1.2 U nilateral Incomplete Cleft Lip (Second- cleft lip. The other side is first-degree cleft lip or second-
Degree Cleft Lip) degree cleft lip (Fig. 1.6).
The upper lip is partially split, and the nasal base is intact. It
can be divided into unilateral shallow second-degree cleft lip 1.1.2.3 Type Three Bilateral Cleft Lip
(the cleft is less than half of the lip height, Fig. 1.2) and uni- Bilateral anterior jaw protruding, with third-degree cleft lip
lateral deep second-degree cleft lip (the cleft is more than (Fig. 1.7).
half of the lip height, Fig. 1.3).
Y.-j. Yu
The First Affiliated Hospital, Zhejiang University School of
Medicine, Hangzhou, China
J.-m. Yao (*)
Hangzhou Plastic Surgery Hospital, Hangzhou, China
© Shanghai Scientific and Technical Publishers 2020 3

J.-m. Yao, J.-h. Xu (eds.), Atlas of Cleft Lip and Palate & Facial Deformity Surgery,
https://doi.org/10.1007/978-981-15-4419-4_1
4 Y.-j. Yu and J.-m. Yao
a b
c d
e f
Fig. 1.1 Minimal cleft lip (first-degree cleft lip). (a) split of red lip; (b) (c) split of red lip with orbicularis oris disruption; D–G crack and gap of
red lip
1 Classification of Cleft Lip and Palate 5
a b
c d
Fig. 1.2 Unilateral shallow second-degree cleft lip. (a–b) split of upper lip; (c–d) the cleft is less than half of the lip height; (e) the cleft is more
than half of the lip height and the height of two lip sides is different
a b
c d
Fig. 1.3 Unilateral deep second-degree cleft lip. (a) big split of upper lip; (b–c) the cleft is more than half of the lip height, and the nasal base is
intact; (d) an adult case
1.1.3 Median Cleft Lip 1.2.1.1 Unilateral First-Degree Cleft Palate

Cleft uvula only, with or without soft palate subfissure
The cleft is in the middle of the lip, including lip crack (Fig. 1.9).
(Fig. 1.8).
1.2.1.2 Unilateral Second-Degree Cleft Palate
Cleft soft palate, with or without partial hard palate cleft
1.2 Classification of Cleft Palate (Fig. 1.10).
Cleft palate can be classified into unilateral cleft palate and 1.2.1.3 Unilateral Third-Degree Cleft Palate
bilateral cleft palate by the fissure site. According to the degree Cleft soft and hard palate completely (Fig. 1.11).
of cracking, it can be divided into cleft uvula, cleft soft palate,
cleft soft and hard palate (first-, second-, and third-degree).
1.2.2 Bilateral Cleft Palate
1.2.1 Unilateral Cleft Palate Bilateral cleft palate can be classified into three levels: first-
degree cleft palate, second-degree cleft palate, and third-
Unilateral cleft palate can be classified into three levels: first- degree cleft palate.
degree cleft palate, second-degree cleft palate, and third-
degree cleft palate.
a b
c d
e f
Fig. 1.4 Unilateral complete cleft lip (third-degree cleft lip). (a) complete cleft lip; (b–f) unilateral complete cleft lip, from upper lip to nasal base,
with cleft alveolus
a b
c d
e f
Fig. 1.5 Type one bilateral cleft lip. (a) without anterior jaw protruding; (b–c) bilateral first-degree cleft lip; (d–f) bilateral second-degree cleft lip
1.2.2.1 Bilateral First-Degree Cleft Palate palate only) and deep second-degree cleft palate (cleft soft
Cleft uvula and soft palate subfissure (Fig. 1.12). palate and partial hard palate cleft) (Fig. 1.13).
1.2.2.2 Bilateral Second-Degree Cleft Palate 1.2.2.3 Bilateral Third-Degree Cleft Palate
Partial cleft palate (middle cleft palate, cleft soft palate, and Cleft soft and hard palate completely. The cleft is Y-shaped,
cleft palate in the back, without cleft lip or alveolar cleft), and vomer is exposed in the oral cavity. This type usually
including superficial second-degree cleft palate (cleft soft accompanies bilateral cleft lip and alveolar cleft (Fig. 1.14).
a b
c d
Fig. 1.6 Type two bilateral cleft lip. (a–b) unilateral anterior jaw protruding; (c–e) unilateral complete cleft lip
a b
c d
e f
Fig. 1.7 Type three bilateral cleft lip. (a–f) bilateral complete cleft lip; (b–f) bilateral anterior jaw protruding, with alveolar clefts and cleft
palate
a b
Fig. 1.8 Median cleft lip. (a) middle lip cleft; (b–c) red lip cleft and white lip crack
a b
Fig. 1.9 Unilateral first-degree cleft palate. (a) cleft uvula; (b) cleft uvula, one side bigger and the other side smaller; (c) cleft uvula with soft
palate subfissure
Fig. 1.9 (continued)
a b
c d
Fig. 1.10 Unilateral second-degree cleft palate. (a–c) unilateral second-degree cleft palate; (d) cleft soft palate;(e–f) cleft soft palate, with partial
hard palate cleft
e f
a b
c d
Fig. 1.11 Unilateral third-degree cleft palate. (a) unilateral third-degree cleft palate; (b–c) cleft soft and hard palate; (d) postoperative view of
cleft lip repair
a b
c d
Fig. 1.12 Bilateral first-degree cleft palate. (a–b) cleft uvula; (c–d) cleft uvula with soft palate subfissure
a b
Fig. 1.13 Bilateral second-degree cleft palate. (a–c) Bilateral second-degree cleft palate; (d) cleft soft palate; (e) partial cleft palate; (f) cleft soft
palate, with partial hard palate cleft
c d
e f
a b
Fig. 1.14 Bilateral third-degree cleft palate. (a–b) exposure of vomer; (c) cleft soft and hard palate; (d) the wide cleft of cleft palate; (e) cleft lip
and palate
c d
Reference
1. Allori AC, et al. Classification of Cleft Lip/Palate: then and now.
Cleft Palate Craniofac J. 2017;54(2):175–88.
Repair Methods for Cleft Lip and Palate
2
Liang Ma, Li-min Tang, and Jian-min Yao
The history of cleft lip and palate is very long. There are 2.1.1.3 Triangular Flap
numerous kinds of surgical method of cleft lip and palate. Triangular flap is used for adjusting red lip defects (Fig. 2.3).
They all have both advantages and disadvantages. This sec-
tion introduces several surgical methods we recommend, 2.1.1.4 Y-V Plasty
modified, or mostly used. Y-V plasty is used to increase red lip thickness (Fig. 2.4) [2].
2.1.1.5 Double-V Plasty

2.1 Repair Methods for Cleft Lip Double-V plasty is used for adjusting red lip defect (Fig. 2.5).
2.1.1 even Surgical Method of Red Lip

S 2.1.1.6 Tongue-Shaped Flap
Reparation Tongue-shaped flap is used to increase red lip thickness
(Fig. 2.6).
Red lip reparation is a major surgical part of cleft lip surgery.
Z-plasty, continuous Z-plasty, triangular flap, Y-V plasty, 2.1.1.7 Deepithelialized Flap
double-V plasty, tongue-shaped flap, and deepithelialized Deepithelialized flap is used to increase red lip thickness
flap are commonly used during cleft lip operation. (Fig. 2.7).
2.1.1.1 Z-Plasty
Z-plasty is used for adjusting red lip deformation (Fig. 2.1) [1]. 2.1.2 Surgical Method of Unilateral Cleft Lip
2.1.1.2 Continuous Z-Plasty Surgical method of unilateral cleft lip includes straight line
Continuous Z-plasty is used for adjusting red lip deforma- suture, triangular flap [3], rectangular flap, and rotating flap.
tion (Fig. 2.2).
Fig. 2.1 Z-plasty, pre-operation and post-operation
L. Ma · J.-m. Yao (*)

L.-m. Tang
Hangzhou Operation Smile Charity Hospital, Hangzhou, China

https://doi.org/10.1007/978-981-15-4419-4_2
18 L. Ma et al.
Fig. 2.2 Continuous Z-plasty, pre-operation and post-operation
Fig. 2.3 Triangular flap, pre-operation and post-operation
Fig. 2.4 Y-V plasty, pre-operation and post-operation
Fig. 2.5 Double-V plasty, pre-operation and post-operation
Fig. 2.6 Tongue-shaped flap, pre-operation and post-operation

2 Repair Methods for Cleft Lip and Palate 19
Fig. 2.7 Deepithelialized flap, pre-operation and post-operation
Fig. 2.8 Straight line suture
2.1.2.1 Straight Line Suture 2.1.3.1 Triangular Flap

Straight line suture is used for first-degree and second-degree Triangular flaps for bilateral cleft lip (Fig. 2.12).
cleft lip only (Fig. 2.8) [4].
2.1.3.2 Rectangular Flap
2.1.2.2 Triangular Flap Rectangular flap for bilateral cleft lip (Fig. 2.13).
Traditional Tennison’s method and its modified method can be
used for all kinds of cleft lip, especially for second-degree cleft 2.1.3.3 Rotary Propulsion Flap
lip. Triangular flap can lower the height of the lip [3, 5], increase Rotating flap for bilateral cleft lip (Fig. 2.14).
the length of the philtrum column. An incision in the unaffected
side can be added to adjust the height of the lip (Fig. 2.9).
2.1.4 Surgical Method of Median Cleft Lip
2.1.2.3 Rectangular Flap
Le Mesurier’s method and its modified method can be used Straight line suture is the most widely used surgical method
for all kinds of cleft lip (Fig. 2.10). of median cleft lip. It can repair the lip with minimal trauma
(Fig. 2.15).
2.1.2.4 Rotary Propulsion Flap
Traditional Millard method and its modified method can be
used for all kinds of cleft lip (Fig. 2.11). 2.1.5 Other Surgical Methods of Cleft Lip
Surgical options are affected by the degree, classification,

2.1.3 Surgical Method of Bilateral Cleft Lip and range of cleft lip. The traditional and modified surgical
methods we introduced focus on anatomical and functional
Surgical method of bilateral cleft lip includes triangular flap, repair, as well as appearance. The surgical results can be
rectangular flap, and rotating flap. Usually, we use one kind improved by optimizing surgical method, choosing appropri-
of surgical method for both sides. ate sutures, and enhancing surgical technique.
20 L. Ma et al.
a b c
d e f
g h i
Fig. 2.9 Triangular flap. (a–d) Traditional triangular flap; (e–i) Modified triangular flap
a b c
Fig. 2.10 Rectangular flap. (a–d) Design of second-degree cleft lip; (e–h) Design of third-degree cleft lip
d e f
g h
a b c
Fig. 2.11 Rotating flap. (a–b) Traditional Millard method; (c–d) Design of second-degree cleft lip
22 L. Ma et al.
a b c
d e f
g h
Fig. 2.12 Triangular flap. (a–b) Triangular flap for bilateral completely cleft lip; (c–d) Attachment of triangular flap. (e–h) Triangular flap for
bilateral incompletely cleft lip
2.1.5.1 Surgical Principles Target: close the crack, bilateral symmetry, correct posi-
Surgery: (1) Shorten the incision, decrease the trauma, and tion of philtrum column, and lessen scars.
use the simplest surgical method; (2) Good performance dur-
ing surgery and correct choice of sutures; (3) Fix vertical 2.1.5.2 Surgical Method of Unilateral Cleft Lip
defect by horizontal tissue. Choose appropriate surgical techniques according to the
Design: (1) Plane design for skin and mucous, three- degree of the cleft lip:
dimensional design for deeper muscles; (2) The shape of the
lip and lip subunit should be considered during the design of 1. Surgical method of unilateral first-degree cleft lip: straight
the incision. Deep tissue such as muscles determines the 3-D line suture and triangular flap (Fig. 2.16).
effect of the lip; (3) Flexible and maneuverable design
throughout the surgical procedure.
a b c
d e f
g h i
Fig. 2.13 Rectangular flap. (a–d) Design of rectangular flap for bilateral cleft lip; (e–i) Design of rectangular flap to increase the height of the lip,
the incision is in the white lip
2. Surgical method of unilateral second-degree cleft lip: 2.1.5.3 Surgical Method of Bilateral Cleft Lip
straight line suture, triangular flap, and rotating flap. Triangular flap, rectangular flap, and rotating flap can be
Figure 2.17 shows the surgical method of unilateral chosen by the cleft degree of bilateral cleft lip (Figs. 2.20
shallow second-degree cleft lip and Fig. 2.18 shows and 2.21). Figure 2.20 shows the surgical method of bilat-
the surgical method of unilateral deep second-degree eral first-degree cleft lip. Figure 2.21 shows the surgical
cleft lip. method of bilateral second-degree cleft lip. Bilateral third-
3. Surgical method of unilateral third-degree cleft lip: trian- degree cleft lip can choose triangular flap (Fig. 2.22), rect-
gular flap, rectangular flap, and rotating flap (Fig. 2.19). angular flap (Fig. 2.23), and rotating flap (Fig. 2.24).
24 L. Ma et al.
Fig. 2.14 Rotary propulsion flap before and after operation
Fig. 2.15 Straight line suture for median cleft lip
2.1.5.4 Surgical Method of Median Cleft Lip 2. Upper lip concave: V-Y plasty to repair mild upper lip
Straight line suture is the most used surgical method of concave. Multiple surgical methods are used in severe
median cleft lip (Fig. 2.25). upper lip concave, such as triangular flap, rectangular
flap, and rotating flap (Figs. 2.28, 2.29, 2.30, and 2.31).
2.1.5.5 S urgical Method of Cleft Lip Secondary Figure 2.28 shows the procedure of V-Y plasty, V shape
Deformation incision, and Y shape suture. Figure 2.29 shows the proce-
Lip and nose deformation are the main deformations of cleft dure of triangular flap, undersurface dissection, and lay-
lip secondary deformation. ered suture. Figure 2.30 shows the procedure of
rectangular flap. Figure 2.31 shows the procedure of
1. Irregularity of red lip: straight line suture (Fig. 2.26) or rotating flap, additional nostrils incision is needed if there
Z-plasty (Fig. 2.27). is nasal deformity.
a b c
Fig. 2.16 Surgical method of unilateral first-degree cleft lip. (a) Unilateral first-degree cleft lip; (b) Straight line incision; (c) Triangular flap
a b c
d e
Fig. 2.17 Surgical method of unilateral shallow second-degree cleft lip. (a) Unilateral shallow second-degree cleft lip; (b) Straight line suture;
(c–d) Triangular flap; (e) Rotating flap
3. Labial arch deformation: if the edge of the red lip is not nasal tip deformation. Figure 2.35 shows the procedure
obvious, the lip shape can be reconstructed. Design a new of crescent-shaped resection. Figure 2.36 shows the pro-
shape of the labial arch, remove the scar according to the cedure of nasal alar cartilage reshaping: explosion of
shape (Fig. 2.32). nasal alar cartilage, adjusting of the position, and
4. Red lip height deformation: Z-plasty is mostly used for fixation.
loosening scars and adjusting the height of the red lip 7. Nostril basal fissure: Diamond resection is used for mild
(Fig. 2.33). nostril basal fissure (Fig. 2.37). V-Y plasty is used for
5. Lip defect: R flap is mostly used for lip defect reparation. severe nostril basal fissure (Fig. 2.38).
Transfer the pedicle tissue flap from the lower lip to the 8. Nostril collapse: Advancement flap and Z-plasty are used
upper lip. Pedicle division after 2–3 weeks (Fig. 2.34). for nostril collapse. V shape resection of scar, take a slid-
6. Nasal tip deformation: nasal tip deformation including ing incision at the base of the nostril, and make it an
twist of nasal tip and skew of nasal tip. Crescent-shaped advancement flap (Fig. 2.39). Adjust the size of the nostril
resection and nasal alar cartilage reshaping are used for by transferring local tissue with Z-plasty (Fig. 2.40).
26 L. Ma et al.
a b
b c
d e f
g h
Fig. 2.18 Surgical method of unilateral deep second-degree cleft lip. (a) Unilateral deep second-degree cleft lip; (b–e) Triangular flap; (f–g)
Rectangular flap; (h) Rotating flap
9. Nostril asymmetry: Z-plasty in alar foot can adjust nostril 2. Reconstruction of palatopharyngeal closure function.
asymmetry (Fig. 2.41). 3. Separate tissue gently to protect the blood supply.
10. Drooping nasal tip: Fig. 2.42 shows V-Y plasty of droop- 4. Surgical safety: hemostasis, prevention of foreign object,
ing nasal tip. Figure 2.43 shows the rectangular flap of and airway maintenance.
drooping nasal tip.
11. Excessively short lip column: W-plasty is used for 2.2.1.2 Design Principles
excessively short lip column (Fig. 2.44). 1. Least damage: avoid unnecessary damage.
2. Enough blood supply of the flap.
3. Accurate cutting, do not waste any tissue.
2.2 Repair Methods for Cleft Palate 4. Sufficient separation of the flap, suture without tension.
2.2.1 Surgical Principles and Surgical Target 2.2.1.3 Target

1. Closing the cleft is the main target of reparation.
2.2.1.1 Surgical Principles 2. Palatopharyngeal closure is the anatomical and physio-
1. Close the cleft. logical basis of vocalization.
a b c
Fig. 2.19 Surgical method of unilateral third-degree cleft lip. (a) Unilateral third-degree cleft lip; (b) Rectangular flap; (c) Triangular flap; (d)
Rotating flap
a b c
Fig. 2.20 Surgical method of bilateral first-degree cleft lip. (a-b) Rectangular flap; (c) Triangular flap
2.2.2 Surgical Method of Cleft Palate nique, vomer flap [6, 8], gingival crevicular flap, etc.
Selection of appropriate surgical method is decided by the
Numerous surgical methods were used in cleft palate, includ- degrees of cleft palate. Figures 2.45, 2.46, 2.47, 2.48, 2.49,
ing straight line suture, rotating reverse flap, Langenbeck’s 2.50, 2.51, 2.52, 2.53, 2.54, and 2.55 shows the design of
technique, Dorrance’s technique, two flap method [6], three different surgical methods.
flap method, four flap method, Z-plasty [7], Furlow’s tech-
28 L. Ma et al.
a b c
Fig. 2.21 Surgical method of bilateral second-degree cleft lip. (a–b) Rectangular flap; (c) Triangular flap
Fig. 2.22 Surgical method of

bilateral third-degree cleft lip
(triangular flap)
Fig. 2.23 Surgical method of

bilateral third-degree cleft lip
(rectangular flap)
2.2.3 Selection of Surgical Method 1. Straight line suture: incision in the edge of cleft, layered
suture nasal mucosa, muscular layer, and pharyngeal
2.2.3.1 Cleft Uvula (First-Degree Cleft Palate) mucosa. The muscle layer should be sutured with (3–0)
The degree of cleft palate is mild; straight line suture and absorbable sutures, and the mucosa can be sutured with
rotating reverse flap can be chosen to close the cleft: (3–0, 4–0, 5–0) nonabsorbent sutures (Fig. 2.56).
Fig. 2.24 Surgical method of bilateral third-degree cleft lip (rotating flap)
a b
Fig. 2.25 Surgical method of median cleft lip (straight line suture). (a) First-degree cleft lip; (b) Second-degree cleft lip
Fig. 2.26 Irregularity of red

lip (straight line suture). (a) a b
design; (b) straight line suture
2. Rotating reverse flap: Design a tongue-shaped flap in the cleft palate. Other surgical methods, such as Z-plasty,
hard palate, make the pedicle in the soft palate, repair the Furlow’s technique, and gingival crevicular flap also can be
cleft uvula and separate the flap, rotate the flap to extend chosen:
the palatal flap, and layered suture (Fig. 2.57).
1. Dorrance’s technique: take an arc incision in the hard pal-
2.2.3.2 Second-Degree Cleft Palate ate, separate the flap to extend the palatal flap, and close
Dorrance’s technique, Langenbeck’s technique, two flap the cleft (Fig. 2.58).
method, three flap method are mostly used for second-degree
30 L. Ma et al.
Fig. 2.27 Irregularity of red

lip (Z-plasty). (a–b) different
a
design of Z-plasty
Fig. 2.28 Upper lip concave

(V-Y plasty)
2. Langenbeck’s technique: take two incisions as the design, 2.2.3.3 Third -Degree Cleft Palate
separate the flap to extend the palatal flap, and close the Surgical methods, such as Langenbeck’s technique, two flap
cleft (Fig. 2.59). method, three flap method, four flap method, Z-plasty, vomer
3. Two flap method: take the incisions as the design and flap, and gingival crevicular flap can be chosen for third-
make it two flaps whose pedicle is in the soft palate, degree cleft palate:
extend the palatal flap, and close the cleft (Fig. 2.60).
4. Three flap method: take the incisions as the design and 1. Langenbeck’s technique: take two incisions as the design,
make it three flaps, separate the flap and rotate the separate the flap to extend the palatal flap, and close the
flap to extend the palatal flap, and close the cleft cleft (Fig. 2.64).
(Fig. 2.61). 2. Two flap method: take two incisions as the design, make
5. Z-plasty: take a Z-shaped incision in the soft palate the pedicle in the soft palate, separate the flap to extend
(Fig. 2.62). the palatal flap, and close the cleft (Fig. 2.65).
6. Furlow’s technique: The solid line shows the pharyngeal 3. Three flap method: take the incisions as the design and
side incision, and the dotted line shows the nasal side make it three flaps, separate the flap and rotate the flap to
incision. Reverse Z-plasty suture (Fig. 2.63). extend the palatal flap, and close the cleft (Fig. 2.66).

(triangular flap). (a) design in a
the edge of red lip; (b) design
in the white lip

(rectangular flap)
32 L. Ma et al.

(rotating flap)
Fig. 2.32 Reconstruction of

labial arch deformation
Fig. 2.33 Z-plasty of red lip

height deformation
a b c
d e
Fig. 2.34 R flap of lip defect. (a–c) design of small lip defect; (d–e) design of big lip defect
Fig. 2.35 (a) Crescent-

shaped resection of nasal tip a
deformation, (b) Z-plasty in
nostril, (c) V-Y plasty are
used for nostril collapse
34 L. Ma et al.

b
Fig. 2.36 Nasal alar cartilage reshaping of nasal tip deformation

Fig. 2.37 Diamond resection

of nostril basal fissure
Fig. 2.38 V-Y plasty of

nostril basal fissure
Fig. 2.39 Advancement flap

of nostril collapse
36 L. Ma et al.
Fig. 2.40 Z-plasty of nostril collapse
Fig. 2.41 Z-plasty of nostril

asymmetry
Fig. 2.42 V-Y plasty of

drooping nasal tip. (a) Classic
a
V-Y plasty; (b) Butterfly-
shaped incision and umbrella-
shaped suture; (c)
Butterfly-shaped incision and
T-shaped suture
c
c
Fig. 2.43 Rectangular flap of

drooping nasal tip
38 L. Ma et al.
Fig. 2.44 W-plasty of

excessively short lip column
Fig. 2.45 Straight line suture Fig. 2.46 Rotating reverse flap
a b
Fig. 2.47 Langenbeck’s technique. (a) Second-degree cleft palate; (b) Third-degree cleft palate
mucosa. Suture the remaining muscle layer and the pha-

ryngeal mucosa, and close the cleft (Fig. 2.69).
7. Gingival crevicular flap: design a tongue-shaped gingival
crevicular mucosal flap, and repair the wound between
soft and hard palate with the flap (Fig. 2.70).
2.2.3.4 Secondary Malformation of Cleft Palate

Secondary malformation of cleft palate includes palatal fis-
tula, cleft palate again, and velopharyngeal incompetence
(VPI). Surgical methods such as tension suture, rotate ten-
sion suture, single flap rotate method, and two flap method
can be used for secondary malformation of cleft palate:
1. Palatal fistula: different surgical methods are chosen by

the location of the palatal fistula. Figure 2.71 shows the
Fig. 2.48 Dorrance’s technique (single flap method) design of tension suture. Figure 2.72 shows the design of
rotate tension suture. Figure 2.73 shows the design of
single flap rotate method. Figure 2.74 shows the design of
4. Four flap method: take the incisions as the design and two flap method.
make it four flaps, separate the flap and rotate the flap 2. Cleft palate again: caused by poor wound healing, the pal-
to extend the palatal flap, and close the cleft (Fig. 2.67). ate cleft again. Tension suture is mostly used for it
5. Z-plasty: separate the palatal flap, and take a Z-shaped (Fig. 2.75).
incision in the soft palate, and close the cleft (Fig. 2.68). 3. Velopharyngeal insufficiency (VPI): narrow the pharynx
6. Vomer flap: take the incisions as the design and separate by posterior pharyngeal rectangular flap (Fig. 2.76).
the flap. The nasal mucosa is sutured with the vomer
40 L. Ma et al.
a b
Fig. 2.49 Two flap method. (a) Second-degree cleft palate; (b) Third-degree cleft palate
Fig. 2.50 Three flap method

Fig. 2.52 Z-plasty
Fig. 2.51 Four flap method Fig. 2.53 Furlow’s technique

Fig. 2.54 Vomer flap Fig. 2.55 Gingival crevicular flap
Fig. 2.56 Straight line suture
Fig. 2.57 Rotating reverse flap

42 L. Ma et al.
Fig. 2.58 Dorrance’s technique (single flap method)
Fig. 2.59 Langenbeck’s technique

Fig. 2.60 Two flap method
a b
Fig. 2.62 Z-plasty

44 L. Ma et al.
Fig. 2.63 Furlow’s technique
Fig. 2.64 Langenbeck’s technique
Fig. 2.65 Two flap method

Fig. 2.67 Four flap method

46 L. Ma et al.
Fig. 2.68 Z-plasty
Fig. 2.69 Vomer flap

Fig. 2.70 Gingival crevicular flap
Fig. 2.71 Tension suture of palatal fistula

48 L. Ma et al.
Fig. 2.72 Rotate tension suture of palatal fistula
Fig. 2.73 Single flap rotate method of palatal fistula
Fig. 2.74 Two flap method of palatal fistula

Fig. 2.75 Tension suture of cleft palate again
Fig. 2.76 Posterior pharyngeal rectangular flap for velopharyngeal insufficiency
References 5. Koh KS, Oh TS, Song JW. Upper triangular flap method for primary
repairs of incomplete unilateral cleft lip patients. Ann Plast Surg.
2015;74(3):318–23.
1. Scheller K, et al. Objective evaluation of vertical Z-plasty with
6. Rossell-Perry P. Two methods of cleft palate repair in patients
double transposition vermillion flaps for secondary whistling
with complete unilateral cleft lip and palate. J Craniofacial Surg.
deformity correction: A method for uni- and bilateral correction. J
2018;29(6):1473–9.
Craniomaxillofac Surg. 2019;47(10):1557–62.
7. Baek RM, et al. The effect of age at surgery and compensatory
2. Cho BC, et al. The correction of a secondary bilateral cleft lip nasal
articulation on speech outcome in submucous cleft palate patients
deformity using refined open Rhinoplasty with reverse-U Incision,
treated with double-opposing Z-plasty: A 10-year experience. J
V-Y plasty, and selective combination with composite grafting:
Plast Reconstr Aesthet Surg. 2017;70(5):646–52.
long-term results. Arch Plast Surg. 2012:39(3).
8. Smarius BJA, Breugem CC. Use of early hard palate closure using a
3. Aranmolate S, et al. Upper triangular flap in unilateral cleft lip
vomer flap in cleft lip and palate patients. J Cranio-Maxillofac Surg.
repair. J Craniofacial Surg. 2016;27(3):756–9.
2016;44(8):912–8.
4. Baek RM, Choi JH, Kim BK. Practical repair method for unilateral
cleft lips: straight-line advanced release technique. Ann Plast Surg.
2016;76(4):399–405.
Surgical Instruments of Cleft Lip
and Palate 3
Wen-yang Wang, Yun-ping Huang, and Jian-min Yao
3.1 Surgical Instruments for Cleft Lip
3.1.1 Cleft Lip Surgical Kit
Seventeen instruments are included: 1 scalpel (3#), 1 needle

holder, 2 ophthalmic scissors (straight, elbow), 1 tissue scis-
sors, 4 mosquito clamps (2 straight, 2 elbow), 1 ophthalmic
tweezers (toothed), 2 plastic tweezers (toothed, non-toothed),
1 claw retractor, 1 double-claw retractor, 2 tissue forceps,
and 1 measuring cup (Fig. 3.1).
3.2 Surgical Instruments for Cleft Palate

Fig. 3.1 Surgical instruments of cleft lip
3.2.1 Cleft Palate Surgical Kit
Sixteen instruments are included: 1 scalpel, 1 tonsil scissors,

1 straight scissors, 1 tissue scissors, 2 vessel clamps, 2 twee-
zers (toothed, non-toothed), 1 tonsil stripper, 1 nasal septum
stripper, 1 periosteal detacher, 1 needle holder, 2 tissue for-
ceps, 1 measuring cup, and 1 kidney basin (Fig. 3.2).
3.2.2 Cleft Palate Mouth Gag
Six instruments are included: 1 frame, 3 tongue plate retrac-

tors, and 2 mouth hooks (Fig. 3.3).
3.3 lacement and Removal of the Mouth

P
Gag
Fig. 3.2 Surgical instruments of cleft palate
Figure 3.4 shows the usage of mouth gag.
W.-y. Wang
Y.-p. Huang · J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_3
52 W.-y. Wang et al.
Fig. 3.3 Cleft palate mouth gag
a b
c d
Fig. 3.4 Usage of mouth gag. (a) Lift up the mouth gag; (b) Put in the hooks; (h) Postoperative position; (i) Fixate the cannula with thumb; (j)
tongue plate; (c) Check the tracheal slot; (d) Put the retractors; (e) Open Loosen the spring, remove the hook; (k) Remove the tongue plate; (l)
the mouth; (f) Observe the position of the cannula; (g) Put in the mouth Remove the mouth gag; (m) Operative position
3 Surgical Instruments of Cleft Lip and Palate 53
e f
g h
i j

54 W.-y. Wang et al.
k l

Special Suture Technique
4
Wei-qiang Tan and Jian-min Yao
4.1 Suture Technique for Cleft Lip ing the nylon, pull the needle back to the subcutaneous dermis.
Reenter the separation area, make a single ring or multiple
4.1.1 Triangular 3-D Suture circles, knotted through the nostril (Figs. 4.3 and 4.4).
4.1.1.1 Usage
Triangular 3-D suture is particularly suitable for sutures of 4.2 Suture Technique for Cleft Palate
triangular flaps in cleft lip. [1]
The suture of the cleft palate is usually very deep. The ten-
4.1.1.2 Method sion of the palate flap is high. To make the closure reliable,
There are two ways of triangular 3-D suture (Figs. 4.1 and we can choose these suture techniques: double-loop suture,
4.2). deep single-loop suture, U-shaped closure, and double-cross
suture.
4.1.1.3 Summary
1. Advantage: easy to operate, smaller damage, only one
knot; the tension is evenly distributed, and the tissue is 4.2.1 Double-Loop Suture
closed in three dimensions; no block to the blood supply
to the tip of the triangular flap. 4.2.1.1 Method
2. Surgical points: each time the needle is inserted from one It is similar as vertical mattress suture, insert from deep
side; each point is in and out two times (three times of layer, out from shallow layer, make a cross in the deep to
point O in apex method); 3-D network suture; use non- close the cleft (Fig. 4.5).
absorbable suture, such as nylon or silk.
4.2.1.2 Advantage
The deep tissue is tightly closed and the closure is reliable.
4.1.2 Nasal Tractive Suture Anti-tension suture makes deep tissue reliably closed as well
as shallow surface well combined.
4.1.2.1 Usage
Nasal tractive suture is used for nasal deformity such as alar
collapse. It can lift up the ala nasi. 4.2.2 Deep Single-Loop Suture
4.1.2.2 Method 4.2.2.1 Method

Separate the alar cartilage first, then insert from the opposite Insert to deep layer, make a single-loop in the deep to close
side of the nasal back, inserted through the nostril and thread- the cleft, out from shallow layer (Figs. 4.6 and 4.7).
4.2.2.2 Advantage
W.-q. Tan No knots are left in the tissue after the stitch is removed.
Sir Run Run Shaw Hospital, Zhejiang University School of According to the pulley principle, the strength of tension
reduction is twice than simple suture. So, the closure is more
J.-m. Yao (*) reliable.

https://doi.org/10.1007/978-981-15-4419-4_4
56 W.-q. Tan and J.-m. Yao
a b
c d
e f
Fig. 4.1 Triangular 3-D suture (trilateral method). (a) Design: point O Point b in; (e) Point O out; (f) Point a in, point b out; (g) Lift the thread;
is the third point of angular bisector, make the extension lines of the two (h) Tie; I Trimming; (j) First needle; (k) Second needle; (l) Third nee-
vertical lines through point O, find points a and b are equal to the mar- dle; (m) Adjust; (n) Tie; (o) Postoperative; (p) The first day after
gin of the point O; (b) Triangular flap; (c) Point a in, point O out; (d) surgery
4 Special Suture Technique 57
g h
i j
k l

m n
o p
4.2.3 U-Shaped Closure 4.2.4 Double Cross Suture
4.2.3.1 Method 4.2.4.1 Method

It is used for closure of the palate flap and reduction of ten- It is used for closure of nasal mucosa and periosteum
sion (Fig. 4.8). (Fig. 4.9).
4.2.3.2 Advantage 4.2.4.2 Cautions

No knots are left in the tissue after the stitch is removed. Not commonly used because of operational complexity. It
can be selected according to clinical conditions.
a b
c d
e f
Fig. 4.2 Triangular 3-D suture (apex method). (a) Design: point O, Point O out; (g) Lift the thread; (h) Tie; (i) Trimming; (j) Clinical case;
points a and b are the same, point w is in the angular bisector, make the (k) Point w in, point O out; (l) Point a in; (m) Point O out; (n) Point b
distance between point O and point w to the triangle point is equal; (b) in, point O out; (o) Adjust; (p) Tie and trimming; (q) 3 months after
Point w in, point O out; (c) Point a in; (d) Point O out; (e) Point b in; (f) surgery
g h
i j
k l

m n
o p

a b
c d
Fig. 4.3 Nasal tractive suture. (a) Single ring suture; (b–c) Multiple circles suture; (d) Knotted through the nostril
a b
Fig. 4.4 Nasal tractive suture (clinical case). (a) Alar collapse; (b) ous dermis; (g) Reenter the separation area; (h) Pull out the thread; (i)
Incision; (c) Separate; (d) Insert from the opposite side of the nasal Knotted through the nostril
back; (e) Threading the nylon; (f) Pull the needle back to the subcutane-
c d
e f
g h

a b
c d
e f
Fig. 4.5 Double-loop suture. (a) Cleft palate; (b) Insert to deep layer; Tie; (h) Trimming; (i) Cleft palate; (j) Double-loop suture; (k) One
(c) Out from shallow layer; (d) Insert from shallow layer; (e) Insert week after surgery
from deep layer and out from shallow layer; (f) Pull out the thread; (g)
g h
i j

a b
c d
e f
Fig. 4.6 Deep single-loop suture. (a) Cleft palate; (b) Insert to deep layer; (c) Sewed over the opposite deep layer; (d) Insert into deep layer again;
(e) Out from shallow layer; (f) Make a single-loop; (g) Pull out the thread; (h) Adjust; (i) Tie; (j) Trimming
g h
i j
a b
Fig. 4.7 Deep single-loop suture (clinical usage). (a) Subcutaneous mass; (b) Excision; (c) Insert to deep layer; (d) Sewed over the opposite deep
layer; (e) Insert into deep layer again; (f) Out from shallow layer; (g) Three deep single-loop sutures; (h) Tie; (i) Trimming; (j) Dressing
c d
e f
g h

i j
a b
c d
Fig. 4.8 U-shaped closure. (a) Insert to deep layer; (b) Cross suture in Close the cleft; (h) Tie and trimming; (i) Clinical usage; (j) U-shaped
the deep layer; (c) Out from shallow layer; (d) U-shaped suture; (e) suture; (k) Tie and trimming
Another U-shaped suture in the opposite; (f) Two U-shaped sutures; (g)
e f
g h
i j

a b
c d
e f
Fig. 4.9 Double-cross suture. (a–b) method I; (c–i) method II. (a) Cross suture of two layers; (b) Pull out the thread and tie; (c) Pre-operation;
(d) Insert from shallow flap; (e) Out from deep flap; (f) Insert from deep flap; (g) Out from shallow flap; (h) Tie; (i) Trimming
g h
Reference
1. Wang X-F, et al. Clinical application of 3-dimensional continu-
ous suturing technique for triangular wounds. Ann Plast Surg.
2018;81(3):316–21.
Part II
Repair of Cleft Lip
Repair of Unilateral Cleft Lip
5
Cheng Liu and Jian-min Yao
5.1 Grade 1 Unilateral Cleft Lip 5. Notes: Relaxation suture should be used when it comes to
submucosa.
Case 1 6. Operation steps: Shown in Fig. 5.2.
1. Introduction of medical history: 3-year-old boy suffers
Grade 1 unilateral cleft lip, vermillion of the upper lip
cleft, and depressed deformity. Case 3
2. Clinical manifestations: 1 mm vermillion of the lip sub- 1. Introduction of medical history: 18-year-old male suffers
fissure, tiny depression, and sulcus defect. The left phil- Grade 1 left partial cleft lip with a slight cleft of the red
trum ridge is flat and subcutaneous subfissure. lip and partial subfissure of the lip white.
3. Surgical methods: (1) Fusiform excision and straight-line 2. Clinical manifestations: 3 mm depression of the red lip with
repair. (2) Subcutaneous subfissure, mattress-suture, and flat philtrum ridge, uneven red lips, subcutaneous fissure.
fixation. 3. Surgical methods: (1) Inferior triangular flap method. (2)
4. Operation points: (1) Design the incision only at the cleft V-Y plasty of intraoral mucosa of the red lips.
lip. (2) The separation path of white lip is to enter from 4. Operation points: (1) The apex angle is 30°. (2) The angle
the wound and separate subcutaneously. insertion tangent is 2 mm parallelly above the lip line.
5. Notes: No incision on subcutaneous subfissure. 5. Notes: Design a triangular flap at the dry and wet junction
6. Operation steps: Shown in Fig. 5.1. of the lip red mucosa, then insert it into the opposite side
to adjust the depression of lip red.
6. Operation steps: Shown in Fig. 5.3.
Case 2
1. Introduction of medical history: 19-year-old female suf-
fers Grade 1 right partial cleft lip with a slight cleft of the 5.2 Unilateral Grade 2 Cleft Lip
red lip.
2. Clinical manifestations: 2 mm fissure of the red lip with Case 1
flat philtrum ridge, uneven red lips, subcutaneous subfis- 1. Introduction of medical history: A 12-year-old female
sure, and different sizes of nostrils. with postoperative deformity of left cleft lip.
3. Surgical methods: (1) Diagonal triangular flap method. 2. Clinical features: Scarring and uneven red mucosa of the
(2) V-Y plasty of the nasal base [1]. upper lip with deformity of unequal height.
4. Operation points: (1) The angle of the diagonal triangular 3. Surgical method: Triangular flap [2].
flap is 60°. (2) The Y length tangent at the base of nose is 4. Techniques: (A) Excise the left upper lip scar. (B) Insert a
the difference between the diameter of the two nostrils small triangular flap to lower the lip height on the affected
(Pay attention to skin flexibility). side. (C) Angle-3D suture [3].
5. Notes: Insert the small triangular flap 2 mm above the lip
margin so that the scar will be relatively hidden.
6. Notes: Insert the small triangular flap 2 mm parallel to the
C. Liu superior margin of the lip so that the scar will be rela-
Jiangxi Provincial People’s Hospital, Nanchang, China
tively hidden.
J.-m. Yao (*) 7. Surgical steps (Fig. 5.4).

https://doi.org/10.1007/978-981-15-4419-4_5
76 C. Liu and J.-m. Yao
a b
c d
e f
Fig. 5.1 Grade 1 unilateral cleft lip repair. (a) Depression of the red lip head to facilitate mattress suture (i) Mattress suture of white and red lip
(b) Incise mucosa (c) Surface Excision (d) Dotted line: Scope of subfis- (j) Layer sutured and the operation completed (k) Satisfactory appear-
sure separation (e) Stealth separation with miniature scissors (f) Pin- ance 1 day after the operation
threading (g) Subcutaneous U-shaped suture (h) Tighten the thread
5 Repair of Unilateral Cleft Lip 77
g h
i j

Fig. 5.2 Grade 1 right partial cleft lip repair. (a) Deformity of the red the bottom of the depression (i) Suture traction and fixation (j) Diagonal
lip (b) Posture during the operation (c) Design of the incision (d) suture (k) Skin suture (l) Design the incision of at the nasal crus (m)
Incision of the mucosa (e) Superficial tissue excision (f) Formation of a skin incision (n) Lift the triangular flap (o) Suture layer by layer (p) The
subcutaneous pedicle flap (g) Reversal the flap (h) Deliver the flap to surgery is completed and the depression is repaired
g h
i j
kk l

m n
o p
a b
Fig. 5.3 Grade 1 left incomplete cleft lip repair. (a) Upper lip deformity (b) Preoperative design (c) Morphology after operation (d) One day after
the operation, the appearance is well repaired
c d
a b
c d
Fig. 5.4 (a) II-degree left cleft lip. (b) Incision design. (c) Incise the mucosa. (i) Angle-3D suture and the first stitch. (j) The second stitch.
surface layer. (d) Excise the surface layer. (e) Subcutaneous suture. (f) (k) The third stitch. (l) Stitch display. (m) Tighten the suture. (n) Knot.
Suture the muscle layer. (g) Suture the muscle layer. (h) Suture the (o) Suture the skin and mucosa. (p) Postoperative day one
e f
g h
i j

k l
m n
o p

Case 2 4. Techniques: (A) Align the labial margin and suture accu-
1. Introduction of medical history: A 5-month-old infant rately. (B) Design parallel incision on the upper red lip
with left upper cleft lip. with lip sulcus margin.
2. Clinical features: Upper red lip slightly split with severe 5. Notes: When suturing red lip, the dry red lip on the
groove deformity. exposed side should be sutured first.
3. Surgical method: Inferior triangular flap. 6. Surgical steps (Fig. 5.5).
a b
c d
e f
Fig. 5.5 (a) Left unilateral II-degree cleft lip. (b) Predesign of incision. (c) Incision design during operation. (d) Incision of skin and mucosa. (e)
Separation of the muscle layer. (f) Suture of subcutaneous tissue. (g) Suture of incision. (h) One day after operation
g h
Case 3 Case 5
1. Introduction of medical history: 10-month-old boy, suf- 1. Introduction of medical history: A 6-month-old boy suffers
fers Grade 2 left cleft lip, with cleft deformity of both red Grade 2 left cleft lip, and upper red lip and partial white lip
and white lip. splitting deformity, with teeth exposed obviously.
2. Clinical manifestations: A maximum fissure is 5 mm, 2. Clinical manifestations: A 4 mm strip-shaped fissure
without reaching basis nasi. presents at the white and red lip, not reaching the basis
3. Surgical methods: Inferior triangular flap method. nasi, lifting the left philtrum column.
4. Operation points: (1) The sharp angle is 30°. (2) The 3. Surgical methods: (1) Inferior triangular flap method. (2)
angle insertion tangent is 2 mm parallelly above the lip Z-plasty at philtrum column [4].
line. 4. Operation points: Use triangular flap + Z-plasty to
5. Notes: Design a triangular flap at the dry and wet junction decrease the lip height.
of the lip red mucosa, then insert it into the opposite side 5. Notes: Before suturing and closing the white lip, the
to adjust the depression of the vermilion of the lip. mucosa of the red lip is suggested to be sutured first to
6. Operation steps: Shown in Fig. 5.6. make it easier to fold.
6. Operation steps: Shown in Figs. 5.7 and 5.8.
Case 4
1. Introduction of medical history: An 8-month-old girl suf- Case 6
fers Grade 2 left cleft lip, vermilion of the lip and partial 1. Introduction of medical history: A 6-year-old boy suffers
white lip cleft, nostril asymmetry. Grade 2 left cleft lip, with red and white lip cleft defor-
2. Clinical manifestations: The maximum fissure is 3 mm, mity, not reaching the basis nasi.
without reaching the basis nasi, but lifting the left phil- 2. Clinical manifestations: With a 6-mm width and 8 mm
trum column. height fissure at the upper lip, a 4-mm height difference
3. Surgical methods: Inferior triangular flap method. presents at the lip.
4. Operation points: (1) The point angle is 30°. (2) The angle 3. Surgical methods: (1) Inferior triangular flap method. (2)
insertion tangent is 2 mm parallelly above the lip line. Z-plasty at philtrum column.
5. Notes: At the edge of dry and wet area of mucosa, design 4. Operation points: Use triangular flap + Z-plasty to reduce
a triangular flap inserting to the opposite side, and adjust the lip height.
the sunken area of the vermilion of the lip. 5. Notes: Z-plasty is a common and useful repair method,
6. Operation steps: Shown in Fig. 5.7. and plays a greater role in reducing the lip height.
a b
c d
e f
Fig. 5.6 Grade 2 left cleft lip repair (a) Left cleft lip (b) Intubation superfluous tissue (p) Align lip margin (q) Adjust the mucosa (r)
anesthesia (c) Design the incision (d) Mucosa tangent (e) Liquid swell- Z-plasty (s) Suture the triangle (t) Skin suture complete (u) One day
ing anesthesia (f) Cut open the shallow layer (g) Skin separation (h) Lift after the operation, the appearance is well repaired (v) Two years after
the incisal margin (i) Expose the muscle layer (j) Separate the muscle the operation, the fissure was repaired, but the deformity of the red lip
layer (k) Suture the muscle layer (l) Complete suture of the muscle remained
layer (m) Muscle layer examination (n) Inverting suture (o) Remove the
g h
i j
k l

m n
o p
q r

s t
u v
Case7 2. Clinical manifestations: A 7-mm width, 8-mm height

1. Introduction of medical history: 11-month-old boy, suf- upper lip incomplete fissure presents a reduction of the
fers Grade 2 left cleft lip, left upper cleft lip, reaching the philtrum column at the healthy side.
upper middle part of the lip. 3. Surgical methods: Inferior triangular flap method.
2. Clinical manifestations: A 7 mm width, 8 mm height fis- 4. Operation points: Use triangular flap method to reduce
sure at the upper lip, with a 3-mm difference in the lip the height of the lip.
height. 5. Notes: Fold the muscular layer, and structure the basic
3. Surgical methods: (1) Inferior triangular flap method. (2) shape.
Z-plasty at philtrum column. 6. Operation steps: Shown in Fig. 5.11.
4. Operation points: Use triangular flap +Z-plasty to reduce
the lip height.
5. Notes: Separating and releasing the muscle is important. Case 9
6. Operation steps: Shown in Fig. 5.10. 1. Introduction of medical history: A boy of 2 years and
3 months old suffers Grade 2 left cleft lip, with a fissure
exceeding the middle and upper part of the lip, and nasal
Case 8 deformity.
1. Introduction of medical history: A 7-year-old boy suffers 2. Clinical manifestations: The upper lip has an incomplete
Grade 2 right cleft lip reaching the upper middle part of fissure that is 8 mm wide and 8 mm in height, with a
the lip. reduced upper lip height at the healthy side.
a b
c d
e f
Fig. 5.7 Grade 2 left cleft lip repair. (a) Preoperative deformity (b) val groove (o) Suture the muscle layer (p) Strengthen the muscular
Design the skin incision (c) Design the mucosa incision (d) Complete layer (q) Suture the skin (r) Suture the triangle (s) Observe the appear-
the designing (e) Cut open the skin (f) Raise the flap (g) Expose the ance (t) Suture the mucosa (u) Separate the nose foot (v) Suture the
muscle layer (h) Incision of the uninjured side (i) Separate the muscle basis nasi (w) Fold the nose foot (x) Suture the skin (y) Complete the
layer (j) Expose the deep layer (k) Release the muscular layer (l) Trim suture (z) One day after the operation, the appearance is well repaired
the mucosa (m) Examination of the mucosa (n) Release the labiogingi-
g h
i j
k l

m n
o p
q r

s t
u v
w x
y z

a b
c d
e f
Fig. 5.8 Grade 2 left cleft lip repair (Step 2). (a) Separate the vermil- result (l) Suture closely (m) check up the appearance(n) Fold the labial
ion of the lip (b) Suture the muscle layer (c) Fold the vermilion of the line (o) Suture and fixing (p) Suture the skin (q) Suture the mucosa (r)
lip (d) check up vermilion of the lip (e) Suture the vermilion of the lip Observe the vermilion of the lip (s) Complete the operation (t) 1 day
(f)) Excision of the redundant tissue (g) Intracutaneous suture (h) close after the operation, the appearance is well repaired
the gap (i) check up the flaps (j) Subcutaneous suture (k) Check the
g h
i j
k l

m n
o p
q r

s
t
a b
Fig. 5.9 Grade 2 left cleft lip repair. (a) Grade 2 cleft lip (b) Fixed to the vermilion of the lip (p) Submucosal suture (q) Triangular incision
point design (c) Piecewise connection (d) tangent connection (e) Full (r) Angle-3D continued suture, first stitch (s) Second stitch (t) Third
line connection (f) Cut open the skin (g) Incision by the design line (h) stitch (u) Tighten and knot (v) Suture the triangle (w) Suture the skin
Excision of the surface tissue (i) The tangent at the point (j) Release (x) Suture the mucosa (y) The operation has been finished, and the
muscle tissue (k) Expose the labiogingival groove (l) Suture the bottom shape of the lip after the repair is good
(m) Suture the muscle layer (n) Contraction the gap (o) Inserting needle
c d
e f
g h
i j

k l
m n
o p
q r

s t
u v
w x

a b
c d
e f
Fig. 5.10 Grade 2 left cleft lip repair. (a) Grade 2 cleft lip (b) needle from the angle flaps. (p) The third stitch (q) Check up suture (r)
Intubation anesthesia (c) Design the points (d) Incision points (e) Tighten the suture (s) Lift the suture and tie a knot (t) Rotate and suture
Piecewise connection (f) Full line connection (g) Cut open the skin (h) the upper angle flap (u) Suture the skin (v) Suture the mucosa in the
Excision of the surface tissue (i) Separate the muscle layer (j) Lift the mouth (w) The operation has been completed (x) One day after the
muscular layer (k) Release the muscle tissue (l) Suture the muscle layer operation, the shape of the lip after the repair is good (y) Eighteen months
(m) Triangle suture, the first stitch (n) The second stitch (o) Pull out the after the operation, the appearance is good
g h
i j
k l
m n

o p
q r
s t
u v

w x
a b
Fig. 5.11 Grade 2 right cleft lip repair. (a) Preoperative deformity (b) Intraoperative anesthesia (c) Design the incision (d) The operation is fin-
ished, the repaired lip is in good shape
c d
3. Surgical methods: Modified Millard method. 5.3 Unilateral Grade 3 Cleft Lip
4. Operation points: The incision point at the nasal colu-
mella located at about 2 mm above the nasal columella Case 1
basis, and it is closer to the healthy side. Extend the inci- 1. Introduction of medical history: A 1 year and 1 month-
sion to the healthy side, but do not exceed the philtrum old boy suffers complete left cleft lip, that reaches the
column at the healthy side; C-flap is used to fill in the basis nasi.
defect remained by the downward rotate flap. 2. Clinical manifestations: The maximum fissure at the
5. Notes: The incision point of the affected side of the lip upper lip is 7 mm wide, 2 mm high, and it is a complete
peak is located on the white lip ridge at the widest part of split involving the red and white lip, reaching the basis
the red lip. It is allowed to move slightly inward and nasi.
upward according to the difference of lip length between 3. Surgical methods: Inferior triangular flap method + phil-
the healthy side and the affected side. trum column Z-plasty.
6. Operation steps: Shown in Fig. 5.12. 4. Operation points: Release the muscular layer thoroughly
with non-strain suture.
5. Notes: Pay attention to the symmetry of nostril.
Case 10 6. Operation steps: Shown in Fig. 5.14.
1. Introduction of medical history: A boy of 10 years old
suffers Grade 2 left cleft lip, with a fissure exceeding the
middle part of the lip, and nasal deformity. Case 2
2. Clinical manifestations: The upper lip has an incomplete 1. Introduction of medical history: A 6-month-old boy suf-
fissure that is 8 mm wide and 6 mm in height, with a fers left complete cleft lip, with nosewing deformity.
reduced upper lip height at the healthy side. 2. Clinical manifestations: The maximum fissure at the
3. Surgical methods: Straight-line method. upper lip is 14 mm wide, 7 mm high, with a complete
4. Operation points: Incision is designed along the philtral split, which reaches the basis nasi, of red and white lip as
column. Triangle flap is designed at the lip mucous mem- well as the alveolar cleft and an 8-mm plane drops at the
brane. Release the muscular layer at the base of the nose skin.
and lower the lip. 3. Surgical methods: Inferior triangular flap method + phil-
5. Notes: After descending the muscular layer, the suture trum column Z-plasty.
was performed. 4. Operation points: Release the muscular layer thoroughly
6. Operation steps: Shown in Fig. 5.13. using non-strain suture.
a b
c d
e f
Fig. 5.12 Grade 2 left cleft lip repair (Modified Millard method). (a) the periosteum at the nasal base (h) Suture the opposite muscular layer
Design the incision (b) After skin incision for making the rotate flap, at the bilateral lip peak (i) Suture the muscle of the upper lip at the
cut along the skin incision line by scissors. (c) Separate the muscular affected side to the deep layer of the inside foot of alar cartilage (j)
layer of the cleft margin at the healthy side (d) Release the inside foot Finish the suture (k) One day after the operation, the appearance is well
of alar cartilage at the cleft side (e) Contralateral incision (f) Separate repaired
the muscular layer of the cleft margin at the affected side (g) Separate
g h
i j

a b
c d
e f
Fig. 5.13 Grade 2 left cleft lip repair (Straight-line method) (a) Cleft Suture the muscular layer (h) Relaxation suture. In the submucosa (i)
lip incomplete (b) Design the incision (c) Cut the mucous membrane Suture the muscular layer at the nasal base. (j) Finish the suture of mus-
(d) Separate the muscular layer of the bilateral cleft margin (e) Release cle (k) The skin and mucous membranes are sewn up. (l) Finish, the
the high edge of the cleft side (f) Suture the mucous membrane (g) appearance is well repaired
g h
i j
k l
5. Notes: Pay attention to the symmetry of the nostril. split of red and white lip, which reaches the basis nasi,
6. Operation steps: Shown in Figs. 5.15, 5.16, and 5.17. and a 2-mm plane drops at the skin.
3. Surgical methods: Inferior triangular flap method + phil-
trum column Z-plasty.
Case 3 4. Operation points: Release thoroughly using non-strain
1. Introduction of medical history: A 9-month-old boy suffers suture.
right complete cleft lip, with a complete split involving 5. Notes: Design a small triangular flap 2 mm above the
both red and white of the lip and a nosewing deformity. labial line.
2. Clinical manifestations: The maximum fissure at the 6. Operation steps: Shown in Fig. 5.18.
upper lip is 15 mm wide, 6 mm high, with a complete
a b
c d
e f
g h
Fig. 5.14 Grade 3 left cleft lip repair. (a) Complete cleft lip (b) suture (j) Suture layer by layer (k) Complete the suture (l) A drain
Intubation anesthesia (c) Design the incision (d) Cut open the affected remained at the nose (m) One day after the operation, the deformity of
side (e) Separate the muscle layer (f) Contralateral incision (g) Suture the lip was well repaired
the inner membrane (h) Suture the muscle layer (i) Intracutaneous
i j
k l
Case 4 3. Surgical methods: Inferior triangular flap method + phil-

1. Introduction of medical history: A 7 years and 8 months- trum column Z-plasty.
old boy suffers left complete cleft lip, completely involv- 4. Operation points: Release the muscular layer thoroughly
ing the red and white lip with alveolar cleft. with non-strain suture.
2. Clinical manifestations: The maximum fissure of the 5. Notes: Pay attention to the mucosa design.
upper lip is 13 mm wide, 5 mm high, with a complete 6. Operation steps: Shown in Fig. 5.19.
split of both red and white lip, and the fissure reaches the
basis nasi, with a 2-mm plane drops at the skin.
a b
c d
e f
g h
Fig. 5.15 Grade 3 left cleft lip repair (preoperative design). (a) Grade 3 cleft lip (b) Healthy side incision design (c) Affected side incision design
(d) Red lip incision design (e) Local observation (f) Gross observation (g) Basis nasi incision design (h) The incision line of the mucosa
a b
c d
e f
g h
Fig. 5.16 Grade 3 left cleft lip repair (inferior triangular flap method). (m) Suture the mucosa and rotator muscle | (n) Suture the skin (o)
(a) Tumescent anesthesia (b) Incision the healthy side (c) Cut open the Suture with continued triangle-3D method for the inferior triangular
mucosa (d) Separate the mucosa (e) Separate the muscle layer (f) flap, the first needle (p) The second needle (q) The third needle (r) Lift
Release the drawstring (g) Cut open the affected side (h) Cut open the the suture and knot (s) Tighten the knot (t) Appearance of the red lip (u)
labiogingival groove (i) Raise the redundant skin (j) Excision of the Suture the inner membrane (v) Suture the labiogingival groove
redundant skin (k) Observe the incision (l) Separate the muscle layer.
i j
k l
m n
o p

q r
s t
u v
Case 5 3. Surgical methods: Inferior triangular flap method + phil-

1. Introduction of medical history: A 6-month-old boy suf- trum column Z-plasty.
fers left complete cleft lip reached the basis nasi. 4. Operation points: Precisely fold with non-strain suture.
2. Clinical manifestations: The maximum fissure of the 5. Notes: Pay attention to observation, and use angle-3D
upper lip is 10 mm wide, 6 mm high, with a complete continued suture method [3].
split of both red and white lip, and the fissure reaches the 6. Operation steps: Shown in Fig. 5.20.
basis nasi, with a 3-mm plane drop at the skin.
a b
c d
e f
Fig. 5.17 Grade 3 left cleft lip repair (philtrum column Z-plasty). (a) out the needle after thoroughly burying the line (g) Tie a knot and fix (h)
Local Z-plasty (b) Suture with the rotating flap (c) Crosscut an osculum Suture finished (i) One1 day after the operation, the deformity of the lip
inside the nostril (d) Stealthily separate (e) Suture the incision (f) Pull was well repaired
g h
a b
Fig. 5.18 Grade 3 right cleft lip repair. (a) Complete cleft lip (b) second stitch: insert from the edge and pull out from the corner (m) The
Design the incision (c) Tumescent anesthesia (d) Incision of the healthy third stitch: insert from the edge and pull out from the margin (n)
side (e) Cut open the affected side (f) Line with the mucosa (g) Suture Slowly lift the suture (o) Tighten the suture. (p) Knot and fix (q) The
the muscle layer (h) Fold the muscular layer (i) Fold the mucosa (j) operation has been completed (r) One year after the operation, the
Suture the skin (k) Angle-3D continued suture method was used. The deformity of the lip was repaired
first stitch: insert from the edge and pull out from the corner (l) The
c d
e f
g h
i j

k l
m n
o p
q r

a b
c d
e f
Fig. 5.19 Grade 3 left cleft lip repair. (a) Grade 3 cleft lip (b) affected side (l) Connect the drawing lines (m) The labiogingival
Intubation anesthesia (c) Find the point at the healthy side (d, e) Find groove line (n) Use dyes to puncture the skin for marking (o) Check up
the point at the basis nasi (f) Find the point at the nostril (g) Connect the design (p) The appearance after the operation (q) One day after the
points (h) The margin of dry and wet lip (i) Draw lines at the affected operation, the appearance was well repaired
side (j) Check the connection lines (k) Design a triangle incision at the
g h
i j
k l

m n
o p

a b
c d
e f
g h
Fig. 5.20 Grade 3 left cleft lip repair. (a) Grade 3 cleft lip (b) Design layer (j) Fix the triangle flap (k) Three-dimensional suture (l) Cut open
the incision (c) Cut open one side (d) Release the labiogingival groove the skin (m) Suture finished (n) One day after the operation, the defor-
(e) Incision of the uninjured side (f) Expose the muscle layer (g) Cut mity of the lip was repaired well (o) One year after the operation, the
open the skin (h) Suture the muscle layer (i) Strengthen the muscular appearance was good
i j
k l
m n

References 3. Wang X-F, et al. clinical application of 3-dimensional continu-

ous suturing technique for triangular wounds. Ann Plast Surg.
2018;81(3):316–21.
1. Cho BC, et al. The correction of a secondary bilateral cleft lip nasal
deformity using refined open rhinoplasty with reverse-U Incision,
deformity correction: a method for uni- and bilateral correction. J
long-term results. Arch Plast Surg. 2012;39(3)
2. Aranmolate S, et al. Upper triangular flap in unilateral cleft lip
repair. J Craniofacial Surg. 2016;27(3):756–9.
Repair of Bilateral Cleft Lip
6
Wen-feng Zhang, Hui Xu, Sheng Chen, and Jian-min Yao
6.1 rade 1 and Grade 2 Bilateral

G 4. Operation points: Rotate the anterior lip mucosa as a lin-
Cleft Lip ing, because it can deepen the labiogingival groove.
5. Notes: Separate and release the muscular layer thor-
Case oughly with non-strain suture.
1. Introduction of medical history: A 1 year and 10 months- 6. Operation steps: Shown in Figs. 6.3 and 6.4.
old boy suffers bilateral mixed type cleft lip.
2. Clinical manifestations: The bilateral cleft lip presents as
Grade 2 left cleft lip and Grade 1 right cleft lip. The maxi- Case 2
mum fissure of upper lip is 12 mm wide, 5 mm high, and 1. Introduction of medical history: A 7-month-old boy suf-
there is an incomplete split of red and white lip, with a fers bilateral cleft lip, with incomplete cleft lip at the left
2-mm plane drop at the skin. side and complete cleft lip at the right side, and the ante-
3. Surgical methods: T-shaped incision + philtrum column rior lip protrusion deformity.
Z-plasty. 2. Clinical manifestations: Bilateral cleft lip, with Grade 2
4. Operation points: Rotate the anterior lip mucosa to act as cleft lip at left and Grade 3 at right. The maximum fissure
a lining, because it can deepen the labiogingival groove. of the upper lip is 12 mm wide, 12 mm high. It is a mixed
5. Notes: Separate the anterior skin and mucosa with a uni- type split, with a 9-mm plane drop at the skin.
form thickness, and pay attention to blood circulation. 3. Surgical methods: Lower triangular flap incision.
6. Operation steps: Shown in Figs. 6.1 and 6.2. 4. Operation points: The anterior lip mucosa is rotated as a
lining, so that it can deepen the labiogingival groove.
5. Notes: Separate and release the muscular layer thor-
6.2 Grade 2 and Grade 3 Bilateral oughly, and use non-strain suture method.
Cleft Lip 6. Operation steps: Shown in Fig. 6.5.
Case 1
1. Introduction of medical history: A 1 year and 3 months- Case 3
old boy suffers mixed type bilateral cleft lip, with differ- 1. Introduction of medical history: A 1.1-year-old boy with
ent degrees of fissures. bilateral mixed cleft lip.
2. Clinical manifestations: The bilateral cleft lip presents as 2. Clinical features: Bilateral cleft lip with III-degree left
Grade 2 left cleft lip and Grade 1 right cleft lip. The maxi- cleft lip and II-degree right cleft lip. The maximum width
mum fissure of the upper lip is 17 mm wide, 13 mm high. It of the cleft on the upper lip is 22mm, the height difference
is a mixed type split, with an 8-mm plane drops at the skin. of the cleft is 9 mm, it is a mixed cleft. The difference in
3. Surgical methods: T-shaped incision + philtrum column the skin plane is 3mm.
Z-plasty. 3. Surgical method: T-type incision
4. Techniques: To fix the points first and then make the con-
nections when designing. Be sure to be steady and brisk,
W.-f. Zhang · S. Chen · J.-m. Yao (*) check repeatedly when operating.
Hangzhou Plastic Surgery Hospital, Hangzhou, China 5. Notes: Completely loosen the muscle layer and suture
H. Xu with low-tension
Xinjiang Uygur Autonomous Region People’s Hospital, 6. Operation steps: Shown in Fig. 6.6.
Ürümqi, China

https://doi.org/10.1007/978-981-15-4419-4_6
128 W.-f. Zhang et al.
a b
c d
e f
g h
Fig. 6.1 Bilateral cleft lip (Grade 1 and Grade 2) repair (Step 1) (a) anterior lip (n) Separate the mucosa and muscular layer (o) Separate the
Mixed type bilateral cleft lip (b) General anesthesia intubation (c) basis nasi. (p) Separate the muscle layer (q) Finish the separation (r)
Design the incision: T-shaped incision + philtrum column Z-plasty. (d) Rotate the mucosa (s) Suture as a lining (t) Suture the mucosa (u)
Cut open the left side (e) Separate the mucosa (f) Release the draw- Release the fibers stretched by labiogingival groove (v) Suture the inner
string (g) Separate the muscle layer (h) Separate the labiogingival layer of upper lip (w) Continued suture, remain the line knot on the
groove (i) Cut open the right side (j) Subsection incision (k) Cut along surface (x) Make the inner layer of the upper lip (y) Interrupted and
the incision line (l) Remove the superfluous tissue (m) Separate the reinforced suture (z) Repair basis nasi
6 Repair of Bilateral Cleft Lip 129
i j
k l
m n
o p

q r
s t
u v
w x

y z
a b
c d
Fig. 6.2 Bilateral cleft lip (Grade 1and Grade 2) repair (Step 2) (a) the lateral angle (l) Suture the lip margin (m) Observe the appearance
Suture the muscle layer (b) Lessen the gap (c) Adjust tension (d) (n) Suture the intraoral mucosa (o) Suture the basis nasi (p) Insert the
Intracutaneous suture (e) Trim the surplus tissues (f) Angle-3D contin- triangular flap to repair the basis nasi (q) repair the nostril (r) Finish
ued suture method, insert from point b and pull out from point O (g) suture (s) One day after the operation, the appearance is well repaired.
Insert from point a and pull out from point O (h) Insert from point b and (t) Fourteen months after the operation, the appearance is good
pull out from point a (i) knot and fix (j) Suture the upper lip (k) Suture
e f
g h
i j
k l

m n
o p
q r
s t

a b
c d
e f
g h
Fig. 6.3 Bilateral cleft lip (Grade 2 and Grade 3) repair (Step 1) (a) the band (m) Expose the incision (n) Separate the muscle layer (o) Full
Bilateral cleft lip (b) General anesthesia intubation (c) Find the point on layer incision (p) Separate the muscle layer (q) Cut open the labiogin-
the left side. (d) Determine the point at bilateral sides (e) Tumescent gival groove (r) Rotate the mucosa as a lining of the upper lip (s) Fix
anesthesia (f) Cut open the anterior lip (g) Separate the anterior lip (h) the mucosa (t) Deepen the labiogingival groove (u) Suture the bottom
raise the flap (i) Cut open the right side (j) Cut open the boundary line (v) Adjust tension (w) Repair layer by layer (x) Suture step by step (y)
of the skin and mucosa (k) Release the labiogingival groove (l) Cut off Suture the mucosa (z) Roating suture
i j
k l
m n
o p

q r
s t
u v
w x

y z
a b
c d
Fig. 6.4 Bilateral cleft lip (Grade 2 and Grade 3) repair (Step 2) (a) out from the edge (h) The third needle: insert from the edge and pull out
Suture the muscle layer (b) Reconstruct the orbicularis oris muscle (c) from the edge (i) Pick up the stitches and knot (j) Rotate the triangular
Intracutaneous suture (d) the appearance preliminary repaired (e) Trim flap to the basis nasi (k) Repair nosewing and red lip (l) One day after
the redundant skin (f) Suture the upper lip mucosa (g) Angle-3D contin- the operation, the shape of the lip is symmetrical, and the deformity is
ued suture method. The second needle: insert from the corner and pull well repaired
e f
g h
i j
k l

a b
c d
e f
g h
i j
Fig. 6.5 Bilateral cleft lip (Grade 2 and Grade 3) repair (a) Preoperative mucosa (h) Suture the muscle layer (i) Suture the skin (j) Complete the
deformity (b) Anesthetic intubate (c) Design the incision (d) Cut open suture, and the fissure was repaired well
the anterior lip (e) left incision (f) Turn up the skin (g) Suture the
a b
c d
e f
g h
Fig. 6.6 Bilateral cleft lip (Grade 2 and Grade 3) repair. (a) Deformity (g) Suture the lip groove. (h–k) Suture the muscle layer. (l) Suture the
of bilateral cleft lip. (b) Incision design. (c) Incise the left side. (d) skin. (m) One day after surgery
Incise the right side. (e) Incise the middle lip. (f) Separate the mucosa.
i j
k l
6.3 Grade 3 Bilateral Cleft Lip 12 mm high. It is a mixed type split, with a 9-mm plane
drops at the skin.
Case 3. Surgical methods: Front labial flap +T shape incision.
1. Introduction of medical history: A 17-month-old girl suf- 4. Operation points: Separate and release the muscular layer
fers Grade 3 bilateral cleft lip, with a serious anterior lip thoroughly with non-strain suture method.
protrusion deformity. 5. Notes: Distinguish the levels, dissect precisely, and oper-
2. Clinical manifestations: Grade 3 bilateral cleft lip with a ate lightly.
maximum fissure at the upper lip of 18 mm wide and 6. Operation steps: Shown in Figs. 6.7 and 6.8.
a b
c d
e f
g h
Fig. 6.7 Bilateral Grade 3 cleft lip repair (Step 1). (a) Bilateral defor- Separate the red lip (o) incision of right side (p) Cut open the mucosa
mity (b) General anesthesia (c) The anterior lip protrudes (d) Lateral (q) Cut open the inner side (r) Separate the muscle layer (s) Separate
view (e) Infiltration anesthesia (f) Puncture through incision (g) the mucosa (t) Release the band (u) Expose the muscle layer (v) Cut
Swelling local anesthesia (h) Incision of left side (i) Cut open the open the basis nasi (w) Make a triangular flap (x) Separate the flap (y)
mucosa (j) Cut the mucosa thoroughly (k) Cut open the labiogingival Separate the labial flap (z) Suture the mucosa for lining
groove (l) Separate the muscle layer (m) Separate the basis nasi (n)
i j
k l
m n
o p

q r
s t
u v
w x

y z
a b
c d
Fig. 6.8 Bilateral Grade 3 cleft lip repair (Step 2) (a) Trim the surplus Folding and fixing the angle flap (h) Removal of the surplus labial flap
mucosa (b) Suture the bilateral upper lip mucosa (c) Complete internal (i) Complete the suture, and cleft lip was repaired well (j) Three years
suture of the upper lip. (d) Suture the bilateral muscular layer (e) Suture after the operation, the appearance is good
the muscle layer (f) Intracutaneous suture to reduce skin tension (g)
e f
g h
i j

Repair of Median Cleft Lip
7
Wen-yan Wu and Jian-min Yao
Case 1 3. Surgical methods: Shuttle-shaped incision, and suture

1. Introduction of medical history: A 13 years and 3 months- along the straight line.
old girl suffers the Grade 1 middle cleft lip, with upper lip 4. Operation points: Design a tangent on both sides of the
middle split, and the vermilion of the lip presents a slight philtrum column.
depression deformity. 5. Notes: Tumescent anesthesia is easier to operate.
2. Clinical manifestations: The maximum fissure is 2 mm 6. Operation steps: Shown in Fig. 7.2.
wide and 2 mm high, with incomplete red lip split. And
the split is 2 mm deep.
3. Surgical methods: Z-plasty [1], V-Y Suture [2]. Case 3
4. Operation points: The operation area is located at the ver- 1. Introduction of medical history: A 15-year-old female
milion of the lip, and the mucosa keeps unchanged within with a median cleft deformity of the upper lip.
the dry and wet zone. 2. Clinical features: Median cleft of upper red lip with
5. Notes: Firstly, operate in the dry area of the red lip, and groove deformity of vermilion tubercle.
then in the wet area from the surface to the inner layer. 3. Surgical method: (a) Design incision in the middle of red
6. Operation steps: Shown in Fig. 7.1. lip and triangular flap at lip margin. (b) Suture the muscle
layer after fusiform excision of red lip tissue mucosa. (c)
Suture the mucosa and the triangular flap.
Case 2 4. Techniques: (a) Align and suture the incision precisely.
1. Introduction of medical history: A 6-month-old boy suf- (b) Suture the two small triangular flaps of the lip margin
fers Grade 2 middle cleft lip, with deformity of upper red together
lip fissure and white lip hidden fissure. 5. Notes: There is no need to worry about the arch deformity
2. Clinical manifestations: The maximum fissure is 3 mm after suture of two small triangular flaps.
wide and 1 mm high, with red lip split, white lip incom- 6. Operation steps: Shown in Fig. 7.3.
plete split (hidden fissure), and a 1-mm skin plane drop.
Wen-y. Wu
Chengdu Bada Medical Aesthetics Hospital, Chengdu, China
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_7
148 Wen-y. Wu and J.-m. Yao
a b
c d
e f
g h
Fig. 7.1 Grade 1 middle cleft lip repair. (a) Middle cleft lip (b) Fissure place (h) Adjust the observation (i) Suture the red lip (j) One day after
of red lip (c) Shows the tangent (d) Design incision of red lip (e) the operation, the appearance is well repaired
Tumescent anesthesia (f) Incision by the line (g) Separate in the right
7 Repair of Median Cleft Lip 149
i j
a b
Fig. 7.2 Grade 2 middle cleft lip repair (a) fissure at the middle of the vermilion of the lip (b) Design the incision (c) Cut open the skin, and suture
the muscle layer and skin. The appearance is good
150 Wen-y. Wu and J.-m. Yao
a b
c d
e f
g h
Figure 7.3 (a) Median cleft deformity of upper lip. (b) Operative position, (c) Incision design. (d) Excision of depressed mucosa. (e) Subcuticular
suture. (f) Diagonal suture. (g) Skin suture. (h) One day after surgery
7 Repair of Median Cleft Lip 151
References 2. Cho BC, et al. The Correction of a secondary bilateral cleft lip nasal
deformity using refined open rhinoplasty with reverse-U Incision,
V-Y Plasty, and selective combination with composite grafting:
deformity correction: A method for uni- and bilateral correction. J
Repair of Secondary Cleft Lip Deformity
8
Lei Zhu, Feng-jing Zhao, Chang-long Zhou,
and Jian-min Yao
Postoperative deformities of cleft lip present at nose and lip, Case 2

including lip deformity, nose deformity, oronasal fistulas 1. Introduction of medical history: A 15-year-old male after
deformity, and bilateral cleft lip postoperative deformity. Lip a cleft lip operation suffers upper lip scar, vermilion of the
deformity repair mainly involves uneven red lip, upper lip lip unevenness, and nosewing deformity.
scar, local depression, red and white lip implantation, fissure 2. Clinical manifestations: Upper lip scar, vermilion of the
relapsing, etc. The repair of nose deformity commonly lip unevenness, uneven thickness of upper lip, nosewing
involves nosewing collapse, nostril asymmetry, nasal colu- collapse.
mella short, apex nasi not round, basis nasi emptiness; oro- 3. Surgical methods: (1) Vermilion of the lip fusiform exci-
nasal fistulas deformity is interlinking among cleft alveolus, sion, straight suture (2) tongue-shaped flap of intraoral
and nasal cavity and labiogingival groove; postoperative mucosa, adjusting depression deformity (3) skin excision
deformity of bilateral cleft lip open shows as upper lip scar, at nostril margin was star-crescent-shaped, stealthily sep-
whistling lips deformity, nasal columella short, etc. arating nosewing, nasal dorsum lifting with incline buried
of suture, fixing.
4. Operation points: (1) Fold the lip margin. (2) Rotate flap
8.1 Lip Deformity with the pedicle. (3) Change the shape of the nostril
margin.
8.1.1 ermilion of the Lip Margin
V 5. Notes: Thread a needle subcutaneously at the nasal dor-
Unevenness sum to the opposite nostril and bury the suture, diagonally
fixing the nose shape.
Case 1 6. Operation steps: Shown in Fig. 8.2
1. Introduction of medical history: A 6-year-old female with
postoperative deformity of the left upper cleft lip.
2. Clinical features: Scarring and uneven red mucosa of the 8.1.2 Inlay of Red and White at Upper Lip
upper lip with deformity of the unequal height on both
sides. Case
3. Surgical method: Triangular flap [1]. 1. Introduction of medical history: A 17-year-old female
4. Techniques: (a) Excise the upper lip scar. (b) Insert a after a cleft lip operation, suffers inlay of red and white at
small triangular flap to lower the lip height on the affected the upper lip.
side. (c) Angle-3D suture. 2. Clinical manifestations: Vermilion of the lip implant, nos-
5. Notes: Insert the small triangular flap 2 mm parallel to the tril asymmetry, nosewing collapse.
superior margin of the lip so that the scar will be rela- 3. Surgical methods: (1) Vermilion of the lip Z-plasty. (2)
tively hidden. Move the nosewing foot by rotating the flap. (3) Nosewing
6. Operation steps: Shown in Fig. 8.1. lifting.
4. Operation points: (1) Rotate flap at vermilion of the lip,
adjust the bit line of the red and white lip. (2) Design a
L. Zhu · F.-j. Zhao · J.-m. Yao (*) triangular flap at nosewing foot, rotate into nostril to
increase nostril. (3) Separate nosewing, burying suture,
C.-l. Zhou and fixing.
Ningbo Medical Treatment Center Lihuili Hospital, Ningbo, China

https://doi.org/10.1007/978-981-15-4419-4_8
154 L. Zhu et al.
a b
c d
e f
Fig. 8.1 Vermilion of the lip margin unevenness repair. (a) Scarring Subcutaneous suture. (h) Suture fixation. (i) Angle-3D suture. (j) The
deformity of the upper lip. (b) Incision design. (c) Incise the skin and second stitch. (k) The third stitch. (l) Thread lifting. (m) Suture
mucosa. (e) Separate the muscle layer. (f) Separate the muscle layer. (g) complete
8 Repair of Secondary Cleft Lip Deformity 155
g h
i j
k l

156 L. Zhu et al.
a b
c d
e f
g h
Fig. 8.2 Vermilion of the lip margin unevenness repair (a) upper lip into the depression (g) Fill in the right side deformity (h) Skin excision
scar, vermilion of the lip unevenness (b) Design the incision (c) at the nasal margin is in star-crescent shape (i) Bury the suture and fix
Fusiform excision (d) Straight suture the upper lip wound, Transverse (j) Suture the skin (k) Indwell the nasal tube (l) The operation is fin-
incision of the intraoral myofascial membrane (e) Raise myofascial ished, and the shape of the lip is well repaired
membrane flap (f) Rotate the myofascial membrane flap and insert it
i j
k l
5. Notes: Subcutaneously bury the suture, and fix the nasal 2. Clinical manifestations: Upper lip scar, upper lip defor-
shape. mity, nostril asymmetry.
6. Operation steps: Shown in Fig. 8.3. 3. Surgical methods: Scar excision, fill in by rotating flap,
nostril reshaped.
4. Operation points: Separate the muscle layer, tighten the
8.1.3 Upper Lip Scar suture, reconstruct the appearance.
5. Notes: Enter from the incision, stealthily separate on the
Case 1 surface of nosewing cartilage, stretch, suture, and fix.
1. Introduction of medical history: A 36-year-old male after 6. Operation steps: Shown in Fig. 8.5.
cleft lip operation suffers left upper lip scar and vermilion
of the lip depression.
2. Clinical manifestations: Upper lip scar, vermilion of the Case 3
lip depression. 1. Introduction of medical history: A 22-year-old female
3. Surgical methods: Repair by straight line incision. after cleft lip operation suffers right upper lip scar and
4. Operation points: (1) The scar acts as a tangent. (2) nostril asymmetry.
Separate the muscular layer, and suture after adjusting. 2. Clinical manifestations: Upper lip scar, nosewing
5. Notes: Separate the skin margin, eversion suture. collapse.
6. Operation steps: Shown in Fig. 8.4. 3. Surgical methods: Scar excision, double flap transfer,
nostril shaping.
4. Operation points: Transfer scar, adjust nose shape.
Case 2 5. Notes: Flaps should be thick, in order to avoid
1. Introduction of medical history: A 17-year-old male after inactivation.
cleft lip operation suffers left upper lip scar and nostril 6. Operation steps: Shown in Fig. 8.6.
deformity.
158 L. Zhu et al.
a b
c d
e f
g h
Fig. 8.3 Inlay of red and white at upper lip repair. (a) Vermilion of the separating and releasing (h) Rotate the triangular flap into the nostril (i)
lip margin unevenness (b) Nostril asymmetry (c) Vermilion of the lip Diagonally bury the suture at nasal dorsum and suture. The operation is
implant into white lip (d) Design the incision (e) Incision by the line (f) finished. (j) One day after the operation, the shape of the lip has been
Suture after exchanging the triangular flap (g) Cut open nosewing foot, improved
i j
a b
c d
Fig. 8.4 Upper lip scar repair (straight line incision repair) (a) Upper lip deformity (b) Vermilion of the lip depression (c) Design the incision (d)
Scar excision (e) Complete suture of incision (f) One day after the operation, the shape of the lip repairs well
160 L. Zhu et al.
e f
a b
c d
Fig. 8.5 Upper lip scar repair (scar excision, fill with the rotated flap to Raise myofascial membrane flap (j) Lower mucosa tunnel (k) Rotate
shape the nostril). (a) Upper lip scar (b) Design the incision (c) Scar myofascial membrane flap (l) Suture the skin, and bury the suture diag-
excision (d) Separate the nosewing (e) Suture the basis nasi (f) Observe onally running through the nostril in the nasal dorsum (m) Bury the
the nostril (g) Vermilion of the lip incision (h) Mucosa excision (i) suture and overhang (n) stretch the lead wire and fix it
e f
g h
i j
k l

162 L. Zhu et al.
m n
a b
c d
Fig. 8.6 Upper lip scar repair (scar excision, double flap transfer, nos- suture (f) Suture the skin (g) One day after the operation, the shape of
tril shaping) (a) Upper lip scar (b) Leafleting design the double flap the lip repairs well
incision (c) Cut open the skin (d) Rotate the double flap (e) Subcutaneous
e f
Case 4 5. Notes: Do not consume the repairing materials too early

1. Introduction of medical history: A 5-year-old girl after and excessively. Keep enough materials for later repair.
cleft lip operation suffers vermilion of the lip deformity 6. Operation steps: Shown in Fig. 8.7
and nostril asymmetry.
2. Clinical manifestations: Vermilion of the lip depression,
upper lip scar, nosewing collapse. 8.1.4 Lip Gap Deformity
3. Surgical methods: (1) Lip: lower small triangular flap
method, depression mucosa excision, straight suture. Case
Intraoral mucosa transverse excision, adjust the thickness 1. Introduction of medical history: A 9-year-old boy after
of the vermilion of the lip. (2) Nose: upper lip scar flap cleft lip operation suffers right upper lip deformity.
transfer, repair and correct the nosewing and nose foot. 2. Clinical manifestations: Vermilion of the lip deformity.
4. Operation points: (1) Use the small triangular flap to 3. Surgical methods: Z-plasty.
repair and reconstruct lip margin. (2) Use scar flap to 4. Operation points: Hidden incision.
repair basis nasi as needed.
164 L. Zhu et al.
a b
c d
e f
g h
Fig. 8.7 Unilateral cleft lip deformity after operation repair (lower tril (f) Mucosa excision (g) Cut open the skin (h) Skin excision (i)
small triangular flap method) (a) Upper lip scar (b) Vermilion of the lip Mucosa excision (j) Suture the muscle layer (k) Subcutaneous suture (l)
depression (c) Skin incision (d) Mucosa incision (e) Z-plasty inner nos- Suture the skin
i j
k l
5. Notes: It is better to make a thick flap deep to the muscular Case 2

layer. 1. Introduction of medical history: A 27-year-old male after
6. Operation steps: Shown in Fig. 8.8. cleft lip operation suffers uneven thickness of vermilion
of the lip.
2. Clinical manifestations: (1) Broken labial line. (2) Left
8.1.5 Hypertrophy of Red Lip vermilion of the lip hypertrophy, locally thickening, phil-
trum column flat. (3) Basis nasi collapse.
Case 1 3. Surgical methods: (1) Repair vermilion of the lip margin.
1. Introduction of medical history: A 7-year-old boy after (2) Reconstruct philtrum column. (3) Thin the lip. (4)
cleft lip operation suffers left upper lip hypertrophy Filling basis nasi.
deformity. 4. Operation points: (1) Insert tiny triangular flap into the ver-
2. Clinical manifestations: Left vermilion of the lip milion of the lip margin, and suture. (2) Stealthily separate
hypertrophy. the philtrum column, bury the suture, fix, and reconstruct.
3. Surgical methods: Transverse spindle-shaped incision. (3) Transfer the thick labial muscle flap, take more and fill
4. Operation points: Repeat testing to definite the scope. less. (4) Modify and filling the basis nasi with V-Y flap.
5. Notes: Carefully treat the fusiform ends, narrow down the 5. Notes: Reliable subcutaneous tension reduction suture
incision to prevent the formation of cat ear deformity. can help to reduce the scar after the operation.
6. Operation steps: Shown in Fig. 8.9. 6. Operation steps: Shown in Fig. 8.10.
166 L. Zhu et al.
a b
c d
e f
Fig. 8.8 Lip gap deformity repair (Z-flap repair) (a) Vermilion of the lip depression (b) Intubation general anesthesia (c) Design the incision (d)
Cut open the mucosa (e) Suture the wound margin (f) After the operation, the appearance is good
a b
c d
e f
Fig. 8.9 Vermilion of the lip hypertrophy repair (Shuttle shaped incision, mucosa incision) (a) Redundant tissue of the vermilion of the lip (b)
Intubation anesthesia (c) Design the incision (d) Cut open the mucosa (e) Mucosa excision (f) Suture the incision margin
168 L. Zhu et al.
a b
c d
e f
Fig. 8.10 Vermilion of the lip uneven thickness deformity after unilateral (h) Inner lip incision (i) Mucosa excision (j) Make sticky muscle flaps (k)
cleft lip operation repair (vermilion of the lip margin repair, reconstruct Raise sticky muscle flap (l) Stealthily separate and make a tunnel (m)
philtrum column, thinning lip, pull up basis nasi) (a) Upper lip deformity Stealthily insert the needle (n) Thread a needle and lead wires (o) Transfer
(b) Design the incision (c) Upper lip incision. (d) Basis nasi incision (e) sticky muscle flap (p) Lead the wire and fix (q) Finish the suture (r) Two
Stealthily separation (f) Bury the suture and fix (g) Suture the lip margin days after the operation, the shape of the lip repairs well
g h
i j
k l
m n

170 L. Zhu et al.
o p
q r
8.1.6 Vermilion of the Lip Margin Breaks means the operation method of upper and lower triangu-
lar flaps
Case 1 4. Techniques: (a) The upper triangular flap is rotated to the
1. Introduction of medical history: A 24-year-old male after base of the nose to reconstruct nostril base (sill) and nos-
cleft lip operation suffers vermilion of the lip line fracture. trils. (b) Lower triangular flap is inserted into the lip peak
2. Clinical manifestations: Vermilion of the lip scar, labial and the lip height can be reduced.
line breaks. 5. Notes: For older patients with wide fissures, the separa-
3. Surgical methods: Tiny triangular flap, folding insert. tion and adhesiolysis of the muscular layer should be suf-
4. Operation points: Observe carefully under the ficient and the suture should be accurate.
microscope. 6. Surgical steps (Fig. 8.12).
5. Notes: Repeat testing, meticulously operate.
8.2 Nose Deformity
Case 2 8.2.1 Nosewing Collapse

1. Introduction of medical history: A 46-year-old female
with a relapse of left cleft lip after the operation. Case
2. Clinical features: Dehiscence deformity from left white 1. Introduction of medical history: A 11-year-old girl suffers
lip to the base of the nose, and the alar collapse. nostril deformation after cleft lip operation.
3. Surgical method: Design surgical incisions according to 2. Clinical manifestations: Upper lip scar, lift vermilion of
the procedure of one-stage operation for cleft lip, which the lip, nosewing collapse.
a b
c d
e f
Fig. 8.11 Vermilion of the lip line broken repair (tiny triangular flap, folding insert) (a) Vermilion of the lip line fracture (b) Lower triangular flap
design (c) Incision by the line (d) Interrupted suture (e) Suture finished (f) One day after the operation, the shape of the lip repair well
3. Surgical methods: Scar excision, insert the tiny flap, 8.2.2 Nostril Collapse
reduce the lip height, Z-plasty, pull up nosewing.
4. Operation points: Cut open the cartilage, adjust the force Case
line, open the nostril. 1. Introduction of medical history: A seven-and-a-half-year-
5. Notes: Bury the suture and fix, and maintain nasal shape. old girl after cleft lip operation suffers flattening nostrils,
6. Operation steps: Shown in Fig. 8.13. asymmetry, and upper lip scar deformity.
172 L. Zhu et al.
a b
c d
e f
Fig. 8.12. (a) Left white lip cleft with nasal mucosa exposure. (b) Operative position. (c) Predesign of incision. (d) Incision design during opera-
tion. (e) Appearance of incision after suture. (f) One day after operation
2. Clinical manifestations: Upper lip scar and flattening 8.2.3 Basis Nasi Deformity
nostrils.
3. Surgical methods: Resection of scar, repair the basis nasi, Case 1
and narrow the nostril. 1. Introduction of medical history: A six-and-a-half-year-
4. Operation points: Use the scar, taking more and filling old girl suffers basis nasi collapse, nostril asymmetry, and
less. upper lip scar deformity after cleft lip operation.
5. Notes: Intracutaneous suture, easy to operate. 2. Clinical manifestations: Upper lip scar, basis nasi defor-
6. Operation steps: Shown in Fig. 8.14. mity, nostril asymmetry.
a b
c d
e f
g h
Fig. 8.13 Nosewing collapse repair (a) Upper lip scar (b) Design tiny Suture the incision (i) Bury the suture in the nostril, fix using the oint-
flap (c) Scar incision (d) Suture the triangle (e) Nasal valve Z-shape ment ribbon gauze (j) One day after the operation (k) Observation
incision, star-crescent incision at nostril margin (f) Separate the flap while looking up
membrane, excision of star-crescent skin (g) Exchange the triangle (h)
174 L. Zhu et al.
i j
3. Surgical methods: Rotate the scar, make basis nasi, and 5. Notes: Thoroughly release the basis nasi; otherwise, it is
narrow the nostril. difficult to pull up the basis nasi.
4. Operation points: Make full use of the scar as needed. 6. Operation steps: Shown in Fig. 8.16.
5. Notes: Separate the cartilage, bury and fix the suture.
8.2.4 Nostril Asymmetry
Case 2 Case
1. Introduction of medical history: A 14-year-old boy suf- 1. Introduction of medical history: A 16-year-old male suf-
fers nostril asymmetry and basis nasi deformity after right fers nostril scar contracture after left cleft lip operation.
cleft lip operation. 2. Clinical manifestations: Upper lip scar, nostril asymmetry.
2. Clinical manifestations: Right basis nasi deformity, 3. Surgical methods: Nostril Z-plasty, open the nostril.
furrow-shaped depression deformity. 4. Operation points: Design tongue shape flap at outside of
3. Surgical methods: V-Y-plasty [2], narrow the nostril. the nostril, transfer the flap to the inner side of the
4. Operation points: Designing a Y-shaped incision, after nostril.
that cut open the skin, separate the basis nasi, insert the 5. Notes: Design a wider flap than the theoretical measure-
triangular flap, pull up the basis nasi, and narrow the ments to offset the loss after the rotation.
nostril. 6. Operation steps: Shown in Fig. 8.17.
a b
c d
e f
g h
Fig. 8.14 Nostril collapse repair (a) Scar deformity (b) Design the skin (j) Insert and take out the needle (k) Knot and suture (l) Observe
incision (c) Local anesthesia (d) Cut open the scar (e) Release basis nasi the upper lip (m) Suture the skin (n) One day after the operation, the
(f) Rotate the scar (g) Repair basis nasi (h) Suture and fix (i) Suture the shape of the lip repairs well
176 L. Zhu et al.
i j
k l
m n

a b
c d
e f
Fig. 8.15 Basis nasi deformity repair (a) Design the incision (b) separation (h) Rotate the scar (i) Bury and fix the suture (j) Suture the
Tumescent anesthesia (c) Cut open scar (d) Separate and raise the adhe- skin (k) The operation is finished and the appearance is good
sion (e) Separate the nosewing (f) Release the band (g) Subcutaneous
178 L. Zhu et al.
g h
i j

a b
c d
e f
Fig. 8.16 Basis nasi deformity repair (a) Basis nasi deformity (b) Design the incision (c) Cut open the skin and release the basis nasi (d)
Subcutaneously suture and tighten the nostril (e) Suture and fix the skin (f) Overlooking, basis nasi repair well
180 L. Zhu et al.
a b
c d
Fig. 8.17 Nostril asymmetry repair (a) Left nostril is smaller (b) Flap design (c) Transfer the flap (d) Suture the incision, and adjust the nostril
8.2.5 Nosewing Deformity 8.3 Oronasal Fistulas Deformity
Case Case
1. Introduction of medical history: A 28-year-old female 1. Introduction of medical history: A 12-year-old girl suffers
suffers vermilion of the lip margin unevenness and nosew- a remained oronasal fistulas after cleft lip operation.
ing collapse deformity after cleft lip operation. 2. Clinical manifestations: Alveolar ridge split, left oronasal
2. Clinical manifestations: Vermilion of the lip depression, fistula.
shallow philtrum column, flat nasal bridge. 3. Surgical methods: Fistula margin incision, the labiogingi-
3. Surgical methods: Vermilion of the lip modification, val groove mucosa flap repair.
reconstruct the ridge line, take out the costal cartilage, 4. Operation points: (1) Fistula margin cut open. (2) Separate
comprehensive rhinoplasty. the mucosa flap to rotate as a lining. (3) Transfer the
4. Operation points: Take out the costal cartilage, build a labiogingival groove mucosa flap, suture layer by layer,
scaffold, use a nasal phantom prosthesis, pull up and repair the fissure.
extend the apex nasi. 5. Notes: When separation is adjacent to the alveolar bone,
5. Notes: Avoid pneumothorax, prevent hematoma, tight mucosa flap is easy to crack.
closure, indwelling drainage. 6. Operation steps: Shown in Fig. 8.19.
a b
c d
e f
Fig. 8.18 Nosewing deformity repair (a) philtrum column is shallow incision (n) Cartilage support (o) Trim the cartilage (p) Cover the carti-
(b) vermilion of the lip depression (c) Uneven labial line (d) Flat nostril lage thin slice upon the apex nasi (q) Side view (r) Implant the nose
(e) Design the incision (f) Cut open the labial line (g) Stealthily separate model (s) The operation is finished and then fix (t) One week after the
(h) Bury and fix the suture (i) Complete mucosa suture. (j) Seventh rib operation (u) Right side view (v) Left side view (w) After 2years
(k) Exclude costal cartilage calcification (l) make cartilage (m) Nasal
182 L. Zhu et al.
g h
i j
k l

m n
o p
q r

184 L. Zhu et al.
s t
u v

a b
c d
e f
Fig. 8.19 Oronasal fistulas repair (a) Oronasal fistulas after cleft lip (h) Separation of labiogingival sulcus mucosal flap (i) Suture the mus-
operation (b) Premaxilla oronasal fistulas (c) Expose the fistulas (d) cle layer, and reduce wound size (j) Suture the mucosa (k) Suture and
Design the incision (e) Cut open the mucosa (f) Suture the mucosa as a knot (l) Thread trimming, and the operation is finished
lining, keep the knot on the cavity surface (g) Closure of nasal mucosa
186 L. Zhu et al.
g h
i j
k l

8.4 ostoperative Bilateral Cleft Lip

P 4. Operation points: Incisal margin precisely, subcutane-
Deformity ously separate.
5. Notes: Fine operation, release thoroughly.
8.4.1 Upper Lip Scar 6. Operation steps: Shown in Fig. 8.20.
Case 1 Case 2
1. Introduction of medical history: A 4-year-old girl suffers 1. Introduction of medical history: A 10-year-old boy suf-
incision scar after bilateral cleft lip surgery. fers scar after bilateral cleft lip operation.
2. Clinical manifestations: The anterior lip scar. 2. Clinical manifestations: The anterior lip scar, whistling
3. Surgical methods: Scar excision, move down white lip. lips deformity.
a b
c d
e f
Fig. 8.20 Upper lip scar repair (a) Upper lip scar (b) Intubation anes- the shape of the lip repair well (i) Six months after the operation, the
thesia (c) Design the incision (d) Scar incision (e) Raise the flap (f) appearance is good
Subcutaneous suture (g) Finish suture (h) One day after the operation,
188 L. Zhu et al.
g h
3. Surgical methods: Lowering white lip, reconstruct the 8.4.3 Whistling Deformity
orbicularis oris muscle.
4. Operation points: Release adequately, adjust muscle strength. Case 1
5. Notes: Close whistle, thoroughly release the scar. 1. Introduction of medical history: A 13-year-old girl suffers
6. Operation steps: Shown in Fig. 8.21. upper lip scar and whistling lip deformity after bilateral
cleft lip operation.
2. Clinical manifestations: Whistling lip deformity, the ante-
8.4.2 Vermilion of the Lip Depression rior lip scar.
3. Surgical methods: Scar excision, lowering white lip.
Case 4. Operation points: Incisal margin precisely, subcutane-
1. Introduction of medical history: A 13-year-old boy suf- ously separate.
fers vermilion of the lip depression and bilateral cleft lip 5. Notes: Precisely operate, enough separation.
after operation. 6. Operation steps: Shown in Fig. 8.23.
2. Clinical manifestations: Upper lip scar, vermilion of the
lip depression.
3. Surgical methods: Z-plasty, reconstruct the orbicularis Case 2
oris muscle. 1. Introduction of medical history: Case 1: A 16-year-old
4. Operation points: Enough release, adjust muscle strength. female with postoperative deformities of the bilateral
5. Notes: Correct the linear deformity, reconstruct vermilion cleft lip.
tubercle. 2. Clinical features: The pitting defects and whistle defor-
6. Operation steps: Shown in Fig. 8.22. mity of the upper lip.
a b
c d
e f
Fig. 8.21 Postoperative scar repair of bilateral cleft lip (a) Whistling (h) Release the scar (i) Fold the mucosa (j) Suture the mucosa (k)
lip deformity (b) Design the incision (c) Scar excision (d) Test tension Suture finished, retain one stitch at the philtrum column to form an
(e) Release and separate (f) Retest tension (g) Separate the muscle layer impression
190 L. Zhu et al.
g h
i j

a b
c d
e f
Fig. 8.22 Vermilion of the lip depression repair (a) Vermilion of the lip depression (b) Upper lip deformity (c) Design the incision (d) Tumescent
anesthesia (e) Cut open and suture (f) One day after the operation, the shape of the lip repair well
192 L. Zhu et al.
a b
c d
e f
Fig. 8.23 Whistling lip deformity repair (a) Upper lip deformity (b) (k) Suture the vermilion of the lip (l) Suture the mucosa (m) Examination
Design the incision (c) Cut open the scar (d) Cut open the mucosa (e) of mucosa (n) adjust the mucosa (o) Check the appearance. (p) Suture
Separate the scar (f) Scar excision (g) Separate the incisal margin (h) the skin (q) The operation is finished, the shape of the lip repair well
Suture the mucosa (i) Suture the muscle layer (j) Suture the lip margin
g h
i j
k l

194 L. Zhu et al.
m n
o p

3. Surgical methods: (a) Excise scars on red lips. (b) 5. Notes: As an alternative method, this procedure has rela-
Transposition of orbicularis oris muscle flap to improve tively minor tissue damage compared with other surgical
pitting deformity of the upper lip. procedures.
4. Techniques: (a) The orbicularis oris muscle flaps should 6. Operation steps: Shown in Fig. 8.24.
be moved down to fill the defect of the red lip.
a b
c d
e f
Fig. 8.24 Operation steps: Show in Fig. 8.24. (a) Whistle deformity. muscles. (f) Suture the muscle layer. (g) Skin suture. (h) Appearance of
(b) Excision of the red lip mucosa. (c) Separation of the orbicularis incision after suture
muscle. (d) Downshift of the orbicularis muscle flaps. (e) Suture to fix
196 L. Zhu et al.
g h
8.4.4 Vermilion of the Lip Deformity 5. Notes: The anterior lip flap should be trimmed evenly, not
too thin.
Case 6. Operation steps: Shown in Fig. 8.26
1. Introduction of medical history: A 17-year-old girl suffers
deformity of upper lip and scar after bilateral cleft lip
operation. 8.4.6 Short Nasal Columella
2. Clinical manifestations: Vermilion of the lip deformity,
upper lip scar. Case
3. Surgical methods: Use the scar as labiogingival groove 1. Introduction of medical history: A 16-year-old female
lining, rotate the anterior lip C-flap to repair the basis suffers nosewing collapse and shorten nasal columella
nasi. Close the upper lip incision, and correct grin after the bilateral cleft lip operation.
deformity. 2. Clinical manifestations: Nosewing collapse, shortening
4. Operation points: (1) After upper lip scar separation, sink of nasal columella.
into the deep layer as the labiogingival groove a lining. 3. Surgical methods: Design W-flap, extend the upper lip.
(2) Cut open the upper lip, regroup and adjust. (3) Rotate Rib cartilage transplantation, make a scaffold to raise the
the anterior lip C-flap to repair the basis nasi. tip of the nose.
5. Notes: Muscle layer separation should be appropriate. 4. Operation points: W-shaped incision of upper lip, extend
Pay attention that ischemia can occur when the radius is the nasal columella. Columnar sculpture of costal carti-
too large. lage, brace nasal columella.
6. Operation steps: Shown in Fig. 8.25. 5. Notes: Take the seventh rib cartilage, hidden incision.
8.4.5 ermilion of the Lip Inosculans

V
Deformity 8.4.7 Shortening Deformity of Upper Lip
Case Case
1. Introduction of medical history: A 22-year-old male suf- 1. Introduction of medical history: A 24-year-old female
fers scar deformity after bilateral cleft lip operation. suffers shortening deformity of upper lip after bilateral
2. Clinical manifestations: Vermilion of the lip inosculans, cleft lip operation.
upper lip scar, vermilion defect of the upper lip. 2. Clinical manifestations: Upper lip shortening, upper lip
3. Surgical methods: (1) Inosculans vermilion of the lip scar.
excision, reduce anterior labial flap. (2) The scar was cut 3. Surgical methods: R-flap repair by stages.
and sew it straight. 4. Operation points: (1) Phase I: Design R-shaped pedicled
4. Operation points: Cut open the upper lip tissue, thorough red lip flap on lower lip. (2) Transfer the tissue of the
separation, regroup. lower lip to the upper lip. The upper and lower lips are
a b
c d
e f
Fig. 8.25 Vermilion of the lip defect repair (a) Upper lip defect (b) (i) Suture the muscle layer (j) Interrupted suture (k) Rotate the C-flap
Incision scar (c) Design the tangent (d) Cut open the left side (e) Incise (l) Repair the nose foot (m) Suture subcutaneously (n) Suture the skin
and release (f) Suture the scar as a labiogingival groove lining. (g) (o) Suture the mucosa (p) One day after the operation, the shape of the
Suture the upper lip mucosa (h) Interrupted suture, and close the layer lip repairs well (q) The shape of opening mouth is good
198 L. Zhu et al.
g h
i j
k l

m n
o p

200 L. Zhu et al.
a b
c d
e f
g h
Fig. 8.26 Vermilion of the lip inosculans deformity repair (a) Scar adhesion (m) Cut open the skin (n) Scar excision (o) Release thor-
depression (b) Design the incision (c) Tumescent anesthesia (d) Tension oughly (p) Suture the muscle layer (q) Left triangle surplus (r) Lift and
state (e) Incision by design line (f) Removal of embedded red lip (g) excision (s) Observe the shape after triangle excision (t) Subcutaneous
Subcutaneous suture (h) Suture at fixed-point (i) Cut open the mucosa. suture (u) Finished suture (v) One day after the operation, the shape of
(j) Separate the mucosa (k) Separate the muscle layer (l) Release the the lip repairs well
i j
k l
m n
o p

202 L. Zhu et al.
q r
s t
u v

a b
c d
e f
g h
Fig. 8.27 Repair of short nasal columella (a) Tip of the nose collapse open the skin (k) Raise the flap (l) Implant the cartilage (m) Suture the
(b) Upper lip scar | (c) Nosewing collapse (d) The seventh rib cartilage double flap (n) Extend the nasal columella (o) Suture the skin (p) The
(e) Expose the cartilage (f) Cut out the cartilage (g) Carve the cartilage operation is finished, the apex nasi has already been lifted up
(h) Cartilage waiting for implantation (i) Design the incision (j) Cut
204 L. Zhu et al.
i j
k l
m n
o p

a b
c d
Fig. 8.28 Repair of upper lip shortening deformity (a) upper lip shortening deformity (b) Design the incision and R-flap (c) Three weeks after
cutting the pedicle and rotate the flap, well healed (d) Repair of wound after pedicle breakage, extend the upper lip, and the deformity is improved
temporarily closed for 3 weeks, with pipe feeding. Three lip depression and deformity. (3) Left nose foot
weeks later, cut off the pedicle and repair the upper and collapse.
lower lip respectively. 3. Surgical methods: (1) Removal of deformed incisors. (2)
5. Notes: The pedicle of the lower lip R-flap should not be Reconstruct the human middle ridge with inferior trian-
too small. Retain more than one-third of the pedicle to gular valve. (3) Adjust the vermilion of the lip. (4) Rotate
ensure blood supply. the scar flap, and raise the basis nasi.
6. Operation steps: Shown in Fig. 8.28 4. Operation points: (1) Insert the micro-triangular flap at
the margin of red lip, lower lip height, and alignment
suture. (2) Rotate the upper lip scar to act as the labiogin-
8.4.8 Fissure Relapsing gival groove lining. (3) Double-loop suture of the muscu-
lar layer. (4) Suture the small triangular flap by angle-3D
Case continued suture method [3, 4].
1. Introduction of medical history: A 16-year-old male suf- 5. Notes: Tissue separation should be accurate and in place
fers fissure relapsing after the bilateral cleft lip operation. due to the severe scar after the previous operation.
2. Clinical manifestations: (1) Left basis nasi split, expo- 6. Operation steps: Shown in Fig. 8.29.
sure of incisor teeth and gingiva. (2) Vermilion of the
206 L. Zhu et al.
a b
c d
e f
g h
Fig. 8.29 Fissure relapsing repair (a) Left upper lip fissure relapsing wound area (l) Suture the muscular layer of red lip (m) Cut open the
deformity (b) Intubation anesthesia (c) Separate the incisor (d) Pull out skin, deep cut and release (n) Intracutaneously suture (o) Insert the tri-
the incisor (e) Suture the wound (f) Design the incision. (g) Cut open angular flap (p) Angle-3D continued suture method, the first stitch (q)
the scar (h) Inverted suture (i) Separate the muscle layer (j) Suture the The second needle (r) The third needle (s) Knot and finished (t) One
muscle layer (k) Reduction suture the muscular layer, and reduce the day after the operation, the appearance of nostril is symmetric
i j
k l
m n

208 L. Zhu et al.
o p
q r
s t
3. Wang X-F, et al. Clinical application of 3-dimensional continu-

References ous suturing technique for triangular wounds. Ann Plast Surg.
2018;81(3):316–21.
1. Aranmolate S, et al. Upper triangular flap in unilateral cleft lip 4. Scheller K, et al. Objective evaluation of vertical Z-plasty with
repair. J Craniofacial Surg. 2016;27(3):756–9. double transposition vermillion flaps for secondary whistling
2. Cho BC, et al. The correction of a secondary bilateral cleft lip nasal deformity correction: a method for uni- and bilateral correction. J
deformity using refined open Rhinoplasty with Reverse-U Incision, Craniomaxillofac Surg. 2019;47(10):1557–62.
Part III
Repair of Cleft Palate
Repair of Unilateral Cleft Palate
9
Jian-min Yao
9.1 he First-Degree Cleft Palate (Bifid

T 2. Clinical manifestation: Nasal voice, cleft soft palate.
Uvula) 3. Surgical method: Single-flap palatoplasty [2].
4. Key points: Design a single-flap incision in the cleft, pro-
Case tect the double pedicle vessels.
5. Precautions: Intraoperative hemostasis should be com-
1. Medical history: A boy, 6 years and 7 months old, pre- pleted; electrocoagulation and tampon can be used.
sented with bifid uvula. 6. Operation steps: See Fig. 9.3.
2. Clinical manifestation: Bifid uvula.
3. Surgical method: Straight-Line Intravelar Veloplasty.
4. Key points: Cut open the cleft edge and suture directly. Case 3
5. Precautions: Lifting the uvula and cutting it horizontally
can extend the uvula. 1. Medical history: A boy, 18 months old, presented with
6. Operation steps: See Fig. 9.1. cleft soft palate.
2. Clinical manifestation: Nasal voice, wider cleft soft
palate.
9.2 he Second-Degree Cleft Palate (Cleft
T 3. Surgical method: Single Z-plasty [3] + bilateral relax-
Soft Palate) ation incision.
4. Key points: Put a Z-shaped flap on the cleft margin, cut
Case 1 open the whole layer, exchange the triangular flap, tightly
stitched.
1. Medical history: A girl, 2 years and 6 months old, pre- 5. Precautions: Bilateral relaxation incision according to the
sented with cleft soft palate. situation.
2. Clinical manifestation: Nasal voice, cleft soft palate. 6. Operation steps: See Fig. 9.4.
3. Surgical method: Unilateral relaxation incision [1].
4. Key points: Cut the cleft edge, loose on one side to reduce
the incision, and suture it in a straight line. Case 4
5. Precautions: Select one or double side relaxation incision
according to the tension. 1. Medical history: A boy, 1 year and 11 months old, pre-
6. Operation steps: See Fig. 9.2. sented with cleft soft palate.
2. Clinical manifestation: Nasal voice, wider cleft soft
palate.
Case 2 3. Surgical method: Single Z-plasty [3] + relaxation inci-
sion [1].
1. Medical history: A boy, 8 months old, presented with 4. Key points: Suture three layers and tightly stitched.
cleft soft palate. 5. Precautions: Relaxation incision according to the
situation.
6. Operation steps: See Fig. 9.5.
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_9
212 J.-m. Yao
a b
c d
e f
Fig. 9.1 Repair of first-degree cleft palate (bifid uvula)—Straight-Line (f) Suture muscle layer (g) Lift the tip (h) Suture muscle layer (i) Suture
Intravelar Veloplasty. (a) Bifid uvula (b) Design incision (c) Cut open muscular mucosa (j) Suture oral mucosa (k) Suture mucosa interrupted
the cleft edge (d) Transverse incision to extend uvula (e) Suture mucosa (l) One day after operation, the patient recovered well
9 Repair of Unilateral Cleft Palate 213
g h
i j
k l

214 J.-m. Yao
a b
c d
e f
Fig. 9.2 Repair of the second-degree cleft palate (cleft soft palate)— muscle layer (d) Suture pharyngeal mucosa (e) Suture muscle layer (f)
unilateral relaxation incision. (a) Cleft soft palate (b) Cleft margin and Suture oral mucosa
one-side relaxation incision (c) Separation of cleft margin, exposure of
a b
c d
e f
Fig. 9.3 Repair of the second-degree cleft palate (cleft soft palate)— margin (d) Lift the palate (e) Suture nasal mucosa (f) Suture muscular
single-flap palatoplasty. (a) Soft cleft palate (b) 1% lidocaine 3–5 ml is layer (g) Suture lingual mucosa (h) Close the incision (i) One day after
injected into each side for swelling anesthesia (c) Cut open the cleft operation, the patient recovered well
216 J.-m. Yao
g h
Case 5 should be placed with a thick layer at the distal end and
a thin layer at the proximal end to facilitate blood
1. Medical history: A girl, 2 years and 3 months old, pre- supply.
sented with cleft soft palate. 6. Operation steps: See Fig. 9.7.
2. Clinical manifestation: Cleft soft palate.
3. Surgical method: Furlow double-opposing Z-plasty.
4. Key points: Overlap the two layers, suture reversely, and 9.3 he Third-Degree Cleft Palate
T
the stitch tension is appropriate. (Complete Cleft Palate)
5. Precautions: Pay attention to the blood supply of the valve
and pedicle. The pedicle of each layer of valve should be Case 1
placed with a thick layer at the distal end and a thin layer
at the proximal end to facilitate blood supply. 1. Medical history: A boy, 4 years old, presented with com-
6. Operation steps: See Fig. 9.6. plete cleft palate.
2. Clinical manifestation: Complete cleft palate, heavy nasal
voice.
Case 6 3. Surgical method: Two-flap palatoplasty [1].
4. Key points: Bilateral incisions, relaxation separation, the
1. Medical history: A boy, 1 year and 3 months old, pre- nasal and lingual mucosal flaps were sutured and fixed
sented with cleft soft palate. together without dead space.
2. Clinical manifestation: Cleft soft palate. 5. Precautions: Separate vascular pedicle and release it. The
3. Surgical method: Furlow double-opposing Z-plasty. hemostasis of incision should be exact. The medial part of
4. Key points: Overlap the two layers, suture reversely, and the uncinate pterygoid process is easy to separate and
the stitch tension is appropriate. release.
5. Precautions: Pay attention to the blood supply of the Or twist the pterygoid process to relax the palate.
valve and pedicle. The pedicle of each layer of valve 6. Operation steps: See Fig. 9.8.
a b
c d
e f
g h
Fig. 9.4 Repair of the second-degree cleft palate (cleft soft palate)— the nasal mucosa (h) Suture the muscular layer (the middle layer) (i)
single Z-plasty. (a) Soft cleft palate (b) Design incision (c) Incision on Suture mucosal, muscular layer interrupted (j–k) Suture muscular layer
the cleft margin (d) Relax the incision (e) Relaxation separation (f) (l–m) Suture lingual mucosa (n) Suture the muscular and mucosal layer
Full-thickness incision according to Z shape (g) Fixed-point suture of (o) After sewing, oil gauze filling
218 J.-m. Yao
i j
k l
m n

a b
c d
e f
g h
Fig. 9.5 Repair of the second-degree cleft palate (cleft soft palate)— sion (h) Cut open the left side of “Z” (i) Cut open the right side of “Z”
single Z-plasty. (a) Second-degree cleft palate (b) Design incision (c) (j) Tension test (k) Suture the nasal mucosa (the first layer) (l) Suture
Relaxation separation (d) Cut open one side of the cleft (e) Separate the the muscular layer (the second layer) (m) Suture the lingual mucosa
palate (f) Cut open the other side of the cleft (g) Relaxation of the inci- (the third layer) (n) Bilateral gauze packing (o) Incision schematic
220 J.-m. Yao
i j
k l
m n

a b
c d
e f
g h
Fig. 9.6 Repair of the second-degree cleft palate (cleft soft palate)— (f) Cut open the deep layer (g) Cut open the deep layer of the opposite
Furlow double-opposing Z-plasty. (a) Cleft soft palate (b) Lingual inci- side (h) Suture the fixed angle points (i) Suture muscular layer (j)
sion is as the continuous line, nasal incision is as the dotted line (c) Suture angle muscle layer (k) Suture muscular layer (l) Suture mucosa
Swelling anesthesia (d) Cut open the left side (e) Cut open the right side (m) Healed well 1 day after operation
222 J.-m. Yao
i j
k l
Case 2 and fixed together. Pad the patient’s back, raise his head,
and expose the oral cavity.
1. Medical history: A boy, 3 years old, presented with com- 5. Precautions: Combine sharply and bluntly to separate the
plete cleft palate. tissue, in order to protect the palatal flaps.
2. Clinical manifestation: Complete cleft palate. 6. Operation steps: See Fig. 9.9.
3. Surgical method: Langenbeck palatoplasty [4].
4. Key points: Tumescent anesthesia is conducive to tissue
separation. The nasal and oral mucosal flaps are sutured
a b
c d
e f
g h
Fig. 9.7 Repair of the second-degree cleft palate (cleft soft palate)—Furlow double-opposing Z-plasty. (a) Design incision (b) Bilateral incision
(c) Lift and separate (d) Relaxation incision (e) Deep incision (f) Suture each layer (g) Close the incision (h) One day after surgery
224 J.-m. Yao
a b
c d
e f
Fig. 9.8 Repair of the third-degree cleft palate (two-flap palatoplasty). uvula mucosa (n) Lift uvula (o) Check uvula (p) Suture uvula (q)
(a) Complete cleft palate (b) Separate one side (c) Separate vascular Edging hemostasis (r) Anterior hemostasis (s) Suture lingual mucosa
bundle (d) Expose pedicle (e) Separate nasal mucosa (f) Release (t) Complete the suture (u) Needle into bone flap (v) Needle out palatal
mucosa (g) Another incision (h) Separate palatal flap (i) Separate nasal flap (w) Lift suture (x) Fix palatal flap and press it (y) Bilateral gauze
mucosa (j) Suture nasal mucosa (k–l) Suture muscular layer (m) Suture packing (z) Healed well 1 day after operation
g h
i j
k l

226 J.-m. Yao
m n
o p
q r
s t

u v
w x
y z

228 J.-m. Yao
a b
c d
e f
Fig. 9.9 Repair of the third-degree cleft palate (Langenbeck palato- and relax incision (g) Separate and release (h) Release the pedicle (i)
plasty). (a) Complete cleft palate (b) Tumescent anesthesia (c) Fill tis- Completed separation (j) Suture deep layer (k) Suture muscular layer
sue (d) Cut open cleft margin (e) Cut open the other side (f) Separate (l) Suture superficial layer
g h
i j
k l

230 J.-m. Yao
Case 3 4. Key points: The palatal flaps are short and not long
enough. A small triangular flap can be formed by an addi-
1. Medical history: A boy, 3 years and 6 months old, pre- tional incision, rotated to extend the palatal flap to repair
sented with complete cleft palate. the incisor side wound.
2. Clinical manifestation: Complete cleft palate with a nar- 5. Precautions: When making the small flap, pay attention
row palatal flap and high palatal arch. that the incision should not exceed the midline of the pal-
3. Surgical method: Two-flap palatoplasty [1] + small flap atal flap, and consider the blood supply of the palatal flap
rotation to repair incisor side wound. and the small flap.
a b
c d
Fig. 9.10 Repair of the third-degree cleft palate (two-flap palatoplasty the knot outside the tissue (i) Suture palatine muscle (j) Suture muscu-
+ small flap rotation to repair incisor side wound). (a) Complete cleft lar layer (k) Suture penetrate upper and lower mucosa (l) Additional
palate (b) Tumescent anesthesia (c) Cut open one side (d) Separate vas- incision on palate flap (m) Small flap (n) Rotating suture, repair ante-
cular bundle (e) Cut open the opposite side (f) Lift palatal flaps and rior palate (o) Repair wound (p) Suture uvula (q) Suture dorsal mucosa
separate nasal side (g) Suture nasal mucosa (h) Suture reversely, leave (r) Repair completed (s) Healed well 1 day after surgery
e f
g h
i j
k l

232 J.-m. Yao
m n
o p
q r

Case 4 sutured in dislocation if the wound surface of the proxi-

mal incisor is insufficient.
1. Medical history: A boy, 4 years and 2 months old, pre- 5. Precautions: The palatal flap with high arch is thin and
sented with complete cleft palate. easy to be damaged. The swelling liquid can be injected
2. Clinical manifestation: Complete cleft palate. more for separation.
3. Surgical method: Two-flap palatoplasty [1]. 6. Operation steps: See Fig. 9.11.
4. Key points: The bilateral palatal flaps are in different
sizes, and the palatal arch is high. The two flaps can be
a b
c d
e f
Fig. 9.11 Repair of the third-degree cleft palate (two-flap palato- layer (muscular layer) (i) Suture palatine muscle (j) Reconstruct uvula
plasty). (a) Tumescent anesthesia (b) Cut open one side (c) Separate (k) Suture the upper and lower palate flaps and mucosal flaps together
palatal flap (d) Cut open the opposite side (e) Separate vascular bundle (l) Suture palate flaps (m) Gauze packing (n) Check after surgery
(f) Release the pedicle (g) Suture nasal mucosa (h) Suture the middle
234 J.-m. Yao
g h
i j
k l
m n

Case 5 4. Key points: Release palatal flap of one side fully, the pala-
tal mucoperiosteal flaps of the other side were fully free
1. Medical history: A girl, 5 years and 6 months old, pre- and then operated routinely.
sented with complete cleft palate. 5. Precautions: The use of single-flap should be based on the
2. Clinical manifestation: Complete cleft palate. width of cleft palate and the principle is tension-free suture.
3. Surgical method: Single-flap palatoplasty [2]. 6. Operation steps: See Fig. 9.12.
a b
c d
Fig. 9.12 Repair of the third-degree cleft palate (single-flap palatoplasty). (a) Complete cleft palate (b) Release palatal flap of one side, suture
each layer (c) Suture mucosa (d) Reconstruct uvula
236 J.-m. Yao
References 3. Tan WQ, Xu JH, Yao JM. The single Z-plasty for cleft pal-
ate repair: a preliminary report. Cleft Palate Craniofac J.
2012;49(5):635–9.
1. Gu M, et al. Modified two-flaps palatoplasty with lateral mucus
4. Smith KS, Ugalde CM. Primary palatoplasty using bipedicle flaps
relaxing incision in cleft repair. Medicine. 2019;98(47):e17958.
(modified von Langenbeck technique). Atlas Oral Maxillofac Surg
2. Kara M, et al. Cleft palate repair using single flap palatoplasty in
Clin North Am. 2009;17(2):147–56.
patient with associated palatal hemangioma. J Craniofacial Surg.
2018;29(5):1332–3.
Repair of Bilateral Cleft Palate
10
Wei-jun Fan and Jian-min Yao
10.1 Incomplete Cleft of Bilateral Palate 4. Key points: When the repair material is insufficient, the
palatal flaps can be used with additional incisions and
Case rotated to repair the anterior palatal wounds. Or the ante-
1. Medical history: A girl, 17 months old, presented with rior palatal wounds could be repaired in the second stage
bilateral incomplete cleft palate. operation.
2. Clinical manifestation: Most of the soft and hard palates 5. Precautions: The incision of small flaps should not exceed
on both sides were cleft, and the plow bone was the midline of palatal flaps in order to avoid necrosis of
dysplasia. flaps.
3. Surgical method: Two-flaps palatoplasty [1]. 6. Operation steps: See Fig. 10.2.
4. Key points: Incision and separation of bilateral mucoperi-
osteal flaps. Separation and rotation of the palatal muscles
to form a circular palatal arch, beneficial for the posterior Case 2
palatal flap to retreat and close palatopharynx. 1. Medical history: A boy, 2 years and 6 months old, pre-
5. Precautions: Depending on the development of the mus- sented with bilateral complete cleft palate.
cular layer of the soft palate, it is not appropriate to sepa- 2. Clinical manifestation: Bilateral cleft palate, bimaxillary
rate the muscular layer excessively. Pay attention to the protrusion.
movement, direction, and blood supply radius of the 3. Surgical method: Two-flaps palatoplasty + vomer muco-
vessels. sal flap [2] + labial mucosal flap.
6. Operation steps: See Fig. 10.1. 4. Key points: Incision and separation of vomer mucosal
flap and bilateral soft and hard palate flap. Suture nasal
mucosa and vomeral mucosa, muscle layer and lingual
10.2 omplete Cleft of Bilateral Palate
C mucosa respectively, and seal soft and hard palate cleft.
(Soft or Hard Palate) Incision of anterior maxillary mucosa, inversion of lining,
tongue-shaped incision of lip mucosa, rotation to repair
Case 1 anterior maxillary wounds.
1. Medical history: A boy, 2 years old, presented with bilat- 5. Precautions: When the repair material is insufficient, the
eral complete cleft palate. anterior jaw fissure can be operated on in the second
2. Clinical manifestation: Bilateral cleft palate. stage.
3. Surgical method: Two-flaps palatoplasty + arbitrary pala- 6. Operation steps: See Fig. 10.3.
tal flap repair.
W.-j. Fan
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_10
238 W.-j. Fan and J.-m. Yao
a b
c d
e f
Fig. 10.1 Repair of bilateral incomplete cleft palate (two-flaps palato- layer: the muscular layer (g) Suture lingual mucosa (h) Suture bilateral
plasty). (a) Bilateral incomplete cleft palate (b) Separate the muscle tensor palatine flap (i) Strengthened suture (j) Reconstruct palatal ring
layers as described above (c) Tension test (d) Reveal the vascular bun- (k) Bilateral gauze packing (l) Separation and rotation of palatine
dle of the palate flap (e) Suture nasal mucosa (f) Suture the middle muscles
10 Repair of Bilateral Cleft Palate 239
g h
i j
k l

a b
c d
e f
Fig. 10.2 Repair of bilateral complete cleft palate (two-flaps palato- (j) Suture palatal muscular layer, form palatopharyngeal ring, retreat
plasty). (a) Bilateral complete cleft palate (b) Cut open one side (c) palatal flap (k) Additional incision to make small flap (l) Rotate small
Separate nasal side (d) Reveal the vessels (e) Separate the opposite side flap to repair anterior palate wound (m) Suture mucosa of palatal flap
(f) Suture nasal mucosa and the vomer mucosa (g) Suture the bilateral (n) Gauze packing after surgery
vomer flaps (h) Suture muscular layer (i) Suture mucosa of soft palate
g h
i j
k l
m n

a b
c d
e f
Fig. 10.3 Repair of bilateral complete cleft palate (two-flaps palato- mucosa (n) Suture one by one (o) Expose the vomer (p) Suture bilateral
plasty + local rotation flap). (a) Bilateral complete cleft palate (b) soft palatal mucosa (q) Suture muscular layer (r) Suture uvula and
Intubation anesthesia, retractor fixation (c) Local swelling anesthesia bilateral muscular layer (s) Suture lingual mucosa (t) Cut open and
(d) Design incision (e) Cut open vomer mucosa (f) Separate mucosa (g) separate the mandibular mucosa (u) Separate mucosa (v) Reverse
Cut open soft and hard palatal flaps (h) Separate nasal mucosa (i) mucosa (w) Suture and fixation (x) Cut the labial mucosal flap, rotate to
Suture nasal mucosa (j) Cut the opposite soft and hard palatal flaps (k) cover repair (y) Gauze packing after surgery (z) Healing condition the
Separate and lift the flaps (l) Separate nasal mucosa (m) Suture nasal next day
g h
i j
k l

m n
o p
q r

s t
u v
w x

y z
2. Smarius BJA, Breugem CC. Use of early hard palate closure using a
References vomer flap in cleft lip and palate patients. J Cranio-Maxillofac Surg.
2016;44(8):912–8.
relaxing incision in cleft repair. Medicine. 2019;98(47)
Repair of Alveolar Cleft
11
Jing-hong Xu and Jian-min Yao
Case 1 5. Precautions: Mucosal sacks should not be leaked, bone

1. Medical history: A boy, 10 years old, presented with alve- cracks should be tightly compressed, and bone should be
olar cleft. tightly wrapped by mucosa and not exposed.
2. Clinical manifestation: Alveolar cleft at the left incisor. 6. Operation steps: See Fig. 11.2.
3. Surgical method: Iliac graft, inverted mucoperiosteal flap
+ local mucosal flap. Case 3
4. Key points: Open the gingiva, expose the cracks to the 1. Medical history: A boy, 17 years old, presented with alve-
root, and peel the cracked gingiva along the alveolar bone olar cleft.
surface. Cut off cancellous granules of iliac bone at iliac 2. Clinical manifestation: Alveolar cleft at the lateral
crest, about 5 ml. Bone cancellous particles were incisor.
implanted, and mucosal flaps were transferred locally to 3. Surgical method: Inverted mucoperiosteal flap [1] + local
cover and repair the fissures. mucosal flap.
5. Precautions: Mucosal sacks should not be leaked, bone 4. Key points: The cleft edge is incised to the front edge of
cracks should be tightly compressed, and bone should be the gingiva, and the back edge can be extended to meet
tightly wrapped by mucosa and not exposed. the need of flipping lining. The principle is tightly embed-
6. Operation steps: See Fig. 11.1. ding the bone graft according to the situation. Cut off can-
cellous granules of iliac bone at iliac crest, about 3–10 ml.
Case 2 Bone cancellous particles were implanted, and mucosal
1. Medical history: A boy, 9 years old, presented with alveo- flaps were transferred locally to cover and repair the
lar cleft. fissures.
2. Clinical manifestation: Alveolar cleft at the lateral incisor. 5. Precautions: Mucosal sacks should not be leaked, bone
3. Surgical method: Inverted mucoperiosteal flap + local cracks should be tightly compressed, and bone should be
mucosal flap. tightly wrapped by mucosa and not exposed.
4. Key points: The cleft edge is incised to the front edge of 6. Operation steps: See Fig. 11.3.
the gingiva, and the back edge can be extended to meet
the need of flipping lining. The principle is tightly embed- Case 4
ding the bone graft according to the situation. Cut off can- 1. Medical history: A girl, 9 years old, presented with alveo-
cellous granules of iliac bone at iliac crest, about 3–10 ml. lar cleft.
Bone cancellous particles were implanted, and mucosal 2. Clinical manifestation: Alveolar cleft at the left incisor,
flaps were transferred locally to cover and repair the dental deformity.
fissures. 3. Surgical method: Iliac graft, inverted mucoperiosteal flap
[1] + local mucosal flap.
4. Key points: Separate the fissures. Make sacks. Iliac
J.-h. Xu
The First Affiliated Hospital, Zhejiang University School of transplantation.
Medicine, Hangzhou, China 5. Precautions: Separate the fissures until the bone surface.
J.-m. Yao (*) The quantity of cancellous bone is as much as possible.
Hangzhou Plastic Surgery Hospital, Hangzhou, China 6. Operation steps: See Fig. 11.4.

https://doi.org/10.1007/978-981-15-4419-4_11
248 J.-h. Xu and J.-m. Yao
a b
c d
Fig. 11.1 Repair of alveolar cleft. (a) Peel gingiva, expose alveolar fissures (b) Autogenous iliac bone transplantation (c) Filling of the cavity with
cancellous bone particles (d) Local mucosal flap transfer to cover the fissures (e) End
11 Repair of Alveolar Cleft 249
a b
c d
e f
g h
Fig. 11.2 Repair of alveolar cleft (inverted mucoperiosteal flap). (a) the cancellous bone (g) Check the wound (h) Fill gelatin sponge (i)
Alveolar cleft (b) Circular incision (c) Cut open, separate mucoperios- Suture periosteum (j) Suture skin or retain drainage tube (k) Cancellous
teal (d) Reverse and suture (e) Cut open skin of iliac crest (f) Excavate bone graft (l) Suture mucosa, embed bone grafts
i j
k l
a b
Fig. 11.3 Repair of alveolar cleft (inverted mucoperiosteal flap). (a) Alveolar cleft (b) Separate and expose (c) Suture the bottom of the sac (d)
Cut off part of iliac (e) Transplant cancellous bone (f) Envelope suture
c d
e f
a b
Fig. 11.4 Repair of alveolar cleft (inverted mucoperiosteal flap). (a) flap (l) Cut the cancellous bone (m) Suture the periosteum, muscle
After cleft lip surgery (b) Alveolar cleft (c) Cut open the mucosa of layer (n) Suture the skin, close the donor area (o) Transplant cancel-
the cleft (d) Separate fissures (e) Peel the bone surface (f) Expose the lous bone (p) Fill the cavity (q) Transfer the upper lip mucosal flap
cavity (g) Cut open the skin of anterior superior iliac (h) Cut open to cover the wound (r) Close the suture (s) End
periosteum (i) Cut open the cortical (j) Chiseling (k) Flip the bone
c d
e f
g h
i j

k l
m n
o p

q r
Reference
1. Anani RA-A, Aly AM. Closure of palatal fistula with local double-
breasted mucoperiosteal flaps. J Plast Reconstr Aesthet Surg.
2012;65(9):e237–40.
Pharyngoplasty (Posterior Pharyngeal
Flaps) 12
Kai Han and Jian-min Yao
Case 5. Precautions: Make a transverse incision at the transverse

1. Medical history: A boy, 4 years old, presented with com- ridge of the posterior pharyngeal wall and make mucosal
plete palate cleft. muscle flaps on both sides with the pedicle above. Flaps
2. Clinical manifestation: Complete palate cleft. were embedded in a transverse incision to form a trans-
3. Surgical method: Lateral myocutaneous flap verse ridge and narrow the nasopharyngeal cavity.
4. Key points: Mucosal muscle flaps were made. Rotate the 6. Operation steps: See Fig. 12.1.
tongue-shaped flap to reduce the nasopharyngeal cavity.
a b
Fig. 12.1 Pharyngoplasty(postpharyngeal flap). (a) Design incision (b) Operation sketch (c) Reduction of pharyngeal cavity after operation
K. Han
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_12
Repair of Postpalateplasty
Complications 13
Chiao-yun Chiu and Jian-min Yao
This section mainly introduces the repair of palatal fistula, 4. Key points: Surface of cleft margin was excised.
including the repair of anterior, middle, and posterior palatal Relaxation of incision and separation of mucoperiosteal
fistula, and the repair of the cleft palate after operation. The flap. Rotate mucoperiosteal flap, suture, and close the
methods include skin grafting, rotatory flaps, repair of flaps fistula.
separation, and loosen. 5. Precautions: When separating the mucoperiosteal flap, it
is relatively hard. It can be peeled off and rotated while
separating. The movement should be careful and light. Do
13.1 Repair of Palatal Fistula not tear or break it.
13.1.1 Anterior Palatal Fistula
Case 1 13.1.2 Anterior and Middle Palatal Fistula

1. Medical history: A male, 20 years old, presented with
anterior palatal fistula. Case 1
2. Clinical manifestation: The large part of the anterior pal- 1. Medical history: A boy, 6 years and 9 months old, pre-
ate is retracted and defected. sented with anterior and middle palatal fistula.
3. Surgical method: Mucoperiosteal flap reversion + skin 2. Clinical manifestation: Anterior and middle palatal
grafting. fistula.
4. Key points: The middle layer of the flap is cut open and 3. Surgical method: Mucoperiosteal flap reversion + rota-
turned over as a lining. Medium-thickness skin graft was tion repair.
taken and transplanted. 4. Key points: Surface of cleft margin was excised.
5. Precautions: When separating the mucosal flaps, the Relaxation of incision and separation of mucoperiosteal
thickness should be uniform. Do not penetrate. flap. Rotate mucoperiosteal flap, suture, and close the
6. Operation steps: See Fig. 13.1. fistula.
5. Precautions: The cleft margin of the middle palate is thin
and can be cut parallel and obliquely to increase the con-
Case 2 tact surface. The mucoperiosteal flap was separated from
1. Medical history: A boy, 15 years old, presented with ante- the anterior palate, rotated to repair the fistula.
rior palatal fistula. 6. Operation steps: See Fig. 13.3.
2. Clinical manifestation: Anterior palatal fistula.
3. Surgical method: Mucoperiosteal flap reversion + trans-
position repair. Case 2
1. Medical history: A boy, 4 years and 4 months old, pre-
sented with middle palatal fistula.
C.-y. Chiu 2. Clinical manifestation: Soft–hard palatal junction fistula.
The First Affiliated Hospital, Zhejiang University School of 3. Surgical method: Separation of palatal flaps and gliding
repair.
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_13
258 C.-y. Chiu and J.-m. Yao
a b
c d
e f
g h
Fig. 13.1 Repair of anterior palatal fistula (mucoperiosteal flap reversion + skin grafting). (a) Anterior palatal fistula (b) Design incision (c) Cut
open (d) Flip flaps (e) Suture mucosa (f) Skin graft (g) Suture skin graft (h) Fixation
13 Repair of Postpalateplasty Complications 259
a b
c d
Fig. 13.2 Repair of anterior palatal fistula (mucoperiosteal flap reversion + transposition repair). (a) Anterior palatal fistula (b) Resect cleft mar-
gin (c) Cut open and relax (d) Separate of mucoperiosteal flap (e) Rotated suture
a b
c d
e
e f
Fig. 13.3 Repair of anterior and middle palatal fistula (mucoperiosteal (e) Flap design (f) Rotate flap (g) Suture anterior palate (h) One day
flap reversion + rotation repair). (a) Soft–hard palatal junction fistula after operation (i) Healed well the next day
(b) Anterior palatal fistula (c) Resect cleft margin (d) Separate one flap
g h
4. Key points: Surface of cleft margin was excised. tact surface. The mucoperiosteal flap was separated from
Relaxation of incision and separation of mucoperiosteal the anterior palate, rotated to repair the fistula.
flap. Rotate mucoperiosteal flap, suture, and close the 6. Operation steps: See Fig. 13.5.
fistula.
5. Precautions: If the tension is high, bilateral tension reduc-
tion incisions can be chosen. 13.2 Repair of Palate Split Again
13.2.1 Anterior and Middle Palate Split Again
Case 3 Case
1. Medical history: A boy, 9 years old, presented with mid- 1. Medical history: A boy, 7 years and 6 months old, pre-
dle palatal fistula. sented with anterior and middle palate split again.
2. Clinical manifestation: Middle palatal fistula. 2. Clinical manifestation: Anterior and middle palate split
3. Surgical method: Mucoperiosteal flap reversion. again.
4. Key points: Surface of cleft margin was excised. 3. Surgical method: Two-flap palatoplasty [2].
Relaxation of incision and separation of mucoperiosteal 4. Key points: Surface of cleft margin was excised.
flap. Rotate mucoperiosteal flap, suture, and close the fis- Relaxation of incision and separation of mucoperiosteal
tula [1]. flap. Rotate mucoperiosteal flap, suture, and close the
5. Precautions: The cleft margin of the middle palate is thin fistula.
and can be cut parallel and obliquely to increase the con-
a b
c d
e f
Fig. 13.4 Repair of middle palatal fistula (Separation of palatal flaps and gliding repair). (a) Middle palatal fistula (b) Cut open cleft margin (c)
Resect surface of cleft margin (d) Tension reduction separation (e) Suture (f) Close-up fistula (g) One day after surgery
a b
c d
e f
Fig. 13.5 Repair of middle palatal fistula (Separation of palatal flaps and gliding repair). (a) Middle palatal fistula (b) Resect surface of cleft
margin (c) Form wound (d) Lift flap (e) Rotate flap (f) Close fistula
5. Precautions: Because of the scar, it is difficult to separate. 2. Clinical manifestation: Middle and posterior palate split
Swelling anesthesia can be used to facilitate the separation. again.
6. Operation steps: See Fig. 13.6. 3. Surgical method: Two-flap palatoplasty [3].
4. Key points: Surface of cleft margin was excised.
Relaxation of incision and separation of mucoperiosteal
13.2.2 Middle and Posterior Palate Split Again flap. Suture and close the fistula.
5. Precautions: The treatment and surgical design of middle
Case and posterior–anterior palate dehiscence is considered as
1. Medical history: A boy, 6 years old, presented with mid- the first stage of cleft palate.
dle and posterior palate split again. 6. Operation steps: See Fig. 13.7.
a b
c d
e f
Fig. 13.6 Repair of anterior and middle palate dehiscence (two-flap palatoplasty). (a) Anterior and middle palate dehiscence (b) Wide fissure (c)
Separate bilateral palatal flaps (d) Suture the nasal side (e) Suture the muscular layer and mucosa (f) Healed well 1 day after surgery
a b
c d
e f
Fig. 13.7 Repair of middle and posterior palate dehiscence (two-flap Suture the first layer: nasal mucosa (e) Lifting the thread, the knot is
palatoplasty). (a) Middle and posterior palate dehiscence (b) Cut open remains on the nasal side (f) Knot (g) Suture the second layer: muscular
the cleft surface (c) Cut open and separate both sides, relax incision (d) layer (h) Knot (i) Suture the third layer: lingual mucosa
g h
References 3. Smith KS, Ugalde CM. Primary palatoplasty using bipedicle flaps
(modified von Langenbeck technique). Atlas Oral Maxillofac Surg
Clin North Am. 2009;17(2):147–56.
1. Anani RA-A, Aly AM. Closure of palatal fistula with local double-
breasted mucoperiosteal flaps. J Plast Reconstr Aesthet Surg.
2012;65(9):e237–40.
Part IV
Repair of Other Congenital Facial Deformities
Repair of Congenital Eye Deformity
14
Ze-ren Shen, Rui-yu Qing, and Jian-min Yao
14.1 Cleft Eyelid eyelids are temporarily sutured and fixed to protect the
cornea.
Case 1 5. Precautions: Early surgery, close the eyelids as soon as
1. Medical history: A girl, 4 years old, presented with lower possible to protect the cornea.
eyelid cleft deformity. 6. Operation steps: See Fig. 14.2.
2. Clinical manifestation: The left eyelid clefts downward.
3. Surgical method: Rectangular flap.
4. Key points: (1) Restore palpebral margin. (2) Repair the 14.2 ilateral Cleft Upper and Lower
B
lower orbicularis oculi muscle. (3) Rectangular flaps Eyelids
repair the wound.
5. Precautions: A rectangular flap is designed on the skin of Case
the loosening side, and two triangular flaps are designed 1. Medical history: A girl, 5 years old, presented with bilat-
in a relatively hidden place. eral upper and lower eyelids cleft deformity, deformity of
6. Operation steps: See Fig. 14.1. brachydactyly, and syndactyly of the left fingers after the
cleft lip and palate repair.
2. Clinical manifestations: Exposure of bilateral large
Case 2 eyeballs with obvious external protrusion, and they
1. Medical history: A boy, 1 day old, presented with con- present with rabbit eye deformity when the eyes are
genital upper left eyelid defect. closed forcefully. Both the upper and lower sides of
2. Clinical manifestations: Left upper eyelid defect defor- bilateral eyelashes are cleft and interrupted. Lower
mity, corneal exposure, and ulcer. eyeball detaches with tears. The left eye has obvious
3. Surgical method: Miniature inferior triangular flap on the strabismus.
palpebral margin. 3. Surgical method: M-W flap for bilateral upper and lower
4. Key points: (1) Design the incision of miniature inferior eyelids, and repair the cleft.
triangular flap on the upper eyelid margin. (2) Incise 4. Key points: Precise incision, careful integration, division
skin and conjunctiva, separate and release orbicularis of three layers for suturing, relaxation suture can be added
oculi. (3) The muscle layer is sutured with absorbable when required.
stitches; the skin is sutured with silk stitches and the 5. Precautions: Conjunctival layer should be sutured with
conjunctiva is not sutured. (4) Cleft upper and lower 6-0 absorbable stitches, do not leave the line knot on the
surface to avoid rubbing the cornea.
Z.-r. Shen
R.-y. Qing
XiaoShan Hospital, Hangzhou, China
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_14
270 Z.-r. Shen et al.
a b
c d
e f
Fig. 14.1 Repair of lower eyelid cleft (rectangular flap). (a) Left eyelid clefts downward (b) Palpebral margin defect (c) Design incision (d) Incise
and suture (e) Remove stitches 1 week later (f) Design
14 Repair of Congenital Eye Deformity 271
a b
c d
Fig. 14.2 Repair of congenital left upper eyelid defect. (a) Eyelid defect (b) Design incision (c) Repair defect (d) Suture cleft eyelid (e) Remove
stitches 1 week later, the eyelid cleft is closed
a b
c d
e f
g h
Fig. 14.3 Repair of bilateral upper and lower eyelid cleft deformity. (a) Eyelid cleft deformity (b) Left ring finger and little finger ectrodactyly
and syndactyly deformity (c) Design incision of M-W flap (d) Incise the eyelids. (e) Suture the conjunctiva with absorbable stitches and the line
knot is inside (f) Suture the muscular layer. (g) Suture skin (h) Repair upper eyelid (i) Resect the strap (j) Incise the eyelids (k) Suture the muscular
layer (l) Suture the palpebral margin (m) Suture skin (n) Repair eyelid cleft (bilateral, upper, and lower) (o) Appearance when eyes open (2 weeks
later) (p) Appearance when eyes close
i j
k l
m n
o p

14.3 tosis of Upper Eyelid with Lower

P 4. Key points: (1) Separate and resect the upper orbicularis
Eyelid Collapse oculi flap, lift the superior palpebral margin. (2) Incise
and separate the inferior palpebral margin, release and lift
Case the inferior palpebral margin. (3) Transfer the superior
palpebral orbicularis oculi flap to repair the lower eyelid
1. Medical history: A male, 23 years old, presented with the wound.
upper and lower eyelids ptosis and collapse [1]. 5. Precautions: (1) When separating the medial and lateral
2. Clinical manifestations: Bilateral upper eyelids ptosis, canthi, the proximal pedicle needs to be wider to protect
lower eyelids collapse. No family history. blood vessels. (2) Subcutaneous separation of the medial
3. Surgical method: Transfer the bipedicle orbicularis oculi and lateral canthi to accommodate the pedicle of the mus-
flap to repair the lower eyelids collapse deformity, and cular flaps.
suspend the upper eyelids. 6. Operation steps: See Fig. 14.4.
a b
c d
e f
Fig. 14.4 Repair of congenital blepharoptosis associated with lower laris oculi flap (e) The flap is transferred to the lower eyelid (f) Suture
eyelid collapse. (a) Upper and lower eyelids ptosis (b) a, b are the inci- the skin of the lower eyelid (g) Remove stitches after a week (h) Heal
sion lines (c) Separate the orbicularis oculi flap (d) Transfer the orbicu- well 3 months after surgery
g h
Reference
1. Xu JH, Tan WQ, Yao JM. Bipedicle orbicularis oculi flap in the
reconstruction of the lower eyelid ectropion [J]. Aesthet Plast Surg.
2007;31(2):161–6.
Repair of Congenital Nasal Deformity
15
Yong-hong Zhu and Jian-min Yao
15.1 Compound Nasal Deformity 15.2 Median Fissure Deformity of Nose
Case Case
1. Medical history: A boy, 11 months old, presented with the 1. Medical history: A boy, 3 years old, presented with defor-
compound nasal deformity. mity of the cleft nasal middle part.
2. Clinical manifestations: The right nostril is repeated with 2. Clinical manifestation: Longitudinal folds on nasal dorsal
a small inner passage, both of which plus the left nostril skin.
form three nostrils. The whole nasal shape is flat and 3. Surgical method: Longitudinal incision +V-Y plasty.
wide, the apex nasi disappears, and the nose is small with 4. Key points: (1) Remove folds and close the wound. (2)
a short column. Retain the triangular flap on the apex nasi for reshaping.
3. Surgical methods: T-shape incision, local flap rotation. 5. Precautions: Apex nasi depression can be partially filled
4. Key points: (1) Incise the skin of the two nostrils. (2) with artificial and autologous materials, or repaired with
Reduction of the nostrils. (3) Rotate the flap to repair the local flap.
wound. 6. Operation steps: See Fig. 15.2.
5. Precautions: T-shape incision can be changed into V-Y
shape incision to reach the purpose of concealing inci-
sion, fusing two holes into a hole and achieving
symmetry.
Y.-h. Zhu
Third Affiliated Hospital of Nanchang Universit, Nanchang, China
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_15
278 Y.-h. Zhu and J.-m. Yao
a b
Fig. 15.1 Repair of compound nasal deformity. (a) Compound nasal deformity (b) Design incision (c) Good appearance after repair
15 Repair of Congenital Nasal Deformity 279
a b
c d
Fig. 15.2 Repair of cleft nose deformity. (a) Longitudinal cleft on nasal back (b) Intubation anesthesia (c) Design incision (d) Incise and suture
(e) Heal well 1 day after surgery
Repair of Congenital Oral Lip Deformity
16
Wei-hua Wu and Jian-min Yao
16.1 Deformity of Cleft Anguli Oris 16.2 eformity of Cleft Bilateral

D
Anguli Oris
Case 1
1. Medical history: A boy, 3 years old, presented with the Case
right angulus oris cleft. 1. Medical history: A girl, 16 years old, presented with bilat-
2. Clinical manifestation: Right angulus oris cleft. eral cleft anguli oris (giant mouth disease).
3. Surgical method: Z-plasty. 2. Clinical manifestation: Bilateral cleft anguli oris.
4. Key Points: (1) Resect the cleft margin. (2) Suture the 3. Surgical method: V-V incision, tongue-shaped flap arched
muscular layer in a straight line. (3) Perform Z-plasty suture and repair.
near the angulus oris. 4. Key points: (1) Incise the cleft margin into a V-shape. (2)
5. Precautions: Only the linear suture method adopted may Remove the mucosal surface, separate and suture the
lead to local depression and unaesthetic appearance. muscle layer. (3) Tongue-shaped mucosal flap is used to
Combined with Z-plasty it can change the direction of the repair and reconstruct the anguli oris.
cleft line, resulting in a plump angulus oris and better 5. Precautions: If the reduction of the anguli oris is not large,
shape that looks more like the healthy side. it can be sutured directly. If it is larger, the linear suture
6. Operation steps: See Fig. 16.1. method adopted alone may lead to local depression and
unaesthetic appearance. Combined with Z-plasty it can
change the direction of the cleft line, resulting in a plump
Case 2 angulus oris and better shape that looks more like the
1. Medical history: A boy, 3 years and 7 months old, pre- healthy side.
sented with right angulus oris cleft. 6. Operation steps: See Fig. 16.3.
2. Clinical manifestation: Cleft deformity of the right angu-
lus oris.
3. Surgical method: Linear suture + Z-plasty. 16.3 Deformity of Cleft Lower Lip
4. Key Points: (1) Resect the cleft margin, rotate the top of
the strip wound, and suture it end to end to form the angu- Case
lus oris. (2) Use the linear suture method to suture the 1. Medical history: A girl, 8 years and 7 months old, pre-
muscular layer. (3) Z-plasty reshapes the incision. sented with cleft deformity of the lower lip.
5. Precautions: The two ends of the angulus oris wound are 2. Clinical manifestation: Cleft deformity of the middle part
designed as semicircular or triangular flaps, which facili- of the lower lip.
tate the formation of the angulus oris. 3. Surgical method: V-Y plasty.
6. Operation steps: See Fig. 16.2. 4. Key points: Design a V-shaped incision in the middle part
of the lip red, use Y-shaped suture to close it.
5. Precautions: Do not make incisions in the dry area of the
lip red.
W.-h. Wu · J.-m. Yao (*)


https://doi.org/10.1007/978-981-15-4419-4_16
282 W.-h. Wu and J.-m. Yao
a b
c d
e f
Fig. 16.1 Repair of angulus oris cleft. (a) Right angulus oris cleft (b) the muscular layer (i) Suture the muscular layer (j) Rotated suture (k)
Design incision (c) Resect the cleft surface (d) Expose the muscular Suture mucosa (l) Auxiliary incision (m) Incise and suture (n)
layer (e) Suture mucosa (f) Separate the muscular layer (g–h) Suture Intradermal suture (o) Suture complete
16 Repair of Congenital Oral Lip Deformity 283
g h
i j
k l

m n

a b
c d
e f
Fig. 16.2 Repair of facial transverse cleft deformity. (a) Cleft defor- Suture mucosa (i) Incise the skin. (j) Exchange triangle flaps (k) Suture
mity of right angulus oris (b) Intubation anesthesia (c) Design incision the skin (l) The shape is good 1 day after operation
(d) Incision (e) Resect mucosa (f) Suture the muscular layer. (g-h)
g h
i j
k l

a b
c d
e f
Fig. 16.3 Repair of bilateral cleft anguli oris. (a) Bilateral cleft anguli oris (b) Design incision (c) Incise one side. (d) Layered suture (e) Same
operation on the opposite side (f) Operation complete
a b
c d
e f
g h
Fig. 16.4 Repair of lower cleft lip deformity. (a) Cleft lower lip (b) Design V-shape incision (c) Incise the mucosa (d) Lift the flap (e) Suture the
mucosa of the muscular layer (f) Advance the flap (g) Completely Suture (h) Defect is well repaired 1 day later surgery
Repair of Congenital Ear Deformity
17
Bao Zhu, Sheng Ding, and Jian-min Yao
Case 4. Key points: (1) Hidden incision. (2) Sneak separation.

1. Medical History: A male, 21 years old, presented with a 5. Precautions: The incision is designed in the lower margin
longitudinal cleft of the earlobe. of the ear, which is relatively hidden. Separation needs to
2. Clinical manifestation: Longitudinal cleft of the left ear- be precise to avoid skin pressure indentation.
lobe with cartilage inside. 6. Operation steps: See Fig. 17.1.
3. Surgical method: Transverse incision under the earlobe,
sneak separation, and longitudinal suture.
B. Zhu
Zhejiang Provincial people’s Hospital, Hangzhou, China
S. Ding · J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_17
290 B. Zhu et al.
a b
c d
Fig. 17.1 Repair of longitudinal cleft of earlobe. (a) Cleft earlobe (b) Design incision (c) Sneak separation by surgical scissor (d) Postoperative
shape
Repair of Congenital Torticollis
Deformity 18
Ming-yuan Xu and Jian-min Yao
Case anesthesia at the end of the tendon. Incise the skin and
1. Medical History: A girl, 15 years old, presented with con- vertically insert the scalpel, then tighten the tendon, hold
genital torticollis deformity. the handle of the scalpel and do not move, and then push
2. Clinical manifestation: Contracture and tension of the left the tendon lightly, the tensive tendon contacts with the
sternocleidomastoid muscle. Torticollis deformity. blade will be immediately broken and separated till the
Asymmetry of left and right faces. complete release of the whole contracted tendon.
3. Surgical method: Local anesthesia. Point-like incision 5. Precautions: Precisely and delicately perform it. Take
and sternocleidomastoid dissection. care to avoid damaging blood vessels, nerves, and the top
4. Key points: A 3-mm incision is designed on the clavicular of the pleura.
head of the left sternocleidomastoid. Local tumescent 6. Operation steps: See Fig. 18.1.
a b
Fig. 18.1 Repair of congenital torticollis deformity. (a) Congenital then the tendon breaks (h) Complete release (i) Suture the incision (j)
torticollis deformity (b) Design incision (c) Look for muscular stop Cover with application (k) 3 mm incision (l) Left rotation of neck (m)
points (d) Local anesthesia (e) Tendon injection of anesthetic agent (f) Right rotation of neck with good effect
Vertical insertion of scalpel (g) Tighten the tendon and turn the skull,
M.-y. Xu
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_18
292 M.-y. Xu and J.-m. Yao
c d
e f
g h

18 Repair of Congenital Torticollis Deformity 293
i j
k l

Part V
Repair of Acquired Facial Deformity
Repair of Eye Defect
19
Jin-ping Ding and Jian-min Yao
19.1 Defect of Upper Eyelid 3. Surgical method: Resection of the nidus, propeller flap
repair [1].
Case 4. Key points: (1) Design propeller flap: A horizontal pris-
1. Medical history: A boy, 15 years old, presented with traumatic incision is made outside of the nidus, the flap is
matic rabbit eye deformity of left upper eyelid for 25 mm long and 6 mm wide. The outer canthus is the
2 months. rotation point of the pedicle. (2) A 2-mm peripheral area
2. Clinical manifestations: Left upper eyelid skin defect, of the nidus is resected. (3) Rotate the flap 180 ̊ to repair
rabbit eye deformity after scar contracture with an area of the wound.
5 mm × 8 mm. 5. Precautions: The diameter of the pedicle should be longer
3. Surgical method: Release the scar and use the propeller than 3 mm to ensure the blood supply for the pedicle
flap to correct the deformity. point.
4. Key points: (1) Design propeller flap: horizontal incision 6. Operation steps: See Fig. 19.2.
is outside of the nidus with the length of 35 mm and width
of 5 mm. The rotation point of the pedicle is 5 mm near
the medial angle of the flap. (2) Incise the scar and release Case 2
the contracture to correct the rabbit eye deformity. (3) Lift 1. Medical history: A male, 35 years old, presented with
the flap and rotate it 180 ̊ to repair the wound. scarring after right lower eyelid trauma, rabbit eye
5. Precautions: The diameter of the pedicle should be longer deformity.
than 3 mm, and part of the orbicularis oculi muscle should 2. Clinical manifestations: Right lower eyelid eversion
be retained at the pedicle point to ensure its blood deformity, local scar contracture.
supply. 3. Surgical method: Transfer the superior palpebral orbicu-
6. Operation steps: See Fig. 19.1. laris oculi flap to repair the deformity of inferior palpe-
bral eversion [2].
4. Surgical Design: (1) Make an incision parallel to the
19.2 Defect of Lower Eyelid upper eyelid. (2) Make pedicles on the medial and lateral
canthi. (3) The width of the flap is approximately 6 mm.
Case 1 5. Key points: (1) Incise skin, separate the orbicularis oculi,
1. Medical History: A female, 64 years old, presented with lift the musculocutaneous flap in the deep layer of mus-
left lower eyelid tumor, lower eyelid defect after surgical cle. (2) Incise the lower margin of the inferior palpebra
resection. and release the contracture of the scar to adjust the posi-
2. Clinical manifestation: Left lower eyelid nevus with a tion of the palpebral margin. (3) The medial and lateral
range of 5 mm × 6 mm. bipedicle orbicularis oculi flaps are transferred to the
wound of the lower eyelid margin, and then suture the
skin.
6. Precautions: When transferring the musculocutaneous
J.-p. Ding flap, sneakily separate the skin at the medial and lateral
Beijing Hospital, Beijing, China
canthus and implant the bipedicle of the flap.
J.-m. Yao (*) 7. Operation steps: See Fig. 19.3.

https://doi.org/10.1007/978-981-15-4419-4_19
298 J.-p. Ding and J.-m. Yao
a b
c d
e f
Fig. 19.1 Repair of upper eyelid defect. (a) Upper eyelid defect (b) Correct the rabbit eye deformity (l) Repair the defect (m) Heal well
Rabbit eye deformity (c) Design incision (d) Incise and release the scar 3 weeks after surgery (n) The appearance when closing eyes
(e) Incise skin along the line (f) Make the flap (g) Lift the flap. (h) completely
Exchange the small triangular flap (i) Rotate the flap (j) Suture skin (k)
19 Repair of Eye Defect 299
g h
i j
k l

m n
Case 3 Case 5
1. Medical history: A male, 59 years old, presented with a 1. Medical history: A female, 39 years old, presented with
traumatic lower eyelid defect. traumatic left lower eyelid extroversion.
2. Clinical manifestations: Scar contracture of the right 2. Clinical manifestations: Scarring contracture of the left
lower eyelid, lower eyelid collapse, rabbit eye deformity. lower eyelid with extroversion deformity.
3. Surgical method: Transfer the superior palpebral bipedi- 3. Surgical methods: Release scar, correct rabbit eye defor-
cle orbicularis oculi flap to repair. mity, skin grafting.
4. Key points: (1) A horizontal incision is made under the 4. Key points: (1) A horizontal incision is made under the
lower eyelid margin, and the incision is as long as the lower eyelid margin, and the incision is as long as the
eyelid margin. (2) Incise the scar and release the contrac- eyelid margin. (2) Incise the scar and release the contrac-
ture. (3) Repair: the medial and lateral bipedicle orbicu- ture to correct the rabbit eye deformity. (3) Full-thickness
laris oculi flaps are transferred to the wound of the lower skin flap behind the ear is taken to repair the wound.
eyelid margin, and then suture the skin and correct the 5. Precautions: Separate and release the scar in a stepped
rabbit eye deformity. manner so that the tension can distribute evenly.
5. Precautions: The width of the flap shall be subject to the 6. Operation steps: See Fig. 19.6.
width of the incision, and the treatment of the medial and
lateral canthus is the same as that of similar flap repair.
6. Operation steps: See Fig. 19.4. Case 6
1. Medical history: A female, 62 years old, presented with
left lower eyelid extroversion 18 months after eye bags
Case 4 surgery.
1. Medical History: A female, 33 years old, presented with 2. Clinical manifestation: Left inferior palpebral rabbit eye
traumatic lower eyelid collapse. deformity.
2. Clinical manifestations: Scars on the left upper and lower 3. Surgical method: Take the skin behind the ear with full-
eyelids, lower eyelid collapse, rabbit eye deformity. thickness skin grafting.
3. Surgical method: Transfer the superior palpebral bipedi- 4. Key points: An incision is made under the lower eyelid
cle orbicularis oculi flap to repair. margin, then subcutaneous separation, release adhesion
4. Key points: (1) A horizontal incision is made under the and correct the lower eyelid extroversion. Take full-
lower eyelid margin, and the incision is as long as the thickness skin behind the ear to graft, pack and fix.
eyelid margin. (2) Incise the scar and release the contrac- 5. Precautions: There may be inferior palpebral extroversion
ture to correct the rabbit eye deformity. (3) Repair: the after most eye bag surgeries, and some patients will
medial and lateral bipedicle orbicularis oculi flaps are recover and correct themselves within 6 months. If more
transferred to the wound of the lower eyelid margin, and than half a year, it is more difficult to correct, and in this
then suture skin. case, skin grafting method can be chosen. Eyelid skin
5. Precautions: The width of the flap shall be subject to the grafting is relatively special, so performing eyelid skin
width of the incision, and the treatment of the medial and grafting needs to obey the following requirements: (1)
lateral canthus is the same as that of similar flap repair. Thinner skin should be selected to facilitate eyelid move-
6. Operation steps: See Fig. 19.5. ment. (2) After operation, ensure that skin will not con-
a b
c d
e f
Fig. 19.2 (Case 1). (a) Left lower eyelid nevus (b) Design incision (c) stitches 1 week after surgery and heal well (k, l) Good appearance
Resection of the lesion (d) Lift the flap. (e) Rotate 90 ̊ (f) Rotate 180 ̊ 2 years later
(g) Suture and fixation (h) Suture skin (i) Repair wounds (j) Remove
g h
i j
k l

a b
c d
e f
Fig. 19.3 Repair of lower eyelid defect (Case 2). (a) Right rabbit eye Suture and fixation (h) One day after surgery (i) One week after surgery
deformity (b) Incision lines (a: Upper Incision, b: Lower incision) (c) (j) Deformity correction with a good shape
Lift the flap (d) Transfer the flap (e) Incise skin (f) Transfer the flap (g)
g h
i j
tract to avoid the recurrence of rabbit eyes. (3) Posterior 3. Surgical method: Resection of the eyelid margin nevus
ear is the best donor area to take the full-thickness skin, separately + skin grafting of the wound.
because the survival rate is high. Avoid multiple skin 4. Key points: (1) Stage I surgery: Resect the nevus on the
grafts affecting the appearance. inner and lateral layers of the palpebral margin (skin,
6. Operation steps: See Fig. 19.7. conjunctival layer), suture directly. (2) Stage II surgery:
Resect the whole nevus of the inferior palpebral mar-
gin, then transplant the full-thickness skin behind the
19.3 efect of Upper and Lower Eyelids
D ear. (3) Stage III surgery: Thinning the local flap for
Defect repairing the swollen deformity of the superior
palpebra.
Case 5. Precautions: (1) Upper eyelid margin is fixed by needle,
1. Medical history: A female, 58 years old, presented with which is convenient for resection. (2) The resection is
right eyelid nevus. performed with the principle of no ectropion.
2. Clinical manifestations: Nevus on the right upper and 6. Operation steps: See Figs. 19.8 and 19.9.
lower eyelid margin, eyelid margin drops with the view
covered.
a b
c d
e f
Fig. 19.4 Repair of traumatic lower eyelid defect. (a) Lower eyelid the flap (i) Prevent blood accumulation, pack it (not skin grafting) (j)
collapse (b) Design incision (c) Incise skin. (d) Release the scar (e) Flatten properly (k) Nine days after surgery, the flap survives, the defor-
Incise the upper eyelid (f) Separate the flap (g) Lift the flap. (h) Transfer mity is corrected, and it appears a good shape
g h
i j

a b
c d
e f
Fig. 19.5 Repair of traumatic lower eyelid collapse. (a) Left rabbit eye flap (k) Interrupted suture (l) Observation when eyes closed (m)
(b) Lower eyelid collapse (c) Prostrate observation (d) Design incision Observation when eyes open (n) Traction and fixation (o) Two weeks
(e) Incise the lower eyelid (f) Incise the upper eyelid (g) Lift the flap (h) after surgery (p) Close eyes (q) Close eyes forcibly (r) Open eyes
Test the length (i) Expose the muscular flap (j) Transfer the muscular forcibly
g h
i j
k l

m n
o p
q r

a b
c d
e f
Fig. 19.6 Repair of traumatic left lower eyelid extroversion. (a) Lower eyelid extroversion (b) Incise the scar. (c) Take the skin graft posterior to
the ear (d) Full-thickness skin (e) Transplant the skin (f) Pack and fix (g) Extroversion deformity correction with a good shape
a b
c d
Fig. 19.7 Repair of rabbit eye deformity in the left lower eyelid. (a) After eye bag operation, lower eyelid extroversion deformity (b) Design of
taking the skin behind the ear (c) Full-thickness skin graft (d) Deformity is corrected with a good shape 8 years after surgery
a b
Fig. 19.8 Resection and repair of upper and lower eyelid margin nevus tion of nevus (j) Suture the upper and lower eyelids, respectively (k)
(resection of eyelid margin nevus). (a) Right eyelid margin (b) Upper Observation when eyes open (l) Suture complete. (m) Eighteen months
and lower nevus (c) Expose conjunctiva (d) Puncture and fixation (e) after surgery (n) Stage II surgery (o) Repair the eyelid margin (p)
Incise part of eyelid margin (f) Incise half of eyelid margin (g) Resect Resect all of lower eyelid nevus
all of eyelid margins (h) Incise the lower eyelid (i) Resect a small por-
c d
e f
g h

i j
k l
m n
o p

a b
c d
e f
Fig. 19.9 Resection and repair of upper and lower eyelid margin nevus (h) The shape 10 weeks later (i) Partially swollen (j) Stage III surgery:
(skin grafting). (a) Take the skin behind the ear (b) Transplant the skin repair again (k) Resect the redundant skin (l) Suture the wound (m) The
(c) Wound skin grafting (d) Pack and fix (e) Resect the nevus margin (f) shape when opening eyes (n) The shape 1 week after the surgery (o)
Nine days after surgery. (g) The shape when closing eyes completely The shape when opening eyes (p) Good shape 3 months after surgery
g h
i j
k l

m n
o p
References 2. Xu JH, Tan WQ, Yao JM. Bipedicle orbicularis oculi flap in the
reconstruction of the lower eyelid ectropion[J]. Aesthet Plast Surg.
2007;31(2):161–6.
1. Ding JP, Chen B, Yao J. Lateral orbital propeller flap technique for
reconstruction of the lower eyelid defect[J]. Ann R Coll Surg Engl.
2018;100:e103–5.
Repair of Nasal Defect
20
Zheng-cai Wang and Jian-min Yao
20.1 Replantation of Severed Nose hemorrhage. Ten days after surgery, the skin color turned
to be normal, until the wound healed. The skin color and
Case texture were similar to the surrounding tissues and had a
1. Medical history: A male, 49 years old, presented with good appearance 3 months later, the two-point resolution
complete broken nose due to glass cutting injury [1]. was 8 mm.
2. Clinical manifestation: The patient was admitted to the 6. Operation steps: See Fig. 20.1.
hospital 4 hours later due to complete broken nose by
glass cutting injury. The wound size was 4 cm × 4 cm,
which accounted for three-fourth of the external nose. 20.2 Defect of Nasal Alar
The defect ranged from nasal dorsum to nasal base,
including ala nasi, apex nasi, columella nasi, nasal sep- Case 1
tum and so on. The disconnected tissues included the 1. Medical history: A male, 58 years old, presented with ala
skin, mucosa, and cartilage. nasi defect caused by cutting injury.
3. Surgical method: Anastomosis of the apex nasi and nasal 2. Clinical manifestation: Right ala nasi defect, local scar
dorsal arteriovenous vessels. deformity.
4. Key points: (1) Nasal wound debridement. (2) An artery 3. Surgical method: Transplantation of auricular composite
with a diameter of 0.4 mm was found at the apex nasi, and tissue to repair ala nasi [2].
a subcutaneous vein with a diameter of 0.3 mm was found 4. Key points: (1) Resect the tissue block from the auricle
at the nasal back. In the corresponding parts of the area, (1 cm × 0.8 cm). (2) Resect the scar at the nostril margin
one artery and one vein were found for anastomosis. (3) to form the wound. (3) Transplant the auricular tissue,
The arteries and veins were anastomosed respectively interrupted suture and fixation. (4) Discontinuously
with 11–0 microsurgical suture needle under 10–20 times remove stitches 1 day and 2 days after surgery, so as to
microscope. Skin and mucosa were respectively sutured, establish the blood circulation of the transplanted tissue
and then the nose was implanted and bandaged under as soon as possible.
appropriate pressure. 5. Precautions: The stitches are used for fixation, but they
5. Precautions: In this case, replantation tissues were filled can block blood circulation. This case is an obvious one.
1 day later, with purple-red color, pressure reaction, and 6. Operation steps: See Fig. 20.2.
Z.-c. Wang
Sir Run Run Shaw Hospital, Zhejiang University School
of Medicine, Hangzhou, China
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_20
318 Z.-c. Wang and J.-m. Yao
a b
c d
e f
Fig. 20.1 Replantation of broken nose. (a) Complete broken nose due resolution is 8 mm (f) Fifteen years after surgery (age 64 years) (g)
to glass cutting injury (b) Anastomosis of blood vessels (c) Observation of the front side
Arteriovenous ratio (1∶1) (d) Three months after surgery (e) Two-point
20 Repair of Nasal Defect 319
4. Key points: (1) Wound debridement, resection, and rear-

g rangement of broken skin, mucosa, and nasal cartilage.
(2) Find arteries on nasal dorsum, with a diameter of
0.4 mm to rebuild blood circulation.
5. Precautions: (1) The wound margin should be neat, which
is conducive to the survival of the tissue. (2) When anas-
tomosing the blood vessels, find the blood vessels first,
and then fix the tissue, turn over the flap on one side so
that the blood vessels will not be pulled or torn.
20.4 Defect of Nostril Rim
Case
1. Medical history: A female, 37 years old, presented with a
Fig. 20.1 (continued) traumatic right nostril margin defect.
2. Clinical manifestation: Right nostril margin notch
deformity.
Case 2 3. Surgical Method: M-W flap repair.
1. Medical history: A male, 33 years old, presented with ala 4. Key points: (1) Design an end-to-end M-W flap incision.
nasi defect caused by glass cutting injury. (2) Incise the skin in accordance with the design, and then
2. Clinical manifestations: Right ala nasi defect, facial skin insert, align, suture, and fix the triangular flap.
laceration. 5. Alternative: Design a unilateral triangular flap.
3. Surgical methods: Separation and transplantation of the 6. Operation steps: See Fig. 20.5.
auricular composite tissue [2].
4. Key points: (1) Wound debridement, resection, and rear-
rangement of broken skin, mucosa, and nasal cartilage. 20.5 Deformity of Distorted Nasal Bridge
(2) Resect unilateral auricular composite tissue. (3)
Transplant the auricular tissue to repair the ala nasi. Case 1
5. Precautions: (1) The volume of auricular tissue should not 1. Medical history: A male, 21 years old, presented with
be too large, generally within 1 cm × 1.5 cm. Reduce and crooked nose deformity 3 months after trauma.
compress the blood supply pressure and burden of the 2. Clinical manifestation: The right nasal bridge was
transplanted tissue in the recipient area. (2) The wound punched, obviously crooked to the left.
margin should be neat, and the contact surface of the 3. Surgical method: Nasal osteotomy and correction.
transplanted tissue should be as large as possible, which 4. Key points: (1) Nasal inside incision. (2) Strip the nasal
can improve the nutrition of the transplanted tissue. bone surface. (3) Use the osteotome resect the bone on
Mortise insertion can be selected to improve the contact both sides of the bridge. (4) Release the nasal bone, then
surface. readjust and correct the nose.
6. Operation steps: See Fig. 20.3. 5. Precautions: (1) Nasal incision is the most suitable
method. (2) During the process, it is necessary to pinch
the nose dorsal skin with one hand to understand the
20.3 Defect of Nasal Dorsum depth and specific location of the device. Implement sep-
aration, bone chisel, and other actions by the other hand.
Case 6. Operation steps: See Fig. 20.6.
defect of the most part of nasal dorsum caused by iron Case 2
cutting. 1. Medical history: A male, 18 years old, presented with
2. Clinical manifestations: Nasal dorsal skin defect, carti- crooked nose deformity caused by trauma 1 week ago.
lage exposure with skin pedicle point. 2. Clinical manifestation: The left side of the nasal bridge
3. Surgical method: Anastomosis of the nasal dorsal was injured with crooked nasal deformity.
arteries. 3. Surgical method: Manipulation and reduction.
a b
c d
e f
Fig. 20.2 Repair of nasal ala defect. (a) Ala nasi defect (b) Nostril scar stitches (k) Two days after surgery, the color turns red, remove all the
(c) Cotton stuffing (d) Resect the epidermis (e) Auricular materials (f) stitches (l) Three days after surgery, the red color is more deep (m) Four
Resect tissues (g) Transplant ala nasi (h) Suture tissue (i) Suture the days after surgery (n) Five days after surgery (o) Overlooking (p) Three
donor area (j) One day after surgery, the color is dim, remove half of the weeks after surgery, the tissues survive (q) Auricle heals well
g h
i j
k l

m n
o p

a b
c d
e f
Fig. 20.3 Repair of nasal ala defect. (a) Glass cutting injury (b) Ala Overlooking (i) Indwelling hose (j) Suture the auricle (k) Three months
nasi defect (c) Design auricular incision (d) Resect the composite tissue after surgery (l) Good shape (m) Good shape of the donor area
(e) Transplant it to nose (f) Suture and fixation (g) Local observation (h)
g h
i j
k l

a b
c d
e f
Fig. 20.4 Repair of nasal dorsal defect. (a) Nasal dorsal defect. (b) Wound defect (c) Find the arteries. (d) Anastomosis of arteries (e) Rebuild the
blood circulation (f) Rosy color (g) One week after surgery (h) Heal well
g h
a b
c d
Fig. 20.5 Repair of nostril margin defect. (a) Nostril defect (b) Face up (c) Design incision (d) Incise and suture (e) After surgery (f) Face up (g)
Frontal observation (h) Remove stitches One week later (i) Deformity correction (j) Six months after surgery (k) Overlooking
e f
g h
i j

a b
c d
e f
Fig. 20.6 Repair of crooked deformity of nose. (a) Crooked nasal treatment of opposite side (j) Shape the bone (k) Adjust the nasal bridge
bridge (b) Preoperative markers (c) Supine position. (d) Disinfection (l) Lateral view (m) Overlooking (n) Fix the hose (o) Two days after
(e) Local anesthesia (f) Nasal incision (g) Bone separation (h) Separate surgery
the nasal bone with a bone chisel along the nasal substrate (i) The same
g h
i j
k l

m n
4. Key Points: After local anesthesia, insert two chopsticks chopsticks, gradually force them. Bone rubbing sound
wrapped in gauze into the nostrils, then tilt the fractured can often be heard, which means effective reduction.
nasal bone and correct the nasal bridge. After the reduction, retain the veil for a moment to stop
5. Precautions: Hold chopsticks in right hand, pinch nasal the bleeding.
dorsal skin in left hand. Slowly operate. When tilting 6. Operation steps: See Fig. 20.7.
a b
c d
Fig. 20.7 Crooked nasal deformity, manipulation reset. (a) Crooked deformity of the nose (b) Local anesthesia (c) Insert chopsticks wrapped in
gauze and tilt the fractured nasal bone (d) Good shape after correction of nasal bridge deformity
References
1. Yao JM, Yan S, Xu JH, et al. Replantation of amputated nose by
microvascular anastomosis[J]. Plast Reconstr Surg.
1998;102(1):171–3.
2. Teltzrow T, Arens A, Schwipper V. One-stage reconstruction of
nasal defects: evaluation of the use of modified auricular composite
grafts. Facial Plast Surg. 2011;27(3):243–8.
Repair of Oral Lip Defect
21
Tao Zhang and Jian-min Yao
21.1 Defect of Upper Lip long, and it reaches deeply into the orbicularis oris mus-
cle. Resect the mucosal muscle layer, rotate it to the left
21.1.1 Small Part of Upper Lip Defect upper lip and insert it into the recipient area, then adjust
the tension of the flap, pull the upper lip, and fill the upper
Case 1 lip at the same time.
1. Medical history: A female, 54 years old, presented with a 5. Precautions: The incision should be designed in a hidden
traumatic defect of the upper lip. wet mucosa.
2. Clinical manifestations: Scarring after upper lip defect 6. Operation steps: See Fig. 21.2.
with red lip margin warped deformity.
3. Surgical method: Inferior triangular flap [1]. Case 3
4. Key points: (1) Design triangular flap. (2) Incise along the 1. Medical history: A boy,14 years old, presented with par-
designed line and resect the surface layer precisely. (3) tial upper lip atrophy after injection for hemangioma.
Suture the muscular layer and skin. 2. Clinical manifestations: Atrophy and scarring of the left
5. Precautions: Suture the muscular layer to reconstruct the upper lip with incisors exposure deformity.
vermilion tubercle. 3. Surgical method: An intraoral incision, resect the sunken
6. Operation steps: See Fig. 21.1. mucosa. Use the Z-plasty to release the contracture, sepa-
rate and suture the atrophic muscular layer. Fold stitches
Case 2 after releasing and lowering the lip height, then correct
1. Medical history: A male, 16 years old, presented with left the deformity of the incisors exposure.
upper lip atrophy deformity after injection for 4. Key points: (1) Release the contracture sufficiently. (2)
hemangioma. Suture the muscular layers to overlap. (3) Perform
2. Clinical manifestations: Atrophy of left upper lip with Z-plasty in mucosa.
gingival exposure. 5. Precautions: (1) Do not make any incision in the lip white,
3. Surgical method: Adhesive musculocutaneous flap with a so as not to form a scar. (2) Fat particles can be injected
single pedicle. locally during stage II surgery to increase the upper lip
4. Key points: Adhesive musculocutaneous flap with a sin- thickness.
gle pedicle is designed at the lower lip; the pedicle point 6. Operation steps: See Fig. 21.3.
is at the angulus oris. The flap is 3 mm wide and 20 mm
T. Zhang
Sir Run Run Shaw Hospital,
Zhejiang University School of Medicine, Hangzhou, China
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_21
334 T. Zhang and J.-m. Yao
a b
c d
e f
Fig. 21.1 Repair of traumatic defect of upper lip. (a) After surgery trimming (i) Layered suture (j) Cover and fix (k) Remove stitches
(b) Skin defect (c) Design incision (d) Incise skin. (e) Resect red lip 1 week after surgery (l) Three months after surgery
(f) Separate and release (g) Suture the muscular layer (h) Local
21 Repair of Oral Lip Defect 335
g h
i j
k l

a b
c d
e f
Fig. 21.2 Repair of upper lip atrophy deformity. (a) Local atrophy (b) Design incision (c) Lift the flap. (d) Make the tunnel (e) Get through the
tunnel (f) Retain the leads (g) Fix the muscular flap (h) Postoperative effect (i) One week after surgery (j) Forty-five days after surgery
g h
i j
a b
Fig. 21.3 Repair of partial atrophy deformity of upper lip. (a) Upper the muscular layer to reduce lip height (f) Z-plasty (g) Correction of
lip atrophy with incisor exposure deformity (b) Design incision (c) incisor exposure 1 day after surgery
Incise the internal mucosa (d) Resect mucosa (e) Separate and suture
c d
e f
Case 4 3. Surgical method: Turn over the soft tissue flap and fill the
1. Medical history: A 60-year-old female with postoperative depression.
deformity of the upper lip trauma. 4. Techniques: (A) Excise the scar on the mucosa of the lip.
2. Clinical features: Scarring of the upper lip, right red lip (B) Cut the inner mucosa of the lip to form the lingual flap,
with local hyperplasia, uneven thickness of lip between rotate the lingual tissue flap and insert it into the contralat-
the left and right side. eral side to improve the deformity of the depression.
5. Notes: Transfer the tissue flap through the submucosal 3. Surgical method: Rotate the lower lip tissue flap (R flap)
tunnel. to reconstruct the upper lip.
6. Operation steps: See Fig. 21.4. 4. Key points: The lower lip tissue flap is pedicled with
the labial artery, the pedicle is in the lower lip. Cut off
the pedicle 3 weeks after the transfer of R flap, and
21.1.2 Most Part of the Upper Lip Defect then repair and reconstruct the upper lip at the same
time.
Case 1 5. Precautions: When making the pedicle, pay attention to
1. Medical history: A male, 45 years old, presented with a protect the blood vessels, so as not to cause damage and
defect of 1/2 upper lip after traumatic surgery. affect the blood supply.
2. Clinical manifestations: Defect of 1/2 upper lip with inci- 6. Operation steps: See Fig. 21.5.
sors exposure.
a b
c d
e f
Fig. 21.4 Repair of partial after upper lip trauma. (a) Thickening of the right upper lip. (b) Excise the mucosa. (c) Cut the pedicled tissue flap. (d)
Make a subcutaneous tunnel. (e) Rotate the tissue flap and insert it into the contralateral submucosa. (f) Suture the mucosa
2. Clinical manifestations: Defect of 2/3 part of the upper lip

a
with gingival exposure deformity.
3. Surgical method: Rotate the upper lip tissue flap to recon-
struct the upper lip.
4. Key points: The lower lip tissue flap is pedicled with
the labial artery, the pedicle is under the angulus oris.
And the width of the incision is as long as the
pedicle.
5. Precautions: When making the pedicle part of the adhe-
sive musculocutaneous flap, blood vessels should be
protected.
b
21.2 2. Defect of Lower Lip
Case 1
postoperative necrosis for 1 week after the lower lip being
bitten.
2. Clinical manifestations: Necrosis of the replantation tis-
sue of the lower lip, which turns to be black.
3. Surgical method: Direct suture, layered repair.
4. Key Points: (1) Clear the inactivated tissue. (2) Anatomical
stratification, precise alignment, careful suture.
5. Precautions: Lip tissue is soft with a strong feeling of
c looseness, and there is a half of defect, but the possibility
of direct suture still exists, so it is unnecessary to use the
complex surgical methods.
d Case 2
traumatic lower lip defect.
2. Clinical manifestations: Broken lower lip with a defect.
3. Surgical method: Direct debridement and suture.
4. Key points: Use the local mucosal tissue, and transfer
the local mucosal flap in accordance with the need to
repair.
5. Precautions: The defect of the lip red tissue, most of
which can be sutured directly without the need for com-
plex surgical methods.
21.3 Minor Defect of the Angulus Oris

Fig. 21.5 Repair of most part of the upper lip defect. (a) Upper lip
defect (b) Surgical design (c) Surgical process (Stage I, Stage II) (d) Six
months after surgery Case
1. Medical history: A female, 35 years old, presented with
deformity of the left angulus oris after traumatic surgery.
Case 2 2. Clinical manifestations: Left angulus oris defect defor-
1. Medical history: A male, 69 years old, presented with a mity, scar exposure, lip margin is not neat.
traumatic defect of the most part of the upper lip. 3. Surgical method: Z-plasty repairs the lip red margin.
a b
c d
e f
Fig. 21.6 Repair of defects in most part of the upper lip. (a) Upper lip defect (b) Design flap (c) Lift flap (d) End-to-end suture (e) Suture the
margin of wound (f) Six months after surgery
a b
c d
e f
Fig. 21.7 Repair of partial defect of the lower lip. (a) Tissue necrosis (b) Clean the wound (c) Suture (d) Alignment (e) Suture the superficial
layers (f) One week after surgery
a b
Fig. 21.8 Repair of partial traumatic defect of the lower lip. (a) Lower lip defect (b) Direct suture (c) Half of a month after surgery
4. Key points: (1) Design Z-plasty incision, two sides of the tumescent anesthesia. (2) Embed stitches around the
incision are located at the margin of the lip red, the middle tumor in advance and pull them through the tumor to pre-
line of incision is located on the line of the deformity. (2) vent the uncontrollable bleeding.
After incision, the separation should be accurate, and there 6. Operation steps: See Fig. 21.10.
shall be no dragging or deformation after exchanging tri-
angular flaps. (3) Use 3–0 absorbable stitches to suture
and use a surgical knot rather than a square knot. Use non- 21.5 Defect of the Whole Lower Lip
absorbable stitches to suture skin. Remove stitches as
early as possible to avoid scarring of stitch trace. Case
5. Operation steps: See Fig. 21.9. 1. Medical history: A male, 58 years old, presented with
traumatic total lip defect.
2. Clinical manifestations: Most of the lower lip defect, gin-
21.4 Defect of Lower Lip and Angulus Oris gival exposure, bone exposure deformity, granulation
wound.
Case 3. Surgical method: Staging surgery. (1) Stage I surgery:
1. Medical history: A boy, 4 years old, presented with lower Repair the lower lip with upper lip tissue flap; glide the
lip hemangioma. cervical bipedicle flap to repair bone wound; sporadic
2. Clinical manifestation: Left side of the lower lip and oral skin grafting. (2) Stage II surgery: Expand the angulus
mucosal hemangioma. oris, repair it with local mucosal flap.
3. Surgical method: (1) Resect hemangioma. (2) Local 4. Key points: (1) Stage I surgery: Use the tissue that pedi-
mucosal flap repair. cled with the upper lip artery to create a local flap, rotate
4. Key points: (1) Resect the nidus completely. (2) Flap the flap to form a complete upper and lower lip margin. A
design should be flexible. bipedicled local flap is designed at the neck with a length
5. Precautions: Pay attention to the opening of the parotid of 12 cm and width of 4 cm, then glide the flap upward to
duct. Prevent the hemorrhage of hemangioma: (1) Local repair the bone wound. Take the full-thickness skin from
a b
c d
e f
g h
Fig. 21.9 Repair of postoperative deformity of the left angulus oris. (a) Scar of angulus oris (b) Uneven margin of red lip (c) Design incision (d)
Incise the skin. (e) Interrupted suture (f) Deformity correction (g) Three months after surgery (h) Lateral observation
a b
c d
e f
Fig. 21.10 Repair of lower lip hemangioma. (a) Lower lip lump (b) Intraoral lump (c) Incise the nidus (d) Resect the tumor body (e) Resect the
nidus (f) Suture the wound (g) Hemangioma (h) Reserved ligation (i) Operation complete. (j) Two weeks after surgery
g h
i j
axilla, implant it on the remaining wound. (2) Stage II 2. Clinical manifestations: Soft and hard cleft palate on the
surgery: Resect the skin of the angulus oris and transfer right side with defect.
the intraoral mucosal flap to repair the wound. 3. Surgical method: Cleft palate repair (two-flap method)
5. Precautions: Stage I surgery mainly closes and repairs the [2].
wound. Stage II plastic surgery expands the contracted 4. Key points: (1) Local tumescent anesthesia is conducive
angulus oris. to the separation of the tissues. (2) Incise the bilateral
6. Operation steps: See Figs. 21.11 and 21.12. relaxation incisions, incise the two sides of the cleft, sepa-
rate and release the bilateral palate flap, respectively, and
completely. (3) The palate flap is sutured in three layers.
21.6 Traumatic Rupture of Palate 5. Precautions: (1) Surgical position: Put a pad under the
back and raise the head to expose the mouth. (2) The
Case upper mucosal flap of the nasal side is sutured and
fixed together with the inferior mucosal flap of the
1. Medical history: A female, 38 years old, presented with oral side.
the whole palate punctured by bull horns, and cleft for 6. Operation steps: See Fig. 21.13.
30 years.
a b
c
d
e
f
Fig. 21.11 Repair of traumatic total lip defect (Stage I). (a) Lower lip Separate the upper margin (j) Separate the lower margin (k) Lift the
wound (b) Design the flap (c) Incise the flap (d) Lift the flap. (e) End- flap. (l) Resect the epidermis. (m) Suture the upper margin (n)
to-end suture (f) Design Z-shape flap. (g) Suture skin (h) Incise skin. (i) Remaining wound (o) Skin grafting (p) Dressing and covering
g h
i j
k l

m n
o
p
a b
Fig. 21.12 Repair of traumatic total lip defect (Stage II). (a) Five plant mucosa (l) Pack and fix (m) Suture complete. (n) Seven days after
months after surgery (b) Contracted angulus oris (c) Design incision (d) surgery (o) One month after surgery (p) Natural state (q) Seven months
Intraoral design (e) Resect the skin (f) Triangular mucosa (g) Suture after surgery (r) Closed state (s) Two years after surgery (t) Mouth open
wound (h) The same treatment of contralateral side (i) Suture the state (v) Neck condition
wound (j) Cut the upper lip tissue block (k) Local depression, trans-
c d
e`
g h

i j
k l
m n

o p
q r
s t

a b
c
d
Fig. 21.13 Repair of traumatic cleft palate. (a) The whole palate is nasal side) (k) Suture mucosa (l) Reverse knotting (m) Suture the first
punctured by bull horns (b) Cleft soft palate (c) Defect on the right side layer. (n) Suture the second layer (muscular layer) (o) Suture uvula (p)
(d) Local anesthesia (e) Incise the cleft margin (f) Incise the relaxation Suture the middle layer (muscular layer) (q) Suture the third layer
incision on the right side (g) Form the palate flap (h) Separate the palate (mucosal layer of D-side) (r) Oil gauze packing (s) Heal well 1 day
flap (i) Separate the cleft margin (j) Suture the first layer (mucosa of the after surgery
e f
g h
i j

k l
m n
o p

q r
References
1. Koh KS, Oh TS, Song JW. Upper triangular flap method for primary
repairs of incomplete unilateral cleft lip patients. Ann Plast Surg.
2015;74(3):318–23.
Repair of Auricle Defect
22
Xiao-feng Wang and Jian-min Yao
22.1 Cavernous Defect of Ear 22.2 Small Defect of the Helix of Ear
Case 1 Case
1. Medical history: A male, 22 years old, presented with the 1. Medical history: A female, 26 years old, presented with a
ear hole deformity after piercing earlobe. broken notch on the right helix of the ear.
2. Clinical manifestation: Big hole deformity of the left ear 2. Clinical manifestation: Triangular notch deformity of the
earlobe. helix of the ear.
3. Surgical method: Annular resection and purse-string 3. Surgical method: V-shape incision, interrupted suture.
suture repair. 4. key points: (1) Incise the skin to form the wound margin.
4. Key points: (1) Annularly resect the surface of the hole. (2) Three layers of suture: suture the middle layer of skin
(2) Three layers of suture: suture the middle layer of skin with absorbable stitches and suture the inner and outer
with absorbable stitches, perform the purse-string suture layers of skin with nonabsorbable stitches.
on the outer skin with nylon stitches, place the interrupted 5. Precautions: Remove the stitches as early as possible and
suture on the inner skin (reverse side). preferably no more than a week to avoid scarring of stitch
5. Alternatives: Design a unilateral triangular flap. trace.
6. Operation steps: See Fig. 22.1. 6. Operation steps: See Fig. 22.3.
Case 2
1. Medical history: A female, 45 years old, presented with 22.3 Damage of Auricle
the ear penetrating deformity after piercing earlobe.
2. Clinical manifestation: Big hole of the left earlobe with Case 1
broken deformity. 1. Medical history: A male, 45 years old, presented with a
3. Surgical method: Annular resection and purse-string traumatic incomplete broken ear.
suture repair. 2. Clinical manifestation: The left ear is torn, only a small
4. Key points: (1) Annularly resect the surface of the hole. part of the tissue is connected, and the wound surface is
(2) Three layers of suture: place the purse-string suture on broken.
the middle layer of skin with absorbable stitches and per- 3. Surgical method: Broken ear replantation (anastomose
form the direct interrupted suture on the inner and outer one artery).
layers of skin with nylon stitches. 4. Key points: (1) Clean up wound margin: wound debride-
5. Precautions: Use the scalpel precisely and do not break ment, removal of the broken and inactivated tissues. (2)
the earlobe. Search for arteries: find an artery that can be sutured on
6. Operation steps: See Fig. 22.2. the dorsal side of auricle. (3) Replantation: (a) Fix ear
cartilage; (b) Use 11-0 undamaged stitches to anastomose
artery, the arterial diameter is 0.3 mm; (c) Remove stitches
X.-f. Wang 1 week later, and the replantation of the ear survives.
Sir Run Run Shaw Hospital, Zhejiang University School 5. Precautions: (1) It is important to clean up the wound
of Medicine, Hangzhou, China
margin. (2) It is critical to recognize and distinguish
J.-m. Yao (*)

https://doi.org/10.1007/978-981-15-4419-4_22
358 X.-f. Wang and J.-m. Yao
a b c
Fig. 22.1 Repair of hole defect of ear. (a) The piercing defect of the earlobe (b) Incision design (c) Purse-string suture (d) One week after
surgery
whether the arteries are healthy or can be sewn. 3. Look 3. Surgical method: Debridement, suture, and repair.
for bleeding points under the mirror behind the ear. 4. Key points: (1) Clear the wound margin: wound debride-
6. Operation steps: See Fig. 22.4. ment, removal of the broken and inactivated tissues. (2)
Debridement and repair: (a) Fix ear cartilage; (b) Suture
Case 2 both sides of the skin; (c) Remove stitches 1 week later,
and the auricle survives.
1. Medical history: A male, 30 years old, presented with 5. Precautions: To distinguish whether the residual ear can
traumatic auricular tear. survive mainly depends on whether the wound margin of
2. Clinical manifestation: Tearing deformity of the most part residual ear is bleeding, whether the filling degree is plump.
of the left ear with irregularly wound. 6. Operation steps: See Fig. 22.5.
22 Repair of Auricle Defect 359
a b
c d
e f
Fig. 22.2 Repair of earlobe hole deformity. (a) Earlobe hole cleft (b) Local scar (c) Incise the surface of the hole(d) Resect scar (e) Perform
subcutaneous purse-string suture. (f) Reduce the wound (g) Interrupted suture (h) Repair complete
g h
a b
c d
Fig. 22.3 Repair of ear wheel minor defect. (a) Triangular notch deformity after tearing of right helix of ear (b) Design incision (c) Suture (d)
One week after surgery (e) Correction of deformity 2 weeks after surgery

e
a b
c d
Fig. 22.4 Repair of auricular tearing injury. (a) Torn left ear (b) Most part disconnected. (c) Replantation complete (d) One week after surgery
(e) Successful replantation
a b
Fig. 22.5 Repair of auricular tearing. (a) Torn left Ear (b) Part of the small pedicle (c) Repair and reconstruction
22.4 Partial Defect of Auricle 5. Precautions: (1) Stage I surgery needs to fold the flap, and
use the longitudinal suture fixation to avoid affecting
Case 1 blood supply. (2) Stage II surgery cuts off the pedicle,
which can reduce the burden of blood supply.
1. Medical history: A male, 21 years old, presented with ear 6. Operation steps: See Fig. 22.6.
defect after being bitten.
2. Clinical manifestation: Defect deformity of right helix of Case 2
the ear. 1. Medical history: A male, 44 years old, presented with the
3. Surgical method: Perform the posterior auricular pedicled bitten and broken auricle.
flap repair surgery in two stages. 2. Clinical manifestations: Left ear is broken, penetrated
4. Operating points: (1) Stage I surgery: (a) Clean up the and crushed.
wound margin: wound debridement, removal of the 3. Surgical method: Debridement and repair.
broken and inactivated tissues; (b) Design pedicle flap at 4. Key points: (1) Clean up the wound margin: wound
the posterior ear: The pedicle is on the hairline side, the debridement, removal of the broken and inactivated tis-
ratio of length and width is 1∶1, the area is close to the sues. (2) Debridement and repair: (a) Fix ear cartilage; (b)
helix size; C. Wound repair: incise the line designed Suture both sides of the skin; (c) Remove stitches 1 week
before, lift the flap to cover the front side of the helix, later, the replantation of the ear survives.
then suture and fix. (2) Stage II surgery: Three weeks 5. Precautions: Auricle is rich in blood supply; there is still
later, cut off the pedicle, repair and reconstruct the helix a chance of survival as long as the auricle is pedicled.
of the ear. 6. Operation steps: See Fig. 22.7.
Case 3 4. Key points: It is lifted that bridge flap by double pedicle,

1. Medical history: A female, 48 years old, presented with a the wound is closed under the flap.
traumatic broken ear was bitten after 1 year. 5. Precautions: Take good care of blood supply from the
2. Clinical manifestation: Defect and deformity of right ear. double pedicle of the flap.
3. Surgical method: Local flap + V-Y flap. 6. Operation steps: See Fig. 22.8.
a b
f
e
Fig. 22.6 Repair of partial defect of auricle. (a) Helix of ear defect (b) Local debridement (c) Design the posterior ear flap (d) Design incision (e)
Stage I surgery and there exists the pedicle (f) Cut off the pedicle (g) Cut off the pedicle 3 weeks later (h) Repair the helix ear
g h
a b
c d
Fig. 22.7 Repair of auricle bitten and broken. (a) Broken auricle (b) Penetration and crush (c) Debridement and repair (d) One week after
surgery
a b
c d
e f
Fig. 22.8 Auricle defect. (a) Defect of right auricle (b) Behind the suture the middle layer. (i) Suture the earlobe (j) Suture skin (k) Finish,
observation (c) Incision(d) Separate the whole layer of the auricle (e) the appearance is well repaired. (l) Posterior observation,
Lift the flap (f) V-Y incision (g) V-shape cutting. (h) Lift the flap and postoperatively
g h
i j
k l

Case 4 (a) Fix ear cartilage; (b) Suture both sides of the skin; (c)
1. Medical history: A male, 60 years old, presented with Remove stitches 1 week later, most of the auricle sur-
traumatic auricular tear. vives. (3) Stage II repair: Use the lobulated and pedicled
2. Clinical manifestation: Most of the left ear is torn, wound flap to repair the residual wound along with a ratio of
is not neat, and skin of the upper end of the helix is still 5∶1 in length and width. Lobulated but with the same
connected. pedicle, and the flap survives after surgery.
3. Surgical method: Debridement and repair. 5. Precautions: If the ratio of the length and width of the lobu-
4. Key points: (1) Debridement: wound debridement, lated flap exceeds 5∶1, the blood supply will be affected.
removal of the broken and inactivated tissues; (2) Repair: 6. Operation steps: See Fig. 22.9.
a b
c d
e f
Fig. 22.9 Repair of auricle tear. (a) Torn left ear (b) Debridement and Incise the skin. (h) Lift the flap. (i) Transfer the flap (j) Earlobe of the
repair (c) One week after surgery (Stage I surgery) (d) Most part of the anterior ear (k) Repair the defect (l) One week after surgery (Stage II
auricle survives (e) Partial defect (f) Design of double-lobe flap (g) surgery) with a good healing
g h
i j
k l
22.5 epair and Replantation of Majority

R 3. Surgical method: Perform the posterior auricular pedicled
of Ear Defects flap repair surgery in two stages.
4. Operating points: (1) Stage I surgery: (a) Cleaning up the
Case 1 wound margin: wound debridement, removal of the broken
1. Medical history: A male, 21 years old, presented with the and inactivated tissues; (b) Design the pedicle flap behind
defect of helix of ear after being bitten. the ear: the pedicle is on the hairline side, the ratio of length
2. Clinical manifestation: Defect deformity of the most part and width is 1∶1, the area of the flap approximately equals
of left helix. to the wound; (c) Wound repair: incise the designed line
behind the ear, and lift the flap to cover the front side of the ble. (2) When creating the helix with the flap of the stage
helix, then suture and fix. (2) Stage II surgery: Three weeks II surgery, use the steel needle to make beams, then
later, cut off the pedicle, repair and reconstruct the auricle. remove them after 2 weeks of shaping.
5. Precautions: (1) The size of the flap depends on the need 6. Operation steps: See Fig. 22.10.
for wound repair, and control the size as much as possi-
a b
c d
e f
Fig. 22.10 Repair of auricular defect. (a) Necrosis of the helix of ear dle pierce as a bridge (h) Penetration and fixation (i) Two weeks after
(b) Wound defect (c) Design flap (d) Repair flap (e) One day after sur- surgery (Stage II surgery) (j) The flap survives
gery (f) Cut off the pedicle 3 weeks later (Stage I surgery) (g) The nee-
g h
i j
Case 2 whether blood vessels are healthy or can be sewn. (3)

1. Medical history: A male, 21 years old, presented with the Look for bleeding points under the mirror behind the ear.
defect of a traumatic broken ear. 6. Operation steps: See Fig. 22.11.
2. Clinical manifestation: Broken left ear with defect
deformity. Case 3
3. Surgical method: Broken ear replantation (anastomosis of 1. Medical history: A female, 42 years old, presented with a
blood vessels). traumatic broken ear with pedicle.
4. Key points: (1) Clean up the wound margin: wound 2. Clinical manifestation: The right ear is torn, but still con-
debridement, removal of the broken and inactivated tis- nects with the residual point-like skin of earlobe.
sues. (2) Search for arteries: find the arterial and venous 3. Surgical method: Broken ear replantation (no vascular
blood vessel that can be anastomosed on the dorsal side of anastomosis).
auricle. (3) Replantation and repair: (a) Fix ear cartilage; 4. Key points: (1) Clean up the wound margin: debridement
(b) Use the 11-0 undamaged stitches to anastomose the of the wound margin. (2) Repair: (a) Fix ear cartilage; (b)
artery and vein, the diameter of the artery is 0.3 mm, the Suture the inner and outer layers of skin, remove stitches
diameter of vein is 0.4 mm; (c) Remove stitches 1 week 1 week later and the replantation of ear survives. (3) One
later, the replantation of the ear survives, and there is week after surgery, if part of the wound splits, suture
edema and exfoliation of a small part of the epidermis, again.
but self-healing will be achieved in the future. 5. Precautions: The space between stitches should be wide
5. Precautions: (1) It is important to clean up the wound to facilitate the blood supply.
margin. (2) It is critical to recognize and distinguish 6. Operation steps: See Fig. 22.12.
a b
c d
e f
Fig. 22.11 Repair of the defect of the broken ear. (a) Left ear defect (b) Residual ear tissue (c) Search for blood vessels (d) Rebuild blood circula-
tion (e) One week after surgery (f) Two weeks after surgery (g) Three weeks after surgery (h) Tissues survive
g h
a b
c d
e f
Fig. 22.12 Repair of incomplete broken ear. (a) Cut the broken ear (b) Only a small part of the pedicle exists. (c) Direct replanting (d) Splitting
1 week after surgery (e) Repair again (f) Six weeks after surgery
Case 4 to repair the helix of the ear. (3) Stage III surgery:
1. Medical history: A male, 22 years old, presented with a Transfer the flap to repair the helix of the ear: Three
defect of helix of the ear after trauma. weeks after the previous operation, cut off the other
2. Clinical manifestation: Defect deformity of the left helix end of the pedicle, and transfer the pedicle to the helix
of the ear. of the ear, then incise the skin-tube, repair and recon-
3. Surgical method: Perform the skin-tube repair surgery in struct the helix of the ear.
three stages. 5. Precautions: Before cutting off the pedicle, a test should
4. Operating points: (1) Stage I surgery: (a) Clean up the be done by wrapping and pinching one end of the pedicle
wound margin: wound debridement, removal of the to observe the blood supply of the skin-tube. A 2-second
broken and inactivated tissues; (b) Make the skin-tube filling means the reliable blood supply; but it is the unreli-
behind the ear, which is parallel to the auricular arc able filling if time exceeds 5 seconds, which means it is
line, and the ratio of the length and width of the tube is necessary to extend the time of cutting off the pedicle and
5∶1. 2. Stage II surgery: Three weeks later, cut off one continue fostering the skin-tube.
end of the pedicle point and transfer the pedicle point 6. Operation steps: See Fig. 22.13.
a b
c d
Fig. 22.13 Repair of auricle defect. (a) Defect of the helix of ear (b) the helix of ear (h) Separate and reveal the subdermal tissue. (i) Cut off
Stage I surgery: debridement (c) Partial suture (d) Reduce the wound the pedicle (j) Incise the skin-tube. (k) Trim the skin-tube (l) Repair the
size (e) Create the skin-tube (f) Transfer the skin-tube for the first time helix of ear (m) Remove stitches 1 week later, the skin survives. (n)
with a good healing (g) Three weeks after surgery, incise the skin along Posterior observation with a good shape
e f
g h
i j
k l

m n
22.6 Reconstruction of Auricular Defect injection port (scalp). Suture the skin and inject 5 ml
saline (10% volume). Remove stitches 1 week after sur-
Case gery, then begin to expand the skin by injection of saline
once a week and 10% each time, and adjust the speed of
1. Medical history: A male, 23 years old, presented with an injection in accordance with the color of skin. (2) Stage II
auricular defect after being bitten, 1 year after abdominal surgery: Repair and reconstruct the auricle: 6 weeks after
embedding and fostering the cartilage. stage I surgery. (a) Remove the ear cartilage and the
2. Clinical manifestations: Left auricular defect deformity, expander: Remove the ear cartilage at the original inci-
incision scarring of the right inferior abdomen caused by sion of the abdomen, and thin it to use; (b) Cut off the
fostering the cartilage. injection tube of the expander, then drain out the saline
3. Surgical methods: Perform the skin expansion and carti- and remove the expander; (c) Repair and reconstruct the
lage replantation surgery in two stages [1]. auricle: Implant the ear cartilage into the cavity that cre-
4. Key points: (1) Stage I surgery: Skin expansion: Insert a ated before and suture skin, then fix skin by oil yarn nail
skin expander behind the ear (kidney-like shape, 50 ml). and shape the auricle.
(a) Check the expander, inject a small amount of saline 5. Precautions: Closely observe the color of the expanded
and drain the gas out; (b) Make a 2 cm incision inside the skin; each expansion should not be excessive to avoid
hairline range, followed by sneak separation, creation of skin necrosis.
cavity, insertion of expander, external placement of the 6. Operation steps: See Figs. 22.14 and 22.15.
a b
c d
e f
g h
Fig. 22.14 Auricular defect reconstruction (Stage I). (a) The bitten left ear (b) Upper half defect of left ear (c) Foster the cartilage (d) Check the
water sac (e) Incision design (f) Incise the scalp (g) Separate the cavity (h) Insert the sac (i) Suture the incision (j) Inject the saline to expand
i j
a b
c d
Fig. 22.15 Auricular defect Reconstruction (Stage-II). (a) Resect the the cartilage (m) Fix the cartilage (n) Suture the incision margin (o)
cartilage (b) Separate the cartilage (c) Lift the cartilage. (d) Remove the Additional incision (p) Thread the needle (q) Penetrate and fix (r) 1
cartilage. (e) Local anesthesia (6 weeks after surgery) (f) Incise the week after surgery (s) Posterior observation (t) 3 months after surgery
skin. (g) Drain the saline out (h) Remove the sac (i) Thin the cartilage (Stage-II) (u) Good shape
(j) Trim the cartilage (k) Observe the back of the cartilage (l) Replant
e f
g h
i j
k l

m n
o p
q r
s t

u Reference
1. Ma T, Xie F, Zhang Z. Modified 2-Stage method for auricular recon-
struction. Ann Plast Surg. 2018;80(6):628–33.

Epilogue
The book is mainly supported by “Operation Smile China” plastic surgery hospital of Beijing Union Lige, the plastic
and its fixed medical base—Hangzhou smile operation hos- surgery team of drum tower hospital affiliated to medical
pital (funded by Mr. Weng Jianxun, a philanthropist in college of Nanjing university, the oral and maxillofacial
Hangzhou). Dr. Yao Jianmin, who is in Hangzhou plastic sur- surgery of stomatological hospital affiliated to medical
gery hospital with an accumulation of clinical practice over college of Xi’an jiaotong university, the plastic surgery
years, was responsible for the collection and compilation of team of Guangzhou children’s hospital, the plastic surgery
the book. Before the book was written, Dr. Han kai, the ini- team of the first hospital affiliated to medical college of Xi
tiator of “Operation Smile China” and the winner of the sixth ‘an jiaotong university, the plastic surgery team of Zhejiang
national moral model, acted as the consultant of the book. people’s hospital, the plastic surgery team of the People’s
Besides, the book was reviewed by professor Wang wei, the Liberation Army 117th hospital, and the plastic surgery
tenured professor in the ninth people’s hospital affiliated to team of Hangzhou first people’s hospital.
medical college of Shanghai jiaotong university. Herein, I Special thanks to professor Wang guomin and professor
would like to express my deep gratitude. Yang yusheng in Shanghai, professor Guo shuzhong, profes-
At the same time, I would like to thank the experts, medi- sor Ma lian, professor Li dong, professor Xie hongbin, and
cal and non-medical volunteers, leaders, and their teams of professor Xue hongyu in Beijing, professor Cui yingqiu in
many domestic hospitals who have been caring about and Guangzhou, professor Shu maoguo, and professor Ren zhan-
supporting “Operation Smile China” since 1991. Thanks to ping in Xi ‘an, professor Tan qian, professor Wu jie, and pro-
your hard work and love, thousands of cleft lip and palate fessor Li sheng in Nanjing, professor Wu suofan, professor
patients who had benefited from the free surgery have a Zhang xudong, and professor Zhang jufang in Hangzhou.
bright smile today and a bright confidence in the future. We Finally, I would like to dedicate this book to all the volun-
have also accumulated a lot of valuable clinical experience teers and kind people of “Operation Smile China”.
and data, which has become the basis of our monograph.
I would also like to thank: the experts in the plastic sur- Editorial board
gery/oral surgery team of the ninth people’s hospital affili- No.333, Wengjiashan, Nanfeng xiaolu, west lake, Hangzhou
ated to medical college of Shanghai jiaotong university, 15 Aug, 2018
the third hospital of Peking university, the first cosmetic

https://doi.org/10.1007/978-981-15-4419-4

Jian Min Yao Editor, Jing Hong Xu Editor Atlas of Cleft Lip and

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Jian-min Yao

Atlas of Cleft Lip

Atlas of Cleft Lip and Palate

© Shanghai Scientific and Technical Publishers 2020

Editor, Jian-min Yao, Hangzhou Plastic Surgery Hospital

Compilers (Surnames Arranged in Number of Strokes)

Jin-ping Ding, Beijing Hospital

Hangzhou, China Jian-min Yao

Part I Classification and Operation of Cleft Lip and Palate

1 Classification of Cleft Lip and Palate����������������������������������������������������������������������� 3

Part II Repair of Cleft Lip

5 Repair of Unilateral Cleft Lip����������������������������������������������������������������������������������� 75

Part III Repair of Cleft Palate

9 Repair of Unilateral Cleft Palate������������������������������������������������������������������������������� 211

Part IV Repair of Other Congenital Facial Deformities

14 Repair of Congenital Eye Deformity������������������������������������������������������������������������� 269

Part V Repair of Acquired Facial Deformity

Jian-min Yao is Chief surgeon, the first leader of key medical

Jing-hong Xu is medical doctor of plastic surgery, chief sur-

1.1.2 Bilateral Cleft Lip

© Shanghai Scientific and Technical Publishers 2020 3

1.1.3 Median Cleft Lip 1.2.1.1 Unilateral First-Degree Cleft Palate

Fig. 1.9 (continued)

Fig. 1.10 (continued)

Fig. 1.13 (continued)

Fig. 1.14 (continued)

2.1.1.5 Double-V Plasty

2.1.1  even Surgical Method of Red Lip

Fig. 2.1 Z-plasty, pre-operation and post-operation

L. Ma · J.-m. Yao (*)

© Shanghai Scientific and Technical Publishers 2020 17

Fig. 2.2 Continuous Z-plasty, pre-operation and post-operation

Fig. 2.3 Triangular flap, pre-operation and post-operation

Fig. 2.4 Y-V plasty, pre-operation and post-operation

Fig. 2.5 Double-V plasty, pre-operation and post-operation

Fig. 2.6 Tongue-shaped flap, pre-operation and post-operation

Fig. 2.7 Deepithelialized flap, pre-operation and post-operation

Fig. 2.8 Straight line suture

2.1.2.1 Straight Line Suture 2.1.3.1 Triangular Flap

Surgical options are affected by the degree, classification,

Fig. 2.10 (continued)

Fig. 2.14 Rotary propulsion flap before and after operation

Fig. 2.15 Straight line suture for median cleft lip

2.2.1 Surgical Principles and Surgical Target 2.2.1.3 Target

Fig. 2.22 Surgical method of

Fig. 2.23 Surgical method of

Fig. 2.26 Irregularity of red

Fig. 2.27 Irregularity of red

Fig. 2.28 Upper lip concave

Fig. 2.29 Upper lip concave

Fig. 2.30 Upper lip concave

Fig. 2.31 Upper lip concave

Fig. 2.32 Reconstruction of

Fig. 2.33 Z-plasty of red lip

Fig. 2.35 (a) Crescent-­

Fig. 2.35 (continued)

Fig. 2.36 Nasal alar cartilage reshaping of nasal tip deformation

Fig. 2.37 Diamond resection

Fig. 2.38 V-Y plasty of

Fig. 2.39 Advancement flap

Fig. 2.40 Z-plasty of nostril collapse

Fig. 2.41 Z-plasty of nostril

Fig. 2.42 V-Y plasty of

Compilers (Surnames Arranged in Number of Strokes)

Hangzhou, China Jian-min Yao

Part I Classification and Operation of Cleft Lip and Palate

1 Classification of Cleft Lip and Palate�� 3

Part II Repair of Cleft Lip

5 Repair of Unilateral Cleft Lip�� 75

Part III Repair of Cleft Palate

9 Repair of Unilateral Cleft Palate�� 211

Part IV Repair of Other Congenital Facial Deformities

14 Repair of Congenital Eye Deformity�� 269

Part V Repair of Acquired Facial Deformity

1.1.2 Bilateral Cleft Lip

1.1.3 Median Cleft Lip 1.2.1.1 Unilateral First-Degree Cleft Palate

2.1.1.5 Double-V Plasty

2.1.1 even Surgical Method of Red Lip

2.1.2.1 Straight Line Suture 2.1.3.1 Triangular Flap

2.2.1 Surgical Principles and Surgical Target 2.2.1.3 Target

Fig. 2.35 (a) Crescent-

2.2.3.4 Secondary Malformation of Cleft Palate

3.1 Surgical Instruments for Cleft Lip

3.1.1 Cleft Lip Surgical Kit

3.2 Surgical Instruments for Cleft Palate

3.2.2 Cleft Palate Mouth Gag

3.3 lacement and Removal of the Mouth

4.1.2.2 Method 4.2.2.1 Method

4.2.3 U-Shaped Closure 4.2.4 Double Cross Suture

4.2.3.1 Method 4.2.4.1 Method

4.2.3.2 Advantage 4.2.4.2 Cautions