return to: Cleft Lip and Palate Protocols

Last updated more than one decade ago (as of August 2023)

TECHNIQUE

• Much different design considerations compared to unilateral repair
• Most often used technique at our institution is that described by John Mulliken
  • Mulliken, JB. Primary Repair of Bilateral Cleft Lip and Nasal Deformity. Plastic & Reconstructive Surgery. Vol 108;1, July 2001.
    • Addresses primary lip and nasal deformities in a single procedure with an equal focus on correction of each element
    • Uses prolabium component to reconstruct philtrum

OPERATIVE PROCEDURE

1. With the patient supine, head off of the Phillipine board, and a donut or head roll in place, the patient is prepped and draped in the usual fashion. Tube is tapped in the midline.
2. Identify and mark the two high points of Cupid’s bow, or the place medially where the white roll ends on each side of the bilateral clefts. From this point carry a mark upward and medially toward the nasal vestibule following the line of the red lip as it moves superiorly. Make a small mark laterally along the white roll a short distance from its origin. At the beginning of the white roll, where you’ve begun your up-coursing mark, make another mark that traverses the red lip vertically from the line of the white roll, carry this mark inferolaterally. Next, mark the prolabial skin as a potential fork flap (the shape of a dart). The skin here will eventually make up the middle of the philthrum, and if there is enough room, the lateral margins of the fork flap can be rotated up to recreate the vestibule filling in the gap for your back cuts.
3. Inject epinephrine 1:200,000
4. Incisions - Incise the lines on one side, and then the other, always working toward the dependent portion of your incision to keep blood out of your way. Come through the dermis or mucosa, but not the underlying musculature.
5. On one side raise the dermis off of the underlying orbicularis using caution not to dissect too far laterally. Then raise the orbicularis off of the underlying mucosa, if you can see the minor salivary glands you’re in the right plane. If you perforate the buccal mucosa, repair it. Follow the orbicularis onto the maxilla and free it from its bony attachment as high as possible (up toward the base of the inferior turbinate) as this will free the maximal amount of muscle to pull across the lip at the end. At this point, make a lateral cut on the internal vestibule / ala that will serve as the floor of the nose / vestibule anteriorly. Separate the muscle off of the underlying maxilla heading laterally toward the maxilla and medially. Make a back-cut in the gingivolabial border. Peel the orbicularis as far laterally as needed to achieve tension-free closure of the muscle across the midline. Do the same on the opposite side.
6. Next, dissect the prolabium. Raise the fork flap up, including the dermis and some underlying fat. Raise the red lip remnant inferiorly to the premaxilla, this flap will create the back side of your gingivo-buccal sulcus. Reduce any redundant sulcal tissue by excising a midline V and removing any excess fat from the back side of the flaps. Reapproximate the flaps in the midline.
7. Closure. Pull the lateral lip segments medially and suture the deep portion of the mucosal lip to what will be the new gingivo-buccal sulcus, you may want to suture to the opposite side of the freshly split sulcus as it will pull the incision closed rather than open. Suture the sulcus mucosa from deep in the sulcus around the curve on one side and repeat the process on the other side.
8. Re-approximate the orbicularis muscle (use 4’0 monocryl here) in the midline.
9. Next, make a stab incision with an 11 blade scalpel through and through the vermillion parallel to the inferior border of the white roll as a back cut of 2-3 mm and through the orbicularis out the underlying mucosa. This move separates the lip musculature from the superior orbicularis. Next, approximate the vermillion border / white roll bilaterally with 4’0 Chromic suture.
10. At this point you can determine if you have enough tissue laxity to create your fork flaps. Fork flaps are created by cutting vertical columns of skin lateral to the central prolabial segment. These fork flaps are rotated supero-laterally into the nasal vestibule back cut space, hence creating the new nasal vestibule. Using 4’0 chromic suture bring the central philtral flap to the columella using 4’0 chromic suture.
11. At this point, the philtral incisions can be closed with chromic, Vicryl suture or 5’0 fast gut suture.
12. Place Dermabond over the skin incisions once they are complete, make sure none gets in the nose by placing Q-tips in the nose prior to application.

REFERENCES

Mulliken, JB. Primary Repair of Bilateral Cleft Lip and Nasal Deformity. Plastic & Reconstructive Surgery. Vol 108;1, July 2001.

Mulliken JB, Wu JK, Padwa BL. Repair of bilateral cleft lip: review, revisions, and reflections. J Craniofac Surg. 2003 Sep;14(5):609-20. doi: 10.1097/00001665-200309000-00003. PMID: 14501318.

Kim DC, Mulliken JB. Direct Anthropometry of Repaired Bilateral Complete Cleft Lip: A Long-Term Assessment. Plast Reconstr Surg. 2017 Aug;140(2):326e-332e. doi: 10.1097/PRS.0000000000003535. PMID: 28746287.

Allori AC, Mulliken JB. Evidence-Based Medicine: Secondary Correction of Cleft Lip Nasal Deformity. Plast Reconstr Surg. 2017 Jul;140(1):166e-176e. doi: 10.1097/PRS.0000000000003475. PMID: 28654617.