return to: Cleft Lip and Palate Protocols

Note: below is of historical perspective

TECHNIQUE

• Fisher Anatomic Subunit Technique 
  • Preferred technique of our craniofacial surgeons at UIHC
  • The incisions and rotation flaps are designed based on several anatomic points with respect to anatomic subunits of the face and nose
    • Fisher, DM. Unilateral Cleft Lip Repair: An Anatomical Subunit Approximation Technique. Plastic and Reconstructive Surgery Vol 116, No 1, July 2005.
• Millard
  • Rotation advancement method, "cut as you go" technique
  • Non-cleft side represents a rotational flap
  • Cleft side represents an advancement flap
• Tennison and Randall
  • Interdigitation of triangular flaps

Sample operative note (UNILATERAL USING FISHER DESIGN):

Informed consent was reviewed. The patient was transferred to the operating room and placed in the supine position on the Phillipine board. After a pre-induction checklist, followed by induction and mask ventilation by anesthesia staff, a time-out was performed. The left ear was examined and cerumen was removed from the canal with a small curette. A myringotomy incision was made in a radial fashion using a Beaver blade and a VT grommet tube was placed using alligator forcep. Next, the right ear was addressed in a similar fashion. Drops were instilled and a cotton ball inserted the canal. At this point, intubation was performed by anesthesia staff and the patient was prepped and draped in a sterile fashion. Measurements and markings were made upon the lip and nose in the Fisher design with minor modifications (see measurements above). These markings were reinforced by stab injection of methylene blue with 27g needle. The lips and nasal base were injected with 0.5% lidocaine with epinephrine 1:200,000. Bull dog clamps were placed bilaterally to ensure upper lip hemostasis while incisions were made. Skin incisions were made on both sides of the cleft lip / premaxilla in a standard fashion using the Fisher approach. The gingivolabial sulcus incision was made and Simonart's band transected with needle point cautery and the premaxillary flap was raised to release the tissue. Elevation of the mucosa/submucosa from the orbicularis oris muscle was performed on the lateral (cleft) flap first using 3397 scissors. The medial (non-cleft) incisions were then made with 15 blade. Excess tissue not to be used in repair was discarded. The greater lip incision was taken down onto the maxillary crest and raised along the non-cleft side of the caudal septum in order to release the septum and bring it toward the crest and cleft side. Bull dogs were removed. The non-cleft nasal aperature was sized with Hager dilator. The nasal sill was designed and using 4-0 vicryl, the alar base was sutured to the medial crural footplate pulling the columella toward the cleft side and suturing this such that the it matched the contralateral side in diameter as measured with the dilator. A transcutaneous interdomal stitch was performed to narrow the columella using stab incisions and through and through stitch with 4-0 PDS. The cleft side alar web was addressed similarly by tacking the internal ala to the alar facial groove in 2 sites. The nasal floor was closed in layers - with muscle layer closed with 4-0 vicryl, the deep dermal layer closed with 4-0 monocryl. The cutaneous lip skin was closed in interrupted fashion with 6-0 fast, the vermillion lip with 5-0 chromic and the wet lip with 4-0 vicryl. The wounds were cleansed and dried and photodocumentation obtained. The entire upper cutaneous lip was dressed in dermabond to prevent traction on the suture line. This concluded the procedure, the baby was turned over to anesthesia for emergence and extubation.