Treatment of Complete Bilateral Cleft Lip-Nasal Deformity

Philip Kuo-Ting Chen, M.D.,1 M. Samuel Noordhoff, M.D., F.A.C.S.,2 and Eric J.W. Liou, M.S., D.D.S.3

ABSTRACT

The modern technique of presurgical orthopedics and nasoalveolar molding produces a better skeletal foundation and nasal shape for the repair of the bilateral cleft lip-nasal deformity. The general principles are as follows: (1) preserve the presurgical columellar length; (2) keep the width of the central lip segment narrow without compromising the blood supply; (3) advance the columella prolabium complex superiorly to allow reconstruction of the orbicularis oris muscle behind the prolabium; (4) release the alar cartilage attachment from the pyriform rim and provide additional coverage of this soft tissue deficiency with the use of inferior turbinate flaps; (5) release and reposition the lower lateral cartilage; (6) adequately dissect above the maxillary periosteum; (7) reconstruct the nasal floor by local mucosal flaps; (8) reconstruct the prolabial buccal sulcus with tissue from the prolabium; (9) reconstruct the orbicularis muscle sphincter and attach it to the anterior nasal spine; (10) reconstruct a new Cupid’s bow, central vermilion, and lip tubercle with tissue from the lateral lips; (11) balance the height of both lateral lips without any incision around the ala; and (12) maintain the presurgical nasolabial angle. The residual nasal deformity remains a problem that needs further improvement. The long-term result in Chang Gung Craniofacial Center suggests overcorrection of columella height before, during, and after lip repair.

KEYWORDS: Bilateral cleft lip, nasoalveolar molding, long-term result

The objective for surgical correction of the bi- trimmed the forked flap and reconstructed the nose with lateral cleft lip is to reconstruct a symmetrically balanced intranasal and nasal tip incisions that allowed approx- lip and nose with good columellar length. The most imation of the splayed lower lateral cartilages for accen- common approach is a two-stage correction with col- tuation of the columella. Trott and Mohan14 advocated umella elongation as a secondary procedure at the age of an open rhinoplasty approach raising the nasal tip with 1 to 5 years.1–10 Noordhoff,11 in 1989, reported a one- the prolabial flap for approximation of the alar domes. stage reconstruction with microscopic dissection of the Cutting et al15 used presurgical nasoalveolar molding to prolabium as an island pedicle flap and interdigitation of stretch the columella to achieve a more satisfactory one- the two-forked flap between the columella and pro- stage repair. Millard et al5 advocated aggressive, active labium for primary elongation. It was abandoned be- presurgical orthopedics, gingivoperiosteoplasty, and lip cause it was technically too complicated. Mulliken12,13 adhesion along with a forked flap elongation of the

Cleft Lip Repair: Trends and Techniques; Editor in Chief, Saleh M. Shenaq, M.D.; Guest Editor, Joseph K. Williams, M.D., F.A.C.S., F.A.A.P.; Seminars in Plastic Surgery, Volume 19, Number 4, 2005. Address for correspondence and reprint requests: Philip Kuo-Ting Chen, M.D., Craniofacial Center, Chang Gung Memorial Hospital, 5, Fu-Hsin Street, Kwei-Shan, Taoyuan, Taiwan. 1Department of Plastic & Reconstructive Surgery, 2Superintendent Emeritus, 3Department of Orthodontic and Craniofacial Dentistry, Chang Gung Memorial Hospital, Taipei, Taiwan. Copyright # 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 1535-2188, p;2005,19,04,329,342,ftx,en;sps00184x. 329 330 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005

side and incomplete on the other. Kernahan’s ‘‘striped Y’’ method16 cannot fully illustrate the range and diversity of the asymmetric cleft. The double-Y numbered classi- fication, reported by Noordhoff in 1990,17 is a more accurate method for recording as well as a more suitable system for computer database documentation (Fig. 1). For patients with a complete cleft of primary and secondary palate on one side and a complete cleft of the secondary palate on the other side, this classification can record the pathology in a more accurate way than the single striped Y classification.

EVALUATION OF PATHOLOGY There is a wide variation in the quality and amount of tissue in the prolabium, premaxilla, nasal cartilages, vomer, and lateral lip elements.18–22 All bilateral clefts have some amount of asymmetry in their horizontal or vertical dimensions.23 All cleft patients have a certain amount of tissue deficiencies. These deficits are most severe in bilateral medial facial dysplasia patients24 Figure 1 The double-Y numbered classification. The numbers 1 (Fig. 2), who, therefore, have a less than optimal out- to 9 represent the right side of the cleft and the numbers 11 to 19 come after lip and nose repair. They always have a represent the left side of the cleft. The number 10 represents a submucous cleft palate. It more accurately defines the nature of significant growth disturbance and require orthognathic the clefts on either or both sides of the primary palate, 1 to 9 (or surgery when they reach skeletal maturity. It is impor- 11–19) as well as either or both sides of the secondary palate, 16 tant to document these deformities or any preexisting to 19 (6–9) or any combination. asymmetry, or both, prior to surgery to assess the post- operative results more accurately. columella. Most of the recent techniques that achieve a better result use the technique of presurgical orthopedics or nasoalveolar molding to stretch the columella pre- GENERAL PLAN OF MANAGEMENT surgically and try to maintain or further lengthen it Presurgical orthopedics, nasoalveolar molding, is started surgically. on the first visit. The aim of this molding process is to centralize the premaxilla, narrow the alveolar gaps, match the alar cartilages, and elongate the columella. RECORDING OF PATHOLOGY This process usually takes 3 to 4 months to achieve an There are many possible variations of the bilateral cleft optimal outcome. The initial surgery is usually per- lip. The morphology can vary from being complete on formed at 3 to 4 months of age, depending on the result both sides to asymmetric with a complete cleft on one of the molding process. The palate is repaired at about

Figure 2 A patient with a diagnosis of bilateral median facial dysplasia. (A) The patient has a relatively small premaxilla and prolabium, very deficient columella, and septal cartilage along with wide alveolar clefts. The premaxilla usually has one central incisor and a weak premaxilla-vomerine suture. (B) There is no lip frenulum. TREATMENT OF COMPLETE BILATERAL CLEFT LIP-NASAL DEFORMITY/CHEN ET AL 331

12 months of age together with the insertion of grommet tubes. Speech assessment is started at 2.5 years. If the patient requires speech therapy, it starts at 3.5 years. Velopharyngeal insufficiency is diagnosed by nasoendo- scopy at 4 years old and corrective surgery for velophar- yngeal insufficiency is performed as soon as the diagnosis is made. Residual alveolar clefts are closed before the eruption of canine teeth, usually when the child is 9 to 11 years old. If the patient has any psychological prob- lems related to any residual lip or nasal deformity, a revision surgery is usually done before the child enters primary school.17 Figure 3 A method to increase the columellar height gradually by adding silicone sheets to the domes of the nasal stent. It can be used for presurgical elongation of the columella in incomplete PRESURGICAL ORTHOPEDICS/ clefts or postoperative maintenance of the nostril configuration in NASOALVEOLAR MOLDING an overcorrected position of the columella. The purpose of presurgical orthopedics or nasoalveolar molding is to restore a more normal nasal shape and a FIGUEROA’S TECHNIQUE balanced skeletal base. The following techniques have all Alveolar molding and nasal molding are performed been used in Chang Gung Craniofacial Center for the simultaneously using an acrylic plate with rigid acrylic past 20 years. nasal extension. Rubber bands are connected to the acrylic plate for gentle retraction of the premaxilla back- ward. A soft resin ball attaching to the acrylic plate Presurgical Orthopedics across the prolabium is sometimes used to maintain the The protruding premaxilla may be gradually pushed nasolabial angle29 (Fig. 4). back by applying micropore tapes across the lip with or without traction rubber bands.25 It is suggested that the LIOU’S TECHNIQUE patient sleep in either the prone or side-lying position The nasoalveolar molding device is composed of a dental to increase pressure on the cheeks. The movement of plate, two nasal components for nasal molding, and the alveolar segments is controlled by an acrylic plate. several micropore tapes for premaxillary retraction. Den- This simple technique is effective in expanding the ture adhesive (Poligrip, Australia) keeps the dental plate prolabial tissue and places the premaxilla in a better on the maxillary lateral segments. The nasal components position.26 are made up of 0.028-inch stainless steel wire projecting forward and upward bilaterally from the anterior part of the dental plate. The top portion contains a soft resin Nasoalveolar Molding molding bulb that fits underneath the nasal cartilages for nasal molding. Micropore tapes are placed across the SILICONE NASAL CONFORMER cleft lips and prolabium to minimize the alveolar cleft A silicone nasal conformer can be used as a tool for and retract the premaxilla. At the same time, they pull presurgical nasal molding when the patient has an both alar bases medially. Retraction of the premaxilla incomplete cleft lip.27 The height of the conformer can and lengthening of the columella are performed at the be adjusted by gradually adding some soft resin or flat same time. The columella is lengthened and stretched by silicone sheets on the domes (Fig. 3). pulling on the premaxilla backward. The nasal tip is kept at the same height while the premaxilla is pulled back. GRAYSON’S TECHNIQUE Rather than pushing forward, the soft resin molding A passive-type orthopedic appliance is used together bulbs basically support the nasal cartilages and nasal tip30 with taping of the lip for premaxilla and alveolar mold- (Fig. 5). ing. The protruding premaxilla is molded first into a The key point of nasal molding in bilateral clefts proper position. When the alveolar gap is approximated is to push the alar domes forward in a sagittal direction and the arch is aligned, a nasal molding device is added for columellar lengthening instead of pushing the domes to the orthopedic appliance to increase the columellar upward in a cephalic direction into a turned-up nasal tip. length as well as to reshape the alar dome. A nonsurgical Nasoalveolar molding techniques require regular patient lip adhesion is performed by placing tape across the follow-up with an interval of 1 to 2 weeks. Grayson’s upper lip. The tape aids in the closure of the clefts, technique approximates the alveolar cleft before the decreases the width of the base of the nose, and helps to nasal molding. Both Figueroa’s and Liou’s method approximate the lip.28 achieve nasal and alveolar molding at the same time. 332 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005

Figure 4 (A) Figueroa’s device with rigid nasal extension for nasal molding: The alar domes are pushed upward and the columella lengthened by the device. (B, C) The nasolabial angle is maintained by a soft resin ball attached to the molding device.

GENERAL SURGICAL PRINCIPLES buccal sulcus with tissue from the prolabium; (9) recon- There are several surgical principles that need to be struct the orbicularis muscle sphincter and attach it to stressed. They are as follows: (1) preserve the presurgical the anterior nasal spine; (10) reconstruct a new Cupid’s columellar length; (2) keep the width of the central lip bow, central vermilion, and lip tubercle with tissue from segment narrow without compromising the blood sup- lateral lips; (11) balance the height of both lateral lips ply; (3) advance the columella prolabium complex supe- without an incision around the ala; and (12) maintain the riorly to allow reconstruction of the orbicularis oris presurgical nasolabial angle.25,31 muscle behind the prolabium; (4) release the alar carti- lage attachment from the pyriform rim and provide additional coverage of this soft tissue deficiency with SURGICAL PROCEDURE the use of inferior turbinate flaps; (5) release and repo- sition the lower lateral cartilage; (6) adequately dissect Markings and Measurements above the maxillary periosteum; (7) reconstruct the nasal The landmarks of the lip are marked out on the pro- floor by local mucosal flaps; (8) reconstruct the prolabial labium and both lateral segments. The various vertical

Figure 5 (A) Liou’s device. The nasal molding device is connected to the intraoral acrylic plate with wires. (B) The nasolabial angle is maintained by tapes across the lip. TREATMENT OF COMPLETE BILATERAL CLEFT LIP-NASAL DEFORMITY/CHEN ET AL 333

Figure 6 The markings and incision lines on the prolabium. The point IS is the center of the prolabium. The points CPHR and CPHR’ are the proposed peak of the Cupid’s bow on the right side, and the points CPHL and CPHL’ are the peak of the Cupid’s bow on the left side. A Trott incision is shown on the right side of the insert. The incision extends through the membranous septum in front of the medial crura of the lower lateral cartilages into an open rhinoplasty incision. The incision on the left side of the insert is an infracartilaginous incision. The incisions on the prolabial mucosa divide the prolabial mucosa and vermilion into three flaps. The medial one is used for lining the raw surface of the premaxilla. The two lateral flaps (the PM flaps) are used for reconstruction of the nasal floor as shown in Figure 8. The insert also shows the incision line on the lateral lip. and horizontal measurements are evaluated for any behind the columella up into the membranous septum asymmetry. The width between CPHL and CPHR is and continuing up along the skin-mucosa junction to the usually maintained at 5 to 6 mm. The central segment is dome area, then along the lower border of the lower gradually narrowed toward the columellar base and main- lateral cartilages (LLCs) as a gull wing open rhinoplasty tained at 4 mm in width at the level of the columellar base. incision or outside the alar rim as a Trott incision (Fig. 6, Traction applied to the alae is usually needed to identify insert). The central segment, the forked flap, and the the nasolabial junction. The incision lines are kept columella are raised as a unit to expose the cartilaginous straight, not curvilinear. The proposed peak of the Cupid’s framework. The central part of the vermilion and mu- bow on the lateral lips (CPHR’ and CPHL’) is marked at cosa of the prolabium is used for the lining of the raw the point where the vermilion first becomes widest and surface on the premaxilla. The lateral parts of the usually would be 13 to 15 mm from the commissure or 3 to prolabial mucosa flaps (PM flaps) are used for nasal floor 4 mm lateral to the converging junction of the red line and reconstruction (Figs. 7 and 8). white skin roll (WSR)(Fig. 6).

Lateral Segments Central Segment The incision is made from the proposed peak of Cupid’s A double hook is used to retract the columella up, and a bow along the cleft edge to the edge of the alveolar cleft. small single hook is used to stretch the prolabium. The The incision is right above the WSR to develop a WSR– central segment is developed by laying a number 11 blade vermilion–free border flap. This flap will be used for on the incision line of the prolabium to give a straight reconstruction of the central Cupid’s bow. An L-mu- cut. The two forked flaps are developed with lateral cosal flap is raised along the cleft edge. The incision is incisions on the skin-vermilion junction extending then turned upward along the pyriform rim and then 334 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005

Figure 7 The orbicularis marginalis white skin roll and vermilion flap on the lateral lip (OM) is incised as a lateral advancing flap for reconstruction of the Cupid’s bow beneath the prolabium. The orbicularis peripheralis (OP) muscle is released in a subdermal plane from the overlying skin and alar base. A mucosal flap (L) based on the alveolar margin and an inferior turbinate flap (T) are raised for lining the pyriform aperture and for reconstruction of the nasal floor. The insert shows the fibrofatty tissue of the nasal tip dissected from the lower lateral cartilages. Both lower lateral cartilages are clearly visible for assessing the pathology and symmetry.

around the inferior turbinate to be incorporated with the extensive to separate the abnormal muscle insertion from inferior turbinate flap. The dissection is carried above the skin. The dissection is carried below the alar base to the periosteum on the maxilla. The abnormal muscle release the abnormal muscle component that inserts to insertion on the lateral segment is released adequately the alar base (Fig. 7). until the lateral segment can be brought medially to touch the medial segment without tension. The cleft edge is then opened to develop the WSR–vermilion–free Nasal Floor and Muscle Reconstruction border flap. The dissection on the mucosal side is limited The inferior turbinate flap is used to fill in the defect to 2 mm, and the dissection on the skin side is quite on the pyriform area after the LLCs are advanced.

Figure 8 The separated lower lateral cartilages are approxi- mated by either absorbable sutures, 5-0 polydioxanone, or non- absorbable sutures, 5-0 polypropylene. The premaxilla is covered by the superior part of the residual central vermilion-mucosa flap of the prolabium (plmf). The pm flaps above the plmf flap attached to the premaxilla are brought laterally for reconstruction of the nasal floor and sulcus. TREATMENT OF COMPLETE BILATERAL CLEFT LIP-NASAL DEFORMITY/CHEN ET AL 335

Figure 9 After releasing the attachments of the lateral crura to the pyriform rim, the LLC is reattached in a superior position to the ULC. The remaining raw surface of the pyriform area is closed by rotating the inferior turbinate flap into the pyriform area and suturing it to the rim of the maxilla (upper illustration). The free edges of the L flap and T flaps are sutured to each other and the tip attached to the membranous septum and upper premaxilla. The outer pm flap on the premaxilla is extended laterally and attached to the maxilla, following which the free edges of the pm and L flaps are approximated. The vestibular skin is rotated medially and sutured to the leading edges of the T flap and L flap and the membranous septum, thus achieving good nasal floor closure. The vestibular skin is advanced as far as needed to the membranous septum to achieve good symmetry, rotation of the ala inward, and appropriate nostril size.

The turbinate and L flaps are sutured together, brought across the cleft, and sutured to the septal incision to reconstruct the nasal floor. Special attention must be focused on the width of the nostril. The PM flap is sutured below the L-flap for lining. The orbicularis muscles are approximated with 4-0 polyglactin sutures with the upper edge sutured to the anterior nasal spine (Figs. 9 and 10).

Nasal Reconstruction and Cupid’s Bow Reconstruction The separated LLCs are approximated by absorbable sutures, 5-0 polydioxanone, or nonabsorbable sutures, 5-0 polypropylene, depending on the surgeon’s prefer- ence (Fig. 8). The fibrofatty tissue on the nasal tip is brought to the top of the approximated nasal tip. The skin flap of the central segment is then sutured to the Figure 10 The advancing vestibular skin is shown attached to lateral lip. Through-and-through alar transfixion sutures the membranous septum to form the nasal floor. Final adjust- ments are made between the membranous septum and vestib- are placed on the alar-facial groove to provide further ular skin to achieve symmetry, turning in of the ala, and support to the LLCs (Fig. 11, insert). The excessive appropriate nostril size. The orbicularis peripheralis (OP) muscles tissue on the nasal floor is adequately trimmed and the are approximated centrally with interrupter absorbable sutures. 336 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005

Figure 11 After approximating the OP muscle, the upper edge of the OP muscle is sutured to the anterior nasal spine or nasal septum to maintain the height of the lip. The insert shows the final appearance after redraping of the nasal tip and approximation of the prolabial flap to the lateral lip. The central lip Cupid’s bow is reconstructed by advancing the WSR-vermilion flaps (OM) from the lateral lip. The LLCs are further supported by alar transfixion sutures (ATSs).

floor is closed. The full-thickness WSR, vermilion, and DISCUSSION free border flap are brought together below the central segment to reconstruct the central lip. Excessive orbicu- Comparison of the Molding Techniques laris marginalis muscle on the tip of the WSR–vermi- The different techniques of alveolar or nasoalveolar lion–free border flaps is preserved for augmentation of molding are used in Chang Gung Craniofacial Center. the lip tubercle (Fig. 11). Grayson’s technique, with emphasis on approximating the alveolar clefts before nasal molding, achieves the best preoperative nasal shape symmetry and skeletal base POSTOPERATIVE CARE balance. However, it is also the most expensive and The wounds on lip and nose are covered by antibiotic time-consuming method. Figueroa’s and Liou’s techni- ointment without any dressing. The sutures are removed ques of performing alveolar and nasal molding at the 5 to 7 days after surgery at the outpatient clinic. The lip same time are simpler and less expensive methods. A scar is supported by micropore tapes as well as silicone study32 comparing the three techniques in unilateral sheets for 6 months. A silicone nasal splint is needed for clefts showed that the latter two techniques tend to 6 to 9 months. Throughout this period, the height of the result in a larger diameter in the cleft side nostril post- splint is gradually increased by adding silicone sheets to operatively. the domes of the splint. The central prolabial portion of the lip will gradually widen and lengthen by the age of GINGIVOPERIOSTEOPLASTY 3 years. The nasal width will also increase, similar to the Millard, Mulliken, and Cutting5,12,13,15,33 all advocated central prolabial portion of the lip width. The columella the importance of primary gingivoperiosteoplasty. The length will shorten slightly after the primary lip repair long-term result from Cutting and Grayson’s report34 and then remain stable without further growth, while the showed that 60% of the patients who received primary rest of the nose will grow significantly in both height and gingivoperiosteoplasty do not need alveolar bone graft- width. This results in a relative relapse appearance of the ing later on. However, it is very difficult to perform a columella.30 Figure 12 shows a series of photographs primary gingivoperiosteoplasty unless the alveolar gap is demonstrating the effect of presurgical nasoalveolar around 1 to 2 mm. Figueroa’s and Liou’s techniques molding and the postoperative changes of the nasal tends to leave the alveolar gap larger, 3 to 4 mm, which shape. limits the possibility of a primary gingivoperiosteoplasty. Figure 12 (A, B) Frontal and mental views of a patient at 3 weeks, first visit at 2 weeks. Liou’s technique was used for nasoalveolar molding. (C, D) Views at 4 months after nasoalveolar molding at time of surgical repair. (E, F) The postoperative appearance of the boy at 1 year of age. (G, H) Frontal and mental views of the boy at 5 years. 338 SEMINARS IN PLASTIC SURGERY/VOLUME 19, NUMBER 4 2005

CENTRAL SEGMENT HEIGHT AND WIDTH forked flaps also end up with unsightly scarring on the There is a significant difference in the outcome of the nasal floor. The authors do not bank these forked flaps. shape of the central lip in the bilateral cheiloplasty with They are trimmed to an adequate size and sutured or without muscle approximation. In the technique backward to the septum to improve the nasolabial angle. without muscle approximation, the central lip tends to The report from Nakajima et al suggested a similar become wider and remains short. With muscle approx- approach.37 imation, the central lip segment has less widening but more lengthening. Mulliken12,13 advocated narrowing SEPTAL INCISION – IN FRONT OR BEHIND THE LLC’S the central lip width down to 2 to 3 mm for a better Cutting et al15 raised the central segment tissue behind long-term result. Noordhoff,11 in attempting a primary the medial crura of LLCs and reported that it has a safer elongation of the columella by interdigitating the forked blood supply to the prolabium. Trott and Mohan14 used flaps into a transverse incision in the columella, found a technique of raising the central segment in front of the two vessels running from the columella to the prolabium. LLCs. The Chang Gung experience comparing the two A central segment that is 2 mm wide at the columellar techniques shows that there is no difference in terms of base may injure the vessels. A 4-mm-wide base of the blood supply to the central prolabium between these two prolabium includes both columellar vessels, providing a techniques. Cutting and Noordhoff believe that the good blood supply to the prolabium. The long-term medial crura need to be elevated superiorly on the septal result shows a tendency of widening as well as length- cartilage, and Trott and Mulliken leave the LLCs ening of the central segment. A wide central segment attached to the septum. In the authors’ experience, the in primary lip repair, although maintaining a good two techniques offer a similar early result. Technically, blood supply, may result in an unnaturally wide Cupid’s the retrograde dissection and approximation as advo- bow. cated by Cutting is more difficult compared with the Regarding the vertical height of the central lip, technique of approximation of cartilages under direct Lee35 advocated that the vertical height of the central lip vision as advocated by Trott. in a 3-month-old baby should be around 7 mm. How- ever, the height is somewhat predetermined by the size NASOLABIAL ANGLE of the prolabium. A prolabium shorter than 7 mm In his anatomical dissection around the nasolabial should not be lengthened on the operating table, as it angle, Wu38 showed that the angle is maintained by will always lengthen vertically with muscle approxima- a ligament from the subcutaneous tissue to the anterior tion and have a satisfactory appearance. A relatively nasal spine. Whenever the columella-prolabium com- longer prolabium can provide additional tissue for the plex is raised, the nasolabial angle tends to be flattened columella and make it easier to achieve a better nose. after operation. However, this procedure is definitely The critical problem in determining the vertical height necessary as the separated orbicularis muscles need to of the lip occurs when there is a marked discrepancy be approximated under the prolabium to achieve an between the vertical height of the central lip and the anatomical repair. The technique with the placement lateral lips. In this situation, the surgeon should verti- of the incision behind the medial crura tends to main- cally shorten the lateral lip to match the vertical height tain a better nasolabial angle postoperatively than the of the central prolabial portion of the lip. Otherwise, technique with the incision located in front of the the nasal tip will be pulled downward because of the medial crura. Restoration of the ligament by a tuck- tension in the central segment. Even a short vertical down suture from skin to anterior nasal spine may length of 4 to 5 mm will elongate adequately with muscle jeopardize the blood supply to the prolabium. Suturing repositioning. the tips of the forked flaps backward to the septum may be more helpful in maintaining the nasolabial FORKED FLAP angle.37 Millard suggested preserving the prolabial tissue lateral to the central segment as forked flaps that are banked on OPEN VERSUS CLOSED RHINOPLASTY the nasal floor. These banked forked flaps are used for The approximation of the LLCs can be achieved columellar lengthening in secondary revisions. The ex- through either an open or closed rhinoplasty. The perience in Chang Gung Craniofacial Center does not authors’ experience shows a similar result with the two support his concept in Oriental patients. Pigott36 studied techniques. Technically, a closed rhinoplasty with two the ratio between dome component and columellar rim incisions or bilateral Tajima39 incisions is simpler component in Caucasians of varying ages. The dome than the open rhinoplasty through a gull wing or Trott columellar ratio is much greater in Orientals than in incision. However, an open gull wing incision, approx- their Caucasian peers. A nose with a disproportionately imating the LLCs through direct vision with nonab- long columella often results after a columellar elongation sorbable sutures, is the author’s preferred method. This procedure using the banked forked flaps. The banked allows the surgeon better visualization for accurate TREATMENT OF COMPLETE BILATERAL CLEFT LIP-NASAL DEFORMITY/CHEN ET AL 339 approximation of the LLCs. The open technique also HORIZONTAL INCISION ON LATERAL LIPS provides a better approach for redraping or redistributing From the experience in unilateral cleft lip repair,53 the the central segment tissue. horizontal incision below the nasal floor is usually un- necessary. Nevertheless, the alar-facial groove has a POSTOPERATIVE NASAL SHAPE MAINTENANCE better appearance if the skin is kept intact. The surgeon Friede et al40 used a postoperative acrylic molding splint needs only to approximate the orbicularis muscles. How- to improve nasal configuration. Other reports used a ever, in the presence of a vertical discrepancy between similar concept for postoperative maintenance.27,41–45 In the central lip and lateral lips, a horizontal incision below Chang Gung Craniofacial Center, a silicone conformer the nasal floor may be needed. The lateral incision is is routinely used after surgery and proved its efficacy in used for shortening of the longer lateral lip. maintaining the postoperative nasal shape in unilateral clefts46 as well as in bilateral clefts. It is necessary to use the splint for at least 6 months postoperatively while LONG-TERM RESULTS waiting for scar maturation. The long-term results in nasal reconstruction usually give an impression of relapse of the nasal shape. How- MUSCLE DISSECTION ever, studies of long-term results for both unilateral and Delaire47 suggested wide subperiosteal dissection on the bilateral clefts by photometric measurements with 1:1 maxilla to achieve a functional closure. There is still photographs show that there is a tendency of increase of controversy about whether a subperiosteal or supraper- the nostril width even when the nostril height is main- iosteal muscle dissection is better in terms of function or tained postoperatively. This condition gives an impres- subsequent facial growth. There are no scientific data sion of relapse.30,54 These studies show the importance supporting the concept that a subperiosteal dissection of overcorrection of the nostril height and nostril width results in less scarring or better facial growth. A muscle during surgery and the need to maintain the nostril dissection above the periosteum seems to offer a better shape in an overcorrected position postoperatively. release of the abnormal muscle insertion around the alar There are no scientific data suggesting the amount of base from both the skin side and periosteal side. The overcorrection during surgery. The postoperative main- technique presented here keeps the extent of muscle tenance can be achieved by gradually adding silicone dissection as minimal as possible but still adequate for sheets or soft resin to the nasal splint to increase the muscle approximation at the center. This should create nostril height. minimal scarring or muscle tension in front of the maxilla. CONCLUSION MUSCLE RECONSTRUCTION Presurgical orthopedics and nasoalveolar molding pro- Manchester48,49 felt that the orbicularis muscle should vide the surgeon with a much better skeletal foundation not be reconstructed as it would cause too much tension for reconstruction of the bilateral cleft lip. The goal is to and growth disturbance. Nagase et al50 showed that restore all the displaced tissue, reconstruct the dynamic there was no significant growth disturbance after sphincter, reconstruct the Cupid’s bow with tissue from muscle reconstruction. There is a definite difference the lateral lips, overcorrect the nasal width, maintain and in the appearance of the bilateral lip repair with or further elongate the columella during surgery, and main- without muscle reconstruction. Muscle reconstruction tain the columellar height postoperatively. Reconstruc- produces a much better result both functionally and tion of the bilateral cleft lip-nasal deformity remains a aesthetically. challenging task. The results vary with any technique as there is a wide range of tissue deficiencies that are also CUPID’S BOW AND LIP TUBERCLE factors in achieving a successful result. The techniques leaving the prolabial WSR and vermi- lion on the prolabium to reconstruct the Cupid’s bow REFERENCES result in a Cupid’s bow with abnormal peaking, indis- tinct prolabial WSR, and irregular vermilion with a 1. Cronin TD. Lengthening columella by use of skin from nasal depressed scar at the central lip. The quality of the floor and alae. 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