xRead - Treatment of Cleft Lip and Cleft Palate (May 2025)

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ALKEBSI ET AL.

KEYPOINTS Question: Can new modifications in unilateral complete cleft lip repair improve the leveling of Cupid’s bow, short lip height and width, and short columella? Findings: Well-aligned Cupid’s bow with symmetrical lip height and width were obtained with satisfactory aesthetic nasal outcomes. Meaning: The new modifications to primary unilateral com plete cleft lip repair could improve the lip and nasal aesthetic results.

Fig. 1. (Left) important reference points in the SM. (Center) The shape and direction of the flaps after incision. Note the leveling of the Cupid’s bow to symmetrical position. (Right) postoperative scar.

study introduces a unique method including a geometri cal theory of Cupid’s bow rotation as described by Shi 8 and new modification in C-flap and superiorly based flap treatment to improve the lip and nose alignment and outcomes in unilateral complete cleft lip (UCCL) re pair. We performed postoperative anthropometric analy ses of lip and nose symmetry by labeling the points and measuring standard distances for evaluation of the Shi modifications (SM). This study was approved by the institutional review board of West China Stomatology Hospital of Sichuan Univer sity. This study included 72 consecutive patients with non syndromic unilateral complete cleft lip and palate between 2015 and 2019 who underwent cleft lip repair by SM. Data were derived from the hospital electronic medical record system, with the following data retrospectively collected: age at the time of operation, gender, cleft side, and follow-up. All surgeries were performed using SM without presurgical nasoalveolar molding. The last follow-up period’s photos were collected before any re vision intervention (follow-up ranged from 1 to 5 years). Surgical technique This modified RA passed through two stages until it reached its final form, as described in this study. In 2009, Shi introduced the bisector theory. 8 In this study, Shi added the superiorly based advanced flap on the cleft side, which helps increase the vertical lip height and fills the space created by the back-cut incision. Meanwhile, the C-flap is rotated to form the nasal sill and part of the columella on the cleft side (see Supplementary Video S1). The anthropometric points on the noncleft side are al most the same as that for the Millard technique (Fig. 1; left). The crucial difference between RA and SM in marking the noncleft side is the placement of the incision end. Mark point 1 at the low peak of Cupid’s bow. Points 2 and 3 are marked equally on both lateral peaks of Cupid’s bow. Points 11 and 12 are marked at the mouth’s commissures on the noncleft and cleft sides, respectively. Downloaded by Travis T Tollefson from www.liebertpub.com at 03/02/25. For personal use only. Materials and Methods Patients

Point 4 is marked where 2-11 = 4-12. In the presence of a high discrepancy in the horizontal lip width between cleft and noncleft sides, we maintain horizontal symmetry by marking point 4 as medially as possible, resulting in a short vertical lip, which can be corrected by an advanced flap on the cleft side, allowing the downward rotation of point 4. Mark point 5 on the middle of the columella base. Mark point 6 on the line bisecting a 2-1-3 angle, where 1-2 = 1-3, 2-6 = 3-6. Since anywhere on the bisec tor will result in 2-6 = 3-6, point 6 can be localized any where on the bisector. In Millard’s technique, point 6 is localized superiorly and medially to the imaginary bisec tor line. 9 Ending the back-cut incision on the angle bisec tor will ensure the horizontal rotation of point 3 to be at the same horizontal level as point 2. Point 7 is marked at the columella level on the cutaneous-mucosal border to form the base of the C flap. Point 8 is marked at the ala level on the cutaneous mucosal border. Point 9 is located in the ala’s base on the cleft side so that 3-5 = 4-9, such that points 9 and 8 will form the base of the advanced flap. Point 10 is located in the ala’s base on the noncleft side. Point 13 is located where 8-9-13-4 = 10-2. Points 3-5-6 and 3-7 are connec ted to form the incision line on the noncleft side, and points 4-9 and 4-8 are connected to form the incision line on the cleft side. In our technique, the skin, muscle, and mucosa are incised separately at different levels. The skin is incised along with points 3-5-6, 3-7, 4-9, and 4-8 (Fig. 1; center). Then the skin is dissected and separated from the under lying orbicularis oris muscle on both sides. After that, the orbicularis oris muscle is dissected from the oral mucosa and horizontally on both sides paying more attention to the dissection of the muscle from the nasal spine to allow greater relief of the deviation of the columella and more controlled rotation of the muscle downward. The muscles are dissected from their abnormal attach ment to the maxilla on the cleft side. The incision on the vermillion is conducted as per Millard’s technique using Noordhoof’s modification. A horizontal incision on the oral mucosa from the vermillion level to the bisec tor line is needed if mucosa restricts the rotation.