Clin Plastic Surg 31 (2004) 191 – 208

Unilateral clef t lip-nose repair – long-term outcome

Kenneth E. Salyer, MDa,*, Edward R. Genecov, DDSb,
David G. Genecov, MDa
a
International Craniofacial Institute, Cleft Lip and Palate Treatment Center, 7777 Forest Lane, Suite C-717, Dallas,
TX 75230, USA
b
Private Practice, 5410 Alpha Road, Dallas, TX 75240, USA

This article presents a 34-year experience with a
proven method for primary unilateral cleft lip-nose
repair. The most important surgical stage is the pri-
mary lip and nose repair. A complete approach with
a proven protocol during the time of growth that
allows and promotes normal function and aesthetics
is necessary to achieve excellence (Tables 1 and 2).
Primary repair in patients with a complete cleft lip,
nose, and palate without proper follow-up support
will most likely result in a poor outcome. A team
approach over time is necessary to achieve excel-
lence in cleft lip-nose and palate deformity. The
correction of the unilateral complete cleft lip and pal-
ate requires a thoughtful long-term protocol over the
period of growth.
The current authors’ protocol, which has evolved
gradually, consistently produces good to excellent
outcomes. The primary lip and nose technique used
by the authors has been improved by modifications
that have led to better symmetry and balance with less
scarring. The primary lip-nose technique involves
ignoring the abnormal skeletal base and the simulta-
neous use of perisurgical passive orthopedics with
primary surgical correction of the lip and nose. Minor
secondary correction of the lip and/or nose, if nec-
essary, is performed before school age, at approxi-
mately 5 years, in approximately 35% of the current
authors’ patients. Definitive rhinoplasty is performed
at or near completion of growth in most cases. Two-
flap palatoplasty is performed before the age of 1 year
and ideally around age 6 to 9 months. Palatal expan-
* Corresponding author.
E-mail address: kes@craniofacial.net (K.E. Salyer).
sion is performed orthodontically at age 5.5 years.
Cancellous iliac bone grafting is performed when 1/3
to 2/3 of the tooth’s root develops before eruption into
the cleft void. This technique provides the orthodon-
tist with enough bone for the erupting teeth in 95%
of cases to allow complete orthodontic restoration.
Limited septoplasty and turbinectomy are performed
as necessary from the age of 5 years to the comple-
tion of the case. An open airway promotes more
normal growth of the face. From age 5 to 15 years, a
Delaire face-mask traction (Great Lakes Orthodon-
tics, Tonawanda, New York) is used when there is up
to a 4-mm retrusion of the maxilla at the occlusal
level; with a retrusion of 6 mm or more, distraction
is currently the treatment of choice when sagittal
growth of the maxilla is delayed because of the cleft
dysmorphogenesis. Ongoing interactive treatment as
growth occurs is key to achieving optimal restoration
and facial balance with orthognathic surgery.
After aligning and leveling the teeth at completion
of growth, orthognathic surgery is performed in
approximately 30% of the current authors’ patients
to achieve optimal facial balance and aesthetics. A
key point to removing cleft stigmata is creating a full,
convex, projecting facial skeleton.
The senior authors (KES and ERG) have followed
this cleft protocol, with certain modifications, for
34 years in treating a large volume of patients; ideal
to good treatment was possible in most compliant
patients. The senior authors have dedicated a major
portion of their practice and time to achieving ex-
cellence in these difficult deformities. Patient self-
esteem is enhanced by early nasal reconstruction and
has become the authors’ standard of care in rehabili-
tation of patients with unilateral cleft lip-nose and

0094-1298/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/S0094-1298(03)00128-7
192 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208
Table 1
Surgical protocol
Patient age/stage
of development Treatment
3 months Primary cleft lip and nose
6 – 9 months Two-flap palatoplasty
5 years 35% Secondary Minor lip surgery
7 – 9 years 100% Cancellous iliac bone graft
to alveolar cleft
7 years-Full Growth Distraction osteogensis in
selected severe cases
Full growth 25 – 30% Orthognathic surgery
12 – 18 Years Rhinoplasty – other soft tissue
palate. Many surgeons remain reluctant to perform
primary nasal repair. With care, proper technique,
and experience, a good cleft surgeon can learn this
technique. For the beginner, conservatism is recom-
mended. An adoptive, flexible attitude toward treat-
ment is important in executing a treatment protocol
over time. In addition, it is important to find, per-
fect, and continue over the long term with a treat-
ment modality.
Unilateral cleft lip-nose repair
Major advances have been made in cleft care in
the last 30 years [1 – 3]. Deformity can consistently
be transformed early in life to minimal or residual
variations from normal so that predictable outcomes
for patients with unilateral cleft lip – nasal deformity
can be achieved. Normal appearance and function
is a realistic treatment goal [4]. A dedicated team
approach that uses a proven surgical-orthodontic-
speech rehabilitation – oriented protocol is necessary
to achieve excellence. More important, it takes over
30 years of careful observation, experience, openness,
and flexibility to evaluate a meaningful protocol.
The most important surgical stage is the primary
repair. At the time of the first operation, the nose and
lip should be primarily reconstructed. Primary lip and
nasal reconstruction at the time of the first operation
has now become the expected standard of care in
the United States and certain other countries. Consist-
ently good results of primary nasal repair currently
have been reported by many different surgeons (H.
Anderl, personal communication, 1986) [5 – 10]. Yet,
many severe secondary deformities continue to be
seen. Surgeons remain reluctant to perform primary
nasal reconstruction at the time of primary cheilo-
plasty. It seems as though not all surgeons or teams
are able to achieve consistently outstanding results.
Why is that? All primary or secondary procedures in
clefts are complex and should be performed only by
very experienced or well-trained surgeons who incor-
porate the team approach into their protocol. Im-
proved results have been demonstrated by surgeons
in situations where experience and a critical number
of procedures are necessary to achieve excellent
results [11]. More important, a self-critical analysis
of the surgeon’s own cases is important.
The technique used for repair of the cleft lip –
nasal deformity has been extensively reported in the
literature by the current authors. This procedure, with
certain variations, has been used by many surgeons.
Modifications and improvements in the authors’
original technique have led to more consistent results,
with better symmetry, balance, and less scarring.
These modifications are reported in this article.
Nasal deformity
The nasal deformity associated with unilateral cleft
lip alveolus, with or without cleft of the palate, in-
volves skeletal and soft tissue structures. The cleft-
nasal deformity results in anatomic abnormalities of
the following regions: the alar base; the alar cartilage,
including the medial and lateral crus; the nasal dome;
the columella; and the nasal septum; and is influenced
by the skeletal base, which includes the alveolus,
maxillary segments, and palate. The position and
degree of displacement and abnormality and hypo-
plasia of the maxillary segments greatly contribute to
the primary nasal deformity. Continued hypoplasia
and displacement of the maxillary segments, particu-
larly the lesser segment, result in varying degrees
of maxillary deficiency. The degree of deformity
depends on the cleft dysmorphogenesis, which in-
fluences subsequent growth. Total correction is a
three-dimensional growth-related rehabilitation. The
authors are currently reviewing dental models taken at
Table 2
Orthodontic protocol
Patient age/stage
of development Treatment
2 wk Passive infant appliance
5.5 – 8.5 y Palate expansion
7–9 y Preparation for bone graft
5 – 10 y Face mask
Mixed dentition Routine orthodontics
14 – 16 y (25% – 30%) Final treatment,
perisurgical orthodontics
 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208
birth in completed cases to see if this hypothesis
is true.
Achieving symmetry of the skeletal base is one
of the major long-term goals for total correction of
the clefting deformity. The current authors believe
that the attempt to achieve skeletal symmetry during
infancy using active orthopedics is misguided treat-
ment. Early periosteoplasty abnormally locks the seg-
ments, producing additional scarring. It does not
consistently produce enough bone to support the teeth
in the cleft defect to allow for excellent orthodontics.
In the primary cleft-nasal deformity, at the initial re-
pair, one of the ‘‘keys to excellence’’ is to ignore the
abnormal skeletal base and reconstruct the soft tissue
structures, using skin and muscular reconstruction.
The primary deformity of the nose results in displace-
ment of the lower lateral cartilage laterally and infe-
riorly on the cleft side. The nasal dome is flattened and
turned or slumped in a downward position. The alar
cartilage on the cleft side is flat and gives it an
apparent or false lengthening when compared with
the noncleft side, which is abnormally displaced to the
other side. The lower lateral cartilages are normal in
their relationship to the septum, but the septum is
tilted, and with the distortion accompanying the al-
veolar cleft, tilts the base of the nose away from the
cleft side and the tip of the nose toward the cleft. The
key to correction of the cleft-nasal deformity is trans-
location of the alar cartilage with its attached vestibu-
lar lining into a normal position, which establishes the
normal vault and shape of the cartilage [5,6,8]. In so
doing, the major deformity of the nose is corrected.
When this is combined with complete freeing of the
soft tissue envelope of the nose and correction of the
alar bases and floor of the nose, the surgeon can con-
sistently achieve good results at the time of the pri-
mary correction.
Lip adhesion
Lip adhesion is an unnecessary procedure. It may
contribute to additional scarring or abnormal tether-
ing of the lip or nasal elements. Many experienced
cleft surgeons continue to use lip adhesion because it
is believed to be of benefit [12]. Nonsurgical lip
adhesion with tape also has been reported to be of
benefit [13]. The current authors’ evaluation of their
early cases led to the abandonment of lip adhesion;,
they demonstrated better aesthetic results in a series
of double-blind evaluations with and without ad-
hesion in 50 patients. Using a lip adhesion treats
the abnormal skeletal base, making it easier for the
surgeon to close the lip at the expense of the overall
193
aesthetic result to the lip and nose. Lip adhesion ac-
tually may cause fixation or scarring of the alar base
or associated adjacent structures in an abnormal po-
sition, making a definitive normal contour of the nose
more difficult.
Surgical orthopedics and abnormal skeletal base
The current authors’ team approach has used
passive perisurgical orthopedics for all complete clefts
involving the alveolus or maxillary segments for
27 years. The orthopedic appliance is made from an
impression taken of the patient in the first few days of
life. An acrylic appliance prevents collapse of the
maxillary segments and aids in feeding. The primary
purpose of the preoperative appliance is to control the
segments once the lip is surgically closed. It guides
the maxillary segments and locks these into posi-
tion after cheiloplasty and before palatoplasty. The
senior orthodontist’s (ERG) clinical impression is that
this improves horizontal and vertical skeletal defi-
ciency by stimulating bone production before and
following lip closure; however, this hypothesis re-
mains to be proven [14]. If the midline is off by more
than 2 mm, it can only be corrected in the patient at a
later date by moving the entire maxilla using a Le Fort
I maxillary osteotomy. This procedure is more easily
accomplished and performed in infants using the
perisurgical orthopedic appliance to treat midline
and maxillary deficiencies. In addition, the current
authors believe that this contributes to better symme-
try of the alar bases on the deficient cleft side
and improves septal deviation by guiding the maxil-
lary segments into a more normal anatomic relation-
ship. No attempt in the authors’ technique is made to
shift the deviated septum at the time of surgery or
to manipulate the skeletal base actively by orthope-
dics. The passive appliance gives better control of
the maxillary segments before the time of the palato-
plasty and is worn from the time of infancy until the
two-flap palatoplasty is performed, at approximately
age 6 to 9 months. This method also may decrease the
amount of maxillary collapse after closure of the pal-
ate by locking in the maxillary segment before the
palate surgery.
Active presurgical orthopedics has been popular-
ized by Millard and Latham [15] and Millard et al
[16]. This philosophy is the opposite of the current
authors’ belief in that active orthopedics with active
force is used to alter the skeletal base before primary
cleft lip – nasal repair. Some advocates of this ap-
proach have added a primary gingivoperiosteoplasty
to close the cleft alveolus. It has recently been re-
194 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208

ported that 60% of these patients do not need bone delineate the ultimate role of distraction. The use of
grafting later [17]. Inadequate bone in 40% of pa- the team approach, particularly combined with surgi-
tients who then require bone grafting is not good cal-orthodontic care, gives optimal results. If primary
enough when a one-time bone-graft procedure gives surgery is performed without the use of orthodontic
a 96% success rate in the authors’ experience. The intervention during growth, the results will uniformly
current authors believe that this approach is not only be poor. Mission surgery without developing a team
unnecessary but also detrimental to growth and is therefore not a good concept for delivery of
detrimental to an excellent outcome [18]. Periosteo- excellence. Excellence in results cannot be expected
plasty has been abandoned in some centers because it during and after growth is complete by surgery alone.
frequently does not produce enough good bone [19]. The multidisciplinary management of the cleft defor-
This early surgery abnormally locks in the maxillary mity is vital in all patients who have complete cleft of
segments and alveolus with scarring, which is detri- the lip and palate [1].
mental to later growth and development of the mid-
face. Performing early distraction and completing
orthodontic treatment in infants is, in the current
Presurgical nasoalveolar orthopedic molding
authors’ opinion, detrimental to growth and develop-
ment [20]. This method of surgery must be proven
The use of nasoalveolar molding has been re-
before others adopt this technique. It will make treat-
ported and is being taught and advocated in unilateral
ment ultimately more complex. Anterior crossbite and
and bilateral deformity [24]. Nasoalveolar molding
anterior open bite are frequent and yet there is not
probably creates more columella tissue by expansion,
enough bone to support the teeth. Why perform early
which is needed in the bilateral cleft deformity. It is
inadequate or detrimental surgery?
unnecessary in the unilateral cleft lip and palate
The authors’ approach of ignoring the abnormal
deformity, however. The nasal and lip elements are
skeletal base at the time of primary surgery has re-
completely present in the ordinary, most frequent type
sulted in 70% of their patients demonstrating near nor-
of cleft deformity, which is presented here. In the rare
mal growth; this approach requires no orthognathic
Tessier facial cleft, there may be missing elements
surgery and uses passive orthopedics and palatal ex-
where tissue expansion or distraction could be of
pansion at the age of 5.5 years coupled with cancel-
benefit. This method is labor intensive, requiring
lous bone grafting at the time of tooth development
weekly adjustments by a dedicated, experienced
along the cleft deficiency. Bone grafting at age 7 to
orthodontist or surgeon. This process is required for
9 years at the time of cuspid or lateral incisor root
months before surgery is performed and is frequently
formation has proved to give consistently excellent,
done in combination with active orthopedics, which
stable long-term results [21,22]. Bone grafting by
the current authors believe is detrimental to growth.
using immobilization at the time of grafting results
The performance of nasoalveolar molding requires
in a 96% success rate in the authors’ experience.
compliant parents and multiple, frequent visits. It is
Abnormal growth exhibited by patients with a
time consuming and expensive, and it is unnecessary
cleft is not necessarily solely related to scarring from
in the unilateral deformity that is presented here. The
the surgery but may be caused by the degree of tissue
use of this modality is not practical or feasible in most
absence and the cleft dysmorphogenesis. The more
places around the world. The New York group [24]
severe the insult of tissue deficiency, the more po-
has provided a new modality that has given them
tentially abnormal the facial growth. The authors are
improved results in their bilateral cases, but the
currently testing that hypothesis in their own cases.
extension to unilateral deformities is unnecessary.
To compensate for this abnormal growth, in certain
cases, facial protraction or distraction is used in pa-
tients aged 5 to 10 years. When there is maxillary
retrusion of 4 mm or less, the Delaire facial protrac- Distraction osteogenesis
tion mask is used. At the authors’ center, they have
demonstrated the production of new bone with ad- In the last 10 years, in certain select patients and
vancement of the anterior and posterior nasal spine in secondary cases where there is 1 cm or more of
using protraction in patients with a cleft [23]. Re- occlusal discrepancy in the sagittal growth of the
cently, with facial distraction, secondary cases with maxilla, the authors now perform distraction of the
maxillary retrusion of 1 cm or more are treated with maxilla during growth. This treatment modality offers
distraction during the time of growth. Further evalua- balancing of the skeleton during growth, allowing
tion and study of these patients is necessary to improvement in appearance, speech, and occlusion,
 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208
which improves self-esteem. This result is important
in the authors’ treatment philosophy and protocol.
Although most of these patients will require fur-
ther definitive skeletal surgery, this procedure pro-
vides ongoing normalization of jaw relationships
during growth and development, which offers a major
advance in cleft care.
New bone can be generated without the disad-
vantages of bone grafting or the necessity of internal
rigid fixation. Distraction provides new bone and
space for tooth eruption, which is also a major
advance in cleft care. It is important that all oste-
otomies stay out of any teeth or tooth buds.
Common surgical errors and pitfalls
In-depth understanding of the cleft lip-nose defor-
mity is important in achieving primary surgical cor-
rection of the deformity. Secondary deformities of the
lip and nose following repair may be the result of
poor planning, operative error, or postoperative scar
contracture. Most of the secondary deformities the
authors see, however, are from inadequate under-
standing of the described technique or of the basic
biology of cleft deformity and surgery. This results
from a lack of technical appreciation on how to
adequately surgically release, reshape, and reconstruct
the lip and nose without producing a detrimental scar.
The inadequate release of the abnormal and displaced
lip and nasal segments makes it impossible to achieve
symmetry or correction of the deformity.
One of the most frequently observed mistakes in
secondary cases is inadequate release of the abnor-
mally attached lower lateral cartilage to the pyriform
rim in unilateral and bilateral cases. Without adequate
release above the inferior turbinate, the displaced alar
cartilage cannot be properly advanced to achieve tip
projection or nasal symmetry. In these secondary
cases, it is apparent that the abnormally tethered alar
base has never been adequately released. The other
related mistake is inadequate release and mobilization
of the nasal lining, which is achieved in this tech-
nique by extending the incision above the inferior
turbinate cephalically or superiorly as far as necessary
in each case to allow mobilization of the displaced
alar cartilage and lining. Many surgeons have erro-
neously believed that it necessitates the addition of
tissue as a mucosa or turbinate flap. This method can
actually tether the alar cartilage instead of allowing
mobilization of all the nasal elements. Exposing or
cutting cartilage lining flaps is unnecessary. The most
important concept is performing enough dissection so
adequate mobilization can be obtained. Tension is
195
another important point. If the lip is closed under
tension, more scarring will result. Scarring of the lip
is the most significant factor in causing facial growth
abnormalities [25].
Careful technique is likewise important to mini-
mize scarring to allow more normal growth. The
current authors believe that raising mucoperiosteal
flaps in palate repair does not in itself cause major
significant growth abnormalities. Any severe scarring
caused by surgery in the space of Ernst can cause
restriction of growth. In palate repair, dissection in the
palate or space of Ernst can cause scarring in the
pterygomaxillary region, producing growth restric-
tion. This result can be avoided. Careful technique
in all cleft surgery is important in achieving excel-
lence. Misguided surgery or technique can result in
unfavorable results. Long-term critical observation of
any new technique is necessary in the treatment of
cleft deformity.
The current authors’ surgical technique
There are varying degrees of displacement and
hypoplasia of the lip, nose, and skeletal base, which
significantly influence the outcome. The alar cartilage
and its adequate release and reshaping is key in the
reconstruction of the unilateral cleft-nasal deformity.
The following procedure demonstrates the most re-
cent modifications the authors use to achieve consist-
ent symmetry and balance of the nose and lip at the
time of the primary repair.
Lip
The authors now use a vertical, transverse, straight-
line incision for the initial incision in the skin and
muscle of the lip. There is little resemblance to the
initial Millard [2] procedure. The remaining procedure
has been modified. The modified method the authors
use is fluid and allows improvisation and artistry by
the surgeon, with good access to the nose for primary
reconstruction. The final skin design is decided after
the muscle and alar symmetry is obtained. Many
surgeons have contributed to the improvement in the
approach to the lip [1,26].
There are many ways to accomplish a good clo-
sure of the lip; surgeons have demonstrated excel-
lence with various methods. There are advantages and
disadvantages to each of these methods with certain
specific indications for their use by the surgeons who
advocate their use.
196 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208

Muscle

Many surgeons have emphasized the importance

of muscle reconstruction at the time of primary lip
repair [27]. The current authors have intuitively per-
formed this step from the beginning of their surgery
experience [5]. The dissection in the preperiosteal
plane, medially and laterally, allows release of the
attachment of the muscles to the abnormal skeletal
base. The key to achieving symmetry of the alar bases
and a normal pout to the upper lip at the primary
operation with a patient who has an abnormal skeletal
base is properly releasing the abnormal attachments of
the muscles and placing them in more normal align-
ment. This procedure also allows creation of a more
normal philtrum and dimple of the lip. It is important
to emphasize that wide dissection of more than 4 mm Fig. 2. The incision on the medial lip segment is performed
with a number 67 beaver blade. The incision on the lateral
or 5 mm between the skin and muscle is not necessary
lip segment is carried through and through with a number
in most cases, and that scarring here can result in 65 beaver blade on the vermilion-cutaneous junction, dis-
untold results. Yet, some surgeons continue to advo- secting a vermilion flap. The incision is carried intranasally
cate wide dissection, which, in the author’s opinion, and cephalically above the inferior turbinate.
is wrong.

Surgical correction of the lip and nose
The peak of the Cupid’s bow on the cleft side is
marked on the vermilion-cutaneous (white skin roll)
junction at an equal distance from the midline of the
lip as the peak of the new Cupid’s bow on the non-
cleft side (Fig. 1). This process facilitates the design
of a symmetric prolabium but is not always easy to
attain. If a small skin hook is placed on the skin of the
unrepaired lip to pull it into position as the markings
are made, better symmetry of the lip can be obtained.
The wet line on the vermilion on each side of the cleft
is marked so it can be matched at the time of closure

Fig. 1. Design of lip repair with the authors’ modification of

the rotation-advancement procedure. The peak of the Cu-
pid’s bow on the noncleft side is marked at an equal distance
from the midline of the columella-lip junction. The incision
lines on the cleft side continue from the vermilion-skin
border into the nasal cavity and on to the lateral nasal wall,
above the inferior turbinate. This incision will free the dis-
placed and abnormally attached soft tissue from the under-
lying bone.
Fig. 3. The obicularis oris muscle is pulled with pick-ups,
and the skin of the lateral lip segment is undermined from
the underlying muscle at a distance of 2 to 4 mm. The me-
dial lip segment is rotated downward and pulled with a
hook until its height matches that of the lip segment on the
cleft side.
 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208
Fig. 4. The medial lip segment is pulled down to match the
length of the lip segment on the cleft side. The skin on
the medial lip segment is undermined from the obicularis
oris muscle.
of the vermilion. Color match of the vermilion gives
improved aesthetic results for the repair [28]. Cutting
the lip to provide muscle in the new vermilion creates
a full vermilion with obicularis marginalis. With a
single hook retraction of the nose on the cleft side, the
Fig. 5. The intranasal incision from the base of the ala is
extended above the inferior turbinate. The extent of the inci-
sion is determined by the degree of nasal deformity. Through
this incision, the soft tissue is dissected from the underlying
abnormal skeletal base. The incision allows symmetric re-
positioning of the nasal components.
197
Fig. 6. The nasal mucosa is dissected from the lower lateral
cartilage, except for the area at the dome.
dotted line marks the incision intranasally above the
inferior turbinate where the displaced and abnormally
attached soft tissues are freed from the underlying
abnormal skeletal base. The incision extends cephali-
cally in each case and as far as necessary to totally
release and connect the abnormal attachment of the
lower lateral cartilage. The transverse cut in the skin
of the lateral rotation advancement has been elimi-
nated in the authors’ most recent modification. This
modification has eliminated scarring around the
alar base and still allows release of the abnormally
tethered alar cartilage. The rotation incision on the
medial lip element extends along the base of the colu-
mella, with no back cut or extension into the colu-
mella, as used earlier when one of the current authors
was evolving this technique (Fig. 2) [29].
Fig. 7. The scissors are inserted through the incision at the
base of the ala on the cleft side to dissect the skin from the
lateral crus of the lower lateral cartilage. The nasal mucosa is
dissected from the lateral cartilage, except for the area at the
dome. Complete mobilization of the lower lateral cartilages
must be achieved before the alar cartilages can be repo-
sitioned with stent sutures.
198 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208
Fig. 8. Dissection of the skin over the lateral cartilage on the
noncleft side.
The incision in the medial lip element is made with
a number 67 beaver blade. The lateral lip element is
incised and cut at the vermilion-cutaneous junction
with a number 65 beaver blade, holding the lateral lip
element in a position to place muscle into the vermil-
ion. This process creates the orbicularis marginalis.
The obicularis muscle is grasped with the forceps, and
the lateral dermal skin element is undermined 2 to
4 mm from the underlying muscle, with careful hemo-
Fig. 9. Straight Keith needles with Dacron pledgets are in-
serted intranasally through the nasal mucosa, lower lateral
cartilage, and skin in the dome area. When tied, this suture
will shift the alar dome to project the nasal tip.
Fig. 10. The nasal mucosa and obicularis oris muscles are
sutured. A stent suture with two pledgets—one placed inside
the nasal cavity in the dome area and one in the skin—is
pulled upward and medially to correct the position of the
lower lateral cartilage.
stasis (Fig. 3). The medial lip element is rotated down
with a hook until the height matches the height of the
lip on the noncleft side. If the cut does not allow
symmetric rotation of the lip, then additional incisions
are made in the skin, muscle, or underlying mucosa to
achieve adequate lengthening of the lip (Fig. 4). The
medial lip element is pulled down into a functional
position as the skin muscle plane is undermined
medially to free up the skin until fully mobilized to
facilitate muscle reconstruction. It is extended as far as
Fig. 11. Stent sutures are in place, positioning the lower
lateral cartilage on the cleft side symmetric to the one on the
opposite side. The floor of the nose, lip, and vermilion are
repaired. In most cases, this procedure results in a well-
balanced lip and nose.
 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208 199

Fig. 12. (A) Preoperative frontal view of a right complete unilateral cleft lip and palate with displaced alar cartilage and
projecting greater segment in the cleft. (B) Postoperative frontal view at age 16. (C) Postoperative left lateral view at age 16.
200 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208

Fig. 13. (A) Preoperative frontal view of a right complete unilateral cleft lip with Simonart’s band. (B) Postoperative frontal view
at age 17. (C) Postoperative submental vertex view at age 17. (D) Postoperative right lateral view at age 17.
 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208 201

Fig. 14. (A) Preoperative frontal view of a left incomplete unilateral cleft lip deformity. (B) Postoperative frontal view at age 16.
(C) Preoperative submental vertex view of a left incomplete unilateral cleft lip with displaced alar cartilage. (D) Postoperative
submental vertex view at age 16.
202 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208

Fig. 15. (A) Preoperative frontal view of a left complete unilateral cleft lip and palate. (B) Postoperative frontal view at age 9.
(C) Postoperative submental vertex view at age 9. (D) Postoperative left oblique view at age 9. (E) Postoperative left lateral
view at age 9.
 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208
Fig. 15 (continued ).
necessary to achieve symmetry when mobilized and
closed. This is a key point (Fig. 5). The incision from
the base of the alar intranasally is made just above the
inferior turbinate. The extension of this incision is
determined by the degree of deformity of the nose
(Fig. 6). Through this incision, separation of the skin
envelope and underlying alar cartilage is performed,
allowing repositioning of the abnormal nasal compo-
nents into a normal symmetric relationship (Fig. 7).
Access through the medial incision facilitates dissec-
tion of the lower lateral cartilage from the overlying
skin and the underlying lining, leaving the cartilage
attached at the dome near the genu. The abnormal
attachment of the foot plate of the medial crus is
released using small tenotomy scissors (Fig. 8). The
abnormally attached muscles of the lip and nose are
likewise freed through this incision. Access to the
nasal dome is gained through the medial incision.
The single most important element in achieving
excellence is freeing all the elements of the lip and
nose so that, when the key sutures are placed in the
muscle, symmetry of the lip and nose is achieved. If
not, additional dissection should be performed. The
dissection over the alar dome is carried on to the
normal side to free the skin to allow repositioning of
the displaced alar cartilage on the cleft and the non-
cleft side. Straight Keith needles (Richard Allen
203
Scientific, Chicago, Illinois) with prolene suture over
Dacron pledges are used to translocate the alar
cartilage and shape it. They are placed according to
the desired positioning of the cartilage, skin, and
vestibular lining. Placement of these needles more
than once may be necessary to achieve the optimal
position and shape. This allows shifting of the alar
dome at the genu, giving projection of the nasal tip
(Fig. 9). The key suture of the operation is next
placed in the obicularis oris muscle of the lip, es-
tablishing the entire symmetry of the lip and nose. It
may be necessary to replace the alar dome stent
because of the shift in the tissues. These sutures
should be placed until the optimal results in reshaping
and repositioning of the displaced elements can be
achieved. Placement of the stent suture is performed
without tying it down. By pulling up on this suture as
the key muscle stitch is placed, symmetry can be
achieved in most cases (Fig. 10).
With the key muscle stitch, the alar base is
brought into proper position by the muscle recon-
struction of the soft tissue platform, which ignores the
abnormal skeletal base. This process may be facili-
tated by using buried alar base sutures from the cleft
side to the normal side to gain symmetry and balance.
The abnormal skeletal base is reconstructed later, at
the age of 7 or 8 years. Once the key muscle suture is
placed and the positioning is good, additional muscle
sutures are used to create a complete closure. An ad-
ditional lateral alar stent suture is placed to adapt the
nasal lining with the cartilage and the overlying skin
above the alar base. This alternately can be used
as a deep buried suture without the use of a stent.
The current authors prefer a stent because it gives a
slightly better contouring to all the tissues and helps
mold and shape the alar cartilage. The alar stent is
tightened to achieve symmetry of the alar dome.
No tissue is excised in the floor of the nose; the
excess skin or lining is sutured and allowed to fall
into the nasal floor deficiency. Closure of the floor
of the nose is achieved with chromic suture or Mono-
cryl (Ethicon, Inc., Somerset, New Jersey).
The transverse incision is now brought into the
floor of the nose to create the sill (M.S. Noordhoff,
personal communication, 1992) [10]. The incision is
minimized according to the positioning of the soft tis-
sue elements of the lip and alar base. The vermilion is
matched at the cutaneous-vermilion junction. Rarely,
a small triangular flap is performed just above the
vermilion and white roll to achieve the proper posi-
tioning of the vermilion. The current authors prefer to
delete this procedure, if possible. The secondary wet
line is lined up to allow for the best vermilion color
notch (Fig. 11). The decision of how the skin and
204 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208

Fig. 16. (A) Preoperative view of a left complete unilateral cleft lip and palate. (B) Postoperative frontal view after completion of
surgical and orthodontic treatment. (C) Postoperative frontal smiling view showing attractive full smile with normal dentition.
 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208
lining are used in closure depends on each particular
case. It is individualized as the nose is positioned into
the proper projection. The skin of the columella
C flap is closed according to how it wants to fall,
without tension in the nostril or nose when the alar
is pulled up with the stent sutures. The remainder of
the rotation closure is achieved with 6-0 nylon in the
skin and 6-0 PDS (Ethicon, Inc., Somerset, New
Jersey) buried as subdermal interrupted suture, with
closure of the mucosa of the lip with 4-0 chromic
suture. This procedure gives consistently good results
of the lip and nose when performed by an experi-
enced surgeon making modifications and alterations
in each step of the operation as needed.
Finally, it is better to delay primary nasal surgery
if the primary technique consistently creates scarring
vestibular stenosis, small nostril, or other deformities.
Results
Pre- and postoperative results
Figs. 12 through 16 show preoperative images
and the postoperative results of the current au-
thors’ technique.
Discussion
At the time of the inception of this technique,
early surgical intervention was considered detrimen-
tal to the growth of the young infant’s nose. The re-
sults and techniques at that time gave poor results. It
was generally accepted that complete growth should
occur before attempting definitive surgical correction.
After 33 years of performing this procedure in more
than 750 patients, the current authors believe that
most lip-nose deformity can be surgically corrected
at the primary operation. The alar repositioning, sill
reconstruction, and tip projection can be achieved
at the time of the primary procedure. This does not
mean that with growth there may not be changes
that may require secondary correction. These changes
are usually related to the septum and skeletal base.
Using their treatment protocol, the results the au-
thors achieve at the primary operation of the soft
tissue remain consistent with subsequent growth.
Failure to achieve perfect or excellent results is ap-
parent to the surgeon at the time of completion of the
primary repair.
The authors’ procedure eliminates the early stig-
mata of primary cleft lip-nose in young children. It also
eliminates alar buckling, which was a consistent find-
205
ing of cleft nasal deformities before primary repair. At
the first procedure, when executed well by the expe-
rienced surgeon, the potential exists to create, in every
patient, a near-normal external nose. When combined
with subsequent procedures using the authors’ surgi-
cal, speech, and orthodontic treatment protocol, the
results can be a normal, attractive child with no
deformity at conversational distance. This procedure
achieves repositioning of the abnormally displaced
segments of the lip and nose and, at the same time,
allows for creation of a normal or near-normal nasal tip
projection and alar base symmetry. When the desired
nose or lip result is not achieved, it is easy to perform
minor secondary procedures, either before school age
or at the time of the final surgical correction. Subse-
quent treatment is needed in all of these patients. A
proven treatment protocol is very important in achiev-
ing excellence.
With experience, this procedure has been changed
to give consistently improved and more predictable
results. When the authors published their experience
at 15 years, this method consistently eliminated the
buckling and flattening of the lower lateral cartilage
on the cleft side noted in patients who only had a
repair of the lip with inadequate nasal repair [5].
There are, in the authors’ series to date, no residual
severe cleft nasal deformities. The perfect nose with
no deformity is unusual, however. Patients that have
excessive nose and lip scarring frequently have poor
results. Patients with compliant parents will have
acceptable nasal contour throughout the period of
growth following the primary repair and may require
only minimal surgery later. Today, the authors are
able to report that most patients have minimal de-
formity and can be corrected with a minor secondary
procedure when indicated. They are critical of their
results and perform minor secondary corrections
before the children start school. Approximately 35%
of patients overall require early minor secondary pro-
cedures. Definitive repair after growth is complete is
an aesthetic surgical correction directed at achieving
optimal facial balance and harmony, not major defor-
mity correction. The authors’ goal for these children
is to achieve optimal facial balance and harmony, nor-
mal speech, a beautiful smile, and full dentition with
normal occlusion, resulting in an attractive face with
no stigmata of clefting at a conversational distance.
This is a realistic goal when the author’s protocol is
properly executed.
It is not necessary to address the primary skeletal
deformity other than trying to align this at the time
of closure using passive perisurgical orthopedics.
Active preoperative surgical orthopedics is currently
popular. The authors believe it is not necessary to use
206 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208
this technique. Many surgeons have used this method
because, by actively moving the maxillary segments,
it facilitates immediate, easy surgical closure on a
closed skeletal base. The current authors believe,
however, that it places the skeletal elements into an
abnormal position, with damage to the growth of
the face, which locks the segments into abnormal
position and ultimately results in more severe defor-
mity when growth is completed. Late results have
proven this assumption [30]. The use of primary
periosteal flaps to close the alveolar cleft early on
is not satisfactory; 40% of patients require additional
bone grafting.
With the nasal procedure described here, most of
the authors’ patients have good to excellent results
after the primary procedure. No external incisions or
exposure of the cartilage is necessary, nor should it be
performed at this age [31,32]. Minor positioning or
sculpting of the alar cartilages, at the time of the
teenage years, to achieve improved aesthetic balance
is all that is necessary. Most of these patients subse-
quently have an abnormal rhinorrhea and some nasal
obstruction. The authors have obtained good results
by doing early inferior turbinectomy or limited sub-
mucosal resection in young children, at the age of
5 to 10 years, and definitive submucosal resection or
inferior turbinate resection after growth is complete.
Early elimination of nasal obstruction has improved
the authors’ results.
The use of this early primary procedure is a visual
method that depends on the surgeon’s ability to place
and position displaced and distorted parts into a
normal relationship by the use of sutures and tempo-
rary stents. The key to achieving consistently good
results is total release and mobilization of all the
elements, including the skin envelope, the nasal car-
tilage, the underlying musculature, and the vestibular
lining and the oral mucosa. Once total mobility has
been obtained, it is simply a matter of suturing all
the parts into a normal-shaped contour of the lip
and nose; matching the normal side becomes easier.
This procedure can be consistently performed in
these patients and maintained using stent sutures
through the nose or, alternately, using sutures without
stents. Early primary correction of deformity contri-
butes to more normal growth and development of
the nose and, more important, it corrects deformity
early, which promotes better psychosocial develop-
ment and a good self-image before the adverse
psychosocial effects of deformity can cause damage.
Modifications in this technique have been made in
the last 10 years. An emphasis on the intranasal
incision is important, which should be placed at the
level of the inferior turbinate extending into the nose
far enough to achieve complete mobility of all the
nasal and lip elements without distortion when re-
positioned. Through this approach, total mobilization
of the abnormally distorted alar base is performed. It
is necessary to undermine, over the maxilla, the ab-
normally attached labial and nasal musculature. This
procedure is performed above the periosteum. The
authors do not believe that this interferes with sub-
sequent growth, which has been demonstrated in their
own patients [33]. Bardach and Salyer [1] previously
emphasized no dissection over the maxilla. The
current authors do not feel that it is necessary to
close the area of the incision along the inferior
turbinate by the use of a turbinate mucosa flap, or
an L or M flap [2]. They believe that this procedure
may, at times, cause distortion of the tissues, inter-
fering with excellence of the nasal result. Again, clo-
sure of the incision is less important than the basic
elements of reconstruction. Total mobilization of all
the displaced structures and placing them in a normal
position is the key to excellence. Whether the surgeon
uses a triangular flap or rotational advancement flaps
for the skin incision itself is of secondary importance.
The upper transverse limb of the lateral advancement
flap design is now eliminated in most cases and de-
layed until the closure, eliminating the scar around
the alar and minimizing the scar in the nostril floor.
This procedure also gives better definition of the alar
groove (M.S. Noordhoff, personal communication,
1992) [10].
The concept of wearing nasal stents postopera-
tively is useful. The current authors insert these at the
time of primary suture removal at 1 week. This more
recent technique splints the nostril with silicon con-
formers to limit the effects of wound contracture and
scarring. The authors believe silicone stents worn in
both nostrils for 3 months improves scaring and
vestibular stenosis in primary cases. They have used
Koken (Silimed, Porex Surgical, Newnan, Georgia)
stents in primary and secondary cases. From the
current authors improved outcomes using Koken
stents, they believe that individualized silicone nostril
stents worn long-term can be recommended as an
adjunctive measure. A method of individualized
design could improve this approach. Preoperative
expansion of the nostril using tissue expansion is
unnecessary in patients with UCLN because it is time
consuming and labor intensive.
The authors have evaluated speech results, facial
balance, and dental occlusion in 50 random completed
cases [34]. Their findings revealed that velopharyng-
eal closure could be achieved in 90% of patients with
treatment before 1 year with two-flap palatoplasty.
Good to excellent facial aesthetic balance of the face,
 K.E. Salyer et al / Clin Plastic Surg 31 (2004) 191–208
lip, and nose could be achieved in all compliant pa-
tients receiving complete treatment. Dental occlusion
was achieved with orthodontic treatment and orthog-
nathic surgery when required. Further reports will
outline and document this preliminary report.
Summary
Good to excellent results have consistently been
achieved by the authors in primary unilateral cleft
lip – nose repair. Modifications and improvements in
their original technique have led to better symmetry
and balance, with less scarring. This technique, when
performed by experienced surgeons, yields consist-
ent, predictable, and achievable outcomes for all pa-
tients with unilateral cleft lip and nose, where normal
appearance and function at conversational distance is
the standard of care. The achievement of excellence
in soft tissue and skeletal restoration optimizing each
patient’s growth potential depends on a surgical-
orthodontic-speech – oriented treatment plan. Long-
term outcomes demonstrating consistently good to
excellent results can be achieved using this primary
technique if it is backed up with a dedicated, multi-
disciplinary ongoing treatment protocol.
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