MOC-CME

Evidence-Based Medicine: The Bilateral Cleft

Lip Repair
Jacques X. Zhang, M.D.
Jugpal S. Arneja, M.D.,
M.B.A.
Vancouver, British Columbia, Canada
Learning Objectives: After reading this article, the participant should be able
to: 1. Understand the epidemiology, abnormal embryology, anatomy, and etio-
pathogenesis of cleft lip. 2. Be able to classify and describe bilateral cleft lip.
3. Recognize the importance of preoperative management of bilateral cleft lip.
4. Recognize the large breadth of differing management options. 5. Describe
key steps and tenets of the surgical repair.
Summary: This fourth Maintenance of Certification/Continuing Medical Edu-
cation article on cleft lip focuses on the topic of bilateral cleft lip. Previous
articles placed an emphasis on the unilateral cleft lip, velopharyngeal insuffi-
ciency, or cleft lip and palate management. The authors focus on summarizing
key points from previous articles and describing the importance of preopera-
tive management and surgical repair of the bilateral cleft lip.  (Plast. Reconstr.
Surg. 140: 152e, 2017.)

T
he purpose of this Maintenance of Certifica-
tion/Continuing Medical Education article
is to help physicians and surgeons under-
stand the various surgical treatment strategies
available for the bilateral cleft lip repair. By no
means comprehensive, this module should serve
as a basis, along with the other Maintenance of
Certification/Continuing Medical Education arti-
cles on the topic, to provide self-assessment in the
Maintenance of Certification/Continuing Medi-
cal Education process of the American Board of
Plastic Surgery, and a way of contrasting differ-
ent practice types against this review. This is the
fourth Maintenance of Certification/Continuing
Medical Education article on cleft lip. The first
article, by Fisher et al. in 2011, focused on clini-
cal features of unilateral cleft lip, briefly touched
on bilateral cleft lip, and provided a description
of the techniques for repair of cleft lip and pal-
ate and management of velopharyngeal insuffi-
ciency.1 The second article, by Monson et al. in
2013, discussed classification, a description of the
Millard procedure, and the authors’ preferred
From the Division of Plastic Surgery, University of British
Columbia; and the Division of Plastic Surgery, British Co-
lumbia Children’s Hospital, University of British Columbia.
Received for publication February 23, 2016; accepted June
17, 2016.
Presented in part at the 63rd Annual Meeting of the
­Canadian Society of Plastic Surgeons, in Kelowna, British
Columbia, Canada, June 16 through 20, 2009.
Copyright © 2017 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000003474
bilateral lip repair.2 The third article, by Greives
et al. in 2014, discussed in more detail the pre-
operative assessments, preoperative interventions,
and postoperative procedures, in addition to the
unilateral lip and nose repair.3 All articles provide
a basic description of the embryology, abnormal
anatomy, incidence rates, and various surgical
techniques used in the repair.
Herein we present a Maintenance of Certi-
fication/Continuing Medical Education article
focused on (1) integrating the most relevant
evidence-based information from previous Con-
tinuing Medical Education/Maintenance of Cer-
tification on the topic of bilateral cleft lip; (2) a
historical presentation of different surgical repair
techniques for bilateral cleft lip and their evolu-
tionary and iterative progression; (3) the preva-
lence of types of surgical repair used in North
America; (4) a description of repair technique
used by the senior author (J.S.A.) of this article;
and (5) controversies and outcomes of bilateral
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
Supplemental digital content is available for
this article. Direct URL citations appear in the
text; simply type the URL address into any Web
browser to access this content. Clickable links
to the material are provided in the HTML text
of this article on the Journal’s website (www.
PRSJournal.com).

152e www.PRSJournal.com
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 140, Number 1 • Bilateral Cleft Lip Repair
cleft lip repair. We hope to enhance the reader’s
comprehension of bilateral cleft lip repair and to
have this article serve as a basic overview of the
topic and a starting point of reference.
EPIDEMIOLOGY, EMBRYOLOGY, and
ABNORMAL ANATOMY
Epidemiology
Cleft lip occurs more frequently in boys, and
occurs more on the left side, with a 6:3:1 ratio of left
to right to bilateral. This is thought to be related to
the later closure of the left side.4 Ethnicity plays a role
as well: Asians have a 2.1 in 1000 chance of develop-
ing cleft lip compared to 1.0 in 1000 in Caucasians
and 0.5 in 1000 in patients of African descent.5
Embryology
Facial development of the fetus occurs
between the third and twelfth weeks of gestation,
with the lip developing between the fourth and
seventh weeks.6,7 An isolated, unilateral, nonfusion
of the median nasal prominence with the maxil-
lary prominence leads to a cleft lip, which occurs
by the end of the sixth week.6 If both sides fail to
fuse, the neonate will have bilateral cleft lip.6,8 The
fusion is thought to occur by mesenchymal tissue
penetration in what is known as the “dynamic
fusion” theory, with work stemming from electron
microscopy of nonhuman primate embryos.9,10
Abnormal Anatomy
The anatomy of the complete bilateral cleft lip
deformity can be summarized by nine features, as
defined by Bardach and Cutting11: (1) the colu-
mella is extremely short; (2) the nasal tip is flat and
broad; (3) the nasal alae are flattened, often with
an S-shaped curvature; (4) the alar bases are dis-
placed laterally and possibly inferiorly and posteri-
orly; (5) the nostrils are oriented horizontally; (6)
the lower lateral cartilages are deformed with short
widely separated medial crura, flattened elongated
lateral crura, and obtusely angled domes; (7) the
nasal floors are absent; (8) there is inferior dis-
placement of the columella, caudal septum, and
anterior nasal spine relative to the alar bases; and
(9) there is asymmetry of the nasal tip and nares.
ETIOPATHOGENESIS
The cause of cleft lip and palate is well defined
elsewhere, but there are multiple genetic and envi-
ronmental factors at play.9,12 Although cleft pal-
ate is associated with Pierre Robin sequence and
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
numerous syndromes that include Van der Woude,
velocardiofacial, Goldenhar, Treacher Collins,
Down, and Stickler,4 cleft lip is mainly sporadic
and associated with Van der Woude, DiGeorge,
and Stickler syndromes.12 The majority of clefts
are not associated with a syndrome and can be
a result of a single-gene change. These include
transforming growth factor alpha and beta, MSX-
1, TBX22, retinoic acid receptor alpha, homeobox
gene, distal-less homeobox 2, and B-cell leukemia
or lymphoma 3.6,13–17 Family history plays an impor-
tant role as well, and it is well established that hav-
ing one or more children with cleft lip or palate
will increase the risk of having another child with
a clefting abnormality; after having one child with
cleft lip, the risk is 4 percent, and after having two
children, the risk is 9 percent.8,18
There also exist environmental, systemic, and
pharmacologic risk factors for cleft lip, including
maternal smoking, alcohol, poor nutrition, viral
infections, medications, and teratogens. Several
studies have linked smoking with isolated cleft lip
with or without palate, and state that the population-
attributable risk is as high as 20 percent.6,19,20 Mater-
nal alcohol consumption is less clear than smoking
and has received mixed associative results.21–23
Other teratogens that may be implicated include
retinoic acids, corticosteroids, and anticonvulsant
drugs (phenytoin and phenobarbital).6,9,24
Nutrition is likely to play a role in clefting, but
this is based on observational data.6 A meta-analysis
suggested that the use of a multivitamin decreased
the prevalence of orofacial defects by 25 percent.25
Folate deficiency has a role in clefting in animals, but
it is unknown how it correlates with humans, with
inconsistent evidence regarding mandatory folate
fortification and decrease in all clefts combined.6,25
Finally, maternal infections such as rubella
and toxoplasmosis,4 and an indirect, mainly
uncorrected pyretic effect, of maternal influenza
in the first trimester of pregnancy also have an
association with clefting.26 Ultimately, clefting can
be attributed to a multifactorial cause.
CLASSIFICATION OF BILATERAL
CLEFT LIP
There are numerous cleft classification systems
described for cleft lip and palate.27–29 Some, includ-
ing the classification by the American Association
for Cleft Palate Rehabilitation, has not received
wide acclaim.30 Other classification methods, such
as the striped-Y method, include nasal and pha-
ryngeal deformities in a diagrammatic representa-
tion.31 Kriens proposed a palindromic method to
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describe complete (capital letters) versus incom-
plete (small letters) clefts of the lip, alveolus,
hard palate, and soft palate, using the LASHAL
acronym.32 Because the use of classification meth-
ods can be so variable between cleft teams, it has
been suggested that, ultimately, a simple, anatomi-
cal method be used.12 The most basic anatomical
characteristics are as follows: bilateral versus uni-
lateral (left or right), complete versus incomplete
(left or right), primary palate or secondary palate,
or a combination of these. A primary palate com-
plete cleft is defined by “the involvement of the lip,
nasal sill, nasal floor, and alveolus.”12
A Simonart band, a bridge on the superior
aspect of the lip, can also be seen with a complete
cleft lip in as high as 30 percent of cases.33,34 Incom-
plete unilateral cleft lip can be further subclassi-
fied into minor, microform, and minimicroform.2
Minor clefts are defined as an interruption of
the vermilion-cutaneous border extending 3 mm
above the peak of the noncleft side of Cupid’s bow,
microform as less than 3 mm, or minimicroform,
which does not elevate the Cupid’s bow peak.35
Bilateral cleft lip can also be classified into minor,
microform, and minimicroform, corresponding
to the above descriptions.36,37
PREOPERATIVE CARE AND
MANAGEMENT OF THE PREMAXILLA
Once a baby is born with a cleft lip (with or
without cleft palate), it is imperative to ensure that
there are no other comorbidities and that feeding
is optimized by means of either breast, traditional
bottle, or a special cleft nurser. In unilateral cleft lip,
the use of preoperative orthopedics is highly center-
dependent.3 There are controversies and limited evi-
dence on the benefit of using preoperative molding,
which shows varying levels of benefit, likely based on
orthodontist experience with molding.38–40 A study
by Sitzman et al. noted that most surgeons elected
not to use lip adhesion, active or passive presurgical
orthopedics, or nasoalveolar molding.41
However, in bilateral cleft lip, preoperative
orthopedics are essential, and used widely, in an
effort to align the three maxillary segments (includ-
ing passive premaxillary setback), lengthen the
prolabium, and elongate the columella.9,42,43 Many
techniques exist, such as finger massage and manual
traction to the prolabium and premaxilla, passive
taping on labial segments, lip adhesion, active intra-
oral appliance (Latham device), and nasoalveolar
molding, with the last two being the most commonly
used.9 These devices serve to decrease the distance
between the maxillary segments, and some studies
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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • July 2017
have shown a benefit.44,45 Disadvantages include the
need for anesthetic use (initial dental impression),
the potential damage to developing teeth, and cost,
over and above the significant time commitment
required by the patient and their families.44,45
Nasoalveolar molding uses a custom palatal
retainer and nasal stents with taping to passively
apply pressure to the alveolar segments and pre-
maxilla, allowing the cleft to narrow and lengthen-
ing the columella.9,46 Nasoalveolar molding should
be started as early as possible to take advantage
of the malleability of the tissues, and should be
coordinated by an interdisciplinary team of par-
ents, the orthodontist, and the surgeon.46 A newer
development, albeit not widely used, includes the
use of preoperative botulinum toxin to paralyze
the orbicularis oris muscle, which can reduce ten-
sion and help with healing.47
HISTORICAL AND CURRENT REPAIR
TECHNIQUES OF BILATERAL
CLEFT LIP
Goals of Surgery
There is great debate between surgeons with
regard to the surgical technique of choice, as
there is no real accepted standard.9,46 However, sev-
eral tenets remain similar among all procedures.
The objectives of the repair4 are to achieve facial
symmetry, repair the orbicularis oris, and obtain
alveolar continuity, among others. Specifically, the
contemporary approach to bilateral cleft lip con-
sists of multifold objectives.36 There are key prin-
ciples, which are summarized as follows36,42,48–50:
1. Symmetry must be established. This is hin-
dered by staged repairs, which lead to asym-
metrical errors, which are accentuated by
growth, and should be reserved only for
bilateral asymmetric cleft lip.
2. The premaxilla must be prepared with mod-
ern dentofacial orthopedics (see above), to
create a tension-free closure, minimizing
scar formation.
3. The surgeon should anticipate fourth-
dimensional changes that occur with growth.
Failure to account for this may result in a
widened philtrum. A morphometric study
shows that this is attributable to slower grow-
ing areas such as the lengthening columella
and projection of the nasal tip, compared
with faster growing areas such as the philtral
width.51 Thus, there is a need to undercor-
rect fast-growing areas and overcorrect the
slow-growing structures.
 Volume 140, Number 1 • Bilateral Cleft Lip Repair
4. The central lip should be constructed using
the lateral labial elements and the prola-
bial vermilion should be discarded, which
avoids forming a “whistle” deformity.
5. The gingivolabial sulcus is deepened using
premaxillary mucosa.
6. Continuity of the orbicularis oris muscle
must be achieved.
7. The nasal deformity should addressed as
well, either at the time of the primary repair
or secondarily.
Prevalence of Repair Type
A survey conducted by Tan et al. sought to
determine the current surgical management of
bilateral cleft lip in North America, with responses
from 241 cleft surgeons across the United States
and Canada.43 It was found that in most respon-
dents (71 percent), dentofacial orthopedics were
commonly used. Nasoalveolar molding, which is
used at our center, was the most commonly used
method, followed by external compression and
the Latham appliance. Also, synchronous closure
was preferred (88 percent) over preliminary labial
adhesions, followed by synchronous repair (11
percent) or staged repair (1 percent). They also
found that approximately half of the surgeons
concurrently performed a primary nasal repair.
The most commonly used repair techniques were
the Millard (38 percent), Mulliken (26 percent),
and Manchester (12 percent) repairs.
Historical Approaches and Evolution of
the Repair
Techniques have evolved from multistage to
two stages, starting with the more affected side,
and currently to single-stage repairs, which avoid
asymmetry and allow greater functional repair
of the orbicularis oris muscle.9,46 Cleft lip repairs
have been described in ancient medical textbooks
but began with straight-line repairs of Rose in
1891 and Thompson in 1912. These repairs often
did not attempt to restore the continuation of
the orbicularis muscle and often failed to repair
the Cupid’s bow.2 Other straight-line techniques
include the Veau, Axhausen, Brown, Schultz,
Vaughan, Cronin, Manchester, Broadbent, and
Woolf repairs. For example, the Manchester repair
preferred to maintain the prolabial vermilion to
create the Cupid’s bow and tubercle, but similar
to the Veau repair, the repair described by Man-
chester did not involve repairing the orbicularis,
as he felt this would create an overly tight lip.46
Next came the triangular flap repairs of Ran-
dall-Tennison and the quadrangular flap repair of
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Le Mesurier and Hagedorn.52,53 Hagedorn’s repair
was the first to suggest using quadrangular flaps
instead of a vertical repair, correcting the protru-
sion of the premaxilla.54 He was also the first sur-
geon to perform a single-stage bilateral cleft lip
repair. Some of the disadvantages of these repairs
included unnatural scarring, long lip, and failure
to address cleft nasal deformities.2
Z-plasty techniques on the lower portion of
the upper lip were also proposed, including the
Berkeley and the Bauer repairs. Upper lip Z-plasty
techniques include the Millard and Wynn repairs.
The Skoog repair includes both upper and lower
Z-plasty. Millard, in 1957, created his rotation-
advancement technique, which is now widely
used, with modification, for cleft lip repair. This
repair allowed rotation of the Cupid’s bow with
the gap filled from skin advanced from the lateral
element.2 The Millard repair allowed complete
elevation of the prolabium and reconstitution of
the orbicularis across the premaxilla. In addition,
Millard banked lateral segments of the prolabium
as “forked flaps” that were meant to add columel-
lar height at a later stage, thus addressing the ver-
tical height deficiency, and it also corrected the
wide alar bases.2 Of course, most surgeons have
stopped the practice of banking forked flaps,
given the problematic vertical columellar scar that
results at the time of secondary columellar length-
ening reconstruction. In addition, although use
of banked fork flaps may initially lengthen the
columella and narrow the alar bases, there is an
undesirable effect on postsurgical growth, specifi-
cally, in the projection of the nasal tip. With fork
flap placement, the footplates of the medial crura
are pushed up into the tip and the domes are left
splayed lateral, and growth of the lower lateral
cartilages causes the tip to become progressively
more broad and flat.55–57
Repair of the cleft lip was historically achieved
without correcting the nasal deformity, sometimes
because of the belief that this repair would impair
growth.42,49 Over the past quarter decade or so,
the emphasis has shifted from the lip to the nose,
with a focus on a primary nasolabial repair, lead-
ing to better cosmesis.9 Although the exact cause
of the cleft nasal deformity is unknown, McComb
postulated that the prolabium is embryologically
lip tissue and that the shortened columella was
the result of the lateral cartilages being retroposi-
tioned and spread too laterally, flattening the col-
umellar height.46,58,59 The overarching principle
of the nasal repair is to dissect the excess tissue
away from the nose and to reposition the lower
lateral cartilages so that the domes meet midline,
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narrowing the nose and improving projection.57
Some surgeons prefer delaying the nasal repair,
as nasal stenosis can occur in primary nasolabial
repair, especially if a circumferential intranasal
skin incision is made.9,57 Other surgeons argue
that the nasal deformity is attributable not only to
the shortened columella but also to a poor nasal
tip projection, which could be improved by using
rhinoplasty and cartilage grafting techniques.60,61
McComb opts for a two-stage repair to position
the alar domes and bring them midline, reform-
ing the columella. The difficulty with bilateral cleft
lip and nose repair is the lack of a normal side to
try to match, which leads to some surgeons opting
to use the McComb procedure in two stages, with
the first operation setting the preoperative stage
for the second.62 Grayson and Cutting use naso-
alveolar molding, which is useful when the nasal
cartilages are still malleable; however, primary
surgery is still required to free up the nasal car-
tilage.63–65 Another repair uses bilateral rim inci-
sions that converge and become continuous with
the philtrum and columella, thus elevating these
structures as a single unit.57
The Mulliken technique features a synchro-
nous bilateral cleft lip and nasal deformity repair.
The nasal repair with bilateral rim incisions ele-
vates the alar cartilages toward the upper lateral
cartilages using interdomal sutures.48 Mulliken
emphasized this as an advantage over the Millard
procedure, which can cause thickened and promi-
nent columellar and philtral scars following sec-
ondary retrieval of banked fork flaps.48,49 Mulliken
also stresses the importance of considering the
changes associated with growth, which he calls the
fourth dimension, or time, where changes occur
related to growth in addition to the other three
dimensions and at different rates based on the
anatomy.48 Mulliken’s repair can best be accom-
plished using active or passive presurgical manip-
ulations to align the three maxillary segments.48
For incomplete bilateral cleft lip, Wolfe et al.
used a rotation-advancement technique to close
one side, lip adhesion to the contralateral side,
and repair of the contralateral side 3 to 4 months
later.66 The authors suggested that this resulted in
a fuller upper lip, creation of a philtral dimple,
and preservation of the Cupid’s bow.66 Millard’s
two-stage repair of bilateral incomplete cleft lip
used a curvilinear incision to avoid a long lip
deformity but ultimately resulted in midline scars
across the columellar-labial junction, when each
of the advancement flaps met.67
If a contralateral lesser form incomplete cleft
lip is present (thus, asymmetrical bilateral cleft lip),
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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • July 2017
some authors recommend a single-stage repair
rather than a two-stage repair, irrespective of the
severity of the “lesser” affected side, as the two-stage
repair can result in imbalance of the Cupid’s bow
and asymmetrical scars.68 Mulliken, for bilateral
asymmetrical cleft lip, advises the use of preopera-
tive unilateral orthopedics to narrow the alveolar
cleft on the more severe side followed by a first-
stage preliminary preparation of this side with a lip
adhesion and gingivoperiosteoplasty.42,43 This pro-
vides the stage for the synchronous bilateral nasola-
bial repair, with overcorrection to the more severe
side, as there will be differences in tension and rate
of growth postoperatively.42,49 In cases of bilateral
cleft lip in a trisomy 13, trisomy 18, or holopros-
encephaly patient, in which life expectancy is now
increasing, there currently exists only scant case
reports of repair techniques, and in the future, this
will likely be an area of further research.69,70
Although there is little literature directly com-
paring the various techniques, there have been
arguments for and against specific techniques.
Millard’s forked flap technique allows adequate
lengthening of the columella but risks damage
to the vascular supply of the philtrum, scarring at
the columella labial junction, excessive columel-
lar length, and an overly obtuse nasal angle.55 The
staged rotation-advancement technique described
by Wolfe and Mejia allows elevation of the alar car-
tilage on one side with a McComb stitch and then
use of this as a “normal” guide to try to match dur-
ing the second stage of repair, a few months later,
in an effort to improve nasal results.62
Preferred Surgical Approach
In previous Maintenance of Certification/
Continuing Medical Education articles, there
has been much discussion of the Millard rota-
tion advancement flap and historical techniques
used in the past, focusing on unilateral cleft lip
repair.1–3,57,71 Although Millard-like repairs exist
for bilateral cleft lip, our Maintenance of Certi-
fication/Continuing Medical Education article
focuses on the single-stage modified Mulliken
repair. The Mulliken technique has been vali-
dated in a prospective 30-patient study looking at
anthropometric outcomes.72 We use presurgical
nasoalveolar molding techniques to reduce the
premaxilla, narrow the cleft width, and lengthen
the columella.49 The cleft lip repair technique
is described as a modified Mulliken repair, with
a limited closed nasal dissection. The alveolus is
repaired using a gingivoperiosteoplasty repair
(Millard) if the segments are less than 2  mm
apart.73
 Volume 140, Number 1 • Bilateral Cleft Lip Repair

Video. Supplemental Digital Content 1, which demonstrates

the preferred surgical technique used by the senior author of
this article, and features a single-stage modified Mulliken repair Fig. 1. Bilateral complete cleft lip.
with a limited closed rhinoplasty, is available in the “Related
Videos” section of the full-text article on PRSJournal.com or, for
Ovid users, at http://links.lww.com/PRS/C221.

Below is a summary of the repair used by this

article’s senior author (J.S.A.), also illustrated in
Video 1 and in the figures. (See Video, Supple-
mental Digital Content 1, which demonstrates
the preferred surgical technique used by the
senior author of this article, and features a sin-
gle-stage modified Mulliken repair with a limited
closed rhinoplasty. This video is available in the
“Related Videos” section of the full-text article
on PRSJournal.com or, for Ovid users, at http://
links.lww.com/PRS/C221.) Primary repair of the
bilateral cleft lip should occur at approximately Fig. 2. The philtral flaps and prolabial flaps are marked. The peak
and trough of the Cupid’s bow are also marked, and these are
age 3 to 4 months after nasoalveolar molding,
extended to the base of the columella to complete the prola-
and when the child is ready for general anes-
bial flap and fork flaps. The length of prolabial vertical marking
thesia.46 First, the lip is surgically marked under
is transposed to the lateral lip elements. The vermilion border is
loupe magnification (Figs.  1  and  2). The mark-
obliquely marked bilaterally.
ings are then scored and local anesthetic is
infiltrated. Supraperiosteal dissection is used to
free the lateral lip elements and alar bases for
mobilization medially and ultimate tension-free
closure. The skin flaps are elevated, and the orbi-
cularis muscle is identified and dissected widely
for approximately 8 to 10 mm laterally (Fig. 3).
The orbicularis oris muscle is then reconstructed
across the premaxilla; this is probably the most
important step in the repair (Fig. 4). Rhinoplasty
is performed with limited dissection of the tip/
rim only, without open approximation. When
necessary, the nasal ala is freed up and brought
midline to reconstruct the tip. The nasal floor
is reconstructed with a forked flap for cases of
complete clefting. Alar lift sutures are placed,
when needed. Next, the lip is closed in three lay- Fig. 3. The orbicularis muscle is dissected off of the buccal and
ers, using 5-0 Vicryl (Ethicon, Inc., Somerville, cutaneous layers. This dissection is critical, as the muscle can be
N.J.) on the buccal mucosa, 4-0 Vicryl buried atrophic or deficient in the prolabium.

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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

Fig. 4. The orbicularis muscle is approximated over the premax-
illa to reform the oral sphincter, a critical step in the operation to
ensure good functional results.
horizontal mattress sutures to reconstruct the
orbicularis muscle, 6-0 Vicryl for deep dermis,
and 6-0 nylon to the cutaneous lip (Fig. 5). Nasal
stents are put in place (Fig.  6) and stent mold-
ing of alar rims occurs for 1 to 2 months postop-
eratively, as tolerated. Lip sutures are removed 1
week postoperatively.
Figure 7 shows a patient preoperatively, after
presurgical nasoalveolar molding, immediately
postoperatively, and 2 years postoperatively.
Similarly, Figures  8 through 10 show a patient
preoperatively (two views) and after presurgi-
cal molding, the dissection, the approximation
of the orbicularis muscle over the premaxilla
(Fig. 9, above, right), immediately postoperatively,
and 2 years postoperatively (two views). Finally,
­Figures 11 and 12 show a patient preoperatively,
after presurgical molding, immediately postop-
eratively, and 2 years postoperatively.
Fig. 5. Cutaneous closure.
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Plastic and Reconstructive Surgery • July 2017
Fig. 6. Nasal stents are used postoperatively.
COMPLICATIONS AND LONG-TERM
OUTCOMES OF SURGERY
Long-term follow-up of bilateral cleft lip
patients is essential by means of a cleft-craniofa-
cial team because, with time and facial growth,
patients often require additional revision/
reconstructive operations.9 Common deformi-
ties from primary repair include a wide philtrum,
tight upper lip, wide/abnormal scars, flattened
nose, wide alar base, and whistle deformity.46
Revision surgery may be necessary, but this may
lead to increased scarring in an anatomical area
already with a dearth of tissue.46 Therefore, reg-
ular and repetitive surgery should be avoided.
We advise revisions before school age or when
children are done growing, as required. Subjec-
tive surgeon ratings, and many other variables
such as healing, scar formation, and growth,
make comparison between patient outcomes
incredibly difficult.46 Also, patient-reported out-
come measures stratified by repair technique
are currently deficient in the assessment of cleft
patients.
CONTROVERSIES AND CHALLENGES
Controversies exist in the management of
bilateral cleft lip, stemming from the multitude of
techniques and methods, illustrating no accepted
standard. There is great discrepancy between sur-
geons with regard to the surgical technique of
choice, and many choices exist.9,46
An important concept to recognize is that,
despite the anthropometric measurements of the
various landmarks, including various two-dimen-
sional and three-dimensional methods, an experi-
enced surgeon will factor in a fourth dimension,
namely, patient growth.12 There is also debate
 Volume 140, Number 1 • Bilateral Cleft Lip Repair

Fig. 7. Case 1. (Above, left) Preoperatively. (Below, left) Intraoperatively. (Below, right) Immediately
postoperatively. (Above, right) Two years postoperatively.

between the use of a one-stage versus two-stage
cheiloplasty, the rhinoplasty technique, and the
type of presurgical management.
Management of the Prominent Premaxilla
As mentioned previously, many techniques
exist to manage the prominent premaxilla, includ-
ing preoperative molding, lip adhesion, and even
premaxillary osteotomy. Although complicated by
the fact that it is difficult to separate the effect of
the nasoalveolar molding and the primary nasal
reconstruction during repair, one study showed
that 77 patients with bilateral cleft lip who under-
went nasoalveolar molding had anthropometric
measurements similar to those of the normal con-
trols.74 Subjective clinician ratings were also higher
for those infants treated with nasoalveolar molding
before definite repair.75 It is postulated that nasoal-
veolar molding even reduces or prevents the need
for secondary nasal surgery, as it helps address the
nasal cartilage during its period of plasticity.76,77
Lip adhesion can also reduce tension and
help align the prominent premaxilla, reduce the
size of the cleft, and serve as a preliminary closure
to decrease tension, especially in wide clefts when
nasoalveolar molding is not available. One study
showed an improvement of 5 mm between alveo-
lar segments with lip adhesion at 6 weeks followed
by definite surgical repair at 6 months, but it is
unclear whether final outcomes may have been
affected by the lip adhesion itself.78 Lip adhesion
can increase risks of dehiscence and produces
more scar tissue. In severe cases, premaxillary
vomerine osteotomy may be needed, albeit at
the risk of creating further maxillary growth
restriction.79,80
Few studies have provided concrete evidence
to support the use of these preoperative tools
because of the wide range of available options
and their user-dependent nature. One review, for
example, stated that the use of presurgical infant
orthopedics had no beneficial effect on maxillary
arch dimensions, facial aesthetics, and dentition
of bilateral cleft lip cases.81 At our center, bilat-
eral cleft lip is treated routinely with nasoalveolar
molding; lip adhesion or premaxillary osteotomy

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 Plastic and Reconstructive Surgery • July 2017

Fig. 8. Case 2. (Above, left) Preoperative frontal view. (Above, right) Preoperative
profile view. (Below) Preoperatively after presurgical orthopedics.

is rarely, if ever, performed. Ultimately, some form
of active or passive setback is required to achieve
well-aligned segments, which are essential to facil-
itate tension-free closure.
Repair Technique and Timing
Cleft surgery is an ever-evolving and iterative
field without an accepted standard repair tech-
nique; as such, many surgeons have developed
their own techniques, and academic surgery has
allowed knowledge to be passed on from expert
to student. However, controversy still exists with
regard to the timing of surgery and which bilat-
eral clef lip repair technique is best.9,46,82
Timing of the repair is controversial. One
reason for this variability stems from the altering
view of priorities. Dentists may believe that active
preoperative manipulation of maxillary segments
can lead to poor facial growth and/or dental com-
plications in the future; conversely, surgeons may
think that these preoperative interventions are
necessary, as they facilitate tension-free closure
and improve appearance.42 Some surgeons fol-
low a rule of 10s: hemoglobin more than 10  g/
dl, weight greater than 10 lb, and age older than
10 weeks, which leads to an operation sometime
between 3 and 6 months of age.3 This is further
complicated by the aforementioned use of pre-
operative manipulations. Ultimately, delaying the
time of repair until 4 to 5 months is currently our
practice, allowing time for molding to become effi-
cacious. In the survey by Tan et al., 49 percent of
primary repairs were performed between 4 and 6
months of age, and 44 percent were performed
between 1 and 3 months.43
The choice of surgical technique is highly
surgeon dependent; however, over time, several
tenets and objectives have emerged, as described
earlier. There is no accepted standard, because of
the numerous available techniques. Very few stud-
ies directly compare surgical techniques; thus, it is
unclear whether a best practice exists. Outcomes

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 Volume 140, Number 1 • Bilateral Cleft Lip Repair

Fig. 9. Case 2. (Left) Dissection and flap elevation. (Above, right) Orbicularis muscle approximated over the pre-
maxilla. (Below, right) Immediately postoperatively.

Fig. 10. Case 2. Two years postoperatively, frontal view (left) and profile view (right).

are largely surgeon dependent, and there exists Management of the Short Columella and Whistle
a strong training and institutional bias. The Mil- Lip Deformity
lard, Mulliken, and Manchester procedures are The short columella is a stigma of bilateral
the most commonly performed.41 cleft lip repair and may require secondary surgical

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 Plastic and Reconstructive Surgery • July 2017

Fig. 11. Case 3. (Above, left) Preoperative frontal view. (Above, right) Preoperative profile
view. (Below, left) Intraoperatively after presurgical orthopedics. (Below, right) Immediately
postoperatively.

management. The three most recognized tech-
niques for managing the short columella are the
Millard (forked flap), Cronin (bipedicled flap),
and V-Y advancement of the prolabium in con-
junction with an Abbe lip switch.
The Millard technique uses a pair of forked
flaps, one from each side of the prolabium, which
are banked within the nasal sills during primary
lip repair until secondary rhinoplasty is per-
formed. Flaps are then retrieved and rotated into
the columella to achieve lengthening at a second-
ary procedure.46 This technique is not commonly
performed because of the visible and aesthetically
unpleasing columellar midline scar.
The Cronin technique uses tissue from the
floor of the nose to lengthen the columella. Inci-
sions are located just inferior to the nostril sills,
with a parallel incision within the nostril and
along the nasal floor, creating bipedicled flaps on
each side that can be advanced anteriorly. Alar
wedge excisions can be used to relocate the ala.
This method is used when there is minimal short-
ening of the columella but is contraindicated in
cases of an abnormal Cupid’s bow or scars requir-
ing revision.83,84
Finally, multiple options for V-Y advancement
exist, ranging from small advancements isolated
to the columella to advancements of the entire

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 Volume 140, Number 1 • Bilateral Cleft Lip Repair
Fig. 12. Case 3. Two years postoperatively, frontal view (left) and (right) profile view.
prolabium. These are used when there is tissue
deficiency in the upper lip requiring an Abbe flap
for upper lip reconstruction. The V-Y advance-
ment is the procedure of choice in patients in
whom an Abbe flap is expected, as the prolabial
skin will be replaced and the midline scar revised
by the Abbe flap.85,86
Secondary lip revision surgery is common
and presents a challenge to the surgeon, as
some deformities are not amenable to primary
repair.87 The Abbe flap solves the problems of
the lower lip appearing protuberant and an
overly tight upper lip, which often presents as a
whistle deformity. When the upper lip is trans-
versely deficient, the Abbe flap is one of the only
available procedures with which to reconstruct
a naturally appearing tension-free philtrum,
Cupid’s bow, and central tubercle, using a full-
thickness (i.e., vermilion, orbicularis oris, and
skin) flap.87,88 The technique involves rotating a
pedicled flap from the lower lip into the phil-
tral landmarks to reconstruct the upper lip defi-
ciency, which is then allowed to neovascularize
and divided secondarily.88 Some surgeons advo-
cate that before the Abbe flap can be used, one
should perform a Le Fort I osteotomy to provide
fullness and advance the midface, and a rhino-
plasty to ensure the correct placement of nasal
tip cartilages.89 This is to avoid multiple repairs
during the delicate lip repair. The Abbe flap can
also be used to repair a deficiency in vermilion,
nonexistent lip tubercle, absent Cupid’s bow, or
an excessively protuberant lower lip.89
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Unfortunately, there are no ideal techniques
for reconstruction of the short columella. Perhaps
microsurgical techniques or tissue engineering
can be future reconstructive frontiers.
CONCLUSIONS
The bilateral cleft lip repair has evolved
immensely over the past half-century. It has been
stated that this repair is half as common and
twice as difficult as the unilateral cleft lip repair;
clearly, it poses great technical and intellectual
challenges for the treating surgeon. However,
thoughtful, meticulous, and timely management
can be rewarding for the surgeon and patient
alike.
Jugpal S. Arneja, M.D., M.B.A.
Division of Plastic Surgery
University of British Columbia
British Columbia Children’s Hospital
K3-131 ACB
4480 Oak Street
Vancouver, British Columbia V6H 3V4, Canada
jugpal.arneja@ubc.ca
PATIENT CONSENT
Parents or guardians provided written consent for
use of patient images.
ACKNOWLEDGMENTS
The authors would like to thank Lindsay Bjornson
for assistance in preparing the illustrations.
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REFERENCES
1. Fisher DM, Sommerlad BC. Cleft lip, cleft palate, and velopha-
ryngeal insufficiency. Plast Reconstr Surg. 2011;128:342e–360e.
2. Monson LA, Kirschner RE, Losee JE. Primary repair of cleft lip
and nasal deformity. Plast Reconstr Surg. 2013;132:1040e–1053e.
3. Greives MR, Camison L, Losee JE. Evidence-based medi-
cine: Unilateral cleft lip and nose repair. Plast Reconstr Surg.
2014;134:1372–1380.
4. Rozzelle AA, Arneja JS. Cleft lip and cleft palate. In: McInerny
T, Adam H, Campbel D, Kamat D, Kelleher K, Hoekelman R,
eds. AAP Textbook of Pediatric Care. 2nd ed. Elk Grove Village,
Ill: American Academy of Pediatrics; 2016;1849–1858.
5. Tse R. Unilateral cleft lip: Principles and practice of surgical
management. Semin Plast Surg. 2012;26:145–155.
6. Mossey PA, Little J, Munger RG, Dixon MJ, Shaw WC. Cleft
27. Li AQ, Sun YG, Wang GH, Zhong ZK, Cutting C. Anatomy of
lip and palate. Lancet 2009;374:1773–1785.
7. Diewert VM. Development of human craniofacial morphol-
ogy during the late embryonic and early fetal periods. Am J
28. Kernahan DA, Stark RB. A new classification for cleft
Orthod. 1985;88:64–76.
8. Thorne CH, ed. Grabb and Smith’s Plastic Surgery. 6th ed. New
York: Lippincott Williams & Wilkins; 2006.
29. Sandham A. Classification of clefting deformity. Early Hum
9. Pham AM, Senders CW. Management of bilateral cleft lip
and nasal deformity. Curr Opin Otolaryngol Head Neck Surg.
2006;14:278–282.
10. Senders CW, Peterson EC, Hendrickx AG, Cukierski
MA. Development of the upper lip. Arch Facial Plast Surg.
2003;5:16–25.
11. Bardach J, Cutting C. Anatomy of the unilateral and
bilateral cleft lip and nose. In: Bardach J, Morris HL,
eds. Multidisciplinary Management of Cleft Lip and Palate.
Philadelphia: Saunders; 1990;150–159.
12. Vyas RM, Warren SM. Unilateral cleft lip repair. Clin Plast
Surg. 2014;41:165–177.
13. Hibbert SA, Field JK. Molecular basis of familial cleft lip and
palate. Oral Dis. 1996;2:238–241.
14. Lidral AC, Murray JC, Buetow KH, et al. Studies of the candi-
date genes TGFB2, MSX1, TGFA, and TGFB3 in the etiology
of cleft lip and palate in the Philippines. Cleft Palate Craniofac
J. 1997;34:1–6.
15. Romitti PA, Lidral AC, Munger RG, Daack-Hirsch S, Burns
TL, Murray JC. Candidate genes for nonsyndromic cleft
lip and palate and maternal cigarette smoking and alcohol
consumption: Evaluation of genotype-environment interac-
tions from a population-based case-control study of orofacial
clefts. Teratology 1999;59:39–50.
16. Suazo J, Santos JL, Carreño H, Jara L, Blanco R. Linkage dis-
equilibrium between MSX1 and non-syndromic cleft lip/pal-
ate in the Chilean population. J Dent Res. 2004;83:782–785.
17. Murray JC, Nishimura DY, Buetow KH, et al. Linkage of an
autosomal dominant clefting syndrome (Van der Woude) to
loci on chromosome Iq. Am J Hum Genet. 1990;46:486–491.
18. Kirschner RE, LaRossa D. Cleft lip and palate. Otolaryngol
Clin North Am. 2000;33:1191–1215.
19. Little J, Cardy A, Munger RG. Tobacco smoking and oral clefts:
A meta-analysis. Bull World Health Organ. 2004;82:213–218.
20. Honein MA, Rasmussen SA, Reefhuis J, et al. Maternal smok-
ing and environmental tobacco smoke exposure and the risk
of orofacial clefts. Epidemiology 2007;18:226–233.
21. Romitti PA, Sun L, Honein MA, Reefhuis J, Correa A,
Rasmussen SA. Maternal periconceptional alcohol con-
sumption and risk of orofacial clefts. Am J Epidemiol.
2007;166:775–785.
22. Bille C, Olsen J, Vach W, et al. Oral clefts and life style fac-
tors: A case-cohort study based on prospective Danish data.
Eur J Epidemiol. 2007;22:173–181.
164e
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
23. Meyer KA, Werler MM, Hayes C, Mitchell AA. Low maternal
alcohol consumption during pregnancy and oral clefts in off-
spring: The Slone Birth Defects Study. Birth Defects Res A Clin
Mol Teratol. 2003;67:509–514.
24. Park-Wyllie L, Mazzotta P, Pastuszak A, et al. Birth defects
after maternal exposure to corticosteroids: Prospective
cohort study and meta-analysis of epidemiological studies.
Teratology 2000;62:385–392.
25. Johnson CY, Little J. Folate intake, markers of folate status
and oral clefts: Is the evidence converging? Int J Epidemiol.
2008;37:1041–1058.
26. Acs N, Bánhidy F, Puhó E, Czeizel AE. Maternal influ-
enza during pregnancy and risk of congenital abnor-
malities in offspring. Birth Defects Res A Clin Mol Teratol.
2005;73:989–996.
the nasal cartilages of the unilateral complete cleft lip nose.
Plast Reconstr Surg. 2002;109:1835–1838.
lip and cleft palate. Plast Reconstr Surg Transplant Bull.
1958;22:435–441.
Dev. 1985;12:81–85.
30. Harkins CS, Berlin A, Harding RL, Longacre JJ, Snodgrasse
RM. A classification of cleft lip and cleft palate. Plast Reconstr
Surg Transplant Bull. 1962;29:31–39.
31. Kernahan DA. The striped Y: A symbolic classification for
cleft lip and palate. Plast Reconstr Surg. 1971;47:469–470.
32. Kriens O. LAHSHAL: A concise documentation system for
cleft lip, alveolus, and palate diagnoses. In: Kriens O, ed.
What Is a Cleft Lip Palate? A Multidisciplinary Update. New York:
Thieme; 1989:30–34.
33. Gibson T. Gustav Simon (1824–1876): Simonart (s)(z) of the
band? Br J Plast Surg. 1977;30:255–260.
34. da Silva Filho OG, Santamaria M Jr, da Silva Dalben G, Semb
G. Prevalence of a Simonart’s band in patients with complete
cleft lip and alveolus and complete cleft lip and palate. Cleft
Palate Craniofac J. 2006;43:442–445.
35. Yuzuriha S, Mulliken JB. Minor-form, microform, and mini-
microform cleft lip: Anatomical features, operative tech-
niques, and revisions. Plast Reconstr Surg. 2008;122:1485–1493.
36. Allori AC, Marcus JR. Modern tenets for repair of bilateral
cleft lip. Clin Plast Surg. 2014;41:179–188.
37. Yuzuriha S, Oh AK, Mulliken JB. Asymmetrical bilateral cleft
lip: Complete or incomplete and contralateral lesser defect
(minor-form, microform, or mini-microform). Plast Reconstr
Surg. 2008;122:1494–1504.
38. Abbott MM, Meara JG. Nasoalveolar molding in cleft care: Is
it efficacious? Plast Reconstr Surg. 2012;130:659–666.
39. Aminpour S, Tollefson TT. Recent advances in presurgical
molding in cleft lip and palate. Curr Opin Otolaryngol Head
Neck Surg. 2008;16:339–346.
40. van der Heijden P, Dijkstra PU, Stellingsma C, van der Laan
BF, Korsten-Meijer AG, Goorhuis-Brouwer SM. Limited
evidence for the effect of presurgical nasoalveolar mold-
ing in unilateral cleft on nasal symmetry: A call for unified
research. Plast Reconstr Surg. 2013;131:62e–71e.
41. Sitzman TJ, Girotto JA, Marcus JR. Current surgical practices
in cleft care: Unilateral cleft lip repair. Plast Reconstr Surg.
2008;121:261e–270e.
42. Mulliken JB, Wu JK, Padwa BL. Repair of bilateral cleft
lip: Review, revisions, and reflections. J Craniofac Surg.
2003;14:609–620.
43. Tan SP, Greene AK, Mulliken JB. Current surgical manage-
ment of bilateral cleft lip in North America. Plast Reconstr
Surg. 2012;129:1347–1355.
 Volume 140, Number 1 • Bilateral Cleft Lip Repair
44. Abu-Rub N, Samsudin AR, Abdullah AB, Abdullah N. Fixed
presurgical orthopaedics for bilateral cleft lip and palate.
Aust Orthod J. 2005;21:39–43.
45. Oosterkamp BC, van Oort RP, Dijkstra PU, Stellingsma K,
Bierman MW, de Bont LG. Effect of an intraoral retrusion
plate on maxillary arch dimensions in complete bilateral cleft
lip and palate patients. Cleft Palate Craniofac J. 2005;42:239–244.
46. Khosla RK, McGregor J, Kelley PK, Gruss JS. Contemporary
concepts for the bilateral cleft lip and nasal repair. Semin
Plast Surg. 2012;26:156–163.
47. Tollefson TT, Senders CM, Sykes JM, Byorth PJ. Botulinum
toxin to improve results in cleft lip repair. Arch Facial Plast
Surg. 2006;8:221–222.
48. Mulliken JB. Primary repair of bilateral cleft lip and
nasal deformity. Plast Reconstr Surg. 2001;108:181–194;
examination,195–196.
49. Mulliken JB. Bilateral cleft lip. Clin Plast Surg. 2004;31:209–220.
50. Manchester W. The repair of bilateral cleft lip and palate. Br
J Surg. 1965;52:878–882.
51. Farkas LG, Posnick JC, Hreczko TM, Pron GE. Growth pat-
terns of the nasolabial region: A morphometric study. Cleft
Palate Craniofac J. 1992;29:318–324.
52. Randall P. A triangular flap operation for the primary repair
of unilateral clefts of the lip. Plast Reconstr Surg Transplant
Bull. 1959;23:331–347.
53. Le Mesurier A. The quadrilateral Mirault flap operation for
hare-lip. Plast Reconstr Surg (1946) 1955;16:422–433.
54. Bhattacharya S, Khanna V, Kohli R. Cleft lip: The historical
perspective. Indian J Plast Surg. 2009;42(Suppl):S4–S8.
55. Seibert RW. Bilateral cleft nasal repair. Facial Plast Surg.
2000;16:69–78.
56. Chang CS, Liao YF, Wallace CG, et al. Long-term comparison
of the results of four techniques used for bilateral cleft nose
repair: A single surgeon’s experience. Plast Reconstr Surg.
2014;134:926e–936e.
57. Henry C, Samson T, Mackay D. Evidence-based medi-
cine: The cleft lip nasal deformity. Plast Reconstr Surg.
2014;133:1276–1288.
58. McComb H. Primary repair of the bilateral cleft lip nose: A
10-year review. Plast Reconstr Surg. 1986;77:701–716.
59. McComb H. Primary repair of the bilateral cleft lip nose: A
15-year review and a new treatment plan. Plast Reconstr Surg.
1990;86:882–889; discussion 890–893.
60. Wolfe SA. A pastiche for the cleft lip nose. Plast Reconstr Surg.
2004;114:1–9.
61. Garri JI, O’Leary K, Gabbay JS, et al. Improved nasal tip pro-
jection in the treatment of bilateral cleft nasal deformity. J
Craniofac Surg. 2005;16:834–839.
62. Wolfe SA, Mejia ML. Staged rotation advancements pro-
vide improved nasal results compared to 1-stage repairs in
patients with complete bilateral cleft lip and palate. Ann Plast
Surg. 2014;72:307–311.
63. Grayson BH, Santiago PE, Brecht LE, Cutting CB. Presurgical
nasoalveolar molding in infants with cleft lip and palate. Cleft
Palate Craniofac J. 1999;36:486–498.
64. Grayson BH, Maull D. Nasoalveolar molding for infants born
with clefts of the lip, alveolus, and palate. Clin Plast Surg.
2004;31:149–158, vii.
65. Grayson BH, Cutting CB. Presurgical nasoalveolar orthope-
dic molding in primary correction of the nose, lip, and alveo-
lus of infants born with unilateral and bilateral clefts. Cleft
Palate Craniofac J. 2001;38:193–198.
66. Wolfe SA, Ghurani R, Mejia M. Use of staged rotation-
advancement procedures for the treatment of incomplete
bilateral clefts of the lip. Ann Plast Surg. 2004;52:263–268;
discussion 269.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
67. Mulliken JB, Kim DC. Repair of bilateral incomplete cleft lip:
Techniques and outcomes. Plast Reconstr Surg. 2013;132:923–932.
68. Bezuhly M, Fisher DM. Single-stage repair of asymmetrical
bilateral cleft lip with contralateral lesser form defects. Plast
Reconstr Surg. 2012;129:751–757.
69. Akamatsu T, Hanai U, Nakajima S, et al. Lip repair surgery for
bilateral cleft lip and palate in a patient diagnosed with trisomy
13 and holoprosencephaly. Tokai J Exp Clin Med. 2015;40:58–62.
70. Karimnejad K, Costa DJ. Otolaryngologic surgery in chil-
dren with trisomy 18 and 13. Int J Pediatr Otorhinolaryngol.
2015;79:1831–1833.
71. Guyuron B. MOC-PS(SM) CME article: Late cleft lip nasal
deformity. Plast Reconstr Surg. 2008;121(Suppl):1–11.
72. Kim SK, Lee JH, Lee KC, Park JM. Mulliken method of bilat-
eral cleft lip repair: Anthropometric evaluation. Plast Reconstr
Surg. 2005;116:1243–1251; discussion 1252–1254.
73. Hopper RA, Al-Mufarrej F. Gingivoperiosteoplasty. Clin Plast
Surg. 2014;41:233–240.
74. Garfinkle JS, King TW, Grayson BH, Brecht LE, Cutting CB.
A 12-year anthropometric evaluation of the nose in bilateral
cleft lip-cleft palate patients following nasoalveolar molding
and cutting bilateral cleft lip and nose reconstruction. Plast
Reconstr Surg. 2011;127:1659–1667.
75. Broder HL, Flores RL, Clouston S, et al. Surgeon’s and care-
givers’ appraisals of primary cleft lip treatment with and
without nasoalveolar molding: A prospective multicenter
pilot study. Plast Reconstr Surg. 2016;137:938–945.
76. Lee CT, Garfinkle JS, Warren SM, Brecht LE, Cutting CB,
Grayson BH. Nasoalveolar molding improves appearance
of children with bilateral cleft lip-cleft palate. Plast Reconstr
Surg. 2008;122:1131–1137.
77. Grayson BH, Garfinkle JS. Early cleft management: The case
for nasoalveolar molding. Am J Orthod Dentofacial Orthop.
2014;145:134–142.
78. Nemes B, Fábián G, Nagy K. Management of prominent pre-
maxilla in bilateral cleft lip and alveolus. Cleft Palate Craniofac
J. 2013;50:744–746.
79. Innis C. Repositioning of the premaxilla and simultaneous
closure of bilateral cleft lips. Br J Plast Surg. 1961;14:153–156.
80. Bishara SE, Olin WH. Surgical repositioning of the premax-
illa in complete bilateral cleft lip and palate. Angle Orthod.
1972;42:139–147.
81. Niranjane PP, Kamble RH, Diagavane SP, et al. Current
status of presurgical infant orthopaedic treatment for cleft
lip and palate patients: A critical review. Indian J Plast Surg.
2014;47:293–302.
82. Manna F, Pensiero S, Clarich G, Guarneri GF, Parodi PC.
Cleft lip and palate: Current status from the literature and
our experience. J Craniofac Surg. 2009;20:1383–1387.
83. Cronin TD, Upton J. Lengthening of the short columella
associated with bilateral cleft lip. Ann Plast Surg. 1978;1:75–95.
84. Cronin TD. Management of the bilateral cleft lip with pro-
truding premaxilla. Am J Surg. 1956;92:810–816.
85. Choi WY, Yang JY, Kim GB, Han YJ. Surgical correction of
whistle deformity using cross-muscle flap in secondary cleft
lip. Arch Plast Surg. 2012;39:470–476.
86. Narayanan PV, Adenwalla HS. Unfavourable results in the
repair of the cleft lip. Indian J Plast Surg. 2013;46:171–182.
87. Monson LA, Khechoyan DY, Buchanan EP, Hollier LH
Jr. Secondary lip and palate surgery. Clin Plast Surg.
2014;41:301–309.
88. Koshy JC, Ellsworth WA, Sharabi SE, Hatef DA, Hollier LH
Jr, Stal S. Bilateral cleft lip revisions: The Abbe flap. Plast
Reconstr Surg. 2010;126:221–227.
89. Cutting CB, Warren SM. Extended Abbe flap for secondary cor-
rection of the bilateral cleft lip. J Craniofac Surg. 2013;24:75–78.
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